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Psychotropic Medications in the Skilled Nursing Facility: How to Manage the Process

The use of psychotropic medications in the skilled nursing facility (SNF) is a controversial issue with implications for resident, regulatory, and financial outcomes. The many requirements can be confusing, especially for a relatively new director of nursing services (DNS). This article reviews psychotropic medication requirements and offers tips to manage them.

Psychotropic Medication Defined

The DNS must first understand which medications are considered psychotropic before learning how to manage their use in the facility. The Centers for Medicare & Medicaid Services (CMS) defines a psychotropic medication in the regulations at §483.45(c)(3), as “any drug that affects brain activities associated with mental processes and behavior” (CMS, 2023). The relevant drug categories are antipsychotics, antidepressants, anxiolytics, and depressants. Additional drugs, such as anticonvulsants, may also be included in this definition, especially if these medications are administered for the same reason as a psychotropic medication.

Federal Regulations

DNSs are expected to understand and implement processes that are compliant with the regulations related to psychotropic medications at F758 in Appendix PP of the State Operations Manual (SOM). These guidelines state, “The facility must ensure that 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 must receive gradual dose reductions (GDRs), and behavioral interventions, unless clinically contraindicated, to try to discontinue these drugs” (CMS, 2023).

Psychotropic medications prescribed on an as-needed (PRN) basis are limited to 14 days, must be deemed medically necessary, and require documentation in the medical record for indication of use. The use of PRN psychotropic medications cannot be prolonged beyond the 14-day limit unless the prescriber documents in the medical record a rationale for the extension and duration of the PRN order. If the medication is an antipsychotic, the prescriber must evaluate the resident in person before extending PRN use past the initial 14 days.

Federal regulations also require a GDR to be completed (1) within the first year in which a resident is admitted on a psychotropic medication, and (2) within the first year after the prescribing practitioner has initiated a psychotropic medication.

The facility must attempt a GDR on a resident in two separate quarters (with at least one month in between), unless clinically contraindicated. The AAPACN F-Tag Library has additional information on F758 and other compliance requirements.

Quality Measures and Use of Psychotropic Medications

The use of psychotropic medications can affect a facility’s Quality Measures (QMs) used in the Five-Star Quality Rating System. Two QMs capture the use of antipsychotic medications: Percent of Residents Who Received an Antipsychotic Medication (Long Stay) and the Percent of Residents Who Newly Received an Antipsychotic Medication (Short Stay). However, both QMs exclude residents who have a diagnosis of schizophrenia, Tourette’s syndrome, or Huntington’s disease coded in section I of the Minimum Data Set (MDS).

There is a prevailing misunderstanding that if a resident has not been diagnosed with one of these three conditions, CMS prohibits physicians from prescribing antipsychotic medication. To clarify, even if a resident does not have any of the three diagnoses just listed, they may still be prescribed an antipsychotic medication. But residents without these three specific diagnoses coded in section I of the MDS will be included in either the short-stay or long-stay antipsychotic use QMs. Indication for use and prescription of any medication should be determined by the resident or his or her representative and the physician.

Schizophrenia Audits

CMS has intensified its scrutiny of erroneous schizophrenia diagnoses to justify the use of psychotropic medications. In January 2023, CMS announced off-site audits will be conducted to ensure appropriate coding of a schizophrenia diagnosis and psychotropic medications on the MDS. These audits will specifically review medical records to ensure the appropriate history, assessment, and documentation support the coding of this diagnosis. Facilities with coding errors identified during this audit will have their QM ratings adjusted as follows:

  • The overall QM and long-stay QM ratings will be downgraded to one star for six months (dropping the facility’s overall star rating by one star).
  • The short-stay QM rating will be suppressed for six months.
  • The long-stay antipsychotic QM will be suppressed for 12 months. (CMS, 2023a)

Medication Management of Psychotropics

Once the DNS is familiar with the definitions and requirements for psychotropic medications, he or she needs a system to manage them. This is clearly a team event; the DNS should not attempt this task single-handedly. The attending physician and facility pharmacist both play key roles in this process in collaboration with the resident, his or her representative, and the interdisciplinary team. An effective management program promotes the following for each resident:

  • Involvement of the resident and his or her representative in the medication management process
  • Selection of medications(s) based on assessing relative benefits and risks to the individual resident
  • Evaluation of a resident to identify the underlying cause(s), including adverse consequences of medications
  • Selection and use of medications in doses and for the duration appropriate to each resident’s clinical condition, age, and underlying causes of symptoms, based on assessing relative benefit and risks, and preferences and goals of the individual resident
  • Use of nonpharmacological approaches, unless contraindicated, to minimize the need for medications, permit use of lowest possible dose, or allow medications to be discontinued
  • Monitoring of medications for efficacy and adverse consequences, along with the effectiveness of nonpharmacological interventions
  • Resident choice: If a resident declines treatment, the facility staff and physician must inform the resident about risks related to stopping the medication. Appropriate alternatives should be suggested, such as offering the medication at another time or in another dosage form, or an alternative medication or nonpharmacological approach.
  • Advance directives: A resident’s advance directives may include withdrawing or withholding medications. Whether or not a resident has an advance directive, the facility must give treatment, support, and other care consistent with the resident’s condition and according to the resident’s care plan (CMS, 2023).

How to Develop a Psychotropic Medication Management Process

Once the goals of the program are thoroughly understood, these steps will help implement a successful medication management program:

Step 1. Review facility policies and procedures related to psychotropic medications to ensure they are current, reflect requirements, and resources are available to follow these policies and procedures.

Step 2. Review medical records of residents receiving psychotropic medications to ensure:

  • All psychotropic medications have appropriate diagnosis(es) and rationale for use
  • PRN psychotropic medications are only in use for 14 days
  • Residents on PRN psychotropic medications are evaluated by a physician before extending their use
  • Other medications, such as antihistamines, anticholinergic medications, and central nervous system agents, are not substituted for a psychotropic medication
  • Other psychotropics are not increased when an antipsychotic medication is decreased
  • Monitoring is completed daily for behaviors and side effects of psychotropic medications
  • Families/responsible parties are notified of psychotropic medication use
  • Care plans are current and include both pharmacological and nonpharmacological interventions in line with resident preferences and goals, and monitoring for effectiveness of interventions
  • The MDS assessment is accurate

Step 3. Implement a process to ensure GDRs are being conducted per requirements.

Step 4. Educate staff, including physicians and physician extenders, regarding psychotropic medications:

  • Ensure nurses, physicians, and physician extenders know which diagnoses are appropriate.
  • Educate nurses and physicians on why a GDR should be done, when it should be done, and the contraindications for a GDR.
  • Train nurses and aides on what to monitor, how often to monitor, along with who to notify when and if a change is seen in the resident.
  • Educate licensed nurses regarding what, where, and when to document.
  • Confirm that all nursing staff understand signs and symptoms of excessive doses of psychotropics and who to inform when noted.
  • Instruct nurses and aides about nonpharmacological interventions and where they can be found for each resident.
  • Train nurses on what should be included in a resident’s care plan and when, and who can be involved in care planning.
  • Make sure that licensed nurses, physicians, and physician extenders know the requirements for PRN medications, specifically the 14-day rule.
  • Educate MDS nurses on appropriate coding practices for diagnoses and psychotropic medications.

Step 6. Review the process with the facility’s quality assurance and performance improvement (QAPI) Committee.

Managing psychotropic medications can be intricate and challenging. But by following the steps listed here, the DNS can implement a successful management process for psychotropic medications.

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