Topic Number2.3.26Effective DateApril 1, 2016
ProcedureMedication Management
PurposeTo establish a Medication Management Program at WWRC that clarifies client rights and responsibilities, staff roles, and related protocols, standards, and expectations
Accountability Indicators
  • Consumers attending WWRC understand that they are expected to comply with their prescribed medication regimen to maintain mental health and medical stability and to enhance their success in WWRC programs.  Consumers attending WWRC also understand that failure to comply will affect their continued enrollment in WWRC programs. 
  • Consumers attending WWRC have an adequate supply of medications, as prescribed by their home physician, on their scheduled admission day, consistent with expectations stated in their admissions letter, and in the WWRC Student Code of Conduct.
  • WWRC monitors medication management compliance levels on clients identified through Student Health Nursing and documents related safety issues and resolutions taken to minimize risk to the consumer and the WWRC campus environment. 
  • A systematic PE/QA plan monitors and evaluates the effectiveness of protocols, standards, and expectations for the management of consumer medications. 


Policy ReferenceDRS Policy & Procedure Manual, Chapter 14.2: Comparable Benefits
Detailed Governance Reference
Executive Staff Contact

Barb Ostrander, Medical Rehabilitation Services Division Director



Every Day, In Every Way, We….. 


Take Care of Customers
Work in Teams
Value Our Staff
Are Organized, Utilized, and Valuable
Preserve Leadership Ethics, Accountability, Center Values, and Public Trust



Governance Procedures

Taking medications as prescribed is required for WWRC admissions and is critical to the success of clients attending WWRC as well as to the safety of the WWRC campus environment.   Non-compliance is a violation of WWRC's Student Code of Conduct and will be addressed in accordance with the Center's protocol on management of student behaviors.   Medication non-compliance, as described in this governance protocol, may qualify as a 'clear and present danger' to self or others under the Center's protocol on management of student behaviors and will result in program interruption until compliance is met.


  • Critical Medication:  Any medication that, if unavailable, will likely result in an acute event and/or rapid destabilization in a medical or mental health condition
  • Other Medication:   Any medication that, if unavailable, may result in an adverse event or destabilization in a medical or mental health condition within a short period of time
  • Adequate Supply:  A level of medications, refills, prescriptions, and/or payment plans to ensure prescribed medications are available

Medication Management:  General Expectations and Requirements

It is the client's responsibility to have an adequate supply of all prescribed medications on the day of admission and to take medications as prescribed by their physician throughout their program.  When a client has an inadequate supply of medication, nursing will determine if the medication is critical and if there is a need to be discharged or put on leave based on review of available information, in consultation with the WWRC medical practitioner and/or with WWRC Behavioral Health staff when the inadequate supply is for treatment of a mental health condition.

The following expectations apply:

  • The client must bring a medication supply with refills or prescriptions to last at least 90 days, or for the length of their program, if shorter than 90 days.
  • Medications must be in the original pharmacy container, labelled with the client's name and to include instructions.  Medications may not be in a pillbox or pill chest when presented at admissions.
  • Supplements, or over-the-counter medications, must be in the original manufacturer's container, with instructions for use included.
  • The client must have a plan in place to refill medications or to obtain additional prescriptions from their home physician.    Transfer to a local pharmacy, depending on length of program time, is recommended.
  • Medications may be kept in the client's room if they are able to take medications, as prescribed, without reminders AND if they are able to manage medication refills and prescriptions without assistance. 
  • The WWRC nurse and assigned Rehabilitation Counselor are able to assist as needed.   WWRC medical areas can store and administer client medications and provide related education.  When this assistance is provided, it is the client's responsibility to come to the designated WWRC medical area during scheduled times to obtain the medication. 
  • Prior to departing the center for extended periods of time the consumer will report to Student Health to pick-up their prescription(s).
  • Upon returning from leave the consumer will return prescriptions to Student Health.  
  • Any cost related to medication is the client's responsibility and follows Agency policy.


Clients who were not admitted or who were placed on leave due to inadequate medication supply must be cleared by medical or Behavioral Health staff prior to campus return.  There must be a documented plan to ensure an adequate supply of medications at all times upon return.  

Note:  At any time from admissions through program completion, if the client states that a medication has been discontinued by a community physician without a corresponding replacement, the client may be asked to produce a written statement from his/her physician.   The note must be received within 72 hours of the request for the client to remain on campus. 

Critical Medications

Upon admission, if a prescribed medication is considered critical and there is no opportunity for the client to obtain an adequate supply before close of the business day, the admitting nurse will inform the client that s/he cannot be admitted at that time.   WWRC nursing staff will notify Admissions if not admitted as scheduled due to an inadequate medication supply.   Admissions will re-schedule the client for services when an adequate medication supply is available.

When a currently enrolled WWRC client has an inadequate supply of critical medications, the medication nurse, or representative, will speak with the client/family to determine a plan to obtain medication(s) and will inform the client/family that if medication is not received at least 24 hours prior to the last dose of medication, the client will be asked to leave for their own safety and the safety of the campus environment until an adequate supply is available.   

Other Medications

 If upon admission or during the WWRC program there is an inadequate supply of medications not ordinarily considered critical, the WWRC nurse or representative may consult with the WWRC Nursing Supervisor, WWRC medical practitioner, or Behavioral Health staff, to determine how long the client may remain on campus without the medication. 

 The nurse will speak with the client/family to determine a plan to obtain medication(s) and will inform the client/family that if medication is not received within the allotted time, the client will be asked to leave campus for their own safety and the safety of the campus environment until an adequate supply is received.   


When WWRC medical personnel determine that a program interruption is necessary due to medication non-compliance, the client is expected to leave campus within 24 hours of the decision.  The WWRC Residential Services Director and the Counselor Manager are accountable to co-facilitate and oversee all discharge transitions to appropriate services, including transportation coordination.  If unique extenuating circumstances exist, the assigned WWRC Rehabilitation Counselor may seek approval for a brief time extension.  Timeline exceptions will be considered on a case-by-case basis and will be the exception, not the norm.  


Program interruptions due to inadequate supply of critical medications will be documented as an AWARE Service Note by the assigned nurse, with an alert email distributed to all nursing staff, the assigned Rehabilitation Counselor, the DRS Counselor, and Behavioral Health Services, as indicated.    The assigned Rehabilitation Counselor, or designee, will manage the consumer's status within AWARE.