WHO IS ACCREDITED?

Private Organization Accreditation

As one of the largest family services agencies in the country, Child & Family Services has dedicated its resources to meet the needs of the community since 1873.
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ORGANIZATION TESTIMONIAL

Joint Base Charleston School Age Program

Paula B. Matthews, School Age Program Coordinator

Preparing for our after school accreditation was an awesome and very valuable learning experience for the Child and Youth Professionals at Charleston Air Force Base. Becoming familiar with and understanding the After School standards was a breeze because of the training webinars and the great customer service we received from all of the COA staff. Thank you for supporting our military families.
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Purpose

Comprehensive, systematic, and effective risk prevention and management practices reduce the organization’s risk, loss, and liability exposure.

FOC
CA-RPM 3: Medication Control and Administration

The organization ensures safe, uniform medication control and administration.

Note: Please see the Medication Control and Administration Policy and Procedure Tool - Private, Public, Canadian, Network for additional assistance with this standard.

Note: RPM 3 does not apply to foster care and kinship care homes. See CA-FKC 16.03.

NA The organization does not prescribe, dispense, administer, or store medication.

Rating Indicators
1
The organization's practices fully meet the standard, as indicated by full implementation of the practices outlined in the CA-RPM 3 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the CA-RPM 3 Practice standards
3
Practice requires significant improvement, as noted in the ratings for the CA-RPM 3 Practice standards; and/or 
  • At least one of the Fundamental Practice Standards received a 3 or 4 rating.
4
The program’s observed administration and management infrastructure and practices are weak or non-existent, as noted in the ratings for the CA-RPM 3 Practice standards; and/or 
  • At least two of the Fundamental Practice Standards received a 3 or 4 rating.

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    • Medication management procedures/protocols
    • Medication logs
    • Documentation of medication management training provided to personnel
    • Interview:
      1. Direct service and supervisory personnel
      2. Medical personnel, as applicable
    • Facility observation

  • FP
    CA-RPM 3.01

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

    Interpretation: When applicable to the organization or program, all staff who are responsible for administering opioid antagonists, such as Naloxone, for emergency overdose treatment are trained in SAMHSA-approved protocols and procedures for reversing opioid drug crises. 

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

  • FP
    CA-RPM 3.02

    When medication is initially prescribed, the prescribing clinician provides education about the medications prescribed, including:

    1. medication name;
    2. dose;
    3. reason for use;
    4. how to administer;
    5. desired effects; and
    6. potential side effects.

    Interpretation: Written detailed information regarding specific medications may be provided by the pharmacy responsible for filling a prescription.

    NA The organization does not prescribe medication.

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.

    Written information along with documented verbal consultation is provided for each and every client.
    2
    Practices are basically sound but there is room for improvement; e.g.,
    • Documentation needs improvement.
    3
    Practice requires significant improvement; e.g.,
    • Education is not consistently provided to clients; or
    • Documentation needs significant strengthening.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.

  • FP
    CA-RPM 3.03

    When service receipients are receiving prescription medication:

    1. qualified personnel obtain and/or update information about the medications the individual is taking at the time of each visit; and
    2. the prescribing clinician  compares  current medications the individual is taking at the time of each visit,  including vitamins or other non-prescription medications, with new or changed medication orders to identify possible adverse interaction of medications.

    Interpretation: The organization must define the personnel qualifications necessary to collect medication information, in accordance with applicable legal, regulatory, and/or contractual requirements.

    NA The organization does not prescribe or administer medication.

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement; e.g.,
    • The required assessments do not happen at each visit, however they occur at least quarterly and/or when new medications are prescribed.
    3
    Practice requires significant improvement; e.g.,
    • One of the elements in not consistently assessed as required.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.

  • FP
    CA-RPM 3.04

    Protocols and controls governing the proper administration and storage of medication include:

    1. locked, supervised storage with access limited to authorized staff and in accordance with law, regulation, and manufacturers instruction;
    2. maintaining medication in original packaging and labelling with the name of person served, medication name, dosage, prescribing physician name, and number or code identifying the written order;
    3. appropriate disposal of expired or unused medication, syringes, medical waste, or medication prescribed to former persons served;
    4. a record of who received medications, what medications were dispensed or administered, and when and by whom medications were dispensed or administered;
    5. protocols for the administration of over-the-counter medications;
    6. policies and procedures for safely dispensing or administering sample medication; and
    7. protocols for the administration of emergency medications, including opioid overdose treatments, as applicable. 

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

    Note: Elements (d), (e), (f), and (g) do not apply to organizations that only store medication.

    Note: Please see Facility Observation Checklist - Private, Public, Canadian for additional assistance with this standard.

    NA The organization does not dispense, administer, or store medication.

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement; e.g., 
    • There are minor problems with storage or labelling but safety has not been compromised; or
    • Documentation needs minor improvement; or
    • Procedures need strengthening.
    3
    Practice requires significant improvement; e.g.,
    • There are problems with storage or labelling that raise concerns about safety; or
    • Documentation is inconsistent, or some documentation is missing or incomplete; or
    • Procedures need significant strengthening.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.

  • FP
    CA-RPM 3.05

    Following administration of medication staff observe and assess the effects of medication on the service recipient and consult with pharmacists/medical professionals, as necessary.

    Research Note: In cases of opioid overdose treatment (e.g. Naloxone kits), it is critical to get patients to a hospital or emergency department as soon as possible after their initial treatment dose. Opioid overdose symptoms and signs of toxicity are likely to return within 20-90 minutes following the administration of opioid antagonist medications. 

    NA The organization does not administer medication.

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement; e.g.,
    • Documentation of observed effects need minor improvement; or
    • Procedures need strengthening.
    3
    Practice requires significant improvement; e.g.,
    • Documentation of observed effects is inconsistent, or some documentation is missing or incomplete; or
    • Procedures need significant strengthening.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.

  • CA-RPM 3.06

    Immediately prior to administration, qualified personnel review with the person the medication to be administered, its purpose, and verify: 

    1. the identity of the individual and the medication ordered; 
    2. that the medication to be administered matches the medication order; and
    3. visually inspect the integrity of the medication. 

    NA The organization does not administer medication.

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement; e.g.,
    • Procedures are consistently followed with minor exceptions; or
    • Documentation needs strengthening.
    3
    Practice requires significant improvement; e.g.,
    • Procedures are not consistently followed; or
    • Documentation needs significant strengthening.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.
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