Welcome back to the Ftag of the Week on the CMSCG Blog, your go-to spotlight for decoding the regulatory landscape of skilled nursing and long-term care. Each week (or sometimes more) we break down a specific Ftag from the CMS State Operations Manual, offering practical insights, survey trends, and actionable guidance to help providers stay ahead of compliance challenges. The CMSCG Ftag of Week series is designed to sharpen your understanding, support quality improvement, and reinforce your commitment to resident-centered care.
Now that we’ve reached Part 4 of this series, this is more like an Ftag of the Month, but this is an important regulation to understand. In Part 3 of our Ftag of the Week for F605, we discussed the importance of GDRs. We’ll continue that discussion now to cover a couple of other areas – when a GDR is clinically contraindicated and required documentation for GDRs.
SOM Appendix PP provides two key reasons that a gradual dose reduction may be clinically contraindicated for a resident but notes that these are not the only reasons. First, continued use of psychotropic medication is in accordance with relevant, current standards of practice and the physician has documented the clinical rationale for why an attempted GDR would likely result in an exacerbation of an underlying medical or psychiatric disorder or impair the resident’s function. This is a typical scenario that we see, including for residents receiving psychotropic medications for many years without even a slight reduction attempt.
It’s important to ensure that the continued use of these medications, which perhaps were initially prescribed for active schizophrenia, remain appropriate for a resident who has changed over the years, become more cognitively impaired and is not exhibiting signs/ symptoms of schizophrenia. The lack of documentation in these circumstances is potentially problematic.
The second reason in the Interpretive Guidance (IG) is that after the most recent GDR attempt within the facility, the resident’s target symptoms returned or worsened and the physician has documented the clinical rationale for why any further GDR attempt at that time would be problematic for the resident, including exacerbating an underlying medical disorder, psychiatric disorder or creating an increase in distressed behavior, or would impair the resident’s functioning.
Documentation for GDR
The resident record should include:
- Date of the GDR attempt
- Outcome of the GDR attempt
- Plan regarding future GDR attempts
- Physician documentation which contains the clinical rationale for why GDR attempts are clinically contraindicated for that resident
Citation Example: F605 S/S: D
A facility was cited for failure to follow-up on a GDR recommendation by Psychiatry to decrease a resident’s Seroquel from twice a day to once a day. The resident continued to receive the same dose for several more weeks until it was identified by the surveyor during the recertification survey.
Don’t forget that what’s coded in Section N of the MDS should match what’s being entered in other areas of the resident’s medical record documentation. If there’s a date of a GDR or a date that a GDR was contraindicated, then there should be corresponding documentation and evidence of an assessment. While it’s not specifically indicated in this part of the IG, note that there should be a lot of documentation regarding the GDR – behavior monitoring, assessments, etc. which provide evidence of whether a GDR is successful or failing and a different approach needs to be taken.
That takes us to the last area we’ll cover for F605 – monitoring.
Monitoring
The IG states, as noted above, that monitoring and accurate documentation of a resident’s response to treatment is essential to evaluate its effectiveness. This includes, but is not limited to:
- Behavior notes
- MARs
- Drug Regimen review
- Progress Notes
- Vital signs
- Lab results
Documentation should show that there is ongoing evaluation of the effectiveness of the psychotropic medication. Documentation should include nonpharmacological approaches to care which are attempted. There should be sufficient evidence in the medical record to show that residents are being adequately monitored and re-evaluated for any adverse consequences which may require re-evaluation of the medication, such as tapering.
Citation Example: F605 S/S: D
It was identified during survey that a resident with an order for Seroquel lacked evidence that the facility had implemented side effect monitoring related to the use of an antipsychotic. The facility also failed to monitor the resident’s targeted behaviors for which the Seroquel was being used.
For a second resident with diagnoses of dementia and adjustment disorder and an order for Risperdal for schizophrenia, the surveyor dug into the record and identified that the Risperdal had initially been ordered for “anxiety/agitation/combative.” Per a recommendation from the consultant pharmacist, “Please provide an appropriate indication for the risperidone order. This medication is typically used to treat Schizophrenia or Bipolar Disorder.” Facility staff then adjusted the resident’s diagnosis. No documentation, including hospital records and documentation since admission, indicated a diagnosis of schizophrenia. The facility also failed to monitor any of the resident’s identified behaviors or conduct any routine behavior monitoring.
Know what else needs to be in the documentation? The clinical rationale for the use of a psychotropic medication which is prescribed by an outside provider or initiated in another care setting. The rationale needs to be indicated and documented in the medical record by the prescribing practitioner. The IG states, “without a rationale, the use of the medication(s) may be unnecessary, and therefore, noncompliant.”
We won’t review the long set of guidance regarding the potential adverse consequences that antipsychotic meds, in particular, may have on the resident population in the majority of nursing homes. Review the black box warnings and ensure you’re making attempts to minimize potential consequences of these meds if you’re going to use them.
Is your facility confident in its psychotropic medication practices—and how they align with F605?
CMS Compliance Group’s latest insights on F605 highlight a critical compliance area: the use of psychotropic medications that may function as chemical restraints. When used improperly, they can restrict a resident’s freedom and trigger serious citations—including Immediate Jeopardy.
Don’t wait for a surveyor to raise the red flag. Our team of compliance experts can help you:
- Review psychotropic medication use and documentation
- Strengthen care planning and interdisciplinary team oversight
- Educate staff on regulatory expectations and resident rights, as well as nonpharmacological behavior management
📞 Contact CMS Compliance Group today to schedule a proactive compliance review and ensure your facility is aligned with F605 requirements.
Protect your residents. Protect your reputation. Stay survey-ready.
