In the complex landscape of geriatric healthcare, medication errors can significantly impact LTC resident health, safety and quality of life. Unfortunately, potential and actual adverse consequences related to medications are prevalent, often occurring during transitions in care. These adverse consequences can result in serious harm or even death, emergency department visits, and rehospitalizations.

One vital strategy to improve resident safety is the drug regimen review, a comprehensive process designed to identify and address potential and actual clinically significant medication issues. In this blog, we explore the significance of drug regimen review, its integration with CMS Standardized Patient Assessment Data Elements, and the penalties for noncompliance with reporting.

Planning for Care

Drug regimen review serves as a crucial component of the overall management and monitoring of a resident’s medication regimen. Its primary goal is the prevention and timely identification of potential and actual medication-related adverse consequences, ultimately reducing the resident’s risk for harm and enhancing quality of life. Key steps to ensure the success of this process include:

  1. Education: Staff should be well-versed in proper medication administration techniques and the adverse effects of medications. This knowledge equips them to be observant and proactive in recognizing adverse effects of medications promptly.
  2. System Implementation: Establish a systematic approach to ensure that each resident’s medication usage is evaluated upon admission and on an ongoing basis. This system should identify risks and problems and take appropriate actions. Use the critical element pathway 20082 Unnecessary Medications to guide QA efforts.

The Centers for Medicare & Medicaid Services (CMS) recognizes the importance of standardized patient assessment data to ensure the quality of care in healthcare settings, including Skilled Nursing Facilities (SNFs). This integration enhances the drug regimen review process by aligning it with CMS’s standards, ensuring a consistent and comprehensive approach to resident care.

CMS Standardized Patient Assessment Data Elements (SPADEs) are a set of essential data elements designed to assess the health and well-being of residents accurately. SPADEs include a range of information related to a resident’s special services, treatments, and interventions, medical conditions and co-morbidities, cognitive function, mental status including depression and dementia, and ability to communicate. The Drug Regimen Review element includes the following:

  1. Medication Reconciliation (N2001): “Clinically significant medication issue is a potential or actual issue that, in the clinician’s professional judgment, warrants physician (or physician-designee) communication and completion of prescribed/recommended actions by midnight of the next calendar day at the latest. ‘Clinically significant’ means effects, results, or consequences that materially affect or are likely to affect an individual’s mental, physical, or psychosocial well-being, either positively, by preventing a condition or reducing a risk, or negatively, by exacerbating, causing, or contributing to a symptom, illness, or decline in status. Any circumstance that does not require this immediate attention is not considered a potential or actual clinically significant medication issue for the purpose of the drug regimen review items.”
  2. Medication Follow-up (N02003): The process of contacting a physician to communicate an identified medication issue and completing all physician- prescribed/recommended actions by midnight of the next calendar day at the latest.
  3. Medication Intervention (N02005): Every time a potential or actual clinically significant medication issue is identified throughout the resident’s stay, it must be communicated to a physician, and the physician-prescribed/-recommended actions must be completed by the clinician in a time frame that maximizes the reduction in risk for medication errors and resident harm.

While compliance with CMS SPADEs and drug regimen review is essential, SNFs must be aware of the potential consequences of noncompliance. Notably, a 2% reduction in the SNF’s annual rate update is applied if noncompliant with reporting requirements. This financial penalty is further incentive for facilities to prioritize adherence to CMS regulations and reporting standards.

The drug regimen review is a vital safeguard in the care of residents, ensuring that their medication regimens are safe, effective, and aligned with their specific needs. By identifying and addressing potential issues proactively, healthcare providers can significantly enhance resident safety, ultimately improving the quality of life for those under their care. Integrating the drug regimen review with CMS Standardized Patient Assessment Data Elements ensures a comprehensive, standardized approach to medication management, reinforcing the commitment to delivering high-quality care in healthcare facilities, including SNFs.

However, SNFs must also recognize the importance of compliance with CMS regulations, as penalties for noncompliance, such as a 2% reduction in the annual rate update, can have substantial financial implications. Therefore, it is imperative that healthcare facilities implement a rigorous drug regimen review processes, continually educate their staff, and ensure strict adherence to CMS reporting requirements to maintain the highest standards of resident medication safety and regulatory compliance.



Written By: Brandy RN, RAC-CT, RAC-CTA
Clinical Consultant

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