CMS Enhanced Oversight Related to Long-Stay Antipsychotic Medication Rates

Nancy Leveille and Lisa Volk in Clinical & Quality

CMS will be assessing the late adopters to reduce long stay residents’ antipsychotic medication usage. They plan to apply new financial remedies to those SNF with higher levels of antipsychotic medication usage who have been cited with survey deficiencies over time. NYSHFA recommends members assess each SNF’s QM percentage against the outlier level to determine if you meet the late adopter level. We encourage any SNF that needs assistance in improving this measure to meet with your Medical Director, Pharmacist, Social Worker, Psychologist and Nursing team to plan the best approach to potential medication reduction and elimination. There are many educational resources available to assist the team through this process. See AHCA’s announcement below for full information and resources. NYSHFA will provide more information as it becomes available about NYS SNF late adopter’s list.

Earlier this week, the Centers for Medicare & Medicaid Services (CMS) issued a memorandum, "Enhanced Oversight and Enforcement of Non-Improving Late Adopters ." This memo details additional enforcement measures for approximately 235 nursing centers that have been cited for noncompliance with federal regulations related to the use of unnecessary or psychotropic medications two or more times and have not shown improvement in their long-stay antipsychotic medication rates. Collectively, CMS refers to these providers as "late adopters." 

Highlights from the memo are:

  • CMS is encouraged that there has been a decrease in the percent of long-stay nursing center residents receiving antipsychotic medication from 23.9% in 2011 Q4 to 14.6% in 2018 Q3. In December 2017, 1,500 nursing centers were identified and notified as being late adopters, meaning the facilities had not improved their high utilization rates since 2011 Q4. CMS next intends to pursue a two-pronged approach:
    1. Enhanced oversight and enforcement action, and
    2. Outreach with corporations that own or operate a significant number of late adopter facilities.
  • CMS has identified 235 late adopter facilities that will undergo enhanced oversight and enforcement. Those 235 facilities will be broken into two groups:
    1. Group One consists of 41 late adopters with three or more prior deficiency citations for unnecessary modifications or inappropriate use of psychotropic medications since January 1, 2016.
    2. Group Two consists of 194 late adopters with two prior deficiency citations for unnecessary medications or inappropriate use of psychotropic medications since January 1, 2016.

To see more details on each group, please refer to page 3 of the memorandum.

  • The memo details enforcement actions that are possible based on a late adopter's current noncompliance determinations; enforcement actions will not be retroactive but rather based on current noncompliance determinations with the requirements specified in the memo. All late adopter facilities are also encouraged to continue focusing on reducing use of antipsychotic medications and using person-centered approaches. CMS will closely monitor progress of the remaining late adopters that are not part of the enhanced oversight.
  • State Agencies (SAs) are directed to monitor the Group One and Group Two facilities and must transfer to the Regional Offices (ROs) all cases that fit the criteria described above for enforcement.
  • CMS notes it is considering opportunities to engage with corporate chains that have a significant number of nursing centers identified as late adopters, although it does not offer additional details on this effort.
  • CMS will re-evaluate this policy in approximately one year.

AHCA has resources to support members. For example, the Antipsychotic Management Toolkit is a two-part webinar series that provides an overview of the AHCA Clinical Considerations of Antipsychotic Management Toolkit and practical application and strategies for reducing antipsychotic medication use. The Antipsychotics Consumer Fact Sheet provides family members and others involved in a resident's care background on the off-label use of antipsychotics, as well as frequently asked questions regarding loved ones living with dementia. Visit for additional resources. 

AHCA will continue to provide updates on these changes. If you have any questions, please contact Sara Rudow at


Nancy Leveille, RN, MS
Executive Director
518-462-4800 x20

Lisa Volk, RN, B.P.S., LNHA
Director, Clinical & Quality Services
518-462-4800 x15