CMS Clarifies Guidance on Medication Errors and Pharmacy Services

On November 2, 2012, CMS (the Centers for Medicare & Medicaid Services) distributed a Survey & Certification Memo (S&C: 13-02) providing guidance on three specific topics related to medication errors and pharmacy services.

  • Medication Errors: Potential medication errors related to medication administration via feeding tube and administration timing for metered dose inhalers and proton pump inhibitors and survey implications.
  • Medication Administration Practices: The practice of “borrowing” medications and issues related to diversion, control, reconciliation and disposal of medications, including fentanyl patches.
  • Medication Regimen Reviews for Stays under 30 days and/or Changes in Condition: The need for pharmacist medication regimen reviews when a resident experiences a change in condition and/or for residents admitted for less than 30 days.

The clarification provides specific Guidance to surveyors for deficiency citations.  The S & C memo notes that additional tags are provided as “links” for the surveyors.  In Virginia medication administration [technique, error, and administration] are consistently being cited under multiple tags, including F332; F333; F281; F425, etc.  The Guidance is effective immediately.