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New Focused Survey for Nursing Facilities – Adverse Drug Events

In a new S&C letter, the Centers for Medicare & Medicaid services (CMS) announced a new focused survey type. Earlier this year, CMS began rolling out MDS-focused surveys that focus on accuracy of MDS 3.0 coding and nursing requirements. The Agency also piloted a focused dementia care survey and has asked states to participate on a voluntary basis with conducting this survey type. CMS has made mention that additional focused surveys were going to be developed, and now we are seeing the first information on the newest survey pilot.

The new focused survey for nursing facilities is the Focused Survey on Medication Safety Systems. In 2014, the Office of the Inspector General (OIG) released a report on its study to estimate the incidence rate, preventability, and cost of adverse events in nursing homes. The findings on “Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries” included that 66% of medication-related adverse events were preventable in the sample reviewed for the study. There has been a resurgence of media coverage on Coumadin and blood thinners causing issues in nursing homes and CMS notes that there have been frequent adverse events of excessive bleeding due to anticoagulant use.

The new survey will review nursing home practices around high-risk and problem-prone medications. It will focus on the identification of preventable adverse drug events, reviewing whether individual interventions would have eliminated or reduced risk factors for these occurrences, and determining whether facilities have implemented effective systems to prevent these events. The systems review will also determine whether facilities have the ability to recognize and respond to adverse drug events to both minimize harm and prevent reoccurrence.

To assist with this, CMS has released a draft tool for facilities to use for risk management and surveyors to use for identifying potential compliance issues. The Adverse Drug Event Tool includes:

  • Potentially preventable medication-related adverse events
  • Risk factors
  • Triggers
  • Probes for investigations and evaluation of systems (for surveyors)

View CMS S&C letter “Medication-Related Adverse Events in Nursing Homes” (Ref: S&C 15-47-NH).

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