There’s been a recent update from CMS that has started to be implemented.  The F-Tags have been given a little facelift and renumbering.  I’m a consultant pharmacist, so I’m going to focus on the changes in Pharmacy Services F-Tags.  The pharmacy services F-Tags run between F755-F761.  There are now seven possible pharmacy services F-Tags. I’ll take them in order;

• F-755; This deficiency can result from a few different concerns at a facility.  In the data I have reviewed thus far, this deficiency is given for inadequate following of standard procedures in the storage and usage of medications.  To give you a few examples, I’ve seen F-755 given for inadequate controls, not following policy and procedures surrounding counting narcotics, insulin beyond use dating, Advair beyond use dating, and orders that were never transcribed to the POS/MAR.  I have a few case examples of drug diversion that can highlight the importance of counting narcotics and following appropriate policies and procedures.

• F-756; This is the classic “Drug Regimen Review” deficiency for a pharmacist who’s recommendations were not acted on or addressed.  This can also be given if the pharmacist did not identify a problem, classically termed “irregularity”.  Real examples of this deficiency include the pharmacist not recognizing appropriate target behaviors for use of Seroquel (antipsychotic), parameters not in place in a resident on numerous analgesics, and the pharmacist questioning the use of PRN Ativan for >14 days without documentation from the provider, and the provider did not address the recommendation.

• F-757; Unnecessary medication is now under F-757.  While this was historically found under the F-329, CMS elected to have psych medications have its own F-tag (I’ll get to that next).  The examples I’ve seen cited thus far involve the use of pain medications; duplicate analgesics without documentation of non-drug interventions tried and failed.  F-757 and F-756 can be and have been “double dipped” with each other if the surveyor felt that the pharmacist did not catch this or if the pharmacist made a recommendation about the concern and it wasn’t acted on.

• F-758; Regimen must be free from unnecessary psychotropic medications; For those experienced in long term care, historically facilities would be tagged under F-329 for psychotropic issues or for any other medication that was deemed “unnecessary”.  F-758 is PSYCH ONLY. The really big new addition here is the reassessment of as needed “PRN” psych medications that are used for greater than 14 days.  Some examples of real deficiencies here are: haloperidol PRN for >14 days without documentation justifying longer term use, trazodone being used for sleep without any form of sleep monitoring being done, inadequate monitoring of Seroquel because an AIMS was not done, PRN Ativan >14 days without long term justification.  F-758 is another category that can and will be double dipped with F-756 (pharmacist failure to notify).  Hospice does not appear to be exempt from F-758.

• F-759; Free of medication error rates >5%. This one definitely isn’t cited very often because usually multiple mistakes have to be made in order to reach the 5% threshold.  I have come across a couple examples where liquid dosages have been measure incorrectly as well as eye ointment not given by the correct procedure.

• F-760; This pharmacy services F-Tag requires that the resident be free of “significant” medication errors.  I have not seen this one cited yet, but you could imagine that there is some subjectivity on what “significant” is.  I’m not a huge fan of the CMS medication error tags F-759 and F-760 because I think there is a ton of subjectivity within these tags and it also attaches punitive action toward individuals making errors.  In general, I think the best strategy to prevent these deficiencies is to have a good error reporting system and good procedures/processes in place to alter administration practices that are thought to be potentially harmful or not standard of care.

• F-761; Labeling and Storage of medications. You could make the argument that this does overlap a little with F-755.  This deficiency will be given if medications are stored incorrectly or if there are issues with labeling.  Examples here include; a nurse writing on a prescription label to change the directions, insulin in a fridge with no thermometer, expired insulin, disposal of fentanyl patches in a sharps container, and expired eye drops.

In summary, the pharmacy services F-Tags have changed a bit. The 14 day PRN deficiency is definitely one to look out for and one that is being cited.  In my recent addition (35 minute video breakdown) to the Insider’s Guide to LTC Consulting Pharmacy, I reviewed 47 facilities and categorized the frequency of each deficiency as well as which medications were most frequently tagged under the new F-Tags.  With this post, I’m giving a special one time discount that expires on Friday this week! Use discount code ftag at checkout.

This article was written by Consultant Pharmacist Eric Christianson, PharmD, BCGP, BCPS.  If you have questions about these deficiencies or medication management in long term care, you can contact him here, or leave us a message at the end of this post!