M2001: CMS OASIS Q&As

Only registered nurses, physical therapists, speech language pathologists and occupational therapists are qualified to perform comprehensive assessments. LPNs are not qualified to perform comprehensive assessments; however, the assessing clinician (RN or therapist) may seek collaboration from other agency staff, including LPNs, in order to complete any or all OASIS items. All staff are expected to function within the scope of their practice and state licensure.

In a therapy only case, it would be acceptable for the therapist to collaborate with a pharmacist when performing the drug regimen review. Agency policy and practice will determine how the pharmacist participates in the drug regimen review process and how it is documented.

Yes. The comprehensive assessment continues to be the responsibility of one clinician, the "assessing clinician". Collaboration, however, is allowed on any and all OASIS items, including the medication/DRR tasks and items. One example of collaboration allows the assessing clinician to visit the patient at home and conduct the actual patient assessment, compiling the medication list and evaluating the patient's status (e.g., presence of potential ineffective drug therapy, side effects or patient nonadherence). In another example of collaboration, the "collaborating clinician" might contact the patient by phone, to discuss issues with the patient regarding side effects they may be experiencing, or effectiveness of the medication. In any case, it is the assessing clinician who is ultimately responsible for ensuring a complete DRR was performed and for reporting the appropriate responses for medication related OASIS items. Note that collaboration options also allow a second clinician to contribute to the drug regimen review by allowing the assessing clinician to utilize information gathered from a second clinician's in-home assessment, during the timeframe in which collaboration is allowed. Agency policy and practice will determine the agency's processes and documentation expectations. The M0090 - Date Assessment Completed, is the last date that information used to complete the comprehensive assessment and determine OASIS coding was gathered by the assessing clinician and documentation of the specific information/responses was completed. It should be noted that in situations where nursing is admitting for a therapy only patient, the nurse could not complete or even start the comprehensive assessment (including drug review tasks) prior to the SOC date.

The Drug Regimen Review (DRR) includes all medications, prescribed and over the counter, including nutritional supplements, vitamins, and herbals administered by any route (e.g., oral, topical, sublingual, and by infusion). The DRR also includes total parenteral nutrition (TPN) and oxygen. Following these guidelines, use clinical judgment to determine whether other substances would be considered when conducting the DRR.

A dash (–) is a valid response for M2001 - Drug Regimen Review. CMS expects dash use to be a rare occurrence. If elements of the drug regimen review were skipped, (for example drug-to-drug interactions were not completed), a dash should be reported, indicating the drug regimen review was not completed. A dash is also a valid response for this item and indicates no information is available. To be compliant, a dash must be available for clinician use where the dash is a valid response option for the OASIS item.

If a medication related problem is identified and resolved by the agency staff not requiring physician/allowed practitioner (or physician-designee) contact by midnight of the next calendar day, the problem does not meet the definition of an actual or potential clinically significant medication issue in M2001- Drug Regimen Review.

While the expanded one clinician convention allows a second clinician to complete the drug regimen review (DRR) in its entirety and collaborate with the assessing clinician, it is expected that an in-person assessment would be included as appropriate in the process. While portions of the DRR may be conducted over the phone and/or by a clinician in the office (i.e., evaluating the medication list to assist with reconciling discrepancies), other portions of the DRR may require in-person assessment (e.g., evaluating the patient for effectiveness of medications or for the presence of significant side effects). The assessment must be completed within the required timeframe, and all requirements for the collaboration must be met. (See Cat. 2 Q15.3.1.)

M2001 - Drug Regimen Review identifies if a drug regimen review was conducted, and whether any potential or actual clinically significant medication issues were found. A potential (or actual) clinically significant medication issue is defined as a potential or actual issue that, in the clinician’s professional judgment, warrants physician/allowed practitioner (or physician-designee) communication and completion of prescribed/recommended actions by midnight of the next calendar day (at the latest). 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. If, in your scenario, the medication alerts triggered by the EMR software do not meet the definition of a potential (or actual) clinically significant medication issue, then they would not be reported as such when coding M2001 - Drug Regimen Review, M2003 - Medication Follow-up, or M2005 - Medication Intervention.

Herbal products, when prescribed or taken as a medication, are considered medication when completing the M OASIS Medication items (M2001, M2003, M2005, M2010, M2020). For example, Echinacea taken daily by mouth to stimulate the immune system, would be considered a medication for M2020 - Management of Oral Medications.