MEDICATION MANAGEMENT
SYSTEM PROCEDURES
Activ All
Medication Management System Procedures
Controlled Document
Contents
1.
Medication Management System.......................................................................................... 4
1.1
Purpose and scope .......................................................................................................... 4
1.2
Related Documents ......................................................................................................... 4
1.3
Consultation..................................................................................................................... 4
1.4
Acknowledgements .......................................................................................................... 5
1.5
Medication Records ......................................................................................................... 5
1.6
Records Retention ........................................................................................................... 5
2.
Medication Information ..................................................................................................... 6
2.1
3.
Consumer Information Services ....................................................................................... 6
Supply of Medication and Documentation ....................................................................... 7
3.1
Internal Transfer of Medication Procedure........................................................................ 7
3.2
External transfer of Medication Procedure........................................................................ 7
3.3
Transfer of Medication Between Group Home and Pharmacy .......................................... 8
3.4
Checking Medication and Documentation ........................................................................ 8
3.5
Medication Incident Follow Up Procedure……………………………………………………..8
3.6
Medication Supply for Residents of Accommodation Group Homes………………………..9
4.
Storage of Medication ..................................................................................................... 11
4.1
Medication Storage at Facilities ......................................................................................... 11
4.2
Medication Storage in Facility Refrigerators ................................................................... 11
4.3
Storage for Services Held Outside Activ Facilities .......................................................... 12
4.4
Storage in a Customers Own Home ............................................................................... 12
4.5
Schedule 8 Medication................................................................................................... 12
5.
Self Administration .......................................................................................................... 13
5.1
Self Administration Assessment ..................................................................................... 13
5.2
Role of Activ Staff/volunteers in Self Administration ....................................................... 14
6.
Supported Medication Administration............................................................................ 15
6.1
Role of Activ staff/volunteers in Supported administration .............................................. 15
6.2
Scope of Medication Administration Services ................................................................. 15
6.3
Medication Administration Processes ............................................................................. 17
6.4
As Required (PRN) Medication ...................................................................................... 19
6.5
Damaged Medication or Packaging................................................................................ 20
6.6
Crushing Oral Medication............................................................................................... 20
6.7
Refusal of Medication .................................................................................................... 21
6.8
Administering Medication without Knowledge of the Customer ......................................... 21
6.9
Withholding medication .................................................................................................. 21
AQuA No: 1656
Version:6
Issue Date: 06/08/15
Review Period: 1 year
Author: Service Development Mgr
Authoriser: TLT 201507.3
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6.10
Documenting Medication Administration ........................................................................ 22
6.11
6.12
Monitoring Medication Administration ............................................................................. 22
Complementary and Alternative Therapies..................................................................... 23
7.
Customer Entry Procedures ........................................................................................... 24
8.
Disposal of Medication .................................................................................................... 25
Return of Medication Following Death – Accommodation Homes Only........................... 25
8.1
9.
Medication Incidents ....................................................................................................... 26
9.1
Reporting a Medication Incident ..................................................................................... 26
9.2
Pharmacy Medication Report – Accommodation Group Homes Only ............................. 27
10.
Monitoring Medication Management .......................................................................... 28
10.1
Annual Health and Medication Reviews – Accommodation Services Only ...................... 28
10.2
Self Monitoring ............................................................................................................... 28
10.3
Medication Incidents ...................................................................................................... 28
10.4
Medication Audit ............................................................................................................ 28
11.
Training and Competency ........................................................................................... 29
11.1
Training ......................................................................................................................... 29
11.2
Maintaining Competency ............................................................................................... 30
11.3
Agency Staff/volunteers ................................................................................................. 30
11.4
Volunteer Staff/volunteers .............................................................................................. 30
12.
References ................................................................................................................... 31
13.
Appendix A: Definitions .............................................................................................. 32
14.
Appendix B: Pharmacy Requirements – Accommodation Group Homes ................ 34
Essential Requirements ............................................................................................................. 34
Desirable Services..................................................................................................................... 34
15.
Appendix C: Dispensing Procedures ......................................................................... 35
Removing Medication Compartments ........................................................................................ 35
Use of PIL-BOB ......................................................................................................................... 35
16.
Appendix D: Individual Storage Containers .............................................................. 37
Storage at Facilities ................................................................................................................... 37
AQuA No: 1656
Version: 4
Issue Date:06/08/15
eview Period: 2 years
Author: Service Development Mgr
Authoriser: TLT 201507.3
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Medication Management System Procedures
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1.
Medication Management System
1.1
Purpose and scope
These procedures provide an operational framework for medication management processes for
all service s within Activ. If a component of a procedure is applicable only to specific services
this is identified.
1.2
Related Documents
As Required PRN Medication Protocol Form (AQuA 1660)
Consent Form (AQuA 1990)
Customer Information on Activ Medication Self Administration (AQuA 1781)
Medications Monitoring Checklist (AQuA 1774)
Medical Examination Outcome Form (AQuA 1623)
Medication
Checking
Record
(AQuA
1599)
Medication Delivery Record (AQuA 1621)
External Medication Transfer Record (AQuA 1600)
Medication Incident Report: Part A (AQuA 1619) *
Pharmacy Supplies Order Form (AQuA 1617)
Records Retention Schedule
Self Administration Assessment Form (AQuA 1657)
Schedule 8 Medication Handover Form (AQuA 2029)
**ActivLink How To guide
1.3
Consultation
Activ’s customers, their family and advocates
Employee Advocacy Committee
General Managers
Managers across all services
Service Advisory Committee
Consumer Liaison and Policy Development Officer
1.4
Acknowledgements
This document was originally produced with the assistance of:
Jilani Khan - B.Pharm, MPS, BSc, C.D. of Kiara Healthlink Pharmacy,
Chris Roberts – J.D., BSc (Hons), Adv DipHE Nursing, RGN, RN Div1, RABQSA (Aged Care),
Michael Harris - Registered Nurse
Karen Lawtie – then Activ Nurse Educator; Registered Nurse; Grad. Dip. Ed.
1.5
Medication Records
The medication management system is comprised of 2 hard copy files. An overall Service
Medication File and then each individual Customer has a Customer Medication File.
AQuA No: 1656
Version:6
Issue Date: 06/08/15
Review Period: 1 year
Author: Service Development Mgr
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1.5.1
Customer Medication File (Red file)
Each Customer should have an individual medication file.
The following hard copy information is to be included in the file:
1. Consumer information service: contact details (see Section 2.1)
2. Pharmacy documentation: profile and signing sheets for all Customer medications
(including packed, regular non-packed and as required [PRN] medications)
3. Activ documentation regarding (as required) PRN Medication Protocol Form
(AquA1660)
4. Consent Form (AQuA 1990) as required
5. Additional for Activ Group Homes Only – Medical Examination Outcome Forms
(AQuA 1623)
1.5.2
Service Medication File (Yellow file)
This hard copy file is used to store:
1. Medication Checking Record (AQuA1599)
2. External Medication Transfer Record (AQuA 1600)
Additional for Activ Group Homes Only:
1. Medication Delivery Records (AQuA1621)
2. Contact details of the Customer’s official pharmacy supplier along with opening
hours available inside the front of the Service File.
1.6
Records Retention
All medication records should be retained by Activ for the nominated length of time identified in
the Activ Records Retention Schedule:

Five years at the facility site (Activ Group Home, Workplace)

