CMS Revises Medication Pass Survey Protocol, Recognizes Terminal Ulcer in LTCHs

July 19, 2013 | Aging Services Risk, Quality, & Safety Guidance

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​The Centers for Medicare and Medicaid Services (CMS) has revised the protocol for the traditional survey for observing medication passes, as described in a June 7, 2013, letter to survey agency directors. Surveyors must now observe a minimum of 25 medication administration opportunities to calculate the organization’s medication error rate. According to the letter, a minimum number is specified because it is acceptable to include more than 25 observations to capture multiple routes, times, and staff members. The requirement to observe for another 20 to 25 opportunities if errors are detected in the first 20 to 25 observations has been eliminated. The letter includes revisions to the interpretive guidelines for surveyors and a new form that surveyors will use to conduct the medication observation.

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