Update on Pharmacy Issues in Long Term Care Lisa Nichols RPh, CGP 1.Review What a Consultant Pharmacist Does and the Role of Pharmacy for Long Term Care Facilities 2.Identify Key Components of a Medication Regimen Review 3.Discuss How the Consultant Pharmacist Can Help You 4.Summarize Recent Survey Trends 5.Review DEA Requirements for Controlled Substances in LTC. Do? (Besides send me all these letters???) Review medications for accuracy (transcription from transfer/admission) Review for firing times in emar, routine vs PRN OR Does facility have process in place to find these possible discrepancies? Review for proper indication 1
Do? (Besides send me all these letters???) Review for drug interactions Warfarin NSAIDs Warfarin Sulfa Warfarin Macrolides Warfarin Quinolones Warfarin Phenytoin ACE inhibitors K supplements ACE inhibitors Spironolactone Digoxin Amiodarone Digoxin Verapamil Theophylline Quinolones Do? (Besides send me all these letters???) Allergy contraindications Appropriate administration Early AM With/after food HS due to sedation Do? (Besides send me all these letters???) Appropriate labs INR with Coumadin CMP with diuretics TSH with Amiodarone CBC with NSAIDs Address CMS required dose reduction evaluations Twice within the first year and annually thereafter Quarterly for hypnotics 2
Do? (Besides send me all these letters???) Review for appropriate side effect monitoring AIMS for antipsychotics Review for duplications in therapy PPI and H2 antagonists Multiple antipsychotics or antidepressants Sedating and Non sedating antihistamine Long acting opioid and short acting opioid both given on a routine basis Do? Appropriate storage of medications Refrigeration Medication labeling Pens Maintain compliance in regards to medication pass and medication administration Less than 5% Record keeping of controlled substances MAR and Controlled Drug Record match Manifest and Controlled Drug Record match What is involved in a medication regimen review? Review for accuracy/medication reconciliation. Dosing make sense for indication? Monitoring in place? Drug interactions? Dose reductions due? Weight and vital sign review Labs present as MD ordered? Medication administration documentation review of MAR and PRN med use 3
Pharmacy Role in Long Term Care? Deliver medication Alert when in survey Aid in meeting insurance coverage Aid with policy and procedures How can the Consultant Pharmacist help YOU? Develop protocols for lab monitoring. Develop OTC formulary (also helps facility with costs and reduces med errors). Identify/investigate med errors. Identify trends metoprolol succinate vs tartrate Mcg vs mg for levothyroxine Look alike sound alike meds hydroxyzine vs hydralazine Develop protocols for special projects (CMS focus on reduction of antipsychotics or sliding scale reduction) Identify Drug Interactions Streamline Drug therapy (reduce duplicate therapies) How can the Consultant Pharmacist help YOU? Falls assessment Medications contributing to weight loss 4
How can the Consultant Pharmacist help YOU? Focus on specific disease states. Diabetes Osteoporosis Provide education that YOU think the staff needs. Coumadin interactions Basal/bolus insulin Customize stat box to your preferences. Recent Survey Trends Infection control (hand washing, gloves) Self administration of nebulizers Expired medications Dignity and Privacy Labels in trash can Recent Survey Trends Medication Pass Tube feeders Timing Patches thrown in trash Antipsychotics Side effect monitoring 5
2013 2014 Trends 332 and 333 Free of Med Errors/Medication Pass Observation Timing of insulin Failure to follow up on ordering medication (ordering procedures) Order not matching the MAR (especially an issue with emar) Medication outside of time frame Eye drop directly to the eye Not waiting one minute between puffs Resident privacy Proper flushing of tube; pushing meds down tube Crushing Potassium Holding BP med without a hold parameter 2013 2014 F tag 329 Unnecessary Drug Failure to DC Lortab once an ulcer was healed. Order specified for ulcer pain Failure to do a dose reduction (also failure to answer pharmacy report) INR not ordered or obtained F tag 425 Pharmacy Services Locking the cart (security) Refrigerator too cold 2013 2014 F tag 428 Drug Regimen Review Failure to make sure a facility to follow up on AIMS testing Not writing a recommendation that a surveyor felt should be written F tag 441 Infection Control Touching inside of souffle cup. Touching inside Silent Knight Pouch. Improper IV procedures Proper handwashing (glucometer, eye drops especially) Improper Glucometer use Dropper use 6
2013 2014 F 281 Service provided or arranged by facility must meet professional standards of quality Failure to order and obtain INR Not waiting proper time between eye drops Out of time frame F 431 Service Consultation with pharmacist (labeling and storage/controlled substances) TB skin test out of date Medication Error (425 and 329) Administering duplicate anticoagulants F 514 Clinical Records Failure to Document (on MAR) DEA Requirements for Controlled Substances DEA Controlled Substance Requirement All controlled substances supplied to long term care facilities must have all of the components of a valid prescription Legitimate medical purpose, usual course of sound professional judgement Dated and signed by practitioner on the date it was issued Full name and address of patient Drug name, strength, dosage form, quantity prescribed, and directions for use Name, address, and registration number of the practitioner Authorized number of refills for III IV 7
DEA Requirements Oral prescriptions for III IV are acceptable. Emergency Schedule II reduced to writing within 7 days from the prescriber. DEA Requirements for Controlled Substances Emergency Box is included Prescription should be provided prior to use Back up pharmacies will need their own prescription Hot off the press!!! 8
Proposed Mega Rule Http://federalregister.gov/a/2015 17207 July 16th Regulations not comprehensively revised since 1991 despite changes in service delivery Improve quality of life, care, and services in LTC facilities New requirements Eliminate duplicate/unnecessary provisions Reorganize Mega Rule Pharmacy Implications Entire medical record review upon return/transfer and every 6 months Review medical chart when resident prescribed a psychotropic drug, an antibiotic, or any med designated by Quality Assessment and Assurance committee Attending physicians must document in the medical record that they have reviewed irregularities identified by pharmacist during drug regimen review Mega Rule Pharmacy Implications Rename antipsychotic drugs as psychotropic Any drug that affects brain activities associated with mental processes and behavior PRN psychotropics be limited to 48 hours Relocate unnecessary drugs, antipsychotic drugs, medication errors, and influenza/pneumococcal immunizations under Pharmacy Services 9
Mega Rule Pharmacy Implications Healthcare Associated Infections Antibiotic stewardship program Medication Reconciliation upon Discharge Improve transitions in care QAPI Systems of care, outcomes, and services for residents and staff Other Pharmacy Related Items Rising Generic Drug Costs 1. Industry Consolidation 2. Drug Shortages Due to Manufacturing Issues 3. Drug Shortages Due to Stricter Regulation Rising Generic costs Propranolol tabs $5 to $45 Armour thyroid up by about 57% Tetracycline AWP $7.50 per cap for 250mg and $15.75 for the 500mg Doxycycline AWP $6.25 per cap for 100mg 10
Other Pharmacy Related Items Drug Shortages Cefepime, Cefazolin,, Cefotaxime (Claforan) Piperacillin and Tazobactam (Zosyn) Imipenem and Cilastatin Vancomycin for injection Tobramycin Sodium Chloride 0.9% injection bags Benzonatate http://www.accessdata.fda.gov/scripts/drugshortages/default.cfm Questions? 11