Twenty years as archived records
The Records Retention Schedule is on Activ’s Alfie intranet site (see link in section 1.2).
AQuA No: 1656
Version: 4
Issue Date:06/08/15
eview Period: 2 years
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2.
Medication Information
Policy Statement:
Staff/volunteers must only utilise Customer medication information from approved services.
Medication is any drug or medicine taken by the Customer to bring about a therapeutic effect
within the Customer.
This may include:

prescription medication

non-prescription medicines (over-the-counter medication)

complementary and alternative health care products
2.1
Consumer Information Services
Activ Customers have the right to be informed about their medication. Staff/volunteers should
assist their Customers to obtain accurate, up-to-date medication information.
Information sourced from the internet is not a substitute for a Doctors’ advice and must not be
used to diagnose or find treatments for Customers.
Contact details for approved information services available for staff/volunteers to use:
Service
Contact Details
Available
The Customers pharmacist
See
Customer
medication file (red) for
details
Pharmacy business hours only
The Customer’s doctor
See:
Customer
personal file for details
Business hours only
National Prescribing
Services Limited
www.nps.org.au
24 hour online service
Poisons Information
Centre
Phone: 13 11 26
24 hour service
Police/Fire/Ambulance
(Emergency Only)
Phone: 000 (landline
& mobile)
24 hour service
Phone: 1300 888 763
Localised
mobile 112


Click on ‘consumer’
Type in medicine name
and click ‘search’
help:
If a Customer is on an extended overseas holiday the international medication information and
contact details should be organised before leaving Australia.
AQuA No: 1656
Version:6
Issue Date: 06/08/15
Review Period: 1 year
Author: Service Development Mgr
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3.
Supply of Medication and Documentation
Policy Statements:
All medication must be supplied in pharmacy dispensed and labeled packaging. Medication in
tablet or capsule form must be provided in a Sealed Dose Administration Aid (SDAA) unless
contraindications have been identified by a Pharmacist.
Current documentation must be provided to Activ to support the administration process.
This will include a Medication Profile, Signing Sheets and an ‘As Required (PRN) Medication
Protocol Form’ (AQuA 1660) if indicated.
Staff/volunteers must record transfer of medication between pharmacies and Activ Group
Homes. Group Homes in each area will have a sole pharmacy supplier to dispense
medication.
3.1
Internal Transfer of Medication Procedure
When transferring medications between Activ services, staff/volunteers are to place only the
required medication and documentation in a suitable container (e.g. plastic sleeve or
envelope). Please note that only single doses of medication are to be transferred each day
and under no circumstances should bulk lots of medication be supplied. I.e. One week’s worth
of lunch time medication. All medication is to be transferred between services daily.
Items to be included in the transfer are:
a. A copy of a current Medication Profile and Signing Sheet administration
record (original document, not photocopies)
b. Copies of ‘As Required (PRN) Medication Protocol Form’ (AQuA 1660), if required
c. Non-packed medication in its original container, if required and/or
d. Sealed Dose Administration Aid (SDAA)
e. Activ Group Homes only - the compartment cut from the Sealed Dose
Administration Aid in a protective container (Appendix C)
3.1.1





Method of Transfer by Activ Bus to Another Service (e.g. Workplace):
As Customers are collected by the bus, accommodation staff to place all Customer medication
and related documentation into the storage bag located in each bus for transportation to the other
service
Storage bags must be fastened securely by the staff member placing medication into them
Upon arrival at the other service, Facility Staff to retrieve the Customer medication from the
storage bag (when meeting Customers at the bus) and check to confirm that all Customer
medication and related documentation has been received
In the event that the bus transports Customers to more than one workplace/service, medication
must be kept separate (e.g. another bag is used and secured in the bus and labeled accordingly)
Customers who self administer are permitted to carry own medications
NB:
 In the event that a Customer uses paid taxi services the taxi driver has no responsibility in
transporting medication
 In instances where Customers regularly attend a day placement service or a business workplace
it is preferable, where provided, to use a separate SDAA for lunch time medications.
 The SDAA utilised at the day placement service must have its own pharmacy generated Signing
Sheet and Medication Profile sheet and be transported on a daily basis.
AQuA No: 1656
Version: 4
Issue Date:06/08/15
eview Period: 2 years
Author: Service Development Mgr
Authoriser: TLT 201507.3
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3.2
External transfer of Medication Procedure
Staff/volunteers transferring medication to a pharmacy, external service, or family member
are to place medication and required documentation in a suitable container.
Also complete an External Medication Transfer Record (AQuA 1600).
3.3
Transfer of Medication between an Activ Group Home and the Pharmacy
A delivery day and time will be nominated by pharmacies who deliver as part of their
contract. If a staff/volunteers member cannot be present to receive a delivery the pharmacy
must be notified at the earliest opportunity and alternative arrangements made.
The following process will be used when receiving medication from the pharmacy:
1. Medication must be received by care staff/volunteers with a photographic Identity Card.
2. Complete the Medication Delivery Record (AQuA 1621)
3. All medication to be checked as soon as possible - using the Medication Checking
Record (AQuA 1599). Checking must be complete within 24 hours.
4. For additional Schedule 8 medication checking controls – see section 4.5
5. Secure the medication in the appropriate locked storage unit(s).
6. Report errors immediately to the pharmacy and complete a Medication Incident Report
(Part A) on ActivLink* before end of shift.
7. Notify the Team Leader. Subsequent investigation and/or follow up will be required by the
Line Manager
3.4
Checking Medication and Documentation
Check all received medication and documentation in a timely manner before administration
process to ensure correct medication and accurate quantities have been supplied.
Report errors immediately and complete a Medication Incident Report (Part A) on ActivLink*
before the end of shift – see section 6.5.
Recreation only – Medication Incident Report (AQuA 1619: Part A) to be completed at time
of incident, but may be submitted at the end of the program.
3.4.1
Staff Requirements for Checking Medication and Documentation
At the start of each shift Staff must:


Check all previous medications have been administered and signing sheets completed
for each Customer
Report any discrepancies to managers immediately and complete a Medication Incident
Report (Part A) on ActivLink* before the end of shift.
At the end of each shift Staff must:


Check all medication has been administered during the current shift on each Customer’s
Signing Sheet
Report any discrepancies to managers immediately and complete a Medication Incident
Report (Part A) on ActivLink* before the end of shift.
AQuA No: 1656
Version:6
Issue Date: 06/08/15
Review Period: 1 year
Author: Service Development Mgr
Authoriser: TLT 201507.3
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3.5
Staff and Volunteer Medication Error Process
All medication incidents are to be investigated and appropriate actions taken by the Line
Manager/Team Leader. Should the incident involve staff error, the following actions are to be
adhered:
First Medication Error:
1. Line Manager/Team Leader to discuss the incident with the staff member and review Activ’s
Medication Management System Policy (AQuA 1776) together. Staff member to sign and date
that they have read and understood the Policy.
2. Line Manager/Team Leader to observe the staff member administrating medication on one
occasion. The discussion is to be documented and constitutes the initial stage of staff
performance management.
3. Line Manager/Team Leader to discuss with their Senior Manager and Human Resource
Manager as required.
Second Medication Error:
1. Suspend staff from administering medication.
2. Line Manager/Team Leader to discuss the incident with the staff member and book them into
first available Medication Training. The discussion is to be documented. The staff member
needs to be made aware that continuation of medication errors will place their future
employment opportunities with Activ at risk.
3. Line Manager/Team Leader to discuss with their Senior Manager and Human Resource
Manager.
Third (and Final) Medication Error:
1. Suspend staff from administering medication.
2. Formal letter of allegation to be given to the staff member followed by response, meeting and
outcome through to final stage of performance management. Discussions regarding possible
termination of employment will be deliberated at this point with staff member, Line
Manager/Team Leader, Senior Manager and Human Resource Manager.
3.6
Medication Supply for Residents of Activ Group Homes
Activ Group Homes in each area will have a sole pharmacy supplier to dispense
medication. The key role of this pharmacist is to:

