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 No psychoactive drug used for discipline or staff convenience that isn't required to treat the resident's assessed medical symptoms; psychotropics tied to a documented diagnosis; PRN time limits observed; GDR attempted or clinically justified as contraindicated.

• 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
• 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 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