1. Familiarize yourself with new regulatory language that places special mandates on drug regimen reviews and the medication reconciliation process. 

“With the newly established CMS Requirements of Participation, the enhanced focus on polypharmacy, unnecessary medications and medication-related adverse events in the elderly have resulted in expansion of medication management processes across multiple care transition points,” notes Frank Grosso, RPh, executive director and CEO of the American Society of Consultant Pharmacists. He strongly urges using the expertise of a consultant pharmacist.

2. Adopt best practices that are proven. Grosso says successful medication management should tap into specialized training in geriatric pharmacotherapy.

“Having specific geriatric-related resources is important to have on-hand for doctors, nurses and pharmacists,” adds Sandy Hebert, director of product management for PointClickCare. 

3. There are proven methods to mitigate addictive and psychotropic drug reactions. Grosso asserts that “non-pharmacological approaches to medication management should be incorporated into the care plan whenever possible.” He also advises thorough pain assessments when opioids are involved and “sleep hygiene” techniques when hypnotics are prescribed.

Prescribing sleep aids can indeed be a common issue, says McGill University researcher Marnie Wilson, M.D. Recently, she worked on a study where patients over age 60 were given a pamphlet on ceasing sedatives after a hospital visit. Two-thirds of those enrolled were able to stay off the sedatives at 30 days post-discharge. One of the big misconceptions is how long seniors need to sleep, she notes. 

“Five to six hours can be fine,” Wilson says. “A sleep aid to get someone to eight to ten hours isn’t reasonable. Education can go a long way.” 

The “Keep Walking” program also was successful at reducing sedative hypnotics and benzodiazepines, says Rhett Barker, PharmD, BCGP, director of operations at Guardian Pharmacy Mid-South, a member of the Guardian Pharmacy Services family. “The activities director coordinated a program where volunteers from the community walked with residents around the halls of the facility or the paths outside the facility when possible.”

Hebert warns against complacency. 

“The most common mistake care providers make in their attempt to avoid an adverse drug event, such as dependence, is believing that what they are currently doing is sufficient,” she says, urging regular audits to avoid such issues. Focusing more on detecting side effects such as cognitive impairment also is a plus.

4. Don’t forget about over-the-counter meds a resident might be taking, says T.J. Griffin, chief pharmacy officer for PharMerica. The company is working with Purdue University researchers to conduct a study on the effects of polypharmacy.

“Don’t focus on just prescription meds,” Griffin says. “Do a deep dive on the over-the-counters as well.”  

For example, it’s easy to forget how “Grandma likes to take St. John’s wort or turmeric capsules. The latter has serious, dangerous interactions with warfarin,” he warns.

5. Barker believes successful medication management in the long-term care setting starts during transitions. His best practices list includes using pharmacy providers and pharmacy consultants in the medication reconciliation process. 

One option is to have a caregiver observe a med pass where the nurse shows each medication to the resident and the family member, Barker says. Other proven safety measures include instituting brightly colored indicator vests and sashes for those performing the medication pass, and the STOPP-START toolset, which includes screening criteria for inappropriate medications and under-treatment, respectively.

6. Another best practice calls for digital efficiency.

Have an electronic health record system and clinical decision support tools within a computerized prescriber order entry system, which allows for drugs meeting Beers Criteria for potentially inappropriate medication use in older adults to be flagged, says Doris Yee, PharmD, a clinical pharmacist in the Consumer Drug Information Group at First Databank Inc. 

Other recommendations include labeling systems that are consistent, user friendly and easy to identify regarding medication and dosage, preventing confusion and frustration, says Joe Kramer, vice president of sales and marketing at Gericare Pharmaceuticals.

Automated dispensing machines can track medications and provide verification, says Brian McNeill, CEO of Touchpoint Medical.

— John Hall

The May release also showed hospital deaths among Medicare patients dropped 30% over the last four years.

The report found that average nursing home quality — the percentage of nursing beds rated four or five stars over a three-month period — was 42.4% for 2017, the same level reported by the group last year.

