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 Uncontrolled Copy When Printed Page 2 of 37 Activ All Medication Management System Procedures Controlled Document 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 Uncontrolled Copy When Printed Page 3 of 37 Activ All Medication Management System Procedures Controlled Document 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 Authoriser: TLT 201507.3 Uncontrolled Copy When Printed Page 4 of 37 Activ All Medication Management System Procedures Controlled Document 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 Author: Service Development Mgr Authoriser: TLT 201507.3 Uncontrolled Copy When Printed Page 5 of 37 Activ All Medication Management System Procedures Controlled Document 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 Authoriser: TLT 201507.3 Uncontrolled Copy When Printed Page 6 of 37 Activ All Medication Management System Procedures Controlled Document 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 Uncontrolled Copy When Printed Page 7 of 37 Activ All Medication Management System Procedures Controlled Document 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 Uncontrolled Copy When Printed Page 8 of 37 Activ All Medication Management System Procedures Controlled Document 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 Version: 4 Issue Date:06/08/15 eview Period: 2 years Author: Service Development Mgr Authoriser: TLT 201507.3 Uncontrolled Copy When Printed Page 9 of 37 Activ All Medication Management System Procedures Controlled Document 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 Authoriser: TLT 201507.3 Uncontrolled Copy When Printed Page 10 of 37 Activ All Medication Management System Procedures Controlled Document 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 Authoriser: TLT 201507.3 Uncontrolled Copy When Printed Page 11 of 37 Activ All Medication Management System Procedures Controlled Document 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 AQuA No: 1656 Version:6 Issue Date: 06/08/15 Review Period: 1 year Author: Service Development Mgr Authoriser: TLT 201507.3 Uncontrolled Copy When Printed Page 12 of 37 Activ All Medication Management System Procedures Controlled Document 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 Authoriser: TLT 201507.3 Uncontrolled Copy When Printed Page 13 of 37 Activ All Medication Management System Procedures Controlled Document 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 Authoriser: TLT 201507.3 Uncontrolled Copy When Printed Page 14 of 37 Activ All Medication Management System Procedures Controlled Document 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 Version: 4 Issue Date:06/08/15 eview Period: 2 years Author: Service Development Mgr Authoriser: TLT 201507.3 Uncontrolled Copy When Printed Page 15 of 37 Activ All Medication Management System Procedures Controlled Document 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 Author: Service Development Mgr Authoriser: TLT 201507.3 Uncontrolled Copy When Printed Page 16 of 37 Activ All Medication Management System Procedures Controlled Document 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 Author: Service Development Mgr Authoriser: TLT 201507.3 Uncontrolled Copy When Printed Do not provide medication administration Medication Route Page 17 of 37 Activ All Medication Management System Procedures Controlled Document 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 Author: Service Development Mgr Authoriser: TLT 201507.3 Uncontrolled Copy When Printed Page 18 of 37 Activ All Medication Management System Procedures Controlled Document 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 Version: 4 Issue Date:06/08/15 eview Period: 2 years Author: Service Development Mgr Authoriser: TLT 201507.3 Uncontrolled Copy When Printed Page 19 of 37 Activ All Medication Management System Procedures Controlled Document 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 Authoriser: TLT 201507.3 Uncontrolled Copy When Printed Page 20 of 37 Activ All Medication Management System Procedures Controlled Document 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 Author: Service Development Mgr Authoriser: TLT 201507.3 Uncontrolled Copy When Printed Page 21 of 37 Activ All Medication Management System Procedures Controlled Document 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 Author: Service Development Mgr Authoriser: TLT 201507.3 Uncontrolled Copy When Printed Page 22 of 37 Activ All Medication Management System Procedures Controlled Document 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 Uncontrolled Copy When Printed Page 23 of 37 Activ All Medication Management System Procedures Controlled Document 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 Version:6 Issue Date: 06/08/15 Review Period: 1 year Author: Service Development Mgr Authoriser: TLT 201507.3 Uncontrolled Copy When Printed Page 24 of 37 Activ All Medication Management System Procedures Controlled Document 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 Authoriser: TLT 201507.3 Uncontrolled Copy When Printed Page 25 of 37 Activ All Medication Management System Procedures Controlled Document 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 Uncontrolled Copy When Printed Page 26 of 37 Activ All Medication Management System Procedures Controlled Document 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 Uncontrolled Copy When Printed Page 27 of 37 Activ All Medication Management System Procedures Controlled Document 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 Uncontrolled Copy When Printed Page 28 of 37 Activ All Medication Management System Procedures 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 Author: Service Development Mgr Authoriser: TLT 201507.3 Uncontrolled Copy When Printed Page 29 of 37 Activ All Medication Management System Procedures Controlled Document 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 Author: Service Development Mgr Authoriser: TLT 201507.3 Uncontrolled Copy When Printed Page 30 of 37 Activ All Medication Management System Procedures Controlled Document 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 Uncontrolled Copy When Printed Page 31 of 37 Activ All Medication Management System Procedures Controlled Document 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 Uncontrolled Copy When Printed Page 32 of 37 Activ All Medication Management System Procedures Controlled Document 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 Uncontrolled Copy When Printed Page 33 of 37 Activ All Medication Management System Procedures Controlled Document 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 Uncontrolled Copy When Printed Page 34 of 37 Activ All Medication Management System Procedures Controlled Document 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 Uncontrolled Copy When Printed Page 35 of 37 Activ All Medication Management System Procedures Controlled Document 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 Uncontrolled Copy When Printed Page 33 of 37 Activ All Medication Management System Procedures Controlled Document 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 Uncontrolled Copy When Printed Page 34 of 37 Activ All Medication Management System Procedures Controlled Document 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 Uncontrolled Copy When Printed Page 35 of 37 Activ All Medication Management System Procedures Controlled Document 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 Uncontrolled Copy When Printed Page 37 of 37