Long-Term Care Survey Alert

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Get ready to revamp your approach to dementia care — even if you think you have already heeded the call to patient-centered care. Without renewed attention to psychotropic drug use among your long-stay residents, you will likely be at risk for citations under survey tag F329 (Unnecessary Drugs) and F222 (Right to be Free from Chemical Restraints), among others, in the coming year. You’ll also find yourself behind the curve in a major push to improve the quality of nursing home care.

Background: This fall, the Centers for Medicare and Medicaid Services (CMS) took its battle against the inappropriate use of antipsychotic drugs to a new level, seeking to reduce the use of antipsychotic medications in long-stay nursing home residents by 25 percent by the end of 2015 and by 30 percent by the close of 2016.

That’s up from the original — and now attained — goal of reducing the drugs’ use by 15 percent nationally compared with the baseline rate in the fourth quarter of 2011 through CMS’s Partnership to Improve Dementia Care in Nursing Homes.

The program is well known to most providers, but although almost all providers support the program’s goals, they also recognize that it can be tough to curtail the use of psychotropic drugs among residents who have behavioral and psychological symptoms associated with dementia (BPSD). In some cases, antipsychotics can play a legitimate role in residents’ care, but it’s wise to think of such cases as an exception to the rule. 

A glance at the statistics so far make the need for further cuts evident: Even having met the original goal of reducing antipsychotic use by 15 percent in 2013, nursing homes have to wrestle with the fact that 20.2 percent of long-stay nursing home residents are still receiving some form of antipsychotic (down from 23.8 percent). 

Ground troops: Armed with a survey guidance updated just last year, surveyors will be the agency’s foot soldiers in the fight to reduce psychotropic drug use. That means citations are likely to soar as surveyors, fresh from training and already well-versed in the guidance (CMS Survey and Certification Memo 13-35-NH), press in to maintain the cuts already achieved and to make additional gains in keeping with the goal of an additional 10 percent reduction by the end of 2015.

Hot spot: Providers in Ohio, Illinois, and neighboring states should take note: CMS’s Region 5 received considerably more F329 citations in 2013 compared with other regions, raking in 1014 of the year’s total of 3535 F329-related citations.

Understanding surveyors’ perspectives can help you fight the battle on your own terms while ensuring survey compliance and enhanced care. Consider these 6 areas of focus, as outlined in CMS’s guidance to surveyors:

1. Person-centered care. Surveyors won’t tolerate anything short of “a supportive environment that promotes comfort and recognizes individual needs and preferences,” as the survey guidance stipulates. With this in mind, providers may want to revisit the interpretive guidelines for another related F-tag — F248 (Activities). According to a surveyor training segment aimed at improving surveyors’ ability to catch F329 noncompliance, preventing unnecessary drug use often hinges on providers’ strengths as “care partners” who take person-centered approach to care. The guidance for F248 is “a great resource for understanding the person-appropriate concept,” CMS coaches in its training video.

2. Quality and quantity of staff. CMS requires that nursing homes provide staff, both in terms of quantity (direct care as well as supervisory staff) and quality to meet the needs of the residents as determined by resident assessments and individual plans of care. Be sure your team has the support of a consultant pharmacist and clinical leaders who buy in to the concept that antipsychotic drug use should be reduced.

3. Thorough evaluation of new or worsening behaviors. “Residents who exhibit new or worsening BPSD should have an evaluation by the interdisciplinary team, including the physician, in order to identify and address treatable medical, physical, emotional, psychiatric, psychological, functional, social, and environmental factors that may be contributing to behaviors,” coaches CMS. 

“Drugs are not the answer for the problem of dementia,” reminds Larry Minnix, president and chief executive officer of Leading Age.

4. Individualized approaches to care. Current guidelines on dementia care from the United States, United Kingdom, Canada, and other countries all recommend individualized care as the best approach for BPSD, with the possible exceptions of documented emergency situations or if other interventions are clinically contraindicated. Key to success on this front is thinking of a resident’s behavior as a way of communication. Understand the need and you may be able to mitigate the resident’s impulse to “act out.”

“[Residents taking psychotropic drugs] aren’t able to engage with their environment because they’re lethargic,” reports Maria Reyes, RN, director of Awakenings, a successful psychotropic drug reduction program developed by Ecumen, a not-for-profit provider of long-term care based in Minnesota. “They aren’t walking or talking as much. By taking them off these medications they just became more alive,” she says.

Minnix agrees, reporting that residents who have been weaned off psychotropic medications often benefit from better sleep and fewer behavior problems, not to mention “even laughter” and an enhanced quality of life.

5. Critical thinking related to antipsychotic drug use. “In certain cases, residents may benefit from the use of medications,” allows CMS. But again, consider this the exception to the rule and make sure your staff proceeds with the utmost caution at every step in the care process, from initiating an antipsychotic drug to tapering dosages with the utmost caution when a drug is no longer needed. 

Key phrase: Keep in mind this important wording from CMS’s survey guidance: “When antipsychotic medications are used without an adequate rationale, or for the purpose of limiting or controlling behavior of an unidentified cause, there is little chance that they will be effective.”

That means that for every antipsychotic prescription, there needs to be a strong and documented explanation for why the medication is warranted. In almost all cases, surveyors will want documentation of non-pharmacologic interventions predating the prescription.

Also vital: Gradual dose reductions are essential in many cases. Hasty changes in dosing can exacerbate behavioral symptoms.

Never: Antipsychotic medication must never be administered for discipline or convenience. If they are — or are used without medical necessity — the survey team is likely to turn to F222 (Right to be Free from Chemical Restraints).

6. Engagement of resident and/or representative in decision-making. “In order to ensure judicious use of psychopharmacological medications, residents (to the extent possible) and/or family or resident representatives must be involved in the discussion of potential approaches to address behavioral symptoms,” stresses CMS in its survey guidance.

Providers should take this to heart, advises William C. Wilson, Esq., attorney with Wilson Getty LLP in San Diego, California. Not doing so can expose you to not only survey citations but also legal action. Informed consent should always be documented in the medical record for any drug with a “black-box warning,” such as antipsychotics, urges Wilson.

Similarly, if a resident returns from an acute care stay along with a psychotropic medication, make sure that the hospital also sends documentation of informed consent.

Some states, including California and Illinois, already have requirements for informed consent of nursing home residents who receive antipsychotic (or other psychotropic) medications, and the federal lawmakers may continue to push for their own informed consent legislation.

Follow the leaders: The states that have had the greatest rates of reduction thus far are: Hawaii (31.4%), North Carolina (29.9%), Vermont (28.2%), and Georgia (28.1%).