Dispense medication accurately

Provide information to promote the quality use of medication in Activ

Check for interactions between a Customer’s medications
Liaise with the Customer’s Doctor to clarify medication queries.
3.6.1
Regular Medication Packed in Sealed Dose Administration Aids
Regular medication in Sealed Dose Administration Aids will be supplied on an ongoing
basis until a change in prescription, or a formal request to cease the medication is made.
3.6.2
Non-Packed Medication and PRN Medication
Non-packed medication, including non-packed tablets, liquids, creams, inhalers and
PRN medication will only be supplied when stock is ordered from the pharmacy. If required,
additional medication must be ordered at least 48 hours prior to the next delivery or collection
using the Pharmacy Supplies Order Form (AQuA 1617).
3.6.3
Non-Prescription (Over-the-counter) Medication
A pharmacist is authorised to supply non-prescription medication. This includes items such as
AQuA No: 1656
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medicated skin care treatments, laxatives, vitamins and natural therapy supplements. If these
are provided by family, they must be discussed with the family in regards to the need of the
medication, sent to the pharmacy in their original packaging for labeling and inclusion on the
medication profile and signing sheet before administration.
3.6.4
Change of Prescription
Where medication changes are prescribed by the Doctor staff/volunteers must:
1. Ensure the Medical Examination Outcome Form (AQuA 1623) is completed, signed
by the Doctor and stored in the (Red) Customer File
2. Fax the Medical Examination Outcome Form and prescription/s to the pharmacy
3. Phone the pharmacy to confirm the request
4. Record the changes of medication in the report book in black or blue ink and highlight
in red to draw attention to these changes
5. Enter new appointments in the home diary
6. Inform other services of changes in writing (i.e. via email or internal mail)
If newly prescribed medication requires a Registered Nurse to administer, then this must
be arranged by the facility’s Senior Manager (or delegate).
3.6.5
Out of Hours Pharmacy Requests
Unless deemed urgent by a Doctor on the Medical Examination Outcome Form (AQuA
1623), do not contact a pharmacist out of hours with pharmacy requests for routine
provision of medication.
3.6.6
Collection of Medication
When collecting medication from a pharmacy or hospital ensure that any additional errands
are completed before hand and that staff/volunteers return immediately to the facility
afterwards.
AQuA No: 1656
Version:6
Issue Date: 06/08/15
Review Period: 1 year
Author: Service Development Mgr
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4.
Storage of Medication
Policy Statement:
Medication that is not under direct supervision must be safely and appropriately stored in a
locked storage unit in individual storage containers.
Where supported medication administration is provided to Customers in their home, Activ
staff/volunteers should assist the Customer to store medication in a safe and responsible
way.
Generally, medicines should be stored in the dispensed packaging container in a cool, dry
place. Some medications require refrigeration.
4.1
Medication Storage at Facilities
At all facilities:

Medication must be stored in a locked storage unit in individual storage containers (see
Appendix D)

Medication is to be placed in storage when not being supervised

Keys for storage must be kept secure or held by staff/volunteers

Medication must be stored according to pharmaceutical and manufacturers’ instructions

Lockers, or suitable secure alternatives, must be made available for Customers who
self administer medication.
4.2
Medication Storage in Facility Refrigerators
All facility refrigerators used for medication storage are to have a lockable medication storage
container.
Medications requiring refrigeration must be stored in a lockable medications storage container
and kept on the upper shelf (lower drawers and the door are too warm for safe medication
storage) of the fridge.
Temperature monitoring must be done once a month by recording temperatures on the Monthly
Food Storage Checklist (AQuA 1711). Replace refrigerator thermometer batteries every three
months and document on this form under ‘action taken’.
For all temperature readings outside of safe temperature range (less than 2oC or greater than
8oC):

Adjust the fridge thermostat to correct temperature range if possible. Otherwise, advise
Team Leader/Manager to have the refrigerator repaired.

Submit a Medication Incident Report (Part A) on ActivLink* before the end of shift.

Discard medication (see Section 8).
AQuA No: 1656
Version: 4
Issue Date:06/08/15
eview Period: 2 years
Author: Service Development Mgr
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4.3
Storage for Services Held Outside Activ Facilities
For activities commencing and finishing on the same day:
1. Store medication in a locked cool-bag used only for this purpose
2. Keep the medication cool bag out of direct sunlight and out of sight and reach of
Customers.
Additionally if the service has an extended or overnight stay component:
3. Transfer medication that requires refrigeration to refrigerated medication storage as
soon as possible upon reaching destination.
4. Transfer non-refrigerated medication to a fixed locked storage unit if available.
4.4
Storage in a Customers Own Home
Where supported medication administration is provided, Activ staff/volunteers should assist the
Customers in storing medication in a safe and responsible way. Staff/volunteers should inform
the Customers:
1. They are responsible for storage and safety of medication in their home environment
2. That appropriate storage of medicines is important and that medicines should be stored
in accordance with any instructions provided
4.5
Schedule 8 Medication
Schedule 8 (Controlled Drug) – Drugs of addiction are administered by the WA Poisons Act
1964. This category is for prescribed medications that require restriction of manufacture, supply,
distribution, possession and use to reduce abuse, misuse and physical or psychological
dependence.
All Controlled Schedule 8 medication must be stored in a locked fixed cabinet.
In addition to checking Schedule 8 medications upon delivery (by completing the Medication
Delivery Record form), the “Schedule 8 Medication Handover Form (AQuA 2029) must be
completed:
1. At the start of each shift Staff must:

Count and record the quantity of all types of Schedule 8 medications for each relevant
Customer and record on the Form;

Check and agree the opening quantities to the recorded closing quantities on the
previous shift Form and sign the previous shift Form confirming quantities on hand;;
2. At the end of each shift Staff must:

Ensure that required recordings of any Schedule 8 medication administered during the
current shift (per the Customer Signing Sheets) has occurred;

Record any Schedule 8 medication spoilage (written details must be attached to the
Form) plus any Schedule 8 medication delivered during the shift;

Count and reconcile Schedule 8 medication closing balances and sign the Form.
3. Report any discrepancies to managers immediately and complete a Medication Incident
Report (Part A) on ActivLink before the end of shift.
4. Where Schedule 8 medication is provided to Customers living independently in their
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own home, Activ staff/volunteers should assist the Customer to store medication in a
safe and responsible way.
5. Arrange the return of Schedule 8 Medication that the Customer has ceased taking to
the pharmacy within forty eight hours and record details on the relevant Schedule 8
Medication Handover Form.
6. The locked storage key to Schedule 8 medications is to be accessed only by nominated
staff/volunteers.
AQuA No: 1656
Version: 4
Issue Date:06/08/15
eview Period: 2 years
Author: Service Development Mgr
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5.
Self Administration
Policy Statement:
All Customers who self administer medication must be assessed as competent by a Doctor,
registered nurse or other allied health professional.
The only exception is where a Customer lives independently in the community or holds a
drivers licence. These Customers are automatically deemed to be competent to selfadminister their medication and do not need to be assessed unless staff / volunteers have
observed medication administering concerns.
The Customer must meet their responsibilities to self administer medication
Activ acknowledges the right of an Activ Customer to choose to participate in their individual
medication management in a safe and effective way, including self-administration independent
of supervision.
Activ also has a duty of care to ensure that Customers who request to self administer
medication are competent to do so.
A Customer’s medication regime must be consistent across all of the services they access (ie if
they receive medication support at a group home they are not permitted to self administer at
their day placement)
5.1
Self Administration Assessment
All Customers, with the exception of those living independently in the community or holding a
drivers licence (ie deemed competent), who request to self administer are required to:

be assessed by a Doctor, a registered nurse or a Certified Assessor as competent –
using the Self Administration Assessment Form (AQuA 1657)

be acknowledged by Activ as a self administering Customer

meet their responsibilities in self administration

Those Customers who refuse to undertake a request by Activ for an assessment as
detailed above will have the matter documented and referred to the General Manager of
the relevant service
5.1.1
Customer Responsibilities in Self Administration
Self administering Customers have the following responsibilities:

Provide an up-to-date list of all medications and inform staff/volunteers of changes to
medication

Inform staff/volunteers of any difficulties during administration

Ensure they have a sufficient medication supply

Store medication in a secure storage unit OR on their person.

