Source anchor
CMS MDS 3.0 RAI Manual v1.20.1 is the governed baseline currently attached to this lookup item.
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MDS Lookup
Drug Regimen Review
Complete only if A0310B = 01.
Matrix review
4 matrix group(s) are already attached for review on this item.
Answer coverage
3 governed answer row(s) are attached for this item.
Answer Codes
Code 0
No
if no clinically significant medication issues were identified during the drug regimen review.
Code 1
Yes
if one or more clinically significant medication issues were identified during the drug regimen review.
Code 9
NA
if the resident was not taking any medications at the time of the drug regimen review.
What this item is
Complete only if A0310B = 01.
When to use it
Use this item when the facility is completing content tied to Section N and needs to stay anchored to v1.20.1.
Reminders
- Current source status: Published.
- Item locator: Manual page N-18
- CMS exact locator: Manual page N-18
- This item has 3 governed answer row(s) attached.
Source awareness
This page is grounded in CMS MDS 3.0 RAI Manual v1.20.1. Review the exact text and locators before treating the item as final reference content.
Source & Review
Manual
CMS MDS 3.0 RAI Manual v1.20.1
Status
Published
Effective start
2025-10-01
Item locator
Manual page N-18
CMS exact locator
Manual page N-18
Full CMS Text
Complete only if A0310B = 01.
Item Rationale
Health-related Quality of Life
Potential and actual resident medication adverse consequences and errors are prevalent in health care settings and often occur during transitions in care. Adverse consequences related to medications may result in serious harm or death, emergency department visits, and rehospitalizations and affect the resident’s health, safety, and quality of life. Drug regimen review is intended to improve resident safety by identifying and addressing potential and actual clinically significant medication issues at the time of a resident’s admission (start of SNF PPS stay) and throughout the resident’s stay (through Part A PPS discharge).
Planning for Care
Drug regimen review is an important component of the overall management and monitoring of a resident’s medication regimen. Prevention and timely identification of potential and actual medication-related adverse consequences reduces the resident’s risk for harm and improves quality of life. Educate staff in proper medication administration techniques and adverse effects of medications, as well as to be observant for these adverse effects. Implement a system to ensure that each resident’s medication usage is evaluated upon admission and on an ongoing basis and that risks and problems are identified and acted upon.
DEFINITION
DRUG REGIMEN REVIEW A drug regimen review includes medication reconciliation, a review of all medications a resident is currently using, and a review of the drug regimen to identify, and if possible, prevent potential clinically significant medication adverse consequences. The drug regimen review includes all medications, prescribed and over the counter (OTC), nutritional supplements, vitamins, and homeopathic and herbal products, administered by any route. It also includes total parenteral nutrition (TPN) and oxygen.
Steps for Assessment
1. Complete a drug regimen review upon admission (start of SNF PPS stay) or as close to
the actual time of admission as possible to identify any potential or actual clinically significant medication issues.
2. Review medical record documentation to determine whether a drug regimen review was
conducted upon admission (start of SNF PPS stay), or as close to the actual time of admission as possible, to identify any potential or actual clinically significant medication issues. Medical record sources include medical records received from facilities where the resident received health care, the resident’s most recent history and physical, transfer documents, discharge summaries, medication lists/records, clinical progress notes, and other resources as available.
3. Discussions (including with the acute care hospital, other staff and clinicians responsible for
completing the drug regimen review, the resident, and the resident’s family/significant other) may supplement and/or clarify the information gleaned from the resident’s medical records.
4. Clinically significant medication issues may include, but are not limited to:
Medication prescribed despite documented medication allergy or prior adverse reaction. Excessive or inadequate dose. Adverse reactions to medication. Ineffective drug therapy. Drug interactions (serious drug-drug, drug-food, and drug-disease interactions). Duplicate therapy (for example, generic-name and brand-name equivalent drugs are both prescribed). Wrong resident, drug, dose, route, and time errors. Medication dose, frequency, route, or duration not consistent with resident’s condition, manufacturer’s instructions, or applicable standards of practice. Use of a medication without evidence of adequate indication for use. Presence of a medical condition that may warrant medication therapy (e.g., a resident with primary hypertension does not have an antihypertensive medication prescribed). Omissions (medications missing from a prescribed regimen). Nonadherence (purposeful or accidental).
