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The Center for Medicare Advocacy (the Center) has reported on the misuse of antipsychotic drugs by nursing homes for many years, discussing Congressional hearings and federal reports and the high personal and financial cost of the misuse of the drugs.[1]  In December 2013, we reported on a study that the Center undertook with Dean Lerner Consulting, funded by the Commonwealth Fund.  In Part One, we described the antipsychotic drug deficiencies that were cited in seven states over a two-year period, reporting that 95% of the nearly 300 deficiencies were described as "no harm."[2]  This Alert discusses the second part of the study – the results of a questionnaire sent to state surveyors and managers in ten states about how, when, and why they cite antipsychotic drug deficiencies, and answers to related questions.[3]  Part Three will discuss recommendations to improve the citing of antipsychotic drug deficiencies.

The Questionnaire

State survey directors in 10 states[4] distributed to their surveyors a questionnaire developed by the Center and Dean Lerner Consulting.  The questionnaire included 49 questions, many with multiple subparts and more than half with open-ended questions.[5]  More than 500 surveyors in the 10 states responded and shared their experiences and recommendations.  Most were registered nurses and were experienced surveyors.

The questionnaire included questions about how and why surveyors cite antipsychotic drug deficiencies; barriers and challenges surveyors face; changes surveyors believe would improve both the Requirements of Participation for facilities and the survey process they use; changes in facility practices that surveyors have seen since the Centers for Medicare & Medicaid Services (CMS) implemented its antipsychotic drug initiative in 2012; and whether surveyors believe their jobs make a difference.

Questionnaire Results

In general, surveyors correctly described the survey protocol and the activities they are required to undertake in determining facilities' compliance with federal standards of care.  One issue surveyors described was the difficulty of establishing harm to residents.  The most common explanations surveyors give for their assignment of low scope and severity levels[6] to deficiencies are that the guidance from CMS is too complicated/long and lacks sufficient examples.

  • Barriers and Challenges to Conducting Surveys and Citing Deficiencies

In response to a question about barriers and challenges to citing deficiencies for anti-psychotic drug use, the largest number of surveyors identified the lack of sufficient time to conduct surveys.  As a second challenge, they describe the federal survey protocol as too long, too complex, not clear, and not specific.

  • A particular challenge for surveyors is the difficulty of challenging physicians who order antipsychotic drugs.  Surveyors described their challenge:[7]
  • "Even with nurses, physicians take offense when we question them and report to higher level staff we are trying to tell them how to practice medicine."
  • "Many doctors refuse to discuss medication reductions or reasons with surveyors."
  • "The physicians are not usually receptive to questions about why they ordered something and usually say the staff wanted it."
  • "Physicians sometimes will not return your call or will tell you they are the physician and you are just a surveyor."

Many surveyors identify pressure from supervisors not to cite antipsychotic drug deficiencies.  They report that supervisors reverse or down-code their scope and severity determinations, from harm to no-harm.  Surveyors wrote:

  • "Our office gerenally [sic] changes the scope/severity of the tag completely."
  • "I believe I try to cite at the guidelines, but the regional office that I work for seems to require more and more to support a citation.  It is never as simple enough as showing the facility failed to do something, our office has to fight and dig and dig to show a deficient practice while CMS says if you see a deficiency, site it, even if it is only for one resident. Not at our office."
  • "I included information regarding giving haldol to a resident with only dementia as a diagnosis. The supervisor said, 'what else are they suppose to use. The doctor prescribed it anyway."
  • "Sometimes seeing that enforcement throws out things you work so hard on can be discouraging."
  • "Yes, there is a lot of pressure to decrease the scope and severity of deficiencies from harm or IJ to no-harm deficiencies."
  • "It seems that we are "permitted" to cite certain citations and even if it belongs at 329 it is changed to something less severe are cited as somehting [sic] that makes the problem apppear [sic] less than it is."

To a lesser extent, surveyors cite pressures from other surveyors and facilities not to cite deficiencies, describing consultants who are brought in to intimidate surveyors, the production of documents at Informal Dispute Resolution that were not available during the survey, and attacks on surveyor credentials.

State politics are another challenge.  One surveyor wrote, "Gov appointed a Secretary very very very  nursing home friendly that stated she hated nursing home surveyors before they started the job and has stated we have too many and need to be laid off.  We are being crushed by political influence of the nursing home groups."

  • Enhanced Enforcement

Many surveyors believe that improving enforcement of federal standards would reduce the inappropriate use of antipsychotic drugs in nursing facilities.  Some cite past success in reducing physical restraints and the current Culture Change movement.[8]  Skeptics say that drug companies will not allow the reduction of drugs and that staffing levels need to be improved.

  • CMS Partnership to Improve Dementia Care in Nursing Homes

The Centers for Medicare & Medicaid Services (CMS) launched an initiative in 2012, now called the Partnership to Improve Dementia Care in Nursing Homes, to reduce the inappropriate use of antipsychotic drugs in nursing homes.[9] 

Many surveyors described positive results from the Partnership.  They said that facilities were more responsive to consultant pharmacists; that facilities increased staff training; that facilities and surveyors were more aware of antipsychotic drug issues and that reductions have already been made in inappropriate antipsychotic drug use. 

