CMS updated guidance in
Appendix PP of the SOM, effective October 2022, regarding F758: Psychotropic Drugs and expanded examples on use of non-psychotropic (antihistamines, anti-cholinergic medications, anticonvulsants) medications used to treat behaviors. CMS indicates that the use of psychotropic medications, other than antipsychotics, should not increase when efforts to decrease antipsychotic medications are being implemented.
In addition, CMS has stated that other medications not classified as anti-psychotic, anti-depressant, anti-anxiety, or hypnotic medications can also affect brain activity and should not be used as a substitution for another psychotropic medication unless prescribed with a documented clinical indication consistent with accepted clinical standards of practice. The requirements pertaining to psychotropic medications also apply to these types of medications (antihistamines, anti-cholinergic medications, anticonvulsants) when their documented use appears to be a substitution for another psychotropic medication rather than for the original or approved indication.
Items for Consideration:
- Ensure these medications are prescribed with appropriate evaluation and documentation.
- If a resident is prescribed an antihistamine, anti-cholinergic medications, or anticonvulsant and it is not being used to treat the indication for their use (nausea, vomiting, itching, seizures, etc.), then is should be consistent with the psychotropic medication requirements under §483.45(e):
- Not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record.
- Receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue the drugs.
- Do not receive these medications PRN unless necessary to treat a diagnosed specific condition documented in the clinical record.
- PRN orders for psychotropic drugs are limited to 14 days; if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident’s medical record and indicate the duration for the PRN order.
- PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Actions for Facilities:
- Review the facility policies and procedures to confirm there are processes in place to ensure appropriate diagnosis for medications prescribed.
- Review medical records of residents taking antihistamines, anti-cholinergic medications, and anticonvulsant medications to ensure appropriate evaluation and diagnosis.
- Ensure residents prescribed antihistamines, anti-cholinergic medications, and/or anticonvulsants are monitored for adverse consequences, such as increased confusion or over-sedation.
- If administering these medications (and if prescribed outside of the indication for their use), ensure all elements outlined above under “Items for consideration” are met.