Do not provide medication to any other Customer

Dispose of medication and medical waste in a safe manner

Have an annual self administration assessment review
AQuA No: 1656
Version:6
Issue Date: 06/08/15
Review Period: 1 year
Author: Service Development Mgr
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5.2
Role of Activ Staff/volunteers in Self Administration
The only assistance to be provided by staff/volunteers to a Customer who self
administers medication is:
 The opening of medication containers on request

Activ Group Home -the maintenance of an adequate supply of medication
If medication is taken out of a container and provided to the Customer by
staff/volunteers this is supported medication administration (Section 6).
Staff/volunteers must ensure:

All Customers self-administration assessments are reviewed annually and the
assessment form (AQuA 1657) completed

All self administering Customers are informed of their self administration responsibilities

Any concerns observed in a Customer’s self-administration practices are acted upon
immediately
5.2.1
Managing Self-Administration Concerns
If staff/volunteers members raise concerns about a Customer’s self-administration practices, the
supervisor/line manager should:
1. Discuss the concern with the Customer and the nominated family / carer (if required)
2. Identify strategies to enable the Customer to safely self administer
3. Document the action taken on a Medication Incident Report (Part A) on ActivLink* as
well as in the Customer file / report book and notify Team Leader / Line Manager
4. Review and document on the Customer’s care plan the effectiveness of strategies at
each service attendance until safe self-administration practices are established.
5.2.2
Transitioning a Customer to Self Administer
Where a Customer living in an Activ Group Home has expressed a desire to self administer, but
does not yet have the skills to do this a transition program will be used. This will be led by
Accommodation Services, but it will require support from other service providers.
A request to a nurse educator to do an initial assessment must be made through the
Accommodation Team Manager. A Care Plan will be developed by the nurse educator in
consultation with the Team Leader and other stakeholders.
The following steps will be used:
1. Initial assessment will identify gaps in skills and knowledge
2. Training plan will be developed to address gaps
3. Training provision
4. Reassess and evaluate
5. Determine if Customer is competent or if further training is required.
If deemed to be competent the Customer must undergo Self administration assessment on an
annual basis and continue to meet their self assessment responsibilities.
AQuA No: 1656
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Issue Date:06/08/15
eview Period: 2 years
Author: Service Development Mgr
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5.2.3
Temporary medication administration support for a self administering Customer
A change in circumstances may require that a self administering Customer be supported with
their medication administration for a period of time.
A Care Plan must be developed to identify the level of support required by the Customer
including a proposed review date for the Customer to begin a transition process back to self
administering.
5.2.4
Manager Responsibilities
It is the responsibility of the managers of each service to ensure that annual self-administration
assessment/reviews are undertaken.
The authorisation to self-administer medication should be revoked immediately if concerns are
raised and the actions of a Customer are a risk to themselves or others. Document all actions
taken on a Medication Incident Report (Part A) on ActivLink*. This should then be reviewed
once appropriate strategies are put in place.
AQuA No: 1656
Version:6
Issue Date: 06/08/15
Review Period: 1 year
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6.
Supported Medication Administration
Policy Statement:
The scope of supported medication administration will be appropriate for the service.
Assisted medication administration must only be performed by staff/volunteers that have been
assessed as competent by a registered nurse and on completion of Activ’s ‘Recognise
Healthy Body Systems’ (HLTAP301B) and ‘Assist Clients with Medication’ (CHCCS305C)
training or be registered to practice as a Registered Nurse (Div.1) with the Australian Health
Practitioner Regulation Agency (AHPRA).
6.1
Role of Activ staff/volunteers in Supported administration
Note: Assistance for a Customer to administer medication is ONLY to be provided when
supported by pharmacy documentation.
Support workers in all services are responsible for understanding the nature of their role when
supporting a Customer with medication. If unsure about their role or if having difficulty to assist
a Customer with their medication, the support worker must seek help from their Team Leader
or Line Manager.
If unexpected problems or issues arise it is the staff member’s responsibility to report as soon
as possible to their line manager.
6.2
Scope of Medication Administration Services
The scope of assisted medication administration skills is outlined in the following table. Some
staff/volunteers may have skill or knowledge gaps that require training before a service can
be provided.
Accommodation and Community Services
Group
Homes
Com.
Respite PSC
Drop In (accom
only)

Oral

Nasal &
Inhaled

Nebulisation



Topical



Ocular (Eye)


Aural (Ear)

(PEG)
Rectal
Gastrostomy
IFS
Rec
Business Transport
Services Services
HACC
(in home
respite
only)
































1
1
1
1
1
1
1
1
1
1
1
1
1
1

1
Vaginal
Injection 1*
AQuA No: 1656
Version: 4
Issue Date:06/08/15
eview Period: 2 years
1
1
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Medication
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Injection 2
2
2
2
2
2
2
2
Oxygen
1
1
1
1
1
1
1
C-Pap
1
1
1
1
1
1
2
Numbering Code:
1. Additional competency training must be provided for staff/volunteers to assist a
Customer via these routes – this training is to be supplied by a Registered Nurse.
*Injection 1 refers to the administration of Insulin via subcutaneous injection. Specific
training is required prior to staff/volunteers being deemed competent in this practice.
2. EPI-PEN ONLY. In a life threatening emergency, specifically trained staff/volunteers may
administer first aid according to an individual medication plan. Ambulance to be called.
 HACC Transport Services, HACC Centre Based Day Care, HACC Social Support
and Recreation Sitter Service do not undertake medication administration assistance
 HACC Respite and Recreation Service Activities may further limit medication Administration
assistance as appropriate to the service/activity.
6.2.1
Authority to Support Administration
If staff/volunteers are required to assist a Customer with their medication, authority must
be obtained using the Consent Form (AQuA 1990).
6.2.2
Customer Involvement
Activ Customers should where appropriate, be actively engaged in medication management.
Strategies used to engage a Customer in medication management must be documented within
their care plan and followed accordingly.
6.2.3
External nursing service providers
Activ has preferred nursing services available to provide support in the management of complex
and specialized medication administration, which sit outside the scope of Activ’s service.

Nursing care in acute situations less than 28 days may be provided by Silver Chain.