Other surveyors described negative outcomes.  They described facilities falsifying records and switching residents to other inappropriate drugs, as well as physicians remaining resistant and sometimes creating false diagnoses to justify the use of antipsychotic drugs. 

Additional concerns are the resistance of drug companies and the increasing number of residents with mental illness who live in nursing facilities. 

Still other surveyors are concerned about the nursing home industry's lack of compliance with federal standards of care, which "doesn't seem to make much difference…and won't until they are actually held ACCOUNTABLE to make changes….and citing the tags just doesn't seem to do the trick…."

A primary surveyor concern was low levels of nursing staff.  When asked if CMS should impose mandatory staffing levels on facilities as one solution, surveyors wrote:

  • "YES! It scares me how little staff is in facilities at night."
  • "Yes.  There should be some kind of staffing guideline because that is the first cut for proprietary homes."
  • "This is really the heart of the problem. There are not enough trained staff to address the residents with advanced dementia or are aggressive frightened or for the psychiatric residents who have no where else to go. If the facility at least increased the number of trained activity staff who could engage residents the nursing staff could then care for sicker residents."
  • "YES! When there is not enough staff to only do the bare minimal care needs of the residents then the team enters for the survey the facilites [sic] call everyone from all shifts so it appears that staff is good. The teams leave and so does the additional help. During the survey it appears there is plenty of staff. Staff will be tripping over each other to assist the residents. When the team leaves then they go back to counting administration nursing staff as hands on care staff for the residents. Direct care staff should be counted separated from the nursing staff not working at a hands [sic] with residents. CNA’s should not care for more than 5-6 resident’s [sic] per shift and one nurse to give medications per 25-30 residents."​
  • Job Makes a Difference

When asked whether they believe their job makes a difference, most surveyors answered in the affirmative. Some surveyors describe themselves as an extra set of eyes for facilities; others describe themselves as advocates for residents.  Many believe that survey and enforcement are critical to ensuring that residents receive the care they need. When asked to explain the positive changes they had seen, surveyors wrote:

  • "Yes, year after year we go back to [sic] and see fewer side rails, fewer inappropriate psyc meds, more homelike and resident centered [care]."
  • "Absolutely!  Have had numerous experiences related to F329 – resident's experienced weight loss, no interest in everyday life, frequent falls, etc. and after surveyor has cited F329 drug was assessed, perhaps reduced or changed.  Have seen resident's later and they don't even look like the same person."
  • "Yes – compared to what was observed from 1994 to the year of 2013 it is clear and unmistakeable [sic] , especially for  restratints [sic], drugs, pressure sores and nutrition."
  • "Yes. Over the last 14 years I have seen tremendous improvement with critical thinking and assessments.  Improved pressure sore care and management.  I used to cite weight loss and now I rarely finding [sic] a deficiency with F325."

Surveyors who are less certain that their jobs make a difference cite the fact that they see the same problems in facilities year after year as reason for their uncertainty.  Some believe that owners are more focused on money than care and that the enforcement system is too weak to bring about sustained change.  Lack of support from supervisors and the increased impact of politics are additional challenges.


The project wanted to give voice to surveyors' concerns.  Part three will discuss their solutions and ours.

For more information, contact attorney Toby S. Edelman ( in the Center for Medicare Advocacy's Washington, DC office at (202) 293-5760.

[1] See the Center's materials on antipsychotic drugs, – _ednref2.

[2] CMA Report: Examining Inappropriate Use of Antipsychotic Drugs in Nursing Facilities" (Weekly Alert, Dec. 12, 2013),
[3] The full Part Two report, 200 pages, is available at
[4] The 10 states were the seven states that the Centers for Medicare & Medicaid Services (CMS) chose – Georgia, Illinois, Massachusetts, Missouri, Oregon, Pennsylvania, and Texas.  In addition, the state survey agency directors in three additional states – Maryland, New Jersey, and Wisconsin – asked us to include their surveyors.
[5] The questionnaire is available at .
[6] 59 Fed. Reg. 56116, 56183 (Nov. 10, 1994) (final enforcement regulations).  See also State Operations Manual, Chapter 7, §7400.5.1,  (scroll down to pages 91- 93).  The grid is:




Immediate jeopardy to resident health or safety




Actual harm that is not immediate jeopardy




No actual harm with potential for more than minimal harm that is not immediate jeopardy




No actual harm with potential for minimal harm (substantial compliance)








[7] We quoted surveyors' responses as submitted and did not correct typographical errors.
[8]  A movement that seeks to create an environment for residents, which follows the residents' routines rather than those imposed by the facility; encourages appropriate assignments of staff with a team focus to make deep culture change possible; allows residents to make their own decisions; allows spontaneous activity opportunities; and encourages and allows residents to be treated as individuals.  See:
[9] CMA, "Misuse of Antipsychotic Drugs in Nursing Homes: Are We Making Any Progress?" (Weekly Alert, Nov. 15, 2013),

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