Medication Policy

Effective date: September 30, 2011

Revised January 2018

Relevant Legislation:

Not applicable to this policy.


It is a belief at LOFT Community Services that the individuals we serve should be encouraged as much as possible to manage their own medications.  Medication self-management is an important part of successful community living and is an attainable goal for most of the people we serve.  Staff is not responsible for whether or not a client takes his/her medication; however, they can facilitate the process in a number of ways, and can monitor whether or not they are being taken.

The intent of the policy requirements is to:

  1. Improve safety, protection and quality of care for service users who are prescribed psychotropic and other medications; and
  2. Provide clear requirements for staff regarding safe administration, storage and disposal of medication and effective communication and sharing of medication information.


Not applicable.


Those clients who enter a LOFT program capable of managing their medications should have full responsibility for doing so.  Others who require some training and/or support to do so, should be assisted using the following guidelines:


  1. Only physicians, RN’s and RPN’s with their medication certificate can legally dispense and administer medications.
  2. Staff, other than those working in the above mentioned capacities, are not permitted to dispense medications, but can assist with self-administration or monitor, when appropriate.
  3. Assisting with self-administration or monitoring of medications can include any of the following:
    • Reminders re: medication times
    • Removing bottle caps, opening tubes
    • Confirming information on the label
  4. Supervision or monitoring of medications DOES NOT include the following:
    • Counting out pills or measuring out liquids
    • Filling dossettes
    • Doing injections
    • Punching out blister paks, except in very rare situations*
  5. Blister paks should be used whenever possible
  6. Staff will not give advice regarding medications. Clients will be directed to utilize other supports regarding medication information: pharmacy, doctor, psychiatrist, specialist or Telehealth (1-866-797-000)

*Rare Situations when more support with self-administration is necessary (eg. With seniors or palliating clients with physical health challenges)

In very rare situations, staff may be required to punch out pills from a blister pak for certain clients.  The staff member who supports the client with their self administration of the medication is responsible and accountable to ensure that the medication is given as prescribed and that proper recording is maintained.  Training for this will be provided by a qualified person such as an RPN or RN.

Please refer to program procedure manuals for procedures related to these rare situations.

Storage and Disposal

This policy focuses on the safe storage and disposal of medication and the improved communication and transfer of medication information.

  1. Only the client can sign for/receive any medication that is delivered to their residence.
  2. The role of staff is to support the client in self-administration. The staff does not administer medication.
  3. Staff can assist clients to contact their pharmacy when ordering repeats, asking a pharmacy for assistance for blister packs or dossetts or setting up delivery of medication by the pharmacy.
  4. Programs will dispose of unused or expired medication, including the use of sharps containers for needle and syringes, to the dispensing pharmacy within a seven day time frame.
  5. Contact information for local pharmacies and poison control are located for clients and staff to see.
  6. Medication may be stored in a locked cabinet in a staff office. Log sheets, signed by the client must be kept to monitor medication in an out of the locked cabinet.
  7. Staff may transport medication to a client’s room if they are unable to get to the locked cabinet. Client must administer the medication themselves.


Medication Incidents

  1. Staff identify, monitor and respond to medication incidents including seeking emergency medical attention as required.
  2. Medication incidents will be reported using LOFT’s incident reporting policy.
  3. Staff from all programs will document any action taken to address medication incidents.


Telephone Orders

Telephone orders should be limited to situations where the physician cannot be present and the order must be followed up in writing by the physician as quickly as possible. Telephone medication orders will only be taken in emergency situations by regulated employees.

  1. At all levels of communication of a medication order, the generic name should be used as much as possible in order to reduce the risk of error. The exception to this rule shall occur when prescribing individual issues the medication order using a trade name.
  2. LOFT designated staff is responsible for recording information received by telephone accurately and ensure the medication order is valid. A valid medication order must contain the following:
    • The name of the client
    • The date prescribed
    • The name of the medication
    • The dosage
    • The route
    • The frequency with which the drug is administered
    • Name and signature of the prescribing individual and his/her professional status
  3. When a telephone order is accepted by a designated staff within the organization, the order in its entirety must be documented and repeated back to the issuer to ensure accuracy. The designated staff shall,
    • Document the medication order within the client’s file.  If it is telephone order, please indicate this.
  4. If there is any doubt, question or possible error concerning a telephone medication order, the following steps must be taken:
    • The staff shall not assist with self-administration of the medication if there is any doubt, question or possible error in the dosage, route, name of the drug, or any other concern.

Data base Entry

Staff will only be required to enter detailed medication information into the client database if the following conditions have been met:

Medications have been confirmed via the following accredited agencies/documents:

  • Client’s pharmacy
  • Actual prescription or a copy of the prescription
  • Seeing the actual prescription pill bottles

In the absence of a confirmation, staff will refer to a client’s pharmacy or file for confirmation. Without confirmation only the medication name will be entered; dosages and other medication will be left blank.


LOFT programs that hold medications for clients will provide training and education regarding medications that include how the medication works; the risks associated with each medicine, the intended benefits, as related the behaviour or symptom targeted by this medication; side effects; contraindications; potential implications between medications and diet/ exercise; risks associated with pregnancy; the importance of taking medications as prescribed including, when applicable, the identification of potential obstacles to adherence; the need for laboratory monitoring; early signs of relapse related to medication prescriptions; potential drug reactions when combining prescription and non-prescription medications including alcohol, tobacco, caffeine, illegal drugs ad alternative medications; and instructions on self-administration, when applicable.

Peer review

A peer review of each program’s medication procedures is conducted by a qualified professional with legal prescribing authority or a pharmacist.  This is conducted annually and is recorded.


See program manual.