Section 144-118-10.J - Drug Regimen Review10.J.1. A pharmacist or registered nurse must review the medication record of each client monthly:a. For rationale, potential adverse reactions, allergies, interactions, contraindications, and response to medications;b. For modifications indicated by any laboratory test; c. To advise the physician of any recommended changes and give the reasons therefor; andd. To propose an alternate drug regimen if indicated. 10.J.2. The pharmacist must: a.Maintain a profile of all prescription and non prescription medications, including quantities and frequency of refills; and b. Participate, as appropriate, in the continuing interdisciplinary evaluation of individual charts for the purposes of beginning, monitoring and following up on individualized programs. 10.J.3. The facility shall have an organized system for drug administration that identifies each drug up to the point of administration. The system must assure that: a. All staff administering medications employ a uniform means for identifying clients; andb. Procedures are established to check administration of medication against the physician's orders. 10.J.4. All drugs must be administered in compliance with the physician's orders. a.Orders for medications must: 1. Be written by the client's physician;2. Contain the name and strength of the medication, the dose, the dosage form, the route of administration, and the frequency to administer the medications;3. Be signed and dated by the physician; and4. Be in effect for the time specified by the physician but in no case to exceed a period of three (3) months unless there is a written reorder.b. Oral orders may be accepted only by a: c. The person taking an oral order shall: 1. Write it in the client's record, immediately;3. Ensure that the physician countersigns according to accepted practice.d. The client's physician shall be notified prior to the discontinuation of a medication.10.J.5. Medication Records a. An individual medication administration record must be kept for each resident of all treatments, drugs and medications ordered by the physician, including the name of the drug, dosage and time to be given.b. An entry must be made on the medication administration record to indicate whenever a medication, including a medication ordered to be administered as needed, or a treatment is started, given, refused, or discontinued.c. Medication errors and reactions must be recorded in the resident's record. Medication errors include omissions, as well as errors of commission. Errors in documentation or charting are errors of omission. 10.J.6. All drugs, including those that are self-administered, are administered without error.a. A record of drug administration errors must: 1. Be reported to the administrator, with a written incident report; and2. Describe the incident and indicate the extent of the injury or reaction and necessary treatment; a.The resident shall be examined and treated by a physician, if necessary; and b.The administrator shall sign and date the incident report. 10.J.7 Personnel Administering Medication a. In ICFs/MR Nursing, all medications must be administered by licensed medical, nursing personnel, or a CNA who has a certificate indicating completion of a course in medication administration given in accordance with Chapter 5 of the Rules and Regulations of the Maine State Board of Nursing. b. In ICFs/MR Group, oral and topical medications may be given by a staff member who has a certificate in the administration of medications, awarded upon successful completion of a state approved medication administration course. The R.N. Consultant is responsible for: 1. Monitoring the policies and procedures related to the administration of medications;2. Regularly observing and evaluating the administration of medications to the clients in the facility;3. Providing inservice relative to the medications prescribed for the clients in the facility;4. Conducting an overview of the policies and procedures relating to the administration of medications with new personnel prior to their performance of this task; and 5. Ensuring that the staff maintain current certification.c. Medications must be administered as soon as possible after doses are prepared and by the same person who prepared the medication for administration.d. An individual medication administration record must be maintained for each client. 1. The record must include: (d) Initials of the administering individual with the full name of the individual written somewhere on the record.2. Entries must be made on the medication record whenever medications are started, given, discontinued, or refused or when a medication error is made. 10.J.8. Drugs used by clients, while not under the direct care of the facility, must be packaged and labeled in accordance with State law. Procedures for sending medications with the client to the external or day program, on vacation, or home, etc., include: a. The pharmacist may provide a separate container or medication pack with an appropriate label.b. Packaging of medication may be done only by the pharmacist. 10.J.9. Drug administration errors and adverse drug reactions must be:a. Recorded in the client's record;b.Reported immediately to a physician; and c. Reviewed monthly, with appropriate recommendations for action.10-144 C.M.R. ch. 118, § 10.J