Long-Term Care Survey Alert

Antipsychotics are back in the news.

Surveyors may soon be scrutinizing with renewed vigor your compliance with survey tag F329 (Unnecessary Drugs), thanks in part to a recent high-profile investigative report by the independent news organization ProPublica. The report, released May 11, calls on the Centers for Medicare and Medicaid Services to crack down on physicians who overprescribe antipsychotics to seniors, including those in nursing homes.

Nursing homes’ nightmare: Miami physician Enrique Casuso has prescribed the antidepressant Seroquel and other antipsychotics to long-term care residents at “an alarming rate,” says the ProPublica report, quoting Casuso as saying “You have to submerge them in medication to avoid a catastrophic event.”

That quote alone is enough to make any good provider cringe — and the report focuses on CMS’ oversight of physicians, not nursing homes. Still, the negative publicity doesn’t help the industry at a time when most nursing homes are trying in earnest to reduce off-label use of conventional and atypical antipsychotic medications to quell problematic dementia-related behaviors.

Double whammy: To make matters worse, the report comes on the heels of industry leaders’ announcement early in May that nursing homes failed in 2012 to meet a self-set and ambitious goal of slashing off-label antipsychotic drug use by 15%.

Background: The American Health Care Association (AHCA) launched a Quality Initiative to reduce off-label use of antipsychotic drugs in February 2012, partnering with CMS.

In May, AHCA revealed that in 2012 its long-term care and post-acute members achieved on average just a 6.7 percent reduction in off label use of antipsychotic drugs. Nationally, the overall change in antipsychotic use dropped 5.9 percent, from 23.6 percent at the end of 2011, to 22.2 percent at the end of 2012.

It’s not all bad: “When we rolled out these Quality Initiative goals last year, we knew they were ambitious,” said AHCA Board Chair Neil Pruitt, Jr. “While we may not have reached our 2012 year-end goal for antipsychotics, that doesn’t negate the nearly 3,000 member facilities that have achieved our goal, nor more importantly, the 11,349 individuals living with dementia who will enjoy a better quality of life without these medications.”

Following the announcement of 2012 results, AHCA renewed its goal of a 15 percent reduction for skilled nursing centers, in keeping with the goal set forth in CMS’s Partnership to Improve Dementia Care in Nursing Homes.

Do Your Part

With that news in mind, it’s especially important for all facilities to renew their commitment to targeting unnecessary or inappropriate use of antipsychotic drugs in nursing homes, says Jonathan Evans, M.D., C.M.D., president of the American Medical Directors Association, an organization that is also active in the Partnership to Improve Dementia Care in Nursing Homes.

Consultants and advisers working in the field to help nursing homes improve care echo that call. Think of it as a paradigm shift — not unlike the drastic reductions in physical restraint usage in the late 1980s and early 1990s, says Janet K. Feldkamp, partner with the law firm Bensch in Columbus, Ohio.

All providers must continue to assess, track — and improve — their usage rates of off-label antipsychotic medications, urges CMS in recent training session for surveyors.

Win-win: Doing so will benefit residents — and your standing with surveyors. To keep your efforts on track, be sure to keep the following in mind:

Remember, a diagnosis of dementia-related behavior is not enough to justify a pharmacologic intervention with antipsychotic medication. CMS asks surveyors to review resident care plans and orders to guide their observations. With that in mind, take steps to ensure that each care plan tells the full story.

If a resident with dementia exhibits a problem behavior, always conduct a full evaluation of all possible causes. Consider medical causes as well as environmental or individual causes of distress, interviewing family members, involved caregivers, and, if possible, the resident himself. Each investigation should also involve the full care team, including physician and pharmacy partners.

Key questions to ask — and document — include these:

·         When did the behavior begin?

·         Could the behavior be related to a recent change in medication?

·         How does the resident typically communicate his needs?

·         What happens before, during, and after the problem behavior?

·         What is the level of risk to the resident and others?

Tip: Be sure that your staff is monitoring and documenting the implementation of the care plan and effectiveness of the interventions relative to target behaviors and changes in symptoms or emergence of adverse outcomes.

Surveyor secret: Providers can glean valuable information for F329 compliance by reviewing the interpretive guidelines for another F-tag — F248 (Activities), according to a surveyor training segment aimed at improving surveyors’ ability to catch F329 noncompliance. That’s because preventing unnecessary drug use often hinges on providers’ strengths as “care partners” who take a 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.