MDS Section N Drug Regimen Review: What You Need to Know!

by Flora Bessey, PharmD, BCGP

The “Improving Medicare Post-Acute Care Transformation (IMPACT) Act” of 2014 is a law that, among many other things, hoped to address issues of rehospitalization. As of October 1st of this year, the MDS has a section addressing drug regimen review, “Section N,” that will be enforced. Are our facilities prepared? In a word, no.

Some background:  Per the Pharmacy Practice Act, the act of dispensing is the pharmacist’s validation that, based on all available information, the meds being dispensed are safe for the patient to take.  The pharmacist provides no written documentation of the review that takes place in order to safely dispense medications. The act of dispensing is the proof. In a perfect world, a dispensing pharmacist should be the one to do a comprehensive drug regimen review prior to dispensing any medication. In our world, it is rare that these pharmacists have all of the requisite information required. This situation is better when the patient/resident has an EMR, but often it is still incomplete.

In 2006, CMS instituted a “short-stay review” process to cover our Medicare/Part A residents. This policy was further emphasized in 2016 with the Mega Rule. Who accomplishes these reviews? Some pharmacies have designated that the consultant pharmacists should conduct them. Some pharmacies have set up a central “hub” where a few pharmacists do these reviews as well as change-of-condition, therapeutic interchanges, etc… 

An important fact to remember is that these short-stay reviews are NOT done automatically (this is a failure on the part of CMS). The facility has to specifically request these reviews. A further shortcoming of this process is that CMS did not specify a time frame for completion of these reviews.

This brings us to MDS Section N, “Drug Regimen Review.” This Section N states that these reviews must be done upon admission OR readmission, and any follow-up/reconciliation with the prescriber must be complete by midnight of the following day. So, if an admission arrives at 5pm on the 26th, this review AND follow-up must be complete by the stroke of midnight on the 28th (31 hours in this case).

How can this be done? Who can do it? This task has historically been done by pharmacists, but not under such a time-crunch. Your consultant pharmacists typically cover 1000 beds per month; the logistical challenges are obvious. Because of this, and the limitations that dispensing pharmacists have, CMS stated that these reviews do not have to be completed by pharmacists. Many professional organizations (ASCP, AMDA, etc.) are understandably leery of this, as these reviews are by definition the purview of pharmacists.

So, what has been the solution? Many pharmacies are providing a “Section N Review Form” to expedite this situation. These are 1 page, and very vague. Often, they have “check mark boxes” that can be used to say “no allergies noted,” or “drug-to-drug interactions reviewed.” It addresses the letter of the law, but not the spirit of the law. To further complicate matters, some pharmacies are charging up to $10 per review for this “service.”

How do we address this need going forward? On the most basic level, we need to know how the reviews within our facilities are being conducted. If they are not being done by your consultant pharmacist, is the designee of the facility competent to safely complete this task? It is vitally important for patient/resident safety, as well as the Medicare license of the building, to know the answer to this question.  There will monetary fines and/or withholding of reimbursement if this is not completed thoroughly.

Finally, if there were not already enough reasons to transition FULLY to an EMR system, this is it. If your buildings are still using paper charts or a “hybrid” paper/EMR system, please encourage them to do so. Having all of the relevant information in one place will at least ease the burden of the individuals who are tasked with these reviews.

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If there are any questions around this, please feel free to reach out to me:

Flora Bessey, PharmD, BCGP
[email protected]