Required Documentation for Antipsychotic Medications in Long-Term Care Facilities
The Centers for Medicare and Medicaid Services (CMS) State Operations Manual – Appendix PP contains the required documentation for use of antipsychotic medications in patients residing in a long-term care facility. 1
Regulatory Framework for Antipsychotic Use in Long-Term Care
The CMS State Operations Manual – Appendix PP establishes the regulatory requirements that nursing homes must follow regarding antipsychotic medication use. This document outlines the survey process that employs quality metrics reported to CMS, with specific scrutiny on psychotropic medication use, particularly antipsychotics which are often employed off-label 1.
Key documentation requirements include:
- Comprehensive assessment and development of a treatment plan
- Clear documentation of risks and objectives for use
- Documentation of attempts at non-pharmacological approaches
- Regular monitoring and reassessment of continued need
Why CMS State Operations Manual Is the Correct Answer
Regulatory Authority: CMS regulations specifically require consideration for deprescribing of psychotropic medications in long-term care facilities 1
Mandatory Compliance: Since October 2005, CMS has required nursing homes participating in Medicare and Medicaid programs to document medication administration and reasons for use or non-use 1
Survey Process: The CMS survey process specifically scrutinizes psychotropic medication use in skilled nursing facilities/long-term care (SNF/LTC) settings 1
Quality Metrics: CMS collects quality metrics on antipsychotic use, making this documentation mandatory rather than advisory 2
Comparison with Other Resources
American Psychiatric Association (APA) 2016 guidance: While this provides clinical recommendations, it is not the required regulatory documentation framework that facilities must follow 1
Beers List: This is an important clinical tool for identifying potentially inappropriate medications in older adults, but it does not establish the required documentation standards for facilities 1
START criteria: This tool helps identify potential prescribing omissions but does not establish documentation requirements for long-term care facilities 1
Impact of CMS Documentation Requirements
CMS initiatives have shown measurable impact on antipsychotic use in nursing homes:
CMS strategies implemented in 2012-2013 were associated with modest but significant reductions in antipsychotic prevalence in nursing homes 2
The National Partnership to Improve Dementia Care in Nursing Homes established by CMS has influenced prescribing patterns 3
CMS documentation requirements have led to increased citations for unnecessary drug use 2
Documentation Requirements for Antipsychotic Use
When documenting antipsychotic use in long-term care facilities per CMS requirements, the following must be included:
- Specific behavioral symptoms being targeted
- Evidence that non-pharmacological interventions were attempted
- Rationale for why the benefits outweigh the risks
- Regular assessment of effectiveness using standardized tools
- Documentation of gradual dose reduction attempts
- Monitoring for adverse effects including extrapyramidal symptoms
Common Pitfalls in Documentation
- Failing to document non-pharmacological approaches attempted before medication initiation
- Inadequate documentation of specific target behaviors
- Missing regular reassessments of continued need
- Lack of documentation regarding gradual dose reduction attempts
- Insufficient monitoring of adverse effects
- Failure to document informed consent discussions with patients/families
Proper documentation according to CMS requirements is essential not only for regulatory compliance but also for ensuring appropriate use of antipsychotics, which can reduce mortality and improve quality of life for residents in long-term care facilities.