CMS: All medications must be on POC

Recently released information and clarification from NAHC

“NAHC Question: Must a patient’s medication list be incorporated into the comprehensive assessment?

CMS Response: All medications, prescription and over the counter (OTC), must be listed on the drug regimen review. It is not necessary for the medications to be listed in the actual comprehensive assessment form that includes OASIS. They can be listed on a separate medication form. This medication form can be used as part of the comprehensive assessment to document the review of meds as listed in 484.55(c). The documentation should include information indicating the drug regimen review was completed as part of the comprehensive assessment. It can include any notations related to drug interactions, side effects, etc.

NAHC Request for Clarification: The practice of many home health agencies is to use the plan of care and interim orders as the “list of medications.”  These agencies do not use a “separate medication form.” The CoP and Interpretive Guidance at G337 language in the State Operations Manual do not include a requirement for a separate medication form or list outside of the plan of care. Does listing the medications on the plan of care meet the requirements?

CMS Response: ALL medications, both prescription and OTC must be listed on the plan of care signed by the physician. Our regulation does not specifically require a separate medication sheet. Surveyors would focus on compliance with 484.55 and 484.55(c).”

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