CMS Manual System - Louisiana Department of Health and Hospitals

Medication management is based in the care process and includes recognition or
identification of the problem/need, assessment, diagnosis/cause identification,
management/treatment, monitoring, and revising interventions, as warranted. The
attending physician plays a key leadership role in medication management by developing,
monitoring, and modifying the medication regimen in conjunction with residents and/or
representative(s) and other professionals and direct care staff (the interdisciplinary team).
When selecting medications and non-pharmacological interventions, members of the
interdisciplinary team participate in the care process to identify, assess, address, advocate
for, monitor, and communicate the resident‘s needs and changes in condition.
This guidance is intended to help the surveyor determine whether the facility‘s
medication management supports and promotes:
Selection of medications(s) based on assessing relative benefits and risks to the
individual resident;
Evaluation of a resident‘s signs and symptoms, in order to identify the underlying
cause(s), including adverse consequences of medications;
Selection and use of medications in doses and for the duration appropriate to each
resident‘s clinical conditions, age, and underlying causes of symptoms;
The use of non-pharmacological interventions, when applicable, to minimize the
need for medications, permit use of the lowest possible dose, or allow medications
to be discontinued; and
The monitoring of medications for efficacy and clinically significant adverse
consequences.
The resident‘s clinical record documents and communicates to the entire team the basic
elements of the care process. Information about aspects of the care process related to
medications may be found in various locations within the record, such as: hospital
discharge summaries and transfer notes, progress notes and interdisciplinary notes,
history and physical examination, Resident Assessment Instrument (RAI), plan of care,
laboratory reports, professional consults, medication orders, Medication Regimen Review
(MRR) reports, and Medication Administration Records (MAR).
Resident Choice – A resident and/or representative(s) has the right to be informed about
the resident‘s condition; treatment options, relative risks and benefits of treatment,
required monitoring, expected outcomes of the treatment; and has the right to refuse care
and treatment. If a resident refuses treatment, the facility staff and physician should
inform the resident about the risks related to the refusal, and discuss appropriate
alternatives such as offering the medication at another time or in another dosage form, or
offer an alternative medication or non-pharmacological approach, if available.