Nationwide analysis of nursing home antipsychotic use on the way

https://www.mcknights.com/news/nationwide-analysis-of-nursing-home-antipsychotic-use-on-the-way/

A federal watchdog is promising a nationwide analysis of antipsychotic use in nursing homes, following a small-scale audit that found medical directors were inappropriately diagnosing residents with schizophrenia to “mask” the misuse of such medications.

The Department of Health and Human Services Office of Inspector General on Monday announced the new project, which is scheduled for completion in fiscal year 2028.

“The overuse of antipsychotic drugs presents a risk to nursing home residents, particularly those with dementia. These drugs are not approved to treat dementia, and the Food and Drug Administration has warned that they may increase the risk of death for these individuals,” the agency said in a workplan update.

“We will conduct a nationwide analysis to determine the extent of antipsychotic drug use among Medicare beneficiaries in nursing homes, including the extent to which those beneficiaries had a dementia diagnosis.”

In March, OIG published two reports based on reviews of inspection data from 40 nursing homes over a three-year period. They were a public rebuke of those nursing homes’ practices, with authors saying facilities were “skirt[ing] Medicare safeguards intended to protect residents” and “compromised residents’ care.” 

“During those inspections, surveyors identified cases in which they felt that residents with dementia were given antipsychotics for staff convenience rather than clinical need,” explained Alicia Cantinieri, managing director of clinical reimbursement and regulatory compliance at Zimmet Healthcare Services Group.

That smaller report followed and “reinforced” changes that the Centers for Medicare & Medicaid Services had already made by launching a series of punishing MDS schizophrenia audits. The State Operations Manual was revised to strengthen tags F-605, F-658, F-757 and F-758, and CMS changed how it calculates it Long-Stay Antipsychotic Measure.

Should they stay or should they go?

Cantinieri told McKnight’s Long-Term Care News Tuesday that it’s too soon to predict how future findings will influence evolving CMS strategy on the use of antipsychotics. The agency has pushed for reductions at the provider level since 2012, always tying its emphasis back to quality of care for nursing home residents living with dementia.

But in recent years, medications have continued to evolve without review of their “black box” warnings or exemptions of new drugs being designed specifically for patients with dementia and other conditions commonly treated in nursing homes.

One report published last fall argued that the CMS antipsychotic quality measure is discouraging use of needed medications. Outside of nursing homes, certain antipsychotics are used frequently to help ease distressing neuropsychiatric symptoms that affect 97% of patients with Alzheimer’s disease.

Providers and pharmacists across the country have bemoaned the tension between a quality measure that strictly discourages the use of antipsychotics, the knowledge that agitation and other quality-of-life issues are often resolved by careful prescribing, and even family members who want their loved ones on the same drugs they took before entering the nursing home.

Congress last year encouraged CMS to review its strong stance against antipsychotics, which the agency acknowledged it was doing this March “with the goal of supporting clinically indicated use while continuing to discourage inappropriate prescribing.”

That confirmation came just days before the explosive OIG findings, based on data collected from 2018 to 2021.

Cantinieri said the results of the new analysis will largely depend on which years the OIG team includes in its next data set.

MDS schizophrenia audits began in 2023,  with surveyor guidance changes coming in November 2024. Some providers are still being selected for their first schizophrenia audits, while others are being re-audited after failing earlier and having their star-ratings suppressed.

In addition, CMS announced a revamped long-stay antipsychotic measure in June 2025, with changes in calculations spiking the national average earlier this year. Canitnieri said data collected after that point would provide a “meaningful assessment” of those strategies.

“Overall, the industry will hopefully show some improvement since CMS adopted these changes,” she wrote in an email. “History does point to potential changes as a result of OIG Work Plan Projects that identify potential gaps in oversight, compliance or quality of care. They tend to lead to updated regulations, audits and recent revisions to quality measures.”