Medicare Conditions of Participation 484.55 or G TAG 337 states:
“The comprehensive assessment must include a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy.”
CHAP standards HH II.7a takes it a step further and adds “effectiveness of pain medication”
It is common that on admission, a home health patient pulls out a box of pill bottles, along with discharge instructions from the hospital, rarely are they reconciled. Further, examination of the bottles reveal multiple pharmacies and multiple doctors. Therefore, the ONLY person who can review the medication as mandated by Medicare is the home health professional sitting at the table with the patient.
It is a basic function of the home health assessment that ensures patient safety. It is so important that the description of a medication review is written into the Federal Register. There were no assumptions that professionals would perform this task consistently and unfortunately, that is for good reason.
There are some medication profile forms that include the language of the CMS Condition; for instance the Med-Pass medication review tool has a place to document the review on admission and anytime there is a new or changed medication. The use of the form would require a process to include documentation on the profile of review and the date.
Most point-of-care systems document drug-to-drug interactions and a medication assessment in the admission note that satisfies the condition. However, many systems require some additional documentation when the med profile is changed. This can be done in the visit note or on the medication profile depending on the software.
Most software vendors will work with agencies to meet the requirements of the Medicare Conditions of Participation.
Medication Review is a documentation process, it is also a nursing process and once an agency identifies a method to document the review, the staff should be educated to actually conduct the review as described and to reinforce that they are the patient’s last line of defense against medication error.