The capped 1% raise will kick in Oct. 1 and become the smallest increase in recent years. Since it was prescribed as part of the Medicare Access and CHIP Reauthorization Act of 2015, however, it was not a surprise.

“It’s unfortunate but expected,” said Cynthia Morton, executive vice president at the National Association for the Support of Long Term Care.

Morton said the rule’s proposal of four new Quality Reporting Program measures addressing functional status is especially exciting.

She’s also pleased the proposed case mix revisions — currently slated for proposal as part of the FY 2019 skilled nursing rule — were released as an advanced notice, since “it’s a big change and people need time to understand it.”

Comments on the skilled nursing payment rule for fiscal 2018 are due by June 26.

A notice appeared on the White House Office of Management and Budget website in late April saying a rule titled “Revision of Requirements for Long-Term Care Facilities: Arbitration Agreements” was pending review. 

While the text of the proposal was not published as of press time, Sen. Al Franken (D-MN) said in a statement that the rule would lift the ban on pre-dispute agreements.

Franken called the proposal a “misguided decision” by the Trump administration that “would be terrible for consumers.” 

Providers’ arbitration agreements got another win in mid-May, when the U.S. Supreme Court ruled in favor of a Kentucky nursing home in Kindred Nursing Ctrs. LP v. Clark. 

With Change of Therapy documentation, “if we have a Medicare meeting, and have the MDS and therapy people talk, we can avoid some of these problems,” said Marcum Senior Manager of Advisory Services Marilyn Mines, RN, BC, RAC-CT, during LeadingAge Illinois’s annual meeting.

Lack of Advance Beneficiary Notices also can cause problems. n

It’s 3 a.m. and the death last week of a resident who failed despite CPR is still keeping me up. The staff members acted appropriately, but they still appear upset. As the director of nursing services, what can I do to help them?

Unanticipated adverse events do occur in nursing facilities, but there are certain ways to assist staff to recover from unsettling events and improve future practices. Staff members involved in an adverse event often suffer emotionally and struggle to cope with the incident. 

Within a week of the adverse event, consider calling a huddle with the team members involved to allow them to discuss how they are coping, but also to share ideas about how to improve care systems. The huddle should have a structure that allows them to safely share their thoughts and feelings regarding the adverse event, while sharing lessons learned from the particular situation being discussed. 

Begin the huddle with a roundtable of questions and answers, such as: 

• Since the adverse event, how have you been feeling or coping? 

• Is there something you would have done differently? 

• What suggestions do you have for how to avoid this situation in the future? 

Your gathering also should have a ground rule of setting time limits, providing each staff member time to express his or her feelings. Open sharing during a huddle encourages staff members to support each other, enhancing the opportunity for closure of a difficult situation. 

An effective huddle helps your staff restore their confidence by providing them with a caring environment in which to emotionally recover from the psychological impact of medical errors. The goal is to support your staff emotionally while developing a more transparent and systems-thinking team. 

The vast majority of American nurses promote a culture of health in their communities but rarely get credit for their efforts, according to a recent study published in the journal Policy, Politics, & Nursing Practice.

Results of the study, co-authored by researchers from the University of North Carolina School of Nursing at Chapel Hill and New York University Rory Meyers College of Nursing, found that as many as 80% of nurses do some form of volunteering in their communities that is directly related to promoting health and wellness. Still, very little information exists on such efforts, the study authors noted.

Nationwide, more than 20,000 nurses currently volunteer with the American Red Cross to assist during large-scale disasters. But about three-quarters of the 315 nurses queried in the study said their health promotion efforts were not work-related. These included fundraising, health fairs, church activities and family- , population- or disease-related volunteering, according to various reports.

Nurses also were asked about their health promotion habits in the 2016 RN Workforce Study, funded by the Robert Wood Johnson Foundation. 

Nurses and doctors may be the healthiest workers in the U.S. labor force. But no field other than firefighters and law enforcement has worse health and eating habits than healthcare aides, 40% of whom are nursing home caregivers. 