Business Services may be eligible to access FAHSCIA Work Based Personal
Assistance for employees.
In other circumstances nursing care may not be included in current funding provision. Where
long term nursing care will be required to support a Customer continuing in a service this should
be referred to the manager for guidance.
AQuA No: 1656
Version:6
Issue Date: 06/08/15
Review Period: 1 year
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6.3
Medication Administration Processes
Policy Statement:
Staff/volunteers must ensure they make the appropriate checks before assisting the
Customer with medication administration. That being the Six Rights:
o Right time
o Right medication
o Right route
o Right dose
o Right Customer
o Right documentation
In all circumstances, it is critical that staff/volunteers are not interrupted during
administration of medications, except in the event of an emergency. Interruptions during
medication administration are the most common cause of administration errors.
Where possible, a second staff member must be present during the administration of
medications. The administering staff signs the signing sheets with their initials. The
second staff member also initials to indicate they have observed the administration of
medication.
6.3.1
Administration Times
The following times are accepted times to administer medication doses for breakfast, lunch,
dinner and bedtime:
Breakfast
6.30am to 9.00 am
Lunch
12 noon to 1.30 pm
Dinner
5.00 pm to 6.30 pm
Bedtime
8.00pm to 10.00 pm
Medication to be administered at specific times must be provided in separate compartments in
Sealed Dose Administration Aids, or as non-packed medication. The specific time must be
clearly labeled.
Different time zones may alter medication administration times and adjustments will be made
and documented. Staff/volunteers are to follow a pharmacy protocol for changing time zones.
6.3.2
Administration Process
Administer medication for only one Customer at a time, following infection control requirements.
Complete the administration process with one Customer, including documentation, before
starting with the next. To administer medication:
1. Perform hand hygiene
2. Check the Customer’s individual health care plan to determine required level and
type of physical assistance
3. Check the pharmacy documentation and the medication packaging to ensure that:
a. The right Customer (Name and Image)
b. Receives the right medication
c. At the right dose
AQuA No: 1656
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Issue Date:06/08/15
eview Period: 2 years
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d. Via the right route
e. At the right time (Time and Day)
f.
In accordance with any documented instructions.
g. Check for any allergy warnings
h. Check the medication expiry date.
4. Check that the packaging is intact (if damaged follow Section 6.6) and that medication is
free from contamination or deterioration
5. Explain the administration procedure and encourage Customer participation
6. Adjust Customer posture if necessary and provide privacy as required
7. Administer medication using the correct method (see Appendix C for correct dispensing
procedure).
8. Confirm that all medication has been taken and ingestion is completed *
9. Document immediately on the singing sheet that medication has been administered **
10. Return undispensed medication to secure medication storage.
11. Clean or dispose of medication equipment as per infection control procedure. All
infectious and biohazard materials must be placed in a plastic bag and tied before
placing in the bin.
Note:
*if oral medication is mixed with food or drink all medication must be consumed before the
medication administration is documented.
**where a Customer has a separate lunch time SDAA and lunchtime signing sheet, the group
home must ensure they mark ‘A’ for absent on the signing sheet used at the group home for
relevant lunchtime medications administered away from the group home.
6.3.3
Percutaneous Endoscopic Gastrostomy (PEG) Tube
Specific instructions and competency training must be provided by the Customer’s healthcare
team before assisting the Customer with medication via a PEG tube.
To minimise risk of tubes blocking from medication administration:

Flush the tube with water before medication administration

Administer each medication separately

Flush the PEG tube with water between each medication administration

Flush the tube with water after medication administration
AQuA No: 1656
Version:6
Issue Date: 06/08/15
Review Period: 1 year
Author: Service Development Mgr
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6.3.4 Administration of Insulin via Subcutaneous Injection
Policy Statement:
Where the medication to be administered is Subcutaneous Insulin, written consent from
the individual, Parent, Guardian or Next of Kin must be obtained prior to the
commencement of the insulin regime.
Staff/volunteers must not administer Subcutaneous Insulin without formalized training
and an instruction in place via a care plan that has been prescribed by the Customer’s
treating Medical Practitioner.
In addition to the Administration Process, the following steps must be completed:
 Follow all instructions as outlined in the individual care plan as prescribed by the Customer’s
Medical Practitioner
 Check blood glucose levels using the equipment specifically purchased for the Customer, and
as outlined in the care plan.
 Following the care plan (matching dosage to care plan)
 Check expire date of insulin
 Check injection sites on individual
 Administer insulin
 Dispose of used needles in the ‘sharps’ bin provided to each Customer.
6.4
As Required (PRN) Medication
Policy Statement:
Staff/volunteers must not administer prescribed, as required (PRN), medication without a
medication protocol
As required (PRN) medication are intended as a short-term measure to control a specific
symptom or set of symptoms. Staff/volunteers must only administer prescribed as required
(PRN) medication as documented (by treating Medical practitioner) in a PRN Medication
Protocol Form (AQuA 1660).
The medication protocol for each individual Customer must clearly describe:

a recognizable symptom or sign requiring a specific response from staff

the minimum amount of time to wait between doses.

the maximum overall dosage permitted within 24 hours

specific circumstances in which the Doctor must be notified

a specific 12 monthly review date for the medication protocol
Administration of all (prescription and over the counter) as required (PRN) medication must be
recorded with post administration notes stored in the Customers file on ActivLink.
In instances where a Customer uses the same PRN over a prolonged period (i.e. years), Staff
are required to obtain a new PRN signing sheet at the beginning of each calendar year.
Please note – depending on the product, the expiry date of some PRN medications may be set
as a fixed time after first opening the manufacturer’s container.

AQuA No: 1656
Version: 4
Check the PRN medication labeling – if this is the case, record the date opened and the
calculated expiry on the medicine package/label;
Issue Date:06/08/15
eview Period: 2 years
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
Be vigilant with product expiry dates; and

Store as recommended by manufacturer
For non-prescribed as required PRN medication, it is a requirement that the item is
dispensed and labelled from the primary pharmacy with related signing documentation
attached. If any requests for non-prescribed PRN Medication exceed the dosage
recommended on the original packaging or if Activ staff are unsure of the contents of the
medication, authorization must be obtained by the Customers GP and the request recorded on
the PRN Medication Protocol Form (AQuA 1660).
6.5
Damaged Medication or Packaging
Do not administer medication if the medication or packaging is damaged in any way or
unreadable. If damage has occurred staff/volunteers must:
1. Retain medication securely for return, where possible in the medication packaging
2. Replace the medication dose according to the following:
a. Non-Packed Medication – Dispense another dose from supply
b. Medication in a Sealed Dose Administration Aid - use the last available dose at the
same administration time that contains correct medication
3. The staff/volunteers member who is directly involved in the incident must report
immediately and complete a Medication Incident Report (Part A) on ActivLink* before
the end of shift.
4. Make arrangements for additional supply of medication.
a. Activ Group Homes only – receipt of the Pharmacy Medication Report will trigger
replacement.
b. Business or day placement services - if a single dose of medication in a dosset box
is unreadable then families/carers or support staff/volunteers should be contacted to
bring in new medication to the day placement for the Customer. Where appropriate,
advice may be sought from a pharmacist.
6.6
Crushing Oral Medication
Some Customers cannot swallow whole tablets. Crushing, breaking or allowing a Customer to
chew a tablet will alter how the medication is absorbed and can minimize or destroy its
therapeutic effect.
Pharmacy documentation clearly identifies which tablets are not allowed to be crushed. If
unsure, contact Poisons Information Centre 13 11 26 for advice.
If a Customer has difficulty swallowing medication their Doctor must be informed and if possible
a suitable formulation prescribed, for example a liquid medication.
If medication is crushed:
1. Mix the crushed medication with a small amount of food or drink.
2. Observe consumption of the food or drink that contains medication.
3. Document medication administration.
4. Encourage the Customer to drink water after medication administration.
5. Clean the crusher between each Customer’s medications.
6.7
AQuA No: 1656
Version:6
Customers Refusing Medication
Issue Date: 06/08/15
Review Period: 1 year
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Customers have the right to consent, or refuse consent to take a medicine. Staff/volunteers
cannot force Customers to take medicine or provide medication without their knowledge unless
authority has been provided.
If a Customer refuses medication:
1. Attempt to find out why they will not take the medication.
2. Explain the reason for medication and attempt to re-administer.
3. If after half an hour a Customer still refuses medication, staff/volunteers must take
action as per a medication incident (section 9).
4. Document the medication refusal on the medication signing sheet with an ‘R’ and put a
circle around the letter so it is not confused with a staff/volunteers worker’s initials.
5. Dispose of the medication according to Activ policy (section 8).
6. Record this on the Medication Incident Report in ActivLink.
6.8
Administering Medication without Knowledge of the Customer
Policy Statement:
Staff/volunteers must not administer medication to adult Customers without their
knowledge, except where medical review has identified a Customer does not have
capacity to consent to medication administration.
Staff/volunteers will follow the Advanced Health Directive, as issued by the State
Administrative Tribunal, which clearly outlines the ‘Hierarchy of Decision Making’
process for when consent for medical treatment decisions are required.
Medication can only be administered without the knowledge and consent of a Customer if:
1. A medical review has identified that a Customer does not have the capacity to
provide informed consent.
2. A written request is provided by the Customer’s Doctor outlining the exact
form of medication and the specific method of administration.
3. Written consent is provided by the Customer’s guardian agreeing to the exact
form of medication and the specific method of administration requested by the
Doctor.
4. The service manager must, in consultation with the Doctor and legal guardian,
determine if the request can be met.
5. Care plans must be put in place and staff/volunteers must administer medication as
documented.
6.9
Withholding medication
The Customer’s medication may be temporarily withheld where there is a good reason not
to proceed with the administration process – for example vomiting, breathing difficulties.
Contact Poisons Information Centre 13 11 26, pharmacy or Doctor for further instructions.
Document all actions taken on a Medication Incident Report (Part A) on ActivLink*.
6.10
AQuA No: 1656
Version: 4
Documenting Medication Administration
Issue Date:06/08/15
eview Period: 2 years
Author: Service Development Mgr
Authoriser: TLT 201507.3
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Policy Statement:
Medication administration must be documented and retained by the service.
All medication administration within a service must be documented and records of this kept as
identified in the Activ Retention Schedule. Standards for medication documentation are as
follows:
1. Documentation should be made on signing sheets. All medical documentation must be:

