Psychotropic medication use is one of the most scrutinized areas during CMS surveys. Facilities that cannot easily demonstrate oversight are at higher risk for citations.
What Surveyors Look For
Supporting Diagnoses
Is there a documented psychiatric or behavioral diagnosis that supports the medication use?
Evidence of Review
Are medications being reviewed and renewed according to required timelines?
GDR Consideration
Has Gradual Dose Reduction been considered and documented?
Interdisciplinary Oversight
Is there evidence of IDT involvement in medication decisions?
Citation Risk: Facilities that cannot easily demonstrate oversight are at higher risk for F758 citations for unnecessary drug use.
Structured Compliance Tracking
Using structured psychotropic compliance tracking allows facilities to demonstrate active monitoring and reduce survey risk. QAPIShield provides:
- Psychotropic medication tracking by resident
- 14-day review alerts for time-limited medications
- GDR consideration documentation
