CMS Manual System - Louisiana Department of Health and Hospitals

Whether the signs, symptoms, or related causes are persistent or clinically
significant enough (e.g., causing functional decline) to warrant the initiation or
continuation of medication therapy;
Whether non-pharmacological interventions are considered;
Whether a particular medication is clinically indicated to manage the symptom or
condition; and
Whether the intended or actual benefit is sufficient to justify the potential risk(s)
or adverse consequences associated with the selected medication, dose, and
duration.
The content and extent of the evaluation may vary with the situation and may employ
various assessment instruments and diagnostic tools. Examples of information to be
considered and evaluated may include, but are not limited to, the following:
An appropriately detailed evaluation of mental, physical, psychosocial, and
functional status, including comorbid conditions and pertinent psychiatric
symptoms and diagnoses and a description of resident complaints, symptoms, and
signs (including the onset, scope, frequency, intensity, precipitating factors, and
other important features);
Each resident‘s goals and preferences;
Allergies to medications and foods and potential for medication interactions;
A history of prior and current medications and non-pharmacological interventions
(including therapeutic effectiveness and any adverse consequences);
Recognition of the need for end-of-life or palliative care; and
The refusal of care and treatment, including the basis for declining it, and the
identification of pertinent alternatives.
NOTE: The CAAs, an integral part of the comprehensive resident assessment,
help identify some possible categories of causes of various symptoms
including: behavioral symptoms of distress, delirium, and changes in
functional status. Refer to 42 CFR 483.20 and the MDS and CAAs.
Circumstances that warrant evaluation of the resident and medication(s) may include:
Admission or re-admission;
A clinically significant change in condition/status;
A new, persistent, or recurrent clinically significant symptom or problem;