Spotlight on CMS F-Tag F755; Pharmacy Services Deficiencies

Pharmacy Services Deficiencies F755

F755 is a pharmacy services deficiency that can be given to long term care facilities based upon a few different factors.  First let’s start with the formal language. This is directly from CMS regulations: the F755 requirement is defined as;

  1. “The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement “
    • This seems pretty straight forward, the long term care facility simply has to provide medications to the residents of the facility.  Where I’ve seen this go awry, is situations where prior authorizations or specialty drugs are ordered, but it takes a while to receive.  Another situation involving a resident not getting their medication is drug shortages.  LTC facilities can’t miraculously invent medications, however, what surveyors are typically looking for is some sort of action by staff that demonstrates something was done about the medication not being available.  (i.e. contacting the prescriber for an alternative or further direction on whether it is essential to the resident to have a medication right away or if it could wait until the medication arrives).
  2. “The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.”
    • This one unfortunately comes down to knowing state laws and scope of practice for aides and unlicensed personnel.  If you aren’t sure on what can and can’t be done by your staff, I would definitely encourage contacting the board of nursing or possibly the department of health in your state.  In my experience, some state agencies are more helpful than others in giving guidance.  I honestly haven’t seen many F755 deficiencies given for this which lends me to believe that most facilities have an understand of the role of nursing aids and what they can and can’t do.
  3. “Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.”
    • In situations where drugs are not getting to the facility in an accurate manner from a dispensing pharmacy, the facility is probably more likely to find a different pharmacy.  There is a possibility that a deficiency could be given for inappropriate administration procedures.  If we aren’t following appropriate administration procedures, F755 could be cited under this section.
  4. “Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who— “
  5. “Provides consultation on all aspects of the provision of pharmacy services in the facility.”
    • This is really a catch all and usually many policies pertaining to medications are reviewed periodically at various meetings, or more likely if there is a concern noted with a current policy or procedure.  I’ve often been the mediator and educator when there is a dispute between staff in what would be a best practice for a given facility.
  6. “Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation;”
    • Notice how there is no requirements spelled out here as to how you need to document receipt.  A system needs to be in place to track controlled substances and keep an accurate count.
  7. “Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.”
    • Again with slightly more detail about controlled substances in referring to accountability of controlled drugs and that we do have to reconcile (or count) medications to make sure that we do not have diversion or significant loss of medication.  Often, I have seen facilities get deficiencies for not following their own policy in regards to tracking and accounting for controlled substances (i.e. not having two staff members sign off, inappropriate disposal of fentanyl patches, etc.)

I think that sums up the basics of F755.  This is definitely a tag that does get cited and I would say from my experience, most often it is due to not following policies and procedures.  In my recent review of 47 facilities, here’s an image with how often F755 occurred in comparison to other pharmacy services tags;

If you would like more examples of pharmacy services deficiencies, you can check out my free webinar and PDF – simply subscribing to the blog by email will get you access!

Eric Christianson, PharmD, BCGP, BCPS



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