09/15/2022

Survey Tip of the Week: Psychotropic Medications

The Long-Term Care Survey Process (LTCSP) requires surveys to identify the use of unnecessary medications. The LTCSP will select five initial pool residents for the unnecessary medication review. F-tag 759 for psychotropic medication states that facilities protocols ensure that only those medications required to treat the resident’s assessed condition are being used. Surveys are to identify if the facility is monitoring behavioral expressions or indications of distress for residents on a psychotropic medication. The record review will identify if the facility:

• Demonstrates a system for and documents gradual dose reduction (GDR) for psychotropic medications, unless contraindicated.
• Within the first year in which a resident is admitted on a psychotropic medication or after the facility has initiated a psychotropic medication:
• GDR attempts in two separate quarters with at least one month between the attempts.
• The GDR must be attempted annually thereafter unless clinically contraindicated.
• Non-pharmacological approaches must be attempted and documented instead of using psychotropic medications, along with use of psychotropic medications, and while GDR is attempted.
• Demonstrates adherence to requirements for as needed (PRN) psychotropic and antipsychotic medications.
• Residents do not receive PRN psychotropic medications unless necessary to treat a diagnosed specific condition which must be documented in the record.
• PRN orders for psychotropic medications which are not antipsychotic medications are limited to 14 days. The attending physician/prescriber may extend the order beyond 14 days if he or she believes it is appropriate. If the attending physician extends the PRN for the psychotropic medication, the medical record must contain a documented rationale and determined duration.
• PRN orders for psychotropic medications which are antipsychotic medications are limited to 14 days. A PRN order for an antipsychotic cannot be renewed unless the attending physician/prescriber evaluates the resident to determine if it is appropriate to write a new PRN order for the antipsychotic medication. The evaluation entails direct evaluation of the resident and assessment of the resident’s current conditions and progress to determine if the PRN antipsychotic medication is still needed. Attending physician/prescribing practitioner documentation of the evaluation should address:
• Whether the antipsychotic medication is still needed on a PRN basis?
• What is the benefit of the medication to the resident?
• Have the resident’s expressions or indications of distress improved as a result of the PRN antipsychotic medication?

As a recommendation, utilize the Long-Term Care Survey Process to evaluate the effectiveness of the facility protocol such as new admissions. Utilize the record review, interviews, and observation pathways as guides to complete audits and interviews of newly admitted residents. Doing this process will also assist an organization in identifying potential system improvement opportunities which could be included in the QAPI process. Additional regulatory language on unnecessary medications can be found in the updated Requirements of Participation.

The updated Requirements of Participation (RoP) states: 

Use of psychotropic medications, other than antipsychotics, should not increase when efforts to decrease antipsychotic medications are being implemented. Risks associated with psychotropic medications still exist regardless of the indication for their use (e.g., nausea, insomnia, itching), therefore the requirements pertaining to psychotropic medications in §483.45(e) apply to the four categories of drugs (anti-psychotic, anti-depressant, anti-anxiety and hypnotic) listed in §483.45(c)(3) without exception. Use of multiple psychotropic medications can increase the risk of adverse consequences and/or confound the effects of individual medications although there may be infrequent times when use of multiple psychotropic medications is indicated, such as to treat multiple symptoms of a condition or to address side effects.

LeadingAge will be developing webinars and resources on the updated guidance which will be located on the LeadingAge learning hub. A QuickCast on the regulatory groups continue to be added.  Updated checklist have also been added on the Nursing Home RoP Tools and Resources webpage. For more information about the updated requirements of participation and citations occurring in Ohio, please join us on the monthly STAT: Survey Tips and Tactics call. Register now for the October 12 call at 10:00AM.

As Ohio annual surveys continue, 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.