CMS Requirements for Medication Reconciliation in Home Health

CMS Requirements for Medication Reconciliation in Home Health

According to the CMS Conditions of Participation, agencies must:

1. Comprehensive Assessment (§484.55)

• The initial assessment must include a thorough review of all medications the patient is currently taking.

• The comprehensive assessment must determine the patient’s ability to manage their medications safely and independently.

• Nurses must document medication dosages, frequencies, routes, and any noted discrepancies.

2. Care Planning (§484.60)

• A personalized plan of care must be developed based on the comprehensive assessment.

• The plan must address medication management, including teaching, monitoring, and coordination with the physician.

• Medication reconciliation findings should inform patient education and safety planning.

3. Clinical Records (§484.110)

• Documentation must demonstrate accurate medication reconciliation.

• All updates, corrections, and communication with the physician regarding medication changes must be included.

• Records should reflect patient teaching, adherence, and any issues identified during home visits.

Best Practices for Medication Reconciliation in Home Health

Step 1: Collect a Complete Medication History

• Include all prescription and over-the-counter medications.

• Document vitamins, supplements, and herbal remedies.

• Verify with pharmacies, caregivers, and prior medical records.

Step 2: Compare Medication Lists

• Review hospital discharge orders, physician instructions, and the patient’s current regimen.

• Identify discrepancies such as duplications, omissions, or incorrect dosages.

Step 3: Clarify and Resolve Issues

• Contact the prescribing physician for clarification.

• Notify the care team of updates immediately.

• Ensure medication orders in the home health record match physician-approved lists.

Step 4: Educate the Patient and Caregiver

• Teach safe administration, side effect monitoring, and adherence strategies.

• Provide written instructions when possible.

• Reassess understanding at each visit.

Step 5: Document Thoroughly

• Record all reconciled medications in the clinical record.

• Note communications with physicians, patient teaching, and adherence monitoring.

• Update the care plan to reflect changes.

Why Medication Reconciliation Matters

• Reduces Hospital Readmissions: Medication errors are among the top causes of rehospitalization.

• Improves Patient Safety: Accurate lists prevent adverse drug interactions and overdoses.

• Enhances Survey Readiness: Thorough reconciliation and documentation demonstrate compliance with CMS standards.

• Supports Quality of Care: Patients feel safer and more supported when their medications are managed effectively.