Long-Term Care Survey Alert

Published on Mon Jan 09, 2006 PDF

CMS surveyor training lays down the gauntlet for facilities under Part D.

If you see Part D primarily as a fiscal issue, your facility needs a survey reality check-up -- fast.

Facilities that don't ensure residents receive medically necessary meds under Part D open the door to a number of F tags, including the OBRA catchall of failure to provide necessary services.

Learn From Others' Mistakes

That's the key message of a recent Centers for Medicare & Medicaid Services' surveyor training Webcast, "Medicare Part D Impact on Nursing Home Surveys," where actors play out a scenario showing how a facility mishandles a resident's formulary change.

In scene one, a surveyor stands outside a resident's door during med pass listening as the resident asks the nurse why one of her usual pills, an antipsychotic, looks different. The nurse tells the resident the doctor changed the medication "so you won't have to pay so much for your drugs."

The surveyor sweeps in after the nurse leaves and asks the resident a few questions that gets a potential survey snowball rolling the facility's way. For one, the resident tells the surveyor that she actually first noticed the pill change about a week ago -- around the same time that she began feeling dizzy.

You guessed it: The facility hadn't assessed the dizziness as a potential adverse drug reaction to the new antipsychotic medication on the resident's Part D prescription drug plan formulary. The resident had reported the dizziness to the care team. But instead of investigating the potential cause of the resident's new symptom as an adverse drug reaction, the physician ordered meclazine (Antivert) PRN to treat the dizziness.

Lesson learned: Nursing facilities should consider any new symptoms to be a potential medication side effect until proven otherwise, emphasized CMS Webcast presenter Nicole Brandt, PharmD. Clinicians should have a "heightened awareness" that medication changes may lead to unnecessary treatment of side effects, which is known as the "prescribing cascade," she emphasized. 

It Gets Worse

Scene two: The surveyor consults with the attending physician about the formulary switch. He thus decides to put the resident back on her original antipsychotic to see if that resolves the dizziness. Three days later, the resident tells the surveyor she feels better and is off to play cards.

If that sounds like "all's well that ends well," forget it. The surveyor checks the medication administration record and finds the nurse hasn't given the resident the newly ordered antipsychotic for three days.

The DON's explanation for the medication lapse? The facility is awaiting the resident's Part D plan to process the facility's exception request. And that's the wrong answer -- and one that shows some confusion on the facility's part about its responsibilities for meeting residents' needs under Part D, said the Webcast panelists.

Even so, "surveyors should never accept facilities' lack of knowledge as a reason for their failure to comply with any regulatory requirement," emphasized Denise Stanley, PharmD, with CMS' Region IV office in Atlanta.

Editor's note: For a systematic plan to ensure residents get medically necessary meds under Part D, see the story included with this issue.