The SNF F-Tag Readiness Checklist

What surveyors look for A licensed pharmacist reviewed each resident's regimen at least monthly; irregularities were reported in writing to the attending physician and the DON / Medical Director; each report was acted on.

• A dated monthly DRR by a licensed pharmacist for every resident, including new admits and short-stays
• Each irregularity report delivered to both the attending physician and the DON
• The prescriber's documented response (accept / reject with rationale) to every flagged irregularity
• Loop closure — unresolved irregularities escalated to the Medical Director
• A date-stamped audit trail connecting flag → report → response for a given month

What surveyors look for Each drug is free of the five triggers — excessive dose (incl. duplicate therapy), excessive duration, inadequate monitoring, inadequate indication, or adverse consequences.

• A documented clinical indication for use for every active medication
• Stop / review dates for time-limited drugs (antibiotics, PPIs, opioids, hypnotics)
• Monitoring parameters / labs for high-risk drugs (anticoagulants, antiepileptics, diuretics)
• A duplicate-therapy / drug-drug interaction screen consistent with Beers / STOPP
• Taper or discontinuation rationale where duration exceeds evidence-based norms

What surveyors look for Psychotropics tied to a documented diagnosis; PRN time limits observed; GDR attempted or clinically justified as contraindicated.

• A PRN psychotropic order ≤14 days, extended only with documented rationale and a defined duration
• PRN antipsychotic orders ≤14 days not renewed without a prescriber in-person evaluation
• A GDR attempt in two separate quarters in the first year (then annually), or a contraindicated rationale
• The documented target symptom, diagnosis, and non-pharmacologic interventions tried
• Informed consent / risk discussion for antipsychotic use where policy requires it

What surveyors look for No psychoactive drug used for discipline or staff convenience that isn't required to treat the resident's assessed medical symptoms.

• The medical symptom each psychoactive drug is treating (not a behavior that inconveniences staff)
• The drug is at the lowest effective dose with a monitored response
• Non-pharmacologic approaches attempted before / alongside the drug
• The consultant pharmacist flag where a regimen appeared to function as a chemical restraint, plus the provider response

What surveyors look for An antibiotic stewardship program within the Infection Prevention & Control Program — use protocols, tracking, and a review / feedback loop.

• Written antibiotic-use protocols (e.g., McGeer / Loeb minimum criteria) in the decision trail
• Indication, dose, duration, and a stop / review date for each antibiotic start
• Culture / sensitivity-driven de-escalation, or a documented rationale for empiric continuation
• The pharmacist's stewardship review and feedback to prescribers