Coding Instructions
Code 0, No: if no clinically significant medication
issues were identified during the drug regimen review.
Code 1, Yes: if one or more clinically significant
medication issues were identified during the drug regimen review.
Code 9, NA: if the resident was not taking any
medications at the time of the drug regimen review.
Coding Tips
A dash (–) value is a valid response for this item; however, CMS expects dash use to be a rare occurrence. The drug regimen review includes all medications, prescribed and over the counter (OTC), including nutritional supplements, vitamins, and homeopathic and herbal products, administered by any route. The drug regimen review also includes total parenteral nutrition (TPN) and oxygen. Adverse drug reaction (ADR) is a form of adverse consequence. It may be either a secondary effect of a medication that is usually undesirable and different from the therapeutic effect of the medication or any response to a medication that is noxious and unintended and occurs in doses for prophylaxis, diagnosis, or treatment. The term “side effect” is often used interchangeably with ADR; however, side effects are but one of five ADR categories, the others being hypersensitivity, idiosyncratic response, toxic reactions, and adverse medication interactions. A side effect is an expected, well-known reaction that occurs with a predictable frequency and may or may not constitute an adverse consequence.
DEFINITIONS
POTENTIAL OR ACTUAL CLINICALLY SIGNIFICANT MEDICATION ISSUE A 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.
Examples
1. The admitting nurse reviewed and compared the acute care hospital discharge medication
orders and the physician’s admission medication orders for Resident D. The nurse interviewed Resident D, who confirmed the medications they were taking for their current medical conditions. The nurse found no discrepancies between the acute care hospital discharge medications and the admitting physician’s medication orders. After the nurse contacted the pharmacy to request the medication, the pharmacist reviewed and confirmed the medication orders as appropriate for Resident D. As a result of this collected and communicated information, the nurse determined that there were no potential or actual clinically significant medication issues.
Coding: N2001 would be coded 0, No—No issues found during review.
Rationale: The admitting nurse reviewed and compared Resident D’s discharge
medication records from the acute care hospital with the physician’s admission medication orders, collaborated with the pharmacist, and interviewed the resident. The nurse determined there were no potential or actual clinically significant medication issues.
2. Resident H was admitted to the nursing facility after undergoing cardiac surgery for mitral
valve replacement. The acute care hospital discharge information indicated that Resident H had a mechanical mitral heart valve and was to continue receiving anticoagulant medication. While completing a review and comparison of Resident H’s discharge records from the hospital with the physician’s admission medication orders and admission note, the nurse noted that the admitting physician had ordered Resident H’s anticoagulation medication to be held if the international normalized ratio (INR) was below 1.0, however, the physician’s admission note indicated that the desired therapeutic INR parameters for Resident H was 2.5–3.5. The nurse questioned the INR level listed on the admitting physician’s order, based on the therapeutic parameters of 2.5–3.5 documented in the physician’s admission note, which prompted the nurse to call the physician immediately to address the issue.
Coding: N2001 would be coded 1, Yes—Issues found during review.
Rationale: The admitting nurse reviewed and compared Resident H’s discharge health
care records from the acute care hospital with the nursing facility physician’s admission medication orders and admission note. The nurse identified a discrepancy between the physician’s documented therapeutic INR level (2.5–3.5) for Resident H in the admission note and the physician’s order to hold anticoagulation medication for an INR level of 1.0. The nurse considered this discrepancy to be a potential clinically significant medication issue that could lead to potential clotting issues for Resident H.
Matrix Applicability
Nursing Home Subsets
NC - Comprehensive
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
NQ - Quarterly
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
NP - PPS 5 Day
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
Swing Bed Subsets
SP - PPS 5 Day
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
Program and Policy Use
QRP Quality Measures (Includes risk adjustment)
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
Item Subset Required Use ISC Skip Patterns
APU Item Admission (A0310B = 01)
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
QRP PPS 5 Day Admission (A0310B = 01)
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4