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Private Organization Accreditation
Southeastern Regional Mental Health, Developmental Disabilities and Substance Abuse Services is a Local Management Entity, covering the geographic areas of Bladen, Columbus, Robeson, and Scotland counties. SER ensures continuity of care to consumers through access to a quality of care system available 24/7/365 days a year through management of our network provider services.
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Rochelle Haimes, ACSW
Volunteer Roles: Commissioner; Peer Reviewer; Standards Panel Member; Team Leader
Rochelle is a Consultant working with a variety of private organizations to become accredited. Her primary area of expertise is in facilitating the development of PQI systems and activities. Her previous experience with both small and large organizations is the cornerstone for her long-standing volunteer activities as a Peer reviewer and as a Team Leader.
Comprehensive, systematic, and effective risk prevention and management practices reduce the agency’s risk, loss, and liability exposure.
PA-RPM 3: Medication Control and Administration
The agency 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: PA-RPM 3 does not apply to foster care and kinship care homes. See PA-FKC 16.03.
NA The agency does not prescribe, dispense, administer, or store medication.
Table of Evidence
|Self-Study Evidence||On-Site Evidence||On-Site Activities|
County/Municipality Administered Agency, State Administered Agency (Central Office), or other Public Entity
State Administered Agency (Regional Office)
Personnel directly involved in medication control and administration receive training and demonstrate competence in medication control and administration, and knowledge of applicable legal requirements.
When medication is initially prescribed, the prescribing clinician provides education about the medications prescribed, including: medication name, dose, reason for use, how to administer, desired effects, and potential side effects.
Interpretation: Written detailed information regarding specific medications may be provided by the pharmacy responsible for filling a prescription.
Interpretation: Agencies have a responsibility to ensure that individuals (including children) and their families fully understand the benefits, risks, and alternatives of medication regardless of whether they prescribe or administer them.
When individuals are receiving prescription medication:
- qualified personnel obtain and/or update information about the medications the individual is taking at the time of each visit; and
- 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 agency must define the personnel qualifications necessary to collect medication information, in accordance with law and regulation.
NA The agency does not prescribe or administer medication.
Protocols and controls governing the proper administration and storage of medication include:
- locked, supervised storage with access limited to authorized personnel and in accordance with law, regulation, and manufacturer’s instruction;
- maintaining medication in original packaging and labeling with the name of person served, medication name, dosage, prescribing physician name, and number or code identifying the written order;
- appropriate disposal of expired or unused medication, syringes, medical waste, or medication prescribed to former persons served;
- a record of who received medications, what medications were dispensed or administered, and when and by whom medications were dispensed or administered;
- protocols for the administration of over-the-counter medications; and
- policies and procedures for safely dispensing or administering sample medications, in accordance with law and regulation.
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, agencies 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. Agencies 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), and (f) do not apply to agencies that only store medication.
Note: Please see Facility Observation Checklist - Private, Public, Canadian for additional assistance with this standard.
NA The agency does not dispense, administer, or store medication.
Following administration of medication, personnel observe and assess the effects of medication on the service recipient and consult with medical professionals, as necessary.
NA The agency does not administer medication.
Immediately prior to administration, qualified personnel review with the person the medication to be administered, its purpose, and verify:
- the identity of the individual and the medication ordered;
- that the medication to be administered matches the medication order; and
- visually inspect the integrity of the medication.
NA The agency does not administer medication.