New CMS Rules on Psychotropic Medications in SNFs

December 4, 2017

Richard G Stefanacci, DO, MGH, MBA, AGSF, CMD—Column Editor


The Access Group, Berkeley Heights, NJ; Thomas Jefferson University, Philadelphia, PA; AtlantiCare/Geisinger, Atlantic City, NJ


The author has no relevant financial relationships to disclose.


Ann Longterm Care. 2017;25(6):19-20. doi:10.25270/altc.2017.10.00014
Published online December 4, 2017.

A major concern for the Centers for Medicare & Medicaid Services (CMS) has been improving the quality of care for skilled nursing facility (SNF) residents, especially when it comes to restraints and what they consider inappropriate medications. Recently, due to concern of the overuse of psychotropic medications to manage agitation and other behavioral problems associated with dementia—which goes contrary to the US Food and Drug Administration black box warning—CMS has been propelled to expand oversight on their use. CMS has had several initiatives to decrease the use of antipsychotic medications including state survey application of unnecessary medication F-tags and quality measures specific to this effort, which have had success. But in an effort to decrease any medication that they consider a chemical restraint, CMS is looking to expand regulation in this area. As a result, effective November 28, 2017, CMS announced several regulatory changes for SNFs including an expanded definition of psychotropic medications and new limitations on the use of as-needed (PRN) psychotropic medications within SNFs.1

The definition of a psychotropic medication now includes “any drug that affects brain activities associated with mental processes and behavior.”1 These drugs include, but are not limited to, the following drug categories: antipsychotic, antidepressant, antianxiety, hypnotic, as well as medication classes that may affect brain activity. This expanded list of psychotropic medications includes central nervous system agents, mood stabilizers, anticonvulsants, muscle relaxants, anticholinergic medications, antihistamines, N-methyl-D-aspartate receptor modulators, and over-the-counter natural or herbal products.1

For the expanded list of psychotropic medications, CMS has placed 14-day limits on their duration of use when prescribed with PRN orders. Extension of use beyond 14 days can occur if the prescribing practitioner: (a) believes it is appropriate to extend the order, (b) documents clinical rationale for the extension, and (c) includes a specific duration of use. As detailed as these rules are for psychotropic medications, the rules regarding PRN antipsychotics specifically are even more explicit.1

For antipsychotics, a 14-day limitation is applied to all PRN orders; as a result, these orders may not be extended beyond the 14-day limit. To continue their use, a new order for the PRN antipsychotic may be written if the prescribing practitioner directly examines and assesses the resident and documents clinical rationale. This clinical rationale must include the benefit of the medication for that resident. This documentation is required every 14 days for a resident receiving a PRN antipsychotic without exception, including hospice patients.1 As per section F757 in the Manual, the continued use of these medications is permitted as long as prescribers heed the following guidance:

"When a resident is experiencing an acute medical problem or psychiatric emergency (e.g., the resident’s expression or action poses an immediate risk to the resident or others), medications may be required, as delirium induced psychosis. As always, medications should only be initiated/used in the presence of active clinical symptoms and after nonpharmacological interventions and least restrictive measures have been attempted."1