CMS New Guidance: Psychotropics & Gradual Dose Reduction, F605
Nursing homes will soon be subject to new, more stringent surveyor guidance about psychotropic medications for residents, effective February 24, 2025. Among CMS’ stated goals is to prevent unnecessary use of psychotropic medications, which now will be addressed under F605.
Free from unnecessary drugs
“Each resident's drug regimen must be free from unnecessary drugs,” states the updated F605 guidance. An “unnecessary drug” is defined as one that is used in excessive dose or duration, without adequate monitoring, without adequate indications for use, and/or in the presence of adverse consequences.
Revised language in a CMS memo and advanced copy of the State Operations Manual Guidance to Surveyors about the changes dated November 18, 2024 stipulates that under F605:
- “Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record”
- “Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs”
- “Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record.” Per the new guidance, PRN orders for psychotropic drugs are limited to 14 days.
Adequate indications for use
To meet the standard for “adequate indication for use,” a practitioner must identify and document a clinical rationale, explains CMS in the advanced copy manual. This must be “based upon an assessment of the resident’s condition and therapeutic goals, and after any other treatments have been deemed clinically contraindicated.”
If a practitioner does not document that they have “determined that other treatments have been deemed clinically contraindicated,” CMS states that the indication for use would be inadequate.
Also, states CMS, to be considered an adequate indication for use, the medication administered must be consistent with one or more of the following:
- Manufacturer’s recommendations
- Clinical practice guidelines
- Clinical professional standards of practice
- Medication references
- Clinical studies or evidence-based review articles that are published in medical and/or pharmacy journals.
Gradual dose reduction (GDR)
Also specified in the new guidance is that “residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.”
By the CMS definition, GDR is “stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued.” (To learn more about GDR, visit the blog, Antipsychotic Reduction: Key Ideas).
A neurology-first approach
Now more than ever, achieving CMS compliance requires a methodical approach to care with neurology in the lead. Neurology provides a meaningful framework for assessment of many nursing home residents, as dementias are rooted in neurology. In addition, some behaviors observed in residents stem from treatable neurological conditions.
Dr. Steven Posar, Founder and CEO of GuideStar Eldercare, recently told Provider magazine that a neurology-first approach can “safely reduce polypharmacy and reliance upon antipsychotic medications while increasing facility ratings, quality of life, and compliance.” As published in JAMDA, the GuideStar care model was successful in achieving a 68% reduction in use of antipsychotics among nursing home residents.
The GuideStar Eldercare team ensures accurate diagnoses through advanced assessment and norm-validated testing. Their protocol also requires comprehensive pharmacy review, identifying unnecessary and/or dangerous medications. Geriatric psychologists provide support for behavioral interventions. An interdisciplinary team ensures input from specialists in neurology, psychiatry, psychology, and geriatric medicine, providing a holistic approach to person-centered care.
As your facility team prepares for CMS surveys, feel free to call on GuideStar Eldercare. We’re here to help.