Codes

Code for Guidance: Management of the administration of medications for high care residents in an aged care service

The Code for Guidance is issued by the Nurses Board of Victoria (the Board) for nurses who manage the administration of medication pursuant to section 36E of the Drugs, Poisons and Controlled Substances Act 1981. Pursuant to 36F of the above Act, a nurse who manages the administration of any drug of dependence, Schedule 4, Schedule 8 or Schedule 9 poison supplied on prescription to a high care resident in an aged care service must do so in accordance with the Code for Guidance.

 

      Code for Guidance

      Code for Guidance: Frequently Asked Questions

 

Exemption Information

Exemptions due to exceptional circumstances

The Code for Guidance (the Code) provides a process to determine exceptional circumstances where compliance with the Code can not be met. In the event of non compliance the Board will consider on a case by case basis applications for exemption of a nurse managing the administration of medication from the requirement to have a supervising registered nurse on the premises where a personal care worker is administering medication to a high care resident from a Dose Administration Aid System. This process can be found in Attachment 1 of the Code.

Questions

 

• Who needs to apply for exemption?
• Is there a form to complete when applying for an exemption?
• Can I request a permanent exemption?
• What is a reasonable time frame for an exemption?
• What is the process for applying for an exemption?
• Exempt organisations - What should I include in my progress report?
• Exempt organisations - What should I include in my final report?
• What happens if my organisation becomes compliant prior to the end of our exemption period?
• Who should I contact for further details?

Who needs to apply for exemption?

Aged care services where the Division 1, 3 or 4 nurse managing the medication administration of any drug of dependence, Schedule 4, Schedule 8 or Schedule 9 poison supplied on prescription to a high care resident in an aged care service does not have a supervising registered nurse on the premises where a personal care worker is administering medication to a high care resident from a Dose Administration Aid System.

Is there a form to complete when applying for an exemption?

No, submissions for exemptions must be made in writing by the nurse managing the administration of medications to high care residents, aged care service or approved provider. It should be noted that the exemption is directed to the nurse managing the administration of medications as the person who has the obligation to comply with the Code.

Expected content of the submission is addressed within 'Attachment 1 Process for Determining Exceptional Circumstances' of the Code.

To enable the Board to review submissions in a timely manner it is recommended that applicants allow two months.

Can I request a permanent exemption?

No, the Board expects that as a part of the application for an exemption the applicant will include an action plan to move towards compliance with the Code.

What is a reasonable time frame for an exemption?

This will depend on the exceptional circumstances documented in the submission and the nature of the plan to achieve compliance with the Code. Submissions are assessed on a case by case basis.

What is the process for applying for an exemption?

Aged care services will be sent a letter to confirm that the Nurses Board of Victoria has received their application. The letter will also indicate the date when the application will be discussed at the next Board meeting.

Notification of the outcome from the Board meeting will be forwarded within 10 (ten) working days.

The exemption period begins on the day of the Board meeting in which the exemption was approved.

Aged care services that are approved for an exemption are required to provide regular progress reports to the Board demonstrating their progress towards achieving compliance. The timing of the required reports will be identified within the exemption approval letter. A final report is also required at the end of the exemption period.

Exempt organisations - What should I include in my progress report?

The progress report is a demonstration of how the aged care service is moving towards compliance.

The following items must be addressed within the progress report:

• Action plan progress: identify progress to date on the action plan strategies highlighted within the submission for an exemption. This should also include information which explicitly identifies current, short and long term strategies to achieve compliance. Long term goals are expected to address sustainability of compliance with the code;
• Data: in order to determine whether or not an organisation is progressing towards compliance it is necessary for the aged care service to compile statistical data. The data requested is in the form a weekly percentage of shift compliance;
• Medication Review Committee: minutes of the medication review committee meetings within aged care service from the past few months need to be included;
• Supporting Documentation: any further supporting documentation believed to be relevant should also be included within the report.

Exempt organisations - What should I include in my final report?

The final report is a demonstration of how the aged care service has achieved compliance.

The following items must be addressed within the progress report:

• Action plan progress: identify progress to date on the action plan strategies highlighted within the submission for an exemption. This should also include information which explicitly identifies long term strategies which address sustainability of compliance with the code;
• Supporting Documentation: any further supporting documentation believed to be relevant should also be included within the report.

What happens if my organisation becomes compliant prior to the end of our exemption period?

Should the aged care service become complaint with the Code prior to the end of the exemption period they are required to inform the Nurses Board of Victoria in writing.

The following items must be addressed in the communication:

• Date of compliance: the date the aged care service achieved compliance;
• Action plan progress: identify progress to date on the action plan strategies highlighted within the submission for an exemption. This should also include information which explicitly identifies long term strategies which address sustainability of compliance with the code;
• Supporting Documentation: any further supporting documentation believed to be relevant should also be included within the report.

Who should I contact for further details?

Nurse Policy Officer:

For further details regarding the Code for Guidance, please contact Nurse Policy Officer:

Kristy Mutsaers, PH: (03) 8635 1253; or via email: kmutsaers@nbv.org.au

Useful links

 

• Guidelines for the use of Dose Administration Aids (DAA) for clients in care in Victoria;

• Guidelines: Scope of Nursing and Midwifery Practice;

• Guidelines: Supervision and Delegation for Registered Nurses and Midwives;

• Drugs, Poisons and Controlled Substances Act 1981;

• Aged Care Act 1997;

• Health Professions Registration Act 2005;

• Australian Pharmaceutical Advisory Council - Guidelines for medication management in residential aged care facilities;

• Aged Care and Accreditation Standards.