That’s according to findings published in the April American Journal of Preventative Medicine. Investigators studied clinical measures and behavioral risk factors behind cardiovascular disease in more than 6,000 workers over age 45.

When factoring in so-called “optimal” behavioral health habits that include diet, smoking and exercise, nursing aides, therapy aides and assistants, and phlebotomists scored the worst, according to a research team from the National Institute for Occupational Safety and Health and the University of Alabama at Birmingham.

Nearly three-quarters of the healthcare support workers surveyed had a poor diet, while slightly more than half had a higher-than-optimal body mass index. 

Moreover, more than 11% of all healthcare support workers smoked cigars or pipes — the highest level among all workforce categories. Support workers scored notably better in terms of exercise, blood glucose and cholesterol levels.

To reverse the disturbing trends, researchers suggested public health programs on targeting cardiovascular disease, universal smoke-free policies, restrictions on mandatory overtime and more paid sick leave. 

An Indiana-based healthcare management group has been hit with a class-action lawsuit after one job applicant claimed she was denied a position at the company based on an allegedly false background check report.

The suit was filed in late April by Michele Petry, who applied for a nursing job with Ide Management Group in March. 

IMG, doing business as Cathedral Health Care Centers, operates skilled nursing and assisted living facilities in Indiana, Illinois and Iowa. 

Petry claims she interviewed with the company and was told she would be offered the job if she successfully passed a background check. 

IMG declined to hire Petry after the report was completed by an unnamed consumer reporting agency showing multiple felonies, including charges for drug paraphernalia and theft.

Despite the report’s findings, Petry never has been convicted of a felony, according to court documents.

Petry requested a copy of the report, which IMG refused to provide. 

Her lawsuit claims IMG violated the Fair Credit Reporting Act by not providing Petry with a copy, or a written description of her rights under the Act. 

The class-action lawsuit was filed on behalf of the “hundreds, possibly thousands” of IMG job applicants over the past five years whom the company screened using a consumer report, and those people the company “took adverse action against” without providing a copy of the report or consumers’ rights, the suit reads.

Petry is seeking punitive damages for violation of the FCRA, as well as actual damages for financial harm and injury of her reputation. 

Starbucks is currently facing a similiar class-action lawsuit bought earlier this year by a job applicant in Colorado who claims he was denied a position at the coffee giant because of an inaccurate report. He also is suing for alleged FCRA violations. 

Employees who were terminated from a California skilled nursing facility one week ahead of a union election must be reinstated and compensated for back pay, a National Labor Relations Board judge ruled in late April.

A complaint was lodged against Novato Healthcare Center in Novato, CA, by the National Union of Healthcare Workers, claiming the facility interrogated employees about their union sympathies before an election in October 2015. Managers eventually suspended and terminated five employees — four of whom were supportive of joining the union — days before the vote. 

An administrator for Novato testified that the firings were due to the employees sleeping outside of break times, jeopardizing resident safety.

In the NLRB’s opinion, Administrative Law Judge Amita Baman Tracy said that two administrators at the Brius-operated facility gave “vague” testimony about what led to the workers’ terminations, and interfered with employees’ rights under the National Labor Relations Act.

“Respondent claims that it would have suspended and terminated the employees regardless of Union activity due to the ‘brazen’ nature of the discriminatees’ conduct,” Tracy wrote. “I find that [Novato] failed to prove that it would have taken the same adverse actions in the absence of union activity.”

Labor counsel for Novato told McKnight’s that the facility was disappointed by Tracy’s ruling and plans to appeal.

“We are confident the full board will overturn the decision as the facility was well within its rights for terminating these individuals for sleeping on the job and placing facility residents at risk,” the counsel said in a statement.

Under the ruling, Novato must offer reinstatement to all five employees; reward them back pay; take any references to the incident off of their files; and post a notice in the facility that the provider “will not interrogate you about your union sympathies.”