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Long-Term Care Survey Alert

Clinical Management:

Here's One Drug List You'd Better Check Twice

Published on Sat Jan 17, 2004

Use updated Beers criteria to stave off F329 and F429 tags.

Don't be surprised if surveyors wave a new list of dangerous drugs in your face on the next survey.
 
An international panel of experts recently updated the 1997 Beers list of risky medications for older adults, which forms the basis for current survey interpretive guidance for F329 (unnecessary drugs) and F429 (drug regimen review). The updated list is published in the Dec. 8, 2003 Archives of Internal Medicine, and contains new medications such as estrogens in older women, non-COX selective NSAIDs and anticholinergics in patients with stress incontinence. 
 
Facilities can view the Beers criteria from a regulatory and best practices angle, suggests pharmacist Tom Clark, spokesman for the American Society of Consultant Pharmacists. "From a survey perspective, the new criteria are not in the current guidelines," he notes. "And the Centers for Medicare & Medicaid Services would have to go through a process to change what's in place now," adds Sam Kidder, PharmD, a long-term care ombudsman in Silver Spring, MD.
 
But don't breathe a sigh of relief yet: Surveyors can still cite a facility at F329 for inappropriate drug use for medications that aren't listed officially in the survey interpretive guidance, Clark cautions.

Update Drug Regimen Reviews
 
Your facility should thus evaluate the new Beers criteria and make a decision in the pharmacy committee about how to use them, advises Barbara Nodiff, a nursing consultant and principal of Associated Geriatric Information Network in New Rochelle, NY.  "It's also a good idea for the consulting pharmacist to do an inservice on the new criteria," Nodiff adds. "And physicians should do a risk-benefit analysis and document the rationale if they are going to use the drugs."
 
Surveyors should not cite a drug as unnecessary (F329), according to the State Operations Manual, if the facility:

 

  •  determines that the benefits of using a drug outweigh the risks of an adverse drug reaction (ADR) in a particular instance, and
     
  • continues to assess and determine that the drug is a "valid therapeutic intervention."
     
    Review the survey investigative protocol for adverse drug reactions at     http://cms.hhs.gov/manuals/pub07pdf/AP-P-PP.pdf. Surveyors will use the protocol if they detect residents taking drugs identified by the SOM as posing a high potential for severe adverse drug reactions.

    Monitor for ADRs
     
    If the resident does receive a medication on the Beers list, monitor him carefully for adverse drug reactions. "But keep in mind that the Beers criteria focus on a small slice of medication-related problems in the elderly," Clark cautions. "Many drugs aren't on the Beers list even though they are just as dangerous" as some that are on the list, agrees Steve Levenson, MD, a medical director for several facilities in Maryland. "Facilities should evaluate all residents' symptoms in the light of their medications, especially for the big three," he says. These are:

     
  •  Mental status changes;
     
  •  Falls; and
     
  •  Weight loss and appetite loss.

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