The Centers for Medicare & Medicaid Services (CMS) published its latest guidelines for long-term care (LTC) surveyors in November 2024. The guidance, currently scheduled to take effect March 24, 2025, reflects CMS’ priorities for protecting the health and safety of residents. While the guidance addresses a variety of LTC topics—from admissions and discharges to infection control and quality of life—it devotes significant attention to prescribing practices for psychotropic medications.
Are you an LTC administrator or staff member concerned about adapting to the new surveyor guidance? Contact PGS about our survey readiness program.
This new guidance does not supplant the judgment of providers following professional standards of practice, consulting with the patient, or collaborating with facility staff. Rather, it attempts to ensure that providers are following good prescribing practices and that surveyors, facilities, and practitioners will monitor for actions or situations that risk harm to patients. Key themes of the guidance include the following:
As part of our commitment to serving our patients, LTC facility partners, and providers, PGS hosted an internal training for our team of psychiatrists and nurse practitioners to ensure they are aware of the latest regulatory updates.
When treating patients with diagnosed mental health conditions, PGS providers pride themselves in delivering individualized care. That means a diagnosis alone is not sufficient to justify prescribing a psychotropic medication. Fortunately, the new LTC surveyor guidance outlines key considerations for providers that align with good prescribing practices.
First, psychotropic medication is only indicated if a patient has behavioral symptoms that present a danger to themselves or others, or if their condition is causing significant distress. Just having a diagnosis does not mean there is a problem that requires medication.
Second, the care team must rule out causes for behavioral symptoms other than a psychological condition. For example:
Finally, after determining that behavioral symptoms are significant and ruling out other underlying causes, care teams must consider non-pharmacological interventions. Appropriate interventions vary based on the patient, behaviors, facility resources, and other factors. However, the following list presents several of the most common interventions to consider:
After attempting non-pharmacological interventions and, if unsuccessful, prescribing a psychotropic, care teams must continuously monitor each patient’s status. If clinically indicated, providers should routinely attempt gradual dose reductions (GDRs) and monitor whether symptoms return.
PGS nurse practitioners and psychotherapists are well-versed in recommending non-pharmacological interventions tailored to the patient and in recommending gradual dose reductions (GDRs) for stable patients. Contact us to learn more about how we collaborate with LTC facilities to care for patients with behavioral symptoms with minimum use of psychotropic medications.
The new guidance aims to focus surveyors on situations that increase risks for LTC patients. In particular, the guidance targets situations that increase the risk of polypharmacy and use of unnecessary medications, including chemical restraints.
Healthcare providers and administrators in the LTC setting should be aware of the risks of polypharmacy. Psychotropics present heightened risks, as older adults are more sensitive to side effects of drugs acting upon the central nervous system (CNS). These include adverse effects such as falls, stroke, and mortality. Further, LTC settings present many situations that increase the risk of polypharmacy. Surveyors will focus their review on the following:
All these situations are common in LTC facilities and contribute to the risks of unnecessary medications. According to the new guidelines, surveyors will consider medications unnecessary if they are:
While providers should always verify correct doses, ensure adequate monitoring, confirm correct indications, and check for adverse consequences, this is even more critical for psychotropics. If a psychotropic medication is deemed to be unnecessary and causes symptoms consistent with sedation—e.g., sleeping, drowsiness, withdrawal, or decreased participation in activities—they can be considered chemical restraints. In cases where a medication is determined to be used as a chemical restraint, LTC facilities should expect a level 3 (patient harm) or level 4 (immediate jeopardy) citation.
By closely monitoring the above situations—particularly for psychotropics—LTC providers can improve care for their patients and mitigate the financial and reputational risks associated with citations.
LTC providers can consider the above factors, but without adequate documentation, they cannot prove required actions to have occurred. The new surveyor guidelines provide significant information about required and recommended documentation, but three key areas stand out: gradual dose reductions (GDRs), informed consent, and PRN orders.
Gradual dose reductions (GDRs) are required for all LTC residents receiving psychotropics on a quarterly basis. When attempting a GDR, the clinician must include the date the attempt was initiated; details regarding the plan, such as the titrating dose and any necessary diagnostic tests; and the outcome of the GDR. If a GDR attempt is unsuccessful or clinically contraindicated, documentation must include the progression or risk factors of the underlying condition, the patient’s overall health status and goals, and alternatives or adjustments to the treatment plan. Finally, adequate documentation should include a plan regarding future GDR attempts, such as the timeline for reassessment and alternative methods to consider.
Informed consent from the patient or their medical POA must be documented. This includes discussion of the risks and benefits of the proposed medication, alternative treatment options, and whether the patient or POA consented to the initiation of the medication. Surveyors’ focus on informed consent ensures that patients or their representatives are fully-informed about treatment options and can make autonomous decisions about their care, which is crucial to safeguarding patient rights and promoting trust between patients and clinicians.
PRN orders, i.e., medications given “as needed,” must include detail for the clinical rationale and are limited to a 14-day duration to ensure appropriate use and monitoring. While most PRN orders can be extended if the prescribing clinician documents a valid clinical justification, this is not the case for antipsychotics, which would require an entirely new order.
