Ftag of the Week – F755 Pharmacy Svcs/Procedures/Pharmacist/Records (Pt 3)

Welcome back to the CMSCG Blog and Part 3 of our “Ftag of the Week” series for F755 Pharmacy Services. As you have seen from the prior two posts, this is an expansive regulation that requires tight systems for compliance, as well as a competent, well-trained staff. To begin, let’s look at some additional components of medication administration.

Clarification of Orders

The Interpretive Guidance (IG) states that facilities need to have procedures in place to ensure that staff, prior to administration, clarify any pharmacy order that presents a concern, including if the order is illegible or incomplete.


The regulatory requirements for documenting medication administration are straightforward, but are quite frequently identified on survey – and potentially at a high scope/severity. A facility must have procedures outlining documentation requirements for:

  • Routine medication administration – If a routine medication is not administered, why not.
  • PRN medication administration, including justification for administration and the resident’s response.
  • Route – If the route is one other than oral, the route used.
  • Administration location site when required for items such as injections or patches.
Reporting Medication Administration Errors

There should be a system in place for documenting and reporting medication errors. Staff need to be aware of how to report a med error, as well as who they are responsible for reporting it too.

Let’s look at how failure to document appropriately and report medication errors has resulted in negative outcomes for some facilities:

Actual Harm Citation Example (S/S: G): A resident was harmed when she fell twice during one shift and was injured after receiving a 400% increase in a physician-ordered medication 29 times before the facility discovered the medication error. The facility failed to document the error in the resident’s clinical record, which contributed to staff failure to consider whether the multiple overdoses had contributed to the resident’s fall. The facility also failed to address information that the pharmacy had sent to it regarding a dosage discrepancy of 300 mg 3x/daily versus the facility’s directions to give 1200 mg 3x/daily.

Immediate Jeopardy Citation Example (S/S: L): A facility was placed in Immediate Jeopardy after 10 of 11 residents sampled did not receive their scheduled medications as ordered. Licensed nursing staff did not document the administration or reason for not administering the medication per facility policy. The facility had been using paper MARs due to an issue with the e-MAR, but a review of the paper MARS for multiple residents lacked administration documentation.


The IG also notes that there should be a procedure in place to reconcile all medication orders. This includes procedures for addressing:

  • Phone orders
  • Monthly/periodic orders
  • Medication Administration Record (MAR) – this should include which staff members are permitted to transcribe prescriber’s orders and enter them onto the MAR.

Citation Example (S/S: D): During a med observation, a surveyor observed that the narcotic blister pack did not match current physician’s orders, and none of the blister packs in the narcotic box in the medication room were a match either. Facility staff had entered orders into the EMR and faxed hand-written prescriptions to the pharmacy, but the pharmacy stated that it had not yet received the orders.

Other Important Requirements

Two additional areas that need to be considered in a facility’s policies include authorized personnel and disposition of medications.

Authorized Personnel

The medication regimen for a typical nursing home resident can be quite complex, depending on the resident’s comorbidities and needs.

Many residents receive multiple types and numbers of medications, which adds to the complexities of proper medication administration. That is part of the reason why the regulation for F755 stresses that facilities need to ensure that only appropriately trained and qualified personnel administer medications, consistent with applicable State laws/regulations.

Per the Interpretive Guidance, a facility may permit unlicensed personnel to administer medications if it is permissible by State law, but the unlicensed personnel need to be under the general supervision of a licensed nurse. As such, the facility needs to assure that all staff administering medications are authorized to do so in accordance with State and Federal requirements. Responsible staff must be oriented to the facility’s medication-related procedures and have access to current information regarding residents’ medications.

Disposition of Medications

Another important area to have comprehensive procedures in place for is medication disposal. Due to the general volume of medications administered in the typical nursing home, disposition considerations are wide-ranging and problem-prone. Some medications require one method of disposition, as is the case with controlled substances, and others may require a different method. Procedures should be in place to address:

  • The identification and removal of medications from the current medical supply for disposition. This includes medications that will be returned to the pharmacy.
  • Where the medications that are waiting for final disposition will be stored.
  • How to ensure medications waiting for final disposition are controlled.
  • Documentation requirements for disposition of the medications. The IG notes that this documentation should include:
    • Resident name
    • Prescription number, if applicable
    • Medication name, strength and quantity
    • Date of disposition
    • Names of facility staff and consultants involved in disposition.
  • Method of disposition to prevent possible diversion and/or accidental exposure, consistent with standards of practice, local ordinances and State and Federal requirements

On survey, the surveyors will be reviewing your medication rooms, carts and storage areas. What will they find when they are in there?

On survey, the surveyors will be reviewing your medication rooms, carts and storage areas. What will they find when they are in there? Facilities are frequently cited for failure to remove expired medications from active medication storage. Even more problematic and easily identifiable by a surveyor is failing to have an accurate reconciliation and accounting of all controlled medications.

In Part 4 of our Ftag of the Week for F755, we will look into the requirements for controlled substances as well as the remaining requirements for this regulation.  

Did you miss Part 1 and/or Part 2 of this Ftag of the Week series? You can visit those CMSCG Blog posts here:

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