Impacted F-tags: F605 Right to Be Free from Chemical Restraints, F757 Drug Regimen is Free from Unnecessary Drugs, F841 Responsibilities of Medical Director, F758 Free from Unnecessary and Psychotropic Medications / PRN Use (was removed)

May 5, 2025

Today, we’re discussing important updates from the Centers for Medicare & Medicaid Services (CMS) that will significantly impact nursing home operations. CMS has issued revisions to the Long-Term Care (LTC) surveyor guidance, detailed in memorandum QSO-25-14-NH, effective April 28, 2025. Among these updates, the changes related to chemical restraints and unnecessary psychotropic medication are particularly noteworthy. Let’s explore what these changes entail and how they will affect nursing home practices.

Key Updates

  1. Incorporation of Regulations for Unnecessary Psychotropic Medication CMS has incorporated the regulations and guidance for the unnecessary use of psychotropic medications into deficiency tag F605, which pertains to chemical restraints. This change aims to streamline the survey process and increase consistency in enforcing regulations.  CMS  states in the updated guidance that psychotropic drugs should only be used “when other nonpharmacological interventions are clinically contraindicated.” There are numerous updates to definitions, which are important for providers to understand and incorporate into their polices as well as training. 
  2. Revised Guidance on “Convenience” CMS has revised the guidance on the use of psychotropic medications for “convenience.” The updated guidelines emphasize that psychotropic medications should not be used as a convenience for staff but rather as a last resort for treatment when necessary.
  3. Unnecessary drugs will be reviewed and are considered as unnecessary, any psychotropic drug for which there is insufficient documentation of indications for use, contraindications of non-pharmacological interventions, and Gradual Dose Reductions (GDR) or contraindications for GDRs will be determined as unnecessary drugs.  Breaks in performance may be tagged at F605, an abuse tag. 
  4. Comprehensive Assessment  All psychotropic drugs require documentation of a comprehensive assessment.  A comprehensive assessment can be completed by the physician, does not require a psychiatrist or other mental health professional. An MDS is not considered a comprehensive assessment.  The medications need to be reviewed upon admission, readmission, change of condition, identified in a pharmacist’s monthly medication regimen review, used as a prn, or ordered as an emergency measure.  The facility’s Medical Director has to ensure that prescribing clinicians follow clinical standards of care when administering or prescribing psychotropic medications. 

Real-Life Scenarios
A resident is prescribed psychotropic medication to manage behaviors that are challenging for staff. Under the new CMS guidelines, nursing homes must ensure that psychotropic medications are not used for staff convenience but are prescribed based on a thorough assessment of the resident’s needs and as a last resort. This involves documenting the rationale for the medication and exploring non-pharmacological interventions first. Failure to comply with these guidelines could result in a citation under deficiency tag F605.

A resident is given psychotropic medication without proper justification. Under the revised CMS guidelines, this practice could lead to a citation under deficiency tag F605, which requires facilities to prevent the unnecessary use of chemical restraints and ensure that any use of psychotropic medications is clinically justified. This proactive approach helps ensure that residents receive appropriate care and are not subjected to unnecessary medication.

Implications for Nursing Homes
These revisions are a significant step towards improving the quality of care in nursing homes. By incorporating regulations for unnecessary psychotropic medication into F605 and revising guidance on “convenience,” nursing homes are now required to adopt more stringent practices regarding the use of psychotropic medications. This means that facilities must conduct thorough assessments before prescribing these medications, ensuring that they are used only when absolutely necessary and not for the convenience of staff. Additionally, nursing homes must document the rationale for any psychotropic medication use and explore non-pharmacological interventions first. This approach aims to protect residents from unnecessary chemical restraints and promote individualized care that addresses their specific needs.

Action Steps for Nursing Homes
To comply with the updated guidance, nursing homes should take the following steps:

  • Review Medication Policies: Ensure that all policies related to the use of psychotropic medications are updated to reflect the new CMS guidelines.
  • Review:  Review nonpharmacological interventions and approaches for each resident receiving psychotropic medications.
  • GDR:  Review all residents on psychotropic medications, correlating comprehensive assessments, review adequate indications for use, contraindications, consents, gradual dose reductions, and  adverse event monitoring
  • Train Staff: Implement regular training sessions for all staff members on the appropriate use of psychotropic medications and the importance of non-pharmacological interventions.
  • Monitor Medication Use: Regularly review the use of psychotropic medications to ensure they are clinically justified and not used for staff convenience.
  • Critical Element Pathway:  Use the CMS Critical Element Pathway for Unnecessary Drugs/Psychotropic Medications to prepare facility leadership and clinical team on the updated guidance. 

Pathway Health Products and Services
Pathway Health offers several services and products to help facilities navigate these rule changes:

Stay tuned for more in-depth insights and discussions on how these changes will impact nursing home care and operations.

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