PART I - Department of Behavioral Health and Developmental ...

3. A statement of attestation from the licensed pharmacist or licensed Registered Nurse that all issues havebeen corrected.xiv. For providers that conduct any laboratory testing on-site, documented evidence is provided that the provider’sClinical Laboratory Improvement Amendment (CLIA) Waiver is current. Refer to the list of waived tests updatedJanuary 15, 2010 on the Centers for Medicaid and Medicare Services website.f. The “Eight Rights” for medication administration are defined with detailed guidelines for staff to implement within theorganization to verify that right:i. Right person: includes the use of at least two identifiers and verification of the physician’s medication order with thelabel on the prescription drug container and the MAR entry to ensure that all are the same every time before amedication is taken via self-administration or administered by a licensed staff member.ii. Right medication: includes verification of the medication order with the label on the prescription drug container andthe MAR entry to verify that all are the same every time before a medication is taken via self-administration oradministered by a licensed staff member. The medication is inspected for expiration date. Insulin must be verifiedwith another person prior to administering.iii. Right time: includes the times the provider schedules medications, or the specific physician’s instructions related tothe drug.iv. Right dose: includes verification of the physician’s medication order of dosage amount of the medication; with thelabel on the prescription drug container and the Medication Administration Record entry to ensure that all are thesame every time before a medication is taken via self-administration or administered by a licensed staff member.The amount of the medication should make sense as to the volume of liquid or number of tablets to be taken.v. Right route: includes the method of administration;vi. Right position: includes the correct anatomical position; individual should be assisted to assume the correctposition for the medication method or route to ensure its proper effect, instillation, and retention.vii. Right documentation includes proper methods of the recording on the MAR; andviii. Right to refuse medications: includes staff responsibilities to encourage compliance, document the refusal, andreport the refusal to the administration, nurse administrator, and physician.g. A Medication Administration Record (MAR) is in place for each calendar month that an individual takes or receivesmedication(s):i. Documentation of routine, ongoing medications occur in one discreet portion of the MAR and include but may notbe limited to:1. Documentation by calendar month that is sequential according to the days of the month;2. A listing of all medications taken or administered during that month including a full replication of informationin the physician’s order for each medication:a. Name of the medication;b. Dose as ordered;c. Route as ordered;d. Time of day as ordered; ande. Special instructions accompanying the order, if any, such as but not limited to:i. Must be taken with meals;ii. Must be taken with fruit juice;iii. May not be taken with milk or milk products.3. If the individual is to take or receive the medication more than one time during one calendar day, each timeof day must have a corresponding line that permits as many entries as there are days in the month;4. All lines representing days and times preceding the beginning or ending of an order for medications shall bemarked through with a single line;5. When a physician discontinues (D/C) a medication order, that discontinuation is reflected by the entry of“D/C” at the date and time representing the discontinuation followed by a mark through of all linesrepresenting days and times that were discontinued.ii. Documentation of medications that are taken or received on a periodic basis, including over the countermedications, occur in a separate discreet portion of the MAR and include but may not be limited to:1. A listing of each medication taken or received on a periodic basis during that month including a full replicationof information in the physician’s order for each medication:a. Name of the medication;b. Dose as ordered;c. Route as ordered;d. Purpose of the medicatione. Frequency that the medication may be takenFY2013 Provider Manual for Community Behavioral Health Providers