In black or blue ink

Be legible and accurate.

Important documentation may be highlighted as necessary
2. Specific abbreviations to be used ONLY on signing sheets when necessary as directed
on the pharmacy documentation. All other abbreviations must not be used in
medication documentation by staff/volunteers. All records must be written out in full.
3. Medication records must be able to identify:

Who has administered the medication

When the medication has been administered i.e. date and time

Dose of medication administered

Route of medication administration
4. Staff/volunteers names and sample signatures are to be recorded on the back of the
pharmacy signing sheets.
6.11
Monitoring Medication Administration
Monitoring of a Customer provides the Doctor with information to know if a medication has the
required effect. Medication may also have unwanted side effects, or adverse reactions.
To ensure Activ maintains its duty of care staff/volunteers must:
1. Monitor any effects of medication
2. Monitor any unusual and unexpected changes
3. Implement first aid as/if required and seek help as appropriate
4. Notify Team Leader, Line Manager and Doctor if required, follow any further instructions
given.
5. Document in Customer’s medical record
6. Inform legal guardians
7. Only cease medication on medical advice.
6.12
Complementary and Alternative Therapies
Activ recognizes the choice of Customers to use complementary and alternative therapies,
however to support staff/volunteers in safe medication administration practices these are
classified and managed in the same way as all other medication.
The following steps must be taken before complementary and alternative medication can be
administered by staff/volunteers:
AQuA No: 1656
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Issue Date: 06/08/15
Review Period: 1 year
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1. Medication must be reviewed by the pharmacist to ensure no contraindications with
current medication
2. Medication must be labeled by the pharmacist to provide administration information
including Customer name, medication name, dose, time and route of administration
3. Medication must be included on the Customer’s medication profile and signing sheets.
AQuA No: 1656
Version: 4
Issue Date:06/08/15
eview Period: 2 years
Author: Service Development Mgr
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7.
Customer Entry Procedures
Policy Statement:
Customers must be fully informed of medication options and procedures when entering a new
service or program provided by Activ
For each Customer entering a new service/program with Activ, the following must be done:
1. A full explanation of self administration [Section 5]) and supported medication
administration [Section 6] and the service requirements for these.
2. Establish or arrange the supply of Customer medication
a. Activ Group Homes – set up Customers on the pharmacy providers system.
b. All other Services

All medication is to be dispensed and labeled by a pharmacist for each
individual Customer. All solid oral medication must be in a Sealed Dose
Administration Aid [packed] unless there are contraindications identified by the
pharmacist.

Pharmacy documentation as outlined in section 1.5 - Medication records.

No more than two weeks medication to be stored by Activ services

If a Customer is on an extended overseas holiday the medication supply will
be appropriate to the individual Customer’s need
3. Inform the Customer of the need to notify service staff/volunteers immediately if
medication administration requirements change.
Inform the Customer that where appropriate, consent will be obtained whenever a
medication change occurs on the Medical Examination Outcome Form (AQuA 1623).
AQuA No: 1656
Version:6
Issue Date: 06/08/15
Review Period: 1 year
Author: Service Development Mgr
Authoriser: TLT 201507.3
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8.
Disposal of Medication
Policy Statement:
Medical waste and medication that requires disposal must be disposed of in a safe and
responsible way
It is important that the safe medicines disposal policy is adhered to, to limit risk to Customers and
other individuals in the community. There is a national government sponsored program that
allows medication to be returned to local community pharmacies for disposal, at no cost.

Any out of date, refused, damaged or discontinued medication provided to the service
must be returned safely to a local pharmacy.

Activ Group Homes - must return medication to their pharmacy supplier.
To dispose of medication:
1. Inform the person who has purchased and/or provided the medication that medication
will be disposed of;
2. Document the medication to be disposed of on the External Medication Transfer
Form (AQuA1600);
3. Store medication for disposal in a clearly identified container in the medication storage
unit;
4. Transfer medication to the pharmacy and document the date the medication is removed
from site;
5. Activ Group Homes only - the pharmacy representative should sign the record to
verify the handover;
6. Business Services, Day Placement Service and Recreation – are not required to
dispose of medication. It should be returned in a clearly identified sealed envelope to
the Customer’s home to be safely and responsibly disposed of.
Return of Medication Following Death – Activ Group Homes Only
8.1
In the event of a death at an Activ Group Home, the resident’s medication must not be disposed
of until a death certificate has been released. Unused medication and the current pharmacy
documentation must be:

Placed in a sealed envelope;

The envelop signed by the Team Leader and witnessed by another member of
staff/volunteer;

Kept in the medication storage unit until the pharmacy collects and disposes of it.
Business Services, Day Placement Services and Recreation staff who have a deceased
Customer’s medication must return it to Customer’s home to be disposed of. If no advocates
are available then it must be returned to a pharmacy.
AQuA No: 1656
Version: 4
Issue Date:06/08/15
eview Period: 2 years
Author: Service Development Mgr
Authoriser: TLT 201507.3
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9.
Medication Incidents
Policy Statement:
Staff/volunteers must report and document all errors in medication management on ActivLink*.
* NB: ALL medication incidents are to be reported through ActivLink. If a staff member reporting
the incident DOES NOT have access to ActivLink, the Medication Incident Report: Part A
(AQuA 1619) is to be completed.
A medication incident occurs when the usual set of procedures has not occurred or been
followed. These may include the following:

Incorrect medication has been supplied

Documentation, such as medication profiles or signing sheets are incorrect, or they have
not been completed correctly by staff/volunteers (e.g. right medication but
staff/volunteers have given wrong dose)

Medication or packaging is damaged

Incorrect medication has been administered

Medication has not been administered (missed dose)

