2022 Edition

Program Administration (CA-PRG) 3: Medication Control and Administration

The organization ensures safe, uniform medication control and administration.

Interpretation

 This standard does not apply to foster care and kinship care homes. See CA-FKC 19.04.
NA The organization does not prescribe, dispense, administer, or store medication.

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Purpose

Service delivery practices guide the administration of safe, effective programs that respect personal dignity and self-determination.
Related Standards:

Note: When an organization’s medication management activities are limited to administering naloxone in the event of an opioid overdose, the NA at CA-PRG 3 applies. See CA-ASE 6.03 for more information on training and procedures related to treating opioid overdose. 

1
The organization's practices fully meet the standard, as indicated by full implementation of the practices outlined in the CA-PRG 3 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the CA-PRG 3 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the CA-PRG 3 Practice standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the CA-PRG 3 Practice standards.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Medication management procedures
  • Resumes and job descriptions from relevant job categories
  • Documentation tracking staff completion of medication management training
  • Medication logs
  • Aggregate reports of psychotropic medication use in children and youth for the past six months
  • Interviews may include:
    1. Relevant personnel
  • Review case records
  • Facility observation

 
Fundamental Practice

CA-PRG 3.01

Personnel directly involved in medication control and administration are qualified by license or training in accordance with applicable legal, regulatory, and/or contractual requirements.

Interpretation

 Physicians who prescribe and dispense approved buprenorphine products for opioid addiction are appropriately credentialed by the Drug Enforcement Agency (DEA) and provide treatment in accordance with DEA policy.

1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • With few exceptions, staff possess the required qualifications.
3
Practice requires significant improvement; e.g.,
  • A significant number of staff do not possess the required qualifications, and as a result the integrity of the service may be compromised.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 
Fundamental Practice

CA-PRG 3.02

When medication is initially prescribed, the prescribing clinician provides education to service recipients about the medication including:
  1. medication name;
  2. dose;
  3. reason for use;
  4. how to administer;
  5. desired effects; and
  6. potential side effects.

Interpretation

Written, detailed information regarding specific medications may be provided by the pharmacy responsible for filling a prescription.
NA The organization does not prescribe medication.
Note: Please see the Case Record Checklist for additional guidance on this standard.
1
The organization's practices reflect full implementation of the standard. Written information along with documented verbal consultation is provided for each and every client.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Documentation needs improvement.
3
Practice requires significant improvement; e.g.,
  • Information is not consistently provided to persons served; or
  • Documentation needs significant strengthening.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 
Fundamental Practice

CA-PRG 3.03

When individuals are receiving prescription medication:
  1. qualified personnel obtain and/or update information about the medications the individual is taking at each visit; and
  2. the prescribing clinician compares current medications the individual is taking at each visit, including vitamins or other non-prescription medications, with new or changed medication orders to identify possible adverse interaction of medications.
NA The organization does not prescribe or administer medication.
Note: Please see the Case Record Checklist for additional guidance on this standard.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • The required assessments do not happen at each visit; however, reviews are conducted regularly and when new medications are prescribed.
3
Practice requires significant improvement; e.g.,
  • One of the elements is not consistently addressed as required; or
  • Assessments are not regularly conducted.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 
Fundamental Practice

CA-PRG 3.04

Procedures for the proper administration and storage of medication address:

  1. locked, supervised storage with access limited to authorized personnel and in accordance with law, regulation, and manufacturer's instruction;
  2. maintaining medication in original packaging and labeling with the name of the service recipient, medication name, dosage, prescribing physician name, and number or code identifying the written order;
  3. appropriate disposal of expired or unused medication, syringes, medical waste, or medication prescribed to former service recipients;
  4. maintaining a record of who received medications, what medications were dispensed or administered, and when and by whom medications were dispensed or administered;
  5. administration of over-the-counter medications; and
  6. safe dispensing or administering of sample medications, in accordance with applicable legal, regulatory, and/or contractual requirements.

Interpretation

Storage of medication in a secure, central location with access by authorized personnel only is an effective risk management measure and best practice. However, COA recognizes that some programs, such as shelters and safe homes, allow service recipients to store medications in a safe, lockable personal space (e.g., individual lock boxes or private use lockers). In these instances, organizations can demonstrate implementation of the standard by providing protocols, procedures or other documents that demonstrate that they have acknowledged the potential risks of this method and subsequently taken appropriate measures to minimize those risks.
 
Organizations also need to clearly communicate that service recipients are personally responsible for administering and storing their own medications. Intake processes should stipulate what service recipients are allowed to store in their secure, personal space and assign responsibility of the space to the client to support this approach to storing medication.
 

Interpretation

Elements (d), (e), (f), and (g) do not apply to organizations that only store medication.
NA The organization does not dispense, administer, or store medication.
Note: Please see the Facility Observation Checklist for additional guidance on this standard.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • There are minor problems with storage or labeling but safety has not been compromised; or
  • Documentation needs minor improvement; or
  • Procedures need strengthening.
3
Practice requires significant improvement; e.g.,
  • There are problems with storage or labelling that raise concerns about safety; or
  • Documentation is inconsistent, or some documentation is missing or incomplete; or
  • Procedures need significant strengthening. 
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 
Fundamental Practice

CA-PRG 3.05

Immediately prior to administration, qualified personnel review with the individual the medication to be administered and its purpose, and verify:
  1. the identity of the individual and the medication ordered;
  2. that the medication to be administered matches the medication order; and
  3. the integrity of the medication through visual inspection.
NA The organization does not administer medication.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Procedures are consistently followed with minor exceptions; or
  • Documentation needs strengthening.
3
Practice requires significant improvement; e.g.,
  • Procedures are not consistently followed; or
  • Documentation needs significant strengthening.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 
Fundamental Practice

CA-PRG 3.06

Following administration of medication, personnel observe and assess the effects of medication on the individual and consult with pharmacists/medical professionals, as necessary.
NA The organization does not administer medication.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Documentation of observed effects needs minor improvement; or
  • Procedures need strengthening.
3
Practice requires significant improvement; e.g.,
  • Documentation of observed effects is inconsistent, or some documentation is missing or incomplete; or
  • Procedures need significant strengthening.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 
Fundamental Practice

CA-PRG 3.07

The organization tracks the use of psychotropic medications in children and youth at the individual and program level and:
  1. engages prescribers and other partnering providers in corrective action when concerns are noted; and
  2. advocates for increased availability and use of non-pharmacological interventions.
NA The organization does not prescribe or administer psychotropic medication for children and youth.
Examples: Measures to prevent inappropriate or unnecessary use of psychotropic medications can include:
  1. ensuring prescribing providers are familiar with child and adolescent trauma symptoms; and
  2. establishing a team- or peer-based prescribing model.
Note: See CA-PRG 1.03 for more information on tracking pharmacological interventions at the individual case level.

Please see the Case Record Checklist for additional guidance on this standard.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Documentation and/or monitoring of corrective actions could be strengthened.
3
Practice requires significant improvement; e.g.,
  • The organization tracks psychotropic medication use but findings and recommendations are not being used; or
  • Procedures need significant strengthening. 
4
Implementation of the standard is minimal or there is no evidence of implementation at all.