OASIS-Central

Q: In regards to M2000 and M2010, if a non-nursing clinician PT or ST opens a case, is it acceptable to answer “no” to these questions?

A: §484.55 (c) of the Home Health Conditions of Participation (CoPs) requires that the comprehensive assessment include a drug regimen review. For this reason, answering “0 – No” to M2000, Drug Regimen Review, would be a red flag that the agency was non-compliant with the CoPs. In therapy-only cases, the agency may make the decision to manage this by having the therapist who performs the initial comprehensive assessment to review and document the patient’s medications (prescribed and over-the-counter), and then have a nurse review the medication list for potential adverse effects, drug reactions, ineffective drug therapy, significant drug interactions, and duplicate drug therapy. The nurse would then communicate this information to the therapist completing the assessment so M2000 can be completed. This may impact the date entered on M0090 (Date assessment completed), since this date should reflect the last date assessment information is obtained.

If the nurse identifies a problem during the drug regimen review, the one calendar day time frame for M2002, Medication Follow up, begins at the point that the problem is identified (by the nurse) and not when the therapist records the medications.

Also, keep in mind that the CoPs also require that the assessing clinician evaluate for any noncompliance with drug therapy. That cannot be done by a nurse reviewing a list of medications. Therapists performing comprehensive assessments need to have the necessary skills to assess for possible noncompliance.