Note: the following sample auditing and monitoring process is based upon a similar sample we have used throughout this compliance guidance. It is designed to be a sample only, to assist providers in developing their own auditing and monitoring program, and to demonstrate one possible way of thinking about and approaching auditing and monitoring the issue of sufficient staffing. We’ve approached auditing and monitoring in this sample as a series of three categories of questions designed to prompt providers to ask key questions that can help avoid and detect potential kickback violations, consisting of the following questions:
- Specifically what are we auditing and monitoring (i.e., what are the specific issues we are looking for in this part of our auditing/monitoring process)?
- What specific sources of information will we examine to find that information (e.g., facility contracts, invoices for services or items purchased, interviews with facility staff and outside contractors, referral patterns and sources, etc.) and specifically, who in the facility or company (by title) will be responsible for each of the individual information source examinations and on what schedule (i.e., how often and when) will they perform these tasks?
- What will we do with the information we obtain as a result of steps 1 – 3, above?
Specifically what are we auditing and monitoring (i.e., what are the specific issues we are looking for in this part of our auditing/monitoring process)?
- Do we have a system to ensure we are aware on an ongoing basis of all residents in the facility who are taking psychotropic medications?
- For each of these, do we have appropriate documentation of symptom-based reasons for the administration of such medications?
- Is that documentation made by the appropriate inter-disciplinary team of care professionals, reflecting all aspects of a resident’s care and behavior?
- Is that documentation, and the use of these medications, both reflected in and consistent with the resident’s care plan and related medical records, and updated as either the care plan or medication regimen changes:
- Do we have documentation of ongoing efforts to reduce the dosage and use of psychotropic medications, unless medically contraindicated (which is supported by appropriate, current documentation by the appropriate care professional), including efforts at behavioral interventions in lieu of psychotropic medications?
- Is this system, our documentation and our use of psychotropic medications regularly reviewed by our consultant pharmacist?
- Do we have a system of checks and balances to ensure consistency among, and proper updating of:
- Care plans relating to medication usage
- Medical records
- Physician orders for psychotropic medications
- Medication administration records
- Oral physician orders for psychotropic medications
- Lab test orders and lab results, along with follow up to ensure tests are properly ordered; results received, recorded and communicated to the attending physician; and follow ups occur where lab results are not received as scheduled.
What specific sources of information will we examine to find that information and specifically, who in the facility or company (by title) will be responsible for each of the individual information source examinations and on what schedule (i.e., how often and when) will they perform these tasks?
For all residents taking psychotropic medications, the [designate by title] will [define a schedule of periodic review of the following – e.g., quarterly, monthly, and as indicated by an individual resident’s condition and/or behavior] review and analyze:
- Resident medical orders for psychotropic medications;
- Care plans;
- Nursing notes and social work/psychosocial notes for documentation of symptom-based reasons for using psychotropic medications;
- The facility’s system for recording oral physician orders for psychotropic medications and for ensuring the signing and implementation of such orders (such as a nursing log);
- The facility’s system for tracking requests for lab tests, ensuring that results are received or where results are not received as expected that follow up occurs, that lab results are reported to the attending physician and appropriate facility staff and appropriate revised orders as indicated are obtained and recorded;
- The facility’s Quality Assurance Committee minutes and facility incident reports related to the use of psychotropic medications to identify failings in this system at any point (e.g., failures to consistently attempt dose reduction or behavioral interventions, failures to follow up on missing lab results, etc.)
- Reports of the facility consulting pharmacist related to his/her review of the facility’s use of psychotropic medications
What will we do with the information we obtain as a result of steps 1 – 3, above?
- The results of the above inquiries will be provided on a regular basis to facility administration and the facility’s Quality Assurance Committee for discussion and revision as needed, with appropriate training or re-training as indicated.
- Applicable policies and procedures on the use and monitoring of psychotropic medications will be revised as needed to address issues and problems in the facility’s use of such medications. Repeat and update the training of staff as appropriate to respond to identified failures in existing policies/procedures and practice.
- As appropriate, the Compliance Officer will discuss the results of these audits with senior management and/or the Board of Directors (or owners) and determine whether any additional measures are required or recommended, whether additional compliance safeguards should be instituted at the facility (including more frequent auditing of applicable procedures), whether training of employees and/or contractors is recommended and such other corrective and monitoring activities are appropriate.