Medication is not stored as required

Medication has been administered by the wrong route
If a Customer receives an incorrect dose of medication, or does not receive their medication as
documented staff/volunteers must:
1. Contact the Poisons Information Centre on 13 11 26 for instructions without delay
2. Record instructions from the Poisons Information Centre in the Customer’s
medical record
3. Follow all instructions and clearly document actions
4. Document the medication incident on the Customer’s signing sheet
5. Contact the Line Manager/Team Leader as soon as possible to inform them of the
incident and actions taken
6. Complete a Medication Incident Report (Part A) on ActivLink*. Part B is to be completed
by the Line Manager/Team Leader.
a. Specific instruction will be provided for staff and volunteers to follow in the
occurrence of a medication incident when the Customer is on an interstate holiday
program or overseas.
9.1
Reporting a Medication Incident
Reporting medication incidents enables Activ to monitor the medication management system
and learn from issues that may have occurred.
Immediately following a medication incident, all Activ services must complete a Medication
Incident Report (Part A) on ActivLink*. Part B is to be activated by the relevant Line
Manger within 48 hours and completed by the Line Manager within 7 days.
AQuA No: 1656
Version:6
Issue Date: 06/08/15
Review Period: 1 year
Author: Service Development Mgr
Authoriser: TLT 201507.3
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Pharmacy Medication Report – Activ Group Homes Only
9.2
Controlled Document
Following a Pharmacy related medication incident, staff must complete a Medication Incident
Report (Part A) on ActivLink*. Part B is to be completed by the Line Manager/Team Leader.
The Pharmacy is to be notified if:

Incorrect documentation or medication has been supplied by the pharmacy

An administration check identifies a difference between medication and medication
profiles or signing sheets
AQuA No: 1656
Version: 4
Issue Date:06/08/15
eview Period: 2 years
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10.
Monitoring Medication Management
Policy Statement:
Customers who receive Activ Group Home services on a continual and ongoing basis must
have annual health and medication reviews
Services must undertake self monitoring every twelve months, or more frequently if identified
by the General Manager.
Medication incidents will be reported to the Executive Team every month
An audit of the Medication Management Policy and Procedures must be undertaken annually
10.1
Annual Health and Medication Reviews – Activ Group Homes Only
All Customers who reside in Activ Group Homes must have an annual health and medication
reviews.
10.1.1
Hospitalisation
Customers must have an immediate pharmacy review of their medications following hospitalisation.
10.1.2
Multiple Medications
Customers who routinely take more than five mediations must have a pharmacy review every
six months.
10.2
Self Monitoring
Each service must undertake self monitoring to assess compliance against these procedures
and to identify areas for corrective action and improvement.
The Medications Monitoring Checklist (AQuA 1774) should be completed twice a year.
Once complete the original should be included in the facility Health and Safety File (section 9), a
copy sent to the Health and Safety Department for inclusion within the Activ Hazards database
and a copy sent to the facility Manager.
Audit and Assurance carry out their own annual Medication Management Review.
10.3
Medication Incidents
Health and Safety will provide reports on medication incidents as defined in this policy.
10.4
Medication Audit
An annual review of medication management will be undertaken by the Audit and Assurance
Department.
AQuA No: 1656
Version:6
Issue Date: 06/08/15
Review Period: 1 year
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11.
Training and Competency
Policy Statement:
Staff/volunteers and Activ volunteers, who are required to administer medication as
identified in their job description, must attend Activ’s ’Assist Clients with Medication’
(CHCCS305C) training program and have been assessed as competent before they
can administer medication, in ANY circumstance.
For the administration of Subcutaneous Insulin, additional training requirements must
be met before staff can be deemed competent.
11.1
Training
Before administering medication to a Customer staff/volunteers must:
1. Have completed the CHCCS305A Assist Customers with Medication training program
2. Be assessed as competent by a registered nurse.
3. Be approved by the Line Manager to proceed with assisting a Customer
with their medication.
4. Have a working knowledge of the medication management system
The nominated Activ assessor must hold a Certificate IV in Training and Assessment.
11.1.1 Training in the Administration of Insulin via Subcutaneous Injection.
Before Insulin can be administered to a Customer the following training and competency must
occur:
1. Only staff who have successfully completed the Australian Qualifications Framework (AQF)
Certificate III in Disability or Certificate III in Aged Care Work (or its equivalent) and
including the two units associated with Assisting Customers with Medication (or the
equivalent) will be authorised to participate in insulin administration. Authorisation will only
be for specific Customers with individual care plans as prescribed by their treating Medical
Practitioner.
2. Staff will need to participate in refresher training every 12 months (or sooner) if required.
3. Staff must also have been deemed ‘medication competent’ according to Activ’s Medication
Management Policy (AQuA 1776).
4. Staff must be assessed and deemed competent by appropriately qualified staff, including a
Registered Nurse, through a Registered Training Organisation. This will occur only after
staff have completed the Diabetes Awareness Training Session and undertaken a practical
assessment.
5. Where a staff member has not been engaged in administering insulin to the Customer for a
period of 3 months then he/she must undergo a re-assessment before recommencing
insulin administration for that or any other Customer.
6. Staff should have access at all times to a Medical Practitioner or Accommodation Team
Manager for consultation.
AQuA No: 1656
Version: 4
Issue Date:06/08/15
eview Period: 2 years
Author: Service Development Mgr
Authoriser: TLT 201507.3
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11.2
Maintaining Competency
Annual workplace observations be organized by managers for staff/volunteers who assist
Customers with medication.
11.3
Agency Staff/volunteers
Agencies who supply relief/casual staff/volunteers to work in Activ services are responsible
to ensure that their staff/volunteers are competent to assist Customers with medication
administration.
When employing casual/relief staff, agencies are to be requested to send only that staff that
are competent to assist a Customer with medication.
11.4
Volunteer Staff/volunteers
Volunteer staff/ Volunteers to undertake CHCCS305A training as required to assist
Customers with medication.
AQuA No: 1656
Version:6
Issue Date: 06/08/15
Review Period: 1 year
Author: Service Development Mgr
Authoriser: TLT 201507.3
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12.
References
Australian Pharmaceutical Advisory Council, November 2002. Guidelines for medication
management in residential aged care facilities. Commonwealth of Australia: Canberra.
Australian Pharmaceutical Advisory Council, June 2006. Guiding Principles for Medication
Management in the Community. Commonwealth of Australia: Canberra.
Department of Health, Government of Western Australia, September 2005. Support worker
medication policy framework and guidelines. Department of Health: Perth
Department of Families, Housing, Community Services and Indigenous Affairs (2007) Disability
Services Standards – Accessed 2010
http://www.fahcsia.gov.au/sa/disability/standards/Pages/policy-nsds2007.aspx
Guardianship and Administration Act WA (1990)
Nurses & Midwives Board of Western Australia, October 2009, Medical Management Guidelines
for Nurses and Midwives, Consultation Draft.
Office of Chief Psychiatrist - Department of Health WA. Phone consultation on 24.6.2010 with
Tim Rolfe.
Poisons Act WA (1964)
Poisons Regulations WA (1965)
King Edward Memorial Hospital, September 2009. Clinical Guidelines – 2.10 Medication and
Vaccine Storage and Administration. Department of Health WA.
Quality Care Pharmacy Program. Protocol for Cold Chain Management in Community
Pharmacy. Accessed 21.6/2010 http://beta.guild.org.au/qcpp/content.asp?id=483
AQuA No: 1656
Version: 4
Issue Date:06/08/15
eview Period: 2 years
Author: Service Development Mgr
Authoriser: TLT 201507.3
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13.
Appendix A: Definitions
Advance Health Directive: (AHD is a legal document that enables you to make decisions now
about the treatment you would want - or not want - to receive if you ever became sick or injured
and were incapable of communicating your wishes. In such circumstances, your AHD would
effectively become your voice.
An Advance Health Directive sits at the top of the hierarchy of treatment decision-makers.
(The hierarchy sets the order in which health professionals must seek treatment decisions
when treating a person with a decision-making disability, as per Sections 110ZJ and 110ZD of
the Guardianship and Administration Act 1990). This means that even if you had an enduring
guardian, the health professional would be obliged to follow your wishes as outlined in your
AHD, except in very limited circumstances.
Customer: includes anyone in receipt of a service from Activ and persons with a disability who
are employed in Activ’s Business Services
Complementary and Alternative Medicine: include items such as herbal preparations,
vitamins, minerals and nutritional supplements, aromatherapy and homeopathic products. They
must be registered by the Therapeutic Goods Administration service to be included on an
individual’s medication profile and signing sheets.
Consumer Medication Information: information from pharmacy manufacturers on when
medication is used, how to take medication, side effects of medication and other key information
about medication.
Contra-indication: a good reason NOT to proceed with assisting a Customer to administer
medication. This includes stating that something is inadvisable to do or take while taking
particular medication because of a likely adverse reaction.
First Aid: immediate medical assistance given in an emergency
Framework: a structure intended to serve as a support to an activity including policy,
procedures and training.
Legal Guardian: a) a person appointed as a guardian (including an alternate guardian under
section 43; b) 2 or more persons appointed as joint guardians under that section; c) the Public
Advocate acting under section 99 of the Guardian and Administration Act 1990.
Medication: any medicine that is administered via any route to support a Customer to maintain
optimum health. It includes prescription and non-prescription medicines, complementary and
alternative health care products.
Medication Administration: includes the dispensing of medication from its container and
delivery to the identified route
Medication Profile: documentation generated by a pharmacist that lists all medications taken,
their dose, when they are taken, and how to take them
Medication Protocol: a documented instruction to administer as required medication in
response to a specific symptom. It communicates what medication and dose to administer and
the maximum dose that can be administered.
Must:a mandatory action.
Non-packed Medication: Medication that cannot be included in Sealed Dose Administration
Aids.
Non-prescription medication: Medication that can be purchased over the counter in a
pharmacy or another licensed outlet
Packed Medication: Medication that has been packed into a Sealed Dose Administration Aid
AQuA No: 1656
Version:6
Issue Date: 06/08/15
Review Period: 1 year
Author: Service Development Mgr
Authoriser: TLT 201507.3
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when dispensed by the pharmacy.
Prescription Medication: Medication that can only be prescribed by a Doctor (Doctor), Dentist
or Nurse Practitioner
PRN (As Required) Medication: medication that is administered as required in response to a
specific target symptom.
Sealed Dose Administration Aid (SDAA): A device into which solid oral medications have
been dispensed, packaged and labelled for an individual by a registered pharmacist.
Medications can be packaged as either a single dose pack (one single type of medicine per
compartment) or a multi-dose pack (different types of medicines per compartment), and are
packaged according to the individuals dose schedule through the day/week
Service: any service provided by Activ to Customers
Self-administration: Medication administration is undertaken independently by the Customer.
Signing Sheet: a sheet provided by a pharmacist to document medication administration
Staff/volunteers: All staff/volunteers and volunteers appointed by Activ, including contract
staff/volunteers
Supported Medication Administration: Medication administration provided by staff/volunteers
AQuA No: 1656
Version: 4
Issue Date:06/08/15
eview Period: 2 years
Author: Service Development Mgr
Authoriser: TLT 201507.3
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14.
Appendix B: Pharmacy Requirements – Activ Group Homes
Essential Requirements
1. Provide all medication for the Facility’s Customers at least fortnightly. For solid oral
medication provided where there are no pharmaceutical contraindications, this should be
provided in a Webster-Pak.
2. Provide medication profiles and signing sheets at least monthly. Medication profile and
signing sheet/s will be updated and provided to the Facility when medication changes.
Signing Sheets must be provided for all medication.
3. Medication Profiles, Signing Sheets and Webster-Pak must include:
a. Current photograph of the Customer
b. Current alert notices as advised by the Facility’s staff/volunteers (allergies, alerts)
c. Administration instructions
d. Times for administration
e. Coloured pill images, or a description of the medication
f.
Start and finish dates for short term medication
4. Manage prescription requests in consultation with the Facility and the Customer’s Doctor
5. Provide information to staff/volunteers on the safe and effective use of medications
6. Provide invoices for each Customer or the facility residents on a monthly basis
7. Receive documentation from Activ to communicate issues with supply of medication and
order medication supplies
8. Deliver the Facility’s Customer’s medication and documentation at least fortnightly to the
Facility at an agreed time and day
Desirable Services
9. Deliver essential medications (e.g. urgent antibiotics) within 4hrs of request if indicated by
the Doctor.
10. Deliver new non-essential medications to the Facility’s the next working day
11. Provide afterhours pharmacy service 24hrs per day 7 days per week through a
registered pharmacist being on-call
12. Provide free annual Home Medication Reviews
AQuA No: 1656
Version: 4
Issue Date: 14.02.2013
Review Period: 2 years
Author: Service Development Mgr
Authoriser: GMACS
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15.
Appendix C: Dispensing Procedures
Removing Medication Compartments
If a compartment from the Sealed Dose Administration Aid can be, and is removed, it must
provide the following minimum information to check when administering medication:

