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Policies and Procedures

Please review the following policies and procedures for our program:

Corrective Action/ Dismissal of Pharmacy Residents

The pharmacy resident must abide by all provisions of the Pharmacy Resident Appointment Agreement (contract). Pharmacy residents are subject to probation or dismissal based on failure to meet obligations of the residency program and expectations as defined in the appointment agreement. Further, the resident will sign a copy of this policy stating that they have reviewed and understand the policy at orientation for the residency program.

If the pharmacy resident fails to successfully complete the Pharmacy licensure examination within the appropriate time frame after the start date of the residency program, the resident may be terminated from the program.

The pharmacy resident is also subject to the dismissal process that applies to all hospital employees with regarding to adherence of all hospital, pharmacy and residency policies.

Minimum Requirements to Receive a Resident Certificate

Residents are expected to satisfactorily complete all requirements of the Pomona Valley Hospital Medical Center Residency Program. Only those residents who satisfactorily complete the requirements will receive their Residency Certificate as evidence of program completion. Evaluation of the residents’ progress in completing the requirements is done as part of the quarterly review process. The Residency Advisory Committee shall assess the ability of the resident to meet the requirements by established deadlines and work with the resident to assure their satisfactory completion. If a resident is failing to make satisfactory progress in any aspect of the residency program, a corrective action plan shall be developed by the Residency Program Director in conjunction with the preceptor(s).

Required activities include but are not limited to the following:

  • Completion of a full-time practice commitment for 12 months
  • Successfully passing the California State Board of Pharmacy pharmacist examination by October 31st of the residency year.
  • Meet all residency requirements as demonstrated by achievement of all required goals and objectives
    • 100% for patient care related goals and objectives
    • ≥ 85% for non-patient care goals and objectives
    • ≤ 1 objective marked as Needs improvement as the final assessment
  • Completion of the Teaching and Research Certificates Program
  • Completion of a major project and presentation at pharmacy conference
  • Completion of a Family Medicine grand rounds lecture at Pomona Valley Hospital Medical Center
  • Completion of a multidisciplinary noon conference grand rounds lecture at Pomona Valley Hospital Medical Center
  • Completion of a pharmacy grand rounds
  • Participation in resident recruitment activities


All residents are required to become a registered pharmacist in the state of California by October 31st of the residency year. However, residents are highly encouraged to have completed all licensure examinations by end of July of the residency year to ensure their training is optimized during the orientation month. Failure to acquire licensure by October 31st will result in probation with the need for an immediate remediation plan, until license is acquired. If licensure is not acquired by January 1, the resident will be dismissed from the residency program.


Upon recommendation of the Program Director, and with the approval of the Residency Advisory Committee, a resident may be dismissed during the term of the residency for unsatisfactory performance or conduct. Examples include, but are not limited to the following:

  • Unprofessional conduct
  • Poor performance in the residency program (as evidenced by failure of a rotation)
  • Non-licensure by the California State Board of Pharmacy by October 31st of the residency year will result in probation with the need for an immediate remediation plan; non-licensure by January will result in automatic dismissal.
  • Revocation of pharmacist licensure by the California State Board of Pharmacy

The recommendation to the Residency Advisory Committee for dismissal shall be in writing, outlining the areas deemed unsatisfactory and the reasons for the dismissal.

Formal Appeals Process

The resident may initiate a formal appeals process by composing a response within 5 business days from the time of written notification of a warning, probationary action, or dismissal.

  • The request to review the action (an appeal) should be submitted in writing to the RPD and Coordinator and received in their office by 4:30pm on the fifth business day after receipt of the warning, probation, or dismissal. Failure to notify the RPD and the Coordinator within this timeframe will be considered acceptance of the warning, probationary action, or dismissal.
  • The resident may appear before the RPD and Resident Advisory Board and be given the opportunity to make a statement.

Attendance/Leave Policy

Attendance Policy

Residents are expected to attend all functions as required by the Residency Program Director (RPD) and rotation preceptors. All leave requests should be discussed in advance with the appropriate preceptor to assure that service responsibilities can be fulfilled. An excused absence is defined as paid time off (PTO) and discussed with and approved by the respective rotation preceptor and RPD. If for any reason the resident is not able to report to work due to an illness or family care, the resident must speak to the RPD or their direct Preceptor. If the resident is unable to contact the appropriate persons, they may send an email or leave a voicemail and contact the pharmacist on duty. If the resident is sick for three or more days, a doctor’s excuse is necessary. If a resident is scheduled for staffing as inpatient pharmacist and they call in sick they must make up this time (additional weekend or shift) on the subsequent schedule. Residents are provided three (3) days for sick leave.

Duty Hours

Duty hours are defined as all scheduled clinical and academic activities related to the pharmacy residency program. This does not include reading and preparation time for presentations, journal clubs or lectures, or travel time to and from conferences. As defined by the American Society of Health System Pharmacists (ASHP) Accreditation Standards for Pharmacy Residencies, all duty hours must meet the following criteria:

  1. Duty hours must be limited to 80 hours per week, averaged over a 4 week period. This includes all in-house activities and moonlighting.

  2. Residents must have at least 1 day free of duty every 7 days, averaged over a 4 week period.

  3. Residents should have 10 hours free of duty between scheduled shifts, and a minimum of 8 hours free of duty between scheduled shifts.

  4. Continuous duty periods should not exceed 16 hours, and at a maximum must not exceed 24 hours.

  5. At-home call hours are not included in the 80 hour per week maximum, but must not be so frequent as to impede rest or reasonable personal time for the resident. No at-home call can occur on the day free of duty.


External or internal hours that are compensated beyond the usual resident salary are considered moonlighting hours. Residents who choose to moonlight must adhere to the following criteria:

  1. All moonlighting hours must be included in the 80 duty hour per week maximum. Residents are allowed up to 2 additional eight-hour shifts per 4 week period, as long as the duty hour maximum is not exceeded.

  2. Work performed outside the organization (external moonlighting) must be reported to and approved by the RPD.

  3. Moonlighting must not interfere with a resident’s ability to perform in the residency and achieve the program’s goal and objectives. The RPD may restrict or suspend all moonlighting if they feel it has negatively impacted a resident’s performance or patient care. Residents who continue to moonlight despite these restrictions can be dismissed from the residency program.

Paid Time Off

Twelve (12) working days per twelve-month contract are granted for paid time off (PTO). Job interviews, personal appointments, days to sit for exams will require use of PTO. Additional leave to attend professional meetings beyond the assigned recruitment or presentation activities will also require use of PTO. PTO should not be scheduled on days the resident is assigned to staff unless prior approval is obtained and due diligence to find coverage has occurred. PTO requests cannot exceed more than 5 days on any one rotation experience without prior approval from RPD and rotation preceptor. PTO requests in June are discouraged and will be reviewed on a case by case basis by the RPD.

Extended Leave Policy

If an extended absence occurs (i.e. extended family or sick leave), extension of the residency program may be necessary. Opportunity to extend the program with pay will depend on the decision of the Residency Advisory Committee.

Sick Call

  • If the resident is unable to come in for an assigned staffing shift, they must follow the same sick call process for all pharmacy staff. If the resident is unable to come in for a rotation day, they must contact their assigned preceptor for the day and the RPD. The preceptor has the discretion to have the resident make up the day(s) missed.