Compliance with medication management

Medication Administration and all the variables involved with providing medication in an ALF can be the
biggest headache (no pun intended) that you come in contact with- that is if you do not have a system in
a place for following the following regulation provided by the Maryland Office of Health Care Quality:

.29 Medication Management and Administration.
A. All staff who administer medications to residents shall have completed the medication administration course
that is taught by a registered nurse who is approved by the Maryland Board of Nursing.
B. The assisted living manager shall document completion of the medication technician training in the personnel
file or another readily available record of each unlicensed staff member who administers medications.
C. All medications shall be administered consistent with applicable requirements of COMAR 10.27.11.
D. An assisted living manager shall ensure that the resident’s initial assessment process identifies whether a resident:
(1) Is capable of self-administration of medication;
(2) Is capable of self-administration of medication, but requires a reminder to take medications or physical
assistance with opening and removing medications from the container, or both; or
(3) Requires that medications be administered by the assisted living program staff or by a spouse or domestic
partner of the resident in accordance with §F of this regulation.
E. For a resident who is capable of self-administration or, although capable, requires a reminder or physical
assistance, as stated in §D(2) of this regulation, the assisted living manager shall ensure that the resident is
reassessed by the delegating nurse quarterly for the ability to safely self-administer medications with or without
F. While residing in the same assisted living facility as their spouse or domestic partner, a resident may administer
medications to their spouse or domestic partner providing the following documentation is maintained in the
resident’s record:
(1) An initial assessment by their health care provider documenting the resident’s competency and ability to
safely administer medications to their spouse or domestic partner;
(2) Quarterly assessments by the delegating nurse documenting the resident’s continued ability to safely
administer medications to their spouse or domestic partner; and
(3) Current signed medical orders.
G. Medication Review Upon Admission.(1) The assisted living manager shall consult within 14 days of a resident’s admission with the individuals set
forth in §G(2) of this regulation to review a new resident’s medication regime.
(2) The medication review may be conducted by a:
(a) Primary care physician;
(b) Certified registered nurse practitioner;
(c) Certified registered nurse midwife;
(d) Registered nurse, who may be the delegating nurse; or
(e) Licensed pharmacist.
H. The purpose of the review required by §G of this regulation is to review with the assisted living manager or
(1) A resident’s current medication profile, including all prescription and nonprescription medications and tube
(2) The potential that current medications have to act as chemical restraints;
(3) The potential for any adverse drug interactions, including potential side effects from the medications; and
(4) Any medication errors that have occurred since admission.
I. The assisted living manager, or designee, shall ensure that the review required by §G of this regulation is
documented in the resident’s records, including any recommendations given by the reviewer.
J. Pharmacy Review.
(1) The assisted living manager of a program shall arrange for a licensed pharmacist to conduct an on-site
review of physician prescriptions, physician orders, and resident records at least every 6 months for any resident
receiving nine or more medications, including over-the-counter and PRN (as needed) medications.
(2) The pharmacist’s review shall include but is not limited to, whether:
(a) The program is in compliance with the Board of Pharmacy’s requirements for packaging of medications;
(b) Each resident’s medications are properly stored and maintained;
(c) Each resident receives the medications that have been specifically prescribed for that resident in the
the manner that has been ordered;
(d) Based on available information, the desired effect of each medication is achieved, and, if not, that
the appropriately authorized prescriber is so informed;
(e) Any undesired side effects, potential and actual adverse drug reactions, and medication errors are
identified and reported to the appropriately authorized prescriber;(f) The resident has a medical condition as documented in the resident’s records that is not currently being treated by medication;
(g) There is drug use without current indication in the resident’s records of a medical condition that warrants
the use of the drug;
(h) There is drug overuse that is causing side effects as documented in the resident records;
(i) Current medication selections result in inappropriate drug dosage;
(j) The resident may be experiencing drug interactions;
(k) The resident is receiving medication, either prescribed or over-the-counter medications, as well as herbal
remedies that could result in drug-drug, drug-food, or drug-laboratory test interactions;
(l) Administration times of medication need to be modified to address drug interactions or meal times, or both;
(m) The resident records need to be reviewed to assure that periodic diagnostic monitoring required by
certain medications have been performed; and
(n) The resident’s medication regimens need to be reviewed to determine if more cost-effective medications
are available to treat current medical conditions.
(3) The pharmacist shall document the pharmacy review as required under this section in each resident’s chart
and this documentation shall be reviewed every 6 months as part of the assisted living program’s quality assurance
activities as required in Regulation .13 of this chapter.
K. The person conducting the on-site review under §G or J of this regulation shall recommend changes, as
appropriate, to the appropriately authorized prescriber and the assisted living manager or designee.
L. If a resident requires that staff administer medications as defined in Regulation .02B(3) of this chapter, and the
administration of medications has been delegated to an unlicensed staff person pursuant to COMAR 10.27.11, the
assisted living manager shall comply with COMAR 10.27.11 by arranging for an on-site review by the delegating
a registered nurse at least every 45 days. The delegating nurse shall make appropriate recommendations to the
appropriately authorized prescriber, and the assisted living manager or designee.
M. Safe Storage of Medication. The assisted living manager, or designee, shall ensure that:
(1) Medications are stored in the original dispensed container;
(2) Medications are stored in a secure location, at the proper temperature; and
(3) The following documentation is maintained for all residents:
(a) Name of the resident;
(b) Name of the medication;
(c) Reason for the medication;
(d) Dose;(e) Physician’s or authorized prescriber’s name;
(f) Date of issuance;
(g) Expiration date;
(h) Refill limits; and
(i) Directions for use.
N. Medications and treatments shall be administered consistent with current signed medical orders and using
professional standards of practice.
O. Required Documentation.
(1) A staff member shall record the documentation required under §M of this regulation for all residents for
whom medications are administered, or who receive assistance in taking their medications, as defined by Regulation
.02B(3)(b) of this chapter, at the time, that the resident takes or receives medications.
(2) A staff member shall record the documentation required under §M of this regulation for residents who selfadminister:
(a) Upon admission; or
(b) When changes in the resident’s medication regimen are ordered by a physician or other authorized health
care practitioner.
P. Accounting for Narcotic and Controlled Drugs.
(1) Staff shall count and record controlled drugs, such as narcotics, before the close of every shift.
(2) The daily record shall account for all controlled drugs documented as administered on the medication administration record.
(3) All Schedule II and III narcotics shall be maintained under a double lock system.

Pro Tip:
It is necessary for your entire clinical team to be well versed in the regulations that is applicable to their
position. The Nursing Director or their designee should hold frequent refresher trainings and have
processes put into place for all matters related to medication administration, storage, procurement as
well as the destruction of expired or discharged medication. It is also suggested to audit your med
passes at the very minimum on a quarterly basis as well as including med pass trainings for the clinical
team upon orientation