CMS tweaks unnecessary drugs F-Tags.

CMS made even more F-Tag changes in December 2006, resulting in the need for skilled nursing facilities (SNF) and their consultant pharmacists to work on their relationships to comply with the agency's final draft of the unnecessary drugs and pharmacy services regulations.

The completed version of the regulations looks similar to the advance copy CMS released in fall 2006, with a few important modifications.

Revisions to August draft

F-Tag #329, Unnecessary Drugs, received the most significant change since the autumn draft. Under Section IV of Medication Management, two bullet points were changed under "Considerations Specific to Antipsychotics." CMS officials added requirements regarding physician documentation of the clinical rationale for why attempting a dose reduction on a resident would be contraindicated.

Beneath these bullet-point changes are two other paragraphs of revisions that detail requirements for tapering medications. For residents on a sedative/hypnotic routinely used beyond the manufacturer's recommendations for duration of use, the facility must attempt to taper the medication quarterly unless clinically contraindicated.

Dose reduction might be clinically contraindicated if it would impair a resident's function or cause or exacerbate a medical or psychiatric instability or disorder. Dose reduction might also be contraindicated if a tapering attempt was made and the resident's symptoms returned or worsened afterward.

The other change in F-Tag #329 is in the medication table under cognitive enhancers. The duration information about cholinesterase inhibitors under "Issues and Concerns" is now deleted, In F-Tag #425, two requirements under "Service Consultation" about establishing a system of records and determining whether drug records are in order and periodically reconciled were moved to F-Tag #431.

What it means for SNFs

The revisions CMS made to the unnecessary drugs and pharmacy services regulations will greatly affect the relationship SNFs have with their consultant pharmacists, says Ellen Mullins, RN, CRNAC, CEO of Integrity Health Care Solutions, LLC, in Montgomery, AL, and a former CMS surveyor.

"These changes will require more time and involvement of the consultant pharmacist, which would significantly increase the demand on his or her time as the expectations of the nursing home increase," she says.

CMS now requires more thoughtful and thorough documentation explaining why a resident should or should not be tapered off of a medication. SNFs and pharmacists may strain to meet these new challenges, especially if few pharmacists currently perform these activities as a routine part of their medication regimen review, Mullins says.