Tick, Tock, Tick Tock, for CMS and Department of Health Surveys, 30 Minutes is All You’ve Got!

Medication administration for most hospitalized patients is a fairly routine process. So why is this seemingly simple task becoming a hot spot for CMS and Department of Health surveys?

Here’s Why

§482.23(c)(1) Outlined expectations for medication administration, include:

• That there are policies and procedures approved by the Medical Staff to determine who is authorized to administer medications, and that the policies are followed;
• That entries on the medication administration records conform to the practitioner’s order, that the order is current, and that drug and dosage are correct and administered as ordered (5 rights);
• That patients are addressed by name and/or their identities are checked;
• That the nurse remains with the patient until medication is taken;
• That drugs are administered within 30 minutes of the scheduled time for administration; and
• That QA/PI activities regularly check to see if the administration of drugs is monitored.

Additional expectations include the need to notify the physician when medications are omitted, held, or delayed, since they have not been administered as ordered. Note that medication administration expectations apply to all types of medications, including respiratory treatments and inhalers.

The Good News

The good news is that CMS has accepted the position statement from the American Association of Respiratory Care, which asserts that respiratory medications may be given within 60 minutes on either side of the scheduled administration time.

The Not So Good News

However, CMS and state surveyors have repeatedly categorized missed and late treatments as medication administration errors and have written citations if they are not captured as medication errors in the QA/PI program. Tracking and trending of all medication errors are expected to be routine elements of every hospital’s QA/PI program.

Another common misinterpretation lies in understanding the CMS expectations for timely medication administration. The CMS interpretive guidelines have historically set the expectations that medication be administered 30 minutes before or after the scheduled time. This permits a one-hour window for administration. Over the years, this “one-hour window” had been misinterpreted to mean one hour before and after the scheduled time, leaving a two-hour window that has proven unacceptable to state surveyors.

What to Do?

Determining your risk for this type of CMS deficiency and addressing the gaps in compliance are the first steps to avoiding this finding during survey. To evaluate your readiness, consider the following actions:

• Conduct observational and chart review studies to determine if medications are given 30 minutes before or after the scheduled administration time.
• Utilize reporting features of automated dispensing devices to compare the time medications were removed from the device as compared to the time the medication was documented as given.
• Evaluate the timeliness of respiratory therapy treatments. Identify if late or missed treatments are being captured in the QA/PI program for action and improvement.
• Assess staff knowledge of the requirement for timely medication administration and periodically reeducate staff members who administer medications.
• Track and trend medication errors related to timeliness issues to identify opportunities for improvement. Consider an FMEA to root out barriers to timely medication administration.

And Don’t Forget

Remember that CMS requires timely medication administration relative to the scheduled administration time. Check your policy to see if it permits staff to change scheduled administration times for patient-centered reasons, such as:

• To align medication administration times with patient’s home routines
• To permit the administration of large volume antibiotics (such as Vancomycin) at recommended infusion rates.
• To prevent drug-drug or drug-food interactions.
• To satisfy a patient request.

Questions?

If you have any questions about this subject or another regulatory or accreditation hot spot, call me, Ruth Elzer at 513.241.0142, or email me @relzer@compassgroupinc.com