02/10/2022

Survey Tip of the Week: Medication Misappropriation

Abuse was the topic reviewed during the February Survey Tips and Tactics (STAT) call. Medication misappropriation is a common cited area under F-tag 602. The Requirements of Participation §483.12 note that each resident has the right to be free from misappropriation of property. The resident’s medication is part of the resident’s property and diversion of the resident’s medication(s), including, but not limited to, controlled substances for staff use or personal gain does fall under the abuse tag F-602. 

CMS provides the following surveyor guidance for allegations of drug diversion, such as:

• If there is evidence and/or potential outcomes such as unrelieved pain. For example, there may be evidence that on a particular shift, or when a particular staff member is working, a resident’s pain symptoms are not relieved to the extent possible, but the pain symptoms are relieved on other shifts, based upon validated evidence (see also tag F697 for concerns related to pain management);
• Whether pharmacy policies at a minimum address safeguarding and access, monitoring, administration, documentation, reconciliation and destruction of controlled substances (see also tag F755 for concerns related to facility procedures for pharmacy services);
• Whether the pharmacist has established a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and that the drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled (see also tag F755 for concerns related to responsibilities of the licensed pharmacist); and
• Determining whether the resident’s clinical record provides accurate documentation of the administration of a controlled medication and resident outcomes related to the medication administration (see also tag F755 for concerns related to procedures for administration and documentation of controlled substances).

LeadingAge Ohio encourages members to work with their contracted pharmacy company to review the organization's processes. The facility, in coordination with the licensed pharmacist, must provide for a system of medication records that enables periodic accurate reconciliation and accounting for all controlled medications; prompt identification of loss or potential diversion of controlled medications; and determination of the extent of loss or potential diversion of controlled medications. Additional guidance can be found under F-tag 755 Pharmacy Services in the State Operations Manual Appendix PP. Providers can evaluate how often the facility monitors the shift change narcotic count, ensuring both nurses are following the standard of practice. Providers can also discuss how often the facility audits records for consistency between the narcotic sheets and the Medication Administration Record (MAR).

LeadingAge Ohio encourages facilities to utilize the LTC survey pathways to monitor for compliance. The survey pathways can be found on the CMS Nursing Home webpage, under the download section, and within the zip file called LTC Survey Pathways.

For more information about the citations occurring in Ohio, please join LeadingAge Ohio on the monthly STAT: Survey Tips and Tactics call. Register now for the March 9 call at 10:00am.

With the annual surveys restarting in January, LeadingAge Ohio is sharing tips to assist members during the survey process. Send questions you’d like addressed in future Tips of the Week to Stephanie DeWees at sdewees@leadingageohio.org.