New CMS Guidance: Prevent Unnecessary Psychotropic Medications
CMS announced major changes in long-term care surveyor guidance that will take effect on February 24, 2025. Under the new provisions, use of psychotropic medications will be subject to deeper scrutiny and stronger controls.
A key objective of the revisions is to “strengthen our message that facilities must prevent the unnecessary use of psychotropic medications,” states CMS in its November 18, 2024 memo about the revisions and an advanced guidance document. “Health and safety updates are regularly made to address emerging trends in deficiency citations nationwide. This ensures that our guidance remains aligned with current standards of practice and reflects the evolving needs of residents. These updates are essential to maintaining the integrity of nursing home care,” the memo states.
Unnecessary use of psychotropics
Among the provisions is recategorization of “unnecessary use of psychotropics,” F758, into tag F605, which specifies a resident’s right to be free from chemical restraints. This change is intended to streamline the survey process and increase consistency, says CMS.
“Chemical restraint” is defined as any drug that is used for discipline or staff convenience and not required to treat medical symptoms, according to CMS. In another change, only non-psychotropic medications will be included in F-tag 757, which addresses “unnecessary medications”.
The current F605 guidance says that “When a medication is indicated to treat a medical symptom, the facility must: use the least restrictive alternative for the least amount of time; provide ongoing re-evaluation of the need for the medication; and not use the medication for discipline or convenience.”
Clarifying chemical restraint
“The indication for use for any medication ordered for a resident must be identified and documented in the resident’s record,” says CMS. With the February update, CMS is refining details about using medications that may cause sedation or impair cognition.
In the current State Operations Manual (08-08-24), CMS addresses chemical restraint: “When any medication restricts the resident’s movement or cognition, or sedates or subdues the resident, and is not an accepted standard of practice for a resident’s medical or psychiatric condition, the medication may be a chemical restraint.”
“Even if use of the medication follows accepted standards of practice, it may be a chemical restraint if there was a less restrictive alternative treatment that could have been given that would meet the resident’s needs and preferences or if the medical symptom justifying its use has subsided,” states the current guidance.
Sedation and “convenience”
“Convenience” is defined as “the result of any action that has the effect of altering a resident’s behavior such that the resident requires a lesser amount of effort or care, and is not in the resident’s best interest,” notes CMS.
Standards around the idea of “convenience” has been updated in the new guidance. The November memo states that “convenience” will include “situations when medications are used to cause symptoms consistent with sedation and/or require less effort by facility staff to meet the resident’s needs.”
“Convenience” is an important topic, as a November 2022 report from the U.S. Office of Inspector General conclude that “higher use of psychotropic drugs was associated with two characteristics: lower RN staffing numbers and higher percentages of residents with low-income subsidies (see details in the blog, CMS to Collect Anticonvulsant Data on MDS Form).
The same report identified an uptick in use of anticonvulsant prescriptions among nursing home residents in response to CMS efforts to reduce antipsychotic usage. Antipsychotics, anticonvulsant medications, anxiolytics, depressants, and other drugs fit the broader category of psychotropic drugs, which CMS defines as “any drug that affects brain activities associated with mental processes and behavior”.
Psychotropic medications – residents’ rights
The revised guidance will also address residents’ rights related to psychotropic medications. Explains CMS in its memo, “Additional guidance has been added to emphasize requirements related to the right to be fully informed of and participate in or refuse treatment.” Before initiating or increasing a psychotropic medication, says CMS, “the resident must be notified of and have the right to participate in their treatment, including the right to accept or decline the medication.”
CMS states that the intent of these requirements is “to ensure residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated.” The November memo further notes that “ residents must only remain on psychotropic medications when a gradual dose reduction and behavioral interventions have been attempted and/or deemed clinically contraindicated.”
Accuracy of assessments
In the November memo, CMS asserts its intent to “assure that each resident receives an accurate assessment, reflective of the resident’s status at the time of the assessment, by staff qualified to assess relevant care areas and are knowledgeable about the resident’s status, needs, strengths, and areas of decline.”
The tag F658, Services Provided Meet Professional Standards, is also addressed in the new CMS memo. Surveyor guidance will include instructions for confirming supporting documentation for use of a psychotropic medication. It will also include guidance for citing noncompliance and will provide examples for surveyors, according to CMS. Documentation supporting the use of an antipsychotic medication is addressed in updated guidance for Accuracy of Assessment F641. Provisions of F642 will be folded into F641, said CMS.
Surveyors could question LTC medical directors
States the CMS memo, surveyors will be instructed “to evaluate psychotropic medication use based on a comprehensive assessment” and “to evaluate the medical director’s oversight of medical care.”
Also included will be Professional Standards guidance addressing the use of antipsychotic medications for a resident without “sufficient supporting documentation” to confirm the diagnosis for which the antipsychotic was prescribed.
The CMS memo states that “it may be necessary to interview the medical director regarding medications that are not required to treat the resident’s medical symptoms” when they “result in the resident being subdued, sedated, or withdrawn or limited in his/her functional capacity.”
Added to the guidance at F841 will be language regarding the Medical Director’s responsibilities related to the implementation of resident care policies. “Interviewing the facility Medical Director was also incorporated into the Unnecessary Medications and Quality Assurance & Performance Improvement (QAPI) pathways,” states the CMS memo.
CMS will also be including “investigative elements to align with the revised guidance,” notes the memo. CMS said it will publish updates in Appendix PP of the State Operations Manual in February 2025, and surveyors will begin using the new guidance on February 24.
Nursing home CMS survey readiness
Is your team prepared for the coming changes? The updated CMS guidance is poised to shine a bright light on clinical care practices in nursing homes. The GuideStar Eldercare team helps facilities ensure accurate assessments, reduce reliance on antipsychotics, and achieve better outcomes for residents. To learn more about how we can support CMS compliance, please get in touch.