Welcome back to CMS Compliance Group’s “Ftag of the Week” series on the CMSCG Blog. This week, we continue to look at the regulation for F755 Pharmacy Services. In our first post, we provide an overview of the regulatory requirements and looked at the some of the procedures required for pharmaceutical services related to acquisition and receipt of medications. In this post, we will continue to look at important components of pharmaceutical services related to dispensing of medications, and some of the aspects of medication administration.
Let’s start with dispensing.
Dispensing
Dispensing medications, per the regulation for F755, refers to the process that includes:
- Interpretation of a prescription
- Selection, measurement, and packing/repacking the product (if needed)
- Labeling of the medication or device per the order
Facilities are responsible for having sound procedures in place to ensure that medications are delivered safely, to minimize the risk of medication errors, and to address what the facility expects of its outside or in-house pharmacy provider.
Specifically, the Interpretive Guidance (IG) provides a list of procedures that should be in place, which includes delivery and receipt of medications, labeling, and types of packaging for the medications.
Citation Example – S/S: E – A facility was cited for failure to ensure that handwritten expiration dates on pharmacy labels for controlled medication blister packs were identical to the corresponding handwritten expiration dates that were affixed to the controlled medication sheets for two residents. The facility’s Consultant Pharmacist was interviewed and he stated that he was not aware of any policy that would allow this practice and that it appeared to be an error.
Administration
Having an appropriate system for medication administration is a complex undertaking for facilities but ensuring that staff are following established procedures can also be potentially problematic. For example, facilities are responsible for having procedures in place to provide continuity of staff to ensure that medication administration can be completed without unnecessary interruptions. What would happen to your med passes if the responsible staff were called to the dining room to assist with supervision or provide meal assistance to residents?
There are many other aspects of medication administration to consider – let’s review a few, along with procedures that should be in place to be compliant with regulatory requirements. First, let’s start with a basic.
The 5 Rights of Medication Administration
One of the most important procedures is have a procedure in place to ensure that the correct medication is administered in the correct dose, in accordance with manufacturer’s specifications and standards of practice, to the correct resident at the correct time, via the correct dosage form and correct route. The commonly used “five rights” of medication administration cover this requirement, but this is often where issues occur.
The commonly used ‘five rights’ of medication administration cover this requirement, but this is often where issues occur.
Here are some actual nursing home citations that were cited at F755 for noncompliance related to “wrongs” versus “rights.”
Citation Example – S/S: E – On survey, a RN was observed to have multiple medications in cups with resident names on them in her med cart. The medications were scheduled for 8am, but it was after 9am when the medications were observed. The medications had all been signed off as administered, yet the RN told the surveyor she was waiting until after breakfast to give the medications to the residents.
Citation Example – S/S: G – A facility was cited for causing actual harm to a resident when the resident received the incorrect dose of a narcotic, which caused an overdose and required a narcotic reversal treatment at the hospital. The resident ultimately expired at the hospital. One RN used a medication cup rather than a syringe for a narcotic medication since the medication did not come with a syringe. The resident’ medication order was for .25 ml to .50 ml, but the RN had been administering 2.5 ml to 5 ml, which was 10 times the ordered dosage. He did not realize that he had been giving the wrong dose until he ran out of medication and needed to reorder it. He also stated that he knew why the resident was struggling to breathe so much – because he had been giving her too much medication.
Medication Administration Schedules
The timing of medication administration needs to be defined with the following considerations in mind:
- Honoring resident choices and activity preferences as much as possible
- Preventing potentially significant medication interactions (i.e. med-med or med-food)
- Maximizing the effectiveness of the medication
Procedures need to consider the above, particularly as it relates to avoiding the medication’s effectiveness being interrupted or altered when given with food, and the timing to maximize the effectiveness of the medication.
The resident’s person-centered care plan should include appropriate information regarding the resident’s preference for receiving medications, or when necessary, be altered to accommodate resident activities, appointments, etc.
We already know that med passes may run beyond the 2-hour administration window as well as that other issues might occur when an agency staff member or a “float” is assigned to an unfamiliar unit and administration schedules are not being met. Does your staff understand that the physician should be advised when medications were not administered on time? This is especially important for medications ordered to be administered multiple times a day for an identified health condition.
Monitoring
Per the Interpretive Guidance for F755, facilities must define general guidelines for monitoring for medications. This guidelines should include:
- Specific item/items to monitor
- Frequency of monitoring
- Timing
- Parameters for notifying the prescriber
The last bullet, regarding parameters for notifying the prescriber, needs to be emphasized. Facility staff needs to understand their responsibility not only for completing monitoring and associated monitoring documentation as ordered, but their responsibility for reporting to the physician when a medication is not administered/held for a low blood sugar finger stick result, a low systolic blood pressure or pulse rate not in the acceptable range to administer. These are a few examples, but give you the idea of what the nurse should be reporting to the physician for further directives.
Alternate Routes
The facility is also responsible for ensuring the techniques used and precautions taken when medications are being administered through alternate routes are in line with current standards of practice. Procedures should define, for each type of alternate route, the following, at a minimum:
- Types of medications appropriate for the route
- Appropriate dosage forms
- Monitoring and verification before administration
- Preparation techniques for different routes of administration
Here’s what can happen on survey:
Citation Example S/S: E – A facility was cited for failure to ensure that medications to be administered via PEG were properly prepared. When the LPN prepared the resident’s medications and put it into the tube, the surveyor observed crushed medications left in the tip of the syringe.
You should have a strong educational/competency system in place for routine competency checks of what your nursing staff is doing during medication administration. Passing a competency evaluation at the time of orientation is not enough.
Now that we have reviewed some of the major areas where facilities need to have strong procedures in place – and ensure staff follow them – we will continue looking at the remaining areas of medication administration in Part 3 of our Ftag of the Week for F755.
