January 10 2013_NH "Dear Administrator"

January 10, 2013

ADSA: NH #2013-001    

Dear Nursing Facility/Home Administrator:

The purpose of this letter is to let you know that the Centers for Medicare & Medicaid Services (CMS) has clarified three issues concerning medication errors and pharmacy services in nursing homes: (1) potential medication errors related to medication administration, (2) the practice of "borrowing" medications and diversion of medications, including fentanyl patches, and (3) medication regimen reviews for resident stays under 30 days and/or changes in condition issues survey and certification (S&C) memorandum on the use  of single dose/single use medications to prevent healthcare-associated infections.

On December 18, 2006, CMS revised its interpretive guidance for tag F329-Unnecessary medications and for Pharmacy services at tags F425, F428, and F431. Since this revision, CMS has received several requests for further clarifications on these and related tags.

Here are the action highlights from the CMS memorandum:

  • Facilities must adhere to current standards of practice for the safe administration of medications via a feeding tube (collectively refers to Nasoenteric i.e. nasogastric or nasointestinal, or Gastrostomy tubes), including types of medications that may be safely administered via a feeding tube, appropriate dosage forms and techniques to monitor and verify that the feeding tube is in the right location for the resident.
  • If more than one puff is required for metered dose inhalers (MDIs), there should be a waiting time of approximately one minute between puffs except for short acting beta agonists.
  • For optimal therapeutic benefit, most proton pump inhibitors (PPIs) should be administered on an empty stomach, ideally 30-60 minutes before meals.
  • Facility staff should have procedures for both routine and emergency use of resident medications and may contract with a pharmacy provider to establish an emergency supply of medications in collaboration with the facility medical director and the director of nurses.  Staff may not borrow or misuse other resident medications.
  • Facility staff or a contracted pharmacist must monitor each resident's medication regimen on a monthly basis at the least; in some cases, depending on the resident's condition, a pharmacist may need to conduct medication regimen review on a weekly basis. The requirement for the medication regimen review applies to all residents, including residents receiving respite care and residents with an anticipated stay of less than 30 days, or residents who have experienced a change in condition.

Please contact your local RCS Field Manager if you have any questions.


Joyce Pashley Stockwell, Director
Residential Care Services