Name of Customer

Day of the week for administration

Time for administration

Medication name

Medication dose
If this information is not included on the compartment the
whole Sealed Dose Administration Aid must be provided.
When removing compartments:
1. A medication box shall be used for transporting the compartment from the Sealed Dose
Administration Aid.
2. The box for transport must be identified with the Customer’s name and date of birth
3. Access a compartment by releasing the strap that holds each row of the Sealed Dose
Administration Aid in place
4. Cut out the compartment
5. Refasten straps on the holder.
Use of PIL-BOB
Each Customer should have a PIL-BOB allocated to their single
use. To remove medication from a WebsterPak using a PILBOB:
1. Check the PIL-BOB before each use and remove any visible medication residue with a
clean tissue.
2. Remove medication from the compartment as follows:
a. Hold the folder in a
horizontal (flat) position
b. Place the PIL-BOB
behind the compartment
to open
c. Insert the serrated tip
up through the foil
d. Sweep the
compartment with the tip
until all medication drops
into the PIL-BOB
3. Transfer medication from the PIL-BOB to a medication cup for administration
4. Wash the PIL-BOB in warm soapy water on a daily basis.
AQuA No: 1656
Version:6
Issue Date: 06/08/15
Review Period: 1 year
Author: Service Development Mgr
Authoriser: TLT 201507.3
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Medication Assistance Techniques
Oral Solid
Use a non- touch technique. Provide the medication cup to the Customer and give appropriate
triggers to put in mouth and swallow.
Oral Liquid
Equipment required - graduated medicine cup
To measure liquid medication for administration:
1. Shake the medication bottle well
2. Hold the bottle with the label uppermost
3. Hold the graduated medicine cup at eye level and pour medication
4. Dispose excess medication in the sink and rinse thoroughly
5. Clean the neck of the bottle and replace lid securely.
Note: A syringe must not be used for medication administration unless this is how the
medication has been dispensed from the pharmacy.
Occular (Eye)
Stand behind a Customer sitting in a chair, with head tilted backwards and looking at the ceiling
pull the lower eye lid down and insert the prescribed number of drops. If an ointment is
prescribed deliver– from inner to outer corners of the eye
If eye is infected, medicate the ‘cleaner’ eye first.
Topical
Put on disposable gloves and use a sterile spatula, gauze swab or gloved finger to administer a
thin layer of cream
AQuA No: 1656
Version: 4
Issue Date: 14.02.2013
Review Period: 2 years
Author: Service Development Mgr
Authoriser: GMACS
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16.
Appendix D: Individual Storage Containers
Medication Storage at Activ Facilities
At all facilities medication must be stored in a locked storage unit in individual storage containers. It is
recommended that individual storage containers:

Are A4 in size and foldable

Have Sealed Dose Administration Aid stored on left side of container and Medication Signing
Sheets stored on right side of container

Are clearly labelled with the Customer’s name on the outside of the container.
AQuA No: 1656
Issue Date: 14.02.2013
Author: Service Development Mgr
Version: 4
Review Period: 2 years
Authoriser: GMACS
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