Navigating Phase II of the RoP: Pharmacy Implications 101

Even though Phase II went into effect back on Nov. 28, 2017, the new RoP still presents a considerable challenge for facilities—especially when, as a provider, it’s just a small piece of what you deal with on a day-day-day basis. As the complexity grows and the stakes increase, a strong pharmacy partner can help you not only comply with the requirements, but set yourselves apart from the competition.

We’re now two months into this transitional time, but it’s never too late to develop and refine systems and processes that not only meet the new requirements, but improve care for those we serve. Here’s a high-level overview of the primary pharmacy implications of Phase II, and some ways we’re working with our clients to navigate them.

Implementation confusion

The CMS announcement that they were going to delay some of the Phase II civil money penalties needs to be clarified. While indeed some penalties were delayed, the Nov. 28, 2017 implementation of Phase II was not, so facilities can still be cited.

Regulation vs. guidance

It’s very important that providers remember they can only be cited on the regulation, not the interpretive guidance. I find that’s a concept that’s often not well understood, so it’s very important for facilities to work with experts who know the difference well and can help guide them.

Redefining psychotropics

CMS has opened up the definition for psychotropic drug to now include all medications that affect brain activities associated with mental process and behavior. So now it’s not just the traditional psychotropics, but also includes many other classes of meds, such as anti-seizure and antihistamines. CMS excludes opioids from this definition.


CMS is requesting that PRN (as needed) orders for psychotropic drugs be limited to 14 days. The prescriber can extend that order, but they must document the rationale in the medical record, and indicate the duration. PRN antipsychotics require an evaluation to extend the order past 14 days.


With Phase II, facilities must have an initial Quality Assurance and Process Improvement (QAPI) plan in place, and be prepared to show it to a surveyor. As you’re developing your QAPI team, remember to include your consultant pharmacist. As I tell our Consonus pharmacists, “If the facility hasn’t invited you, invite yourselves!” It’s that important.

Antibiotic stewardship

Phase II requires that a facility have antibiotic protocols in place, and a system to monitor antibiotic use. There’s so much literature and so many tools and resources out there, that it’s easy for facilities to become paralyzed, but I encourage them to follow the basic Centers for Disease Control (CDC) Core Elements, and start small.

For our Consonus clients, we help break it down and keep it as simple as possible to get acceptable policies in place, and once again the pharmacist is an indispensable partner on the interdisciplinary team to get this done. We also do a lot of Trusted Adviser presentations at national and state conferences to help facilities through this, and I participated in a CDC long-term care workgroup on antibiotic stewardship. It’s exciting to be helping define how the CDC will continue to give guidance to the long-term care profession in this important area.

Medication crushing

This one got a lot of nurses really riled up. Survey guidance states that the best practice is to separately crush and administer oral meds one by one, but as we all know, nurses are very busy during med passes and rightly wonder how they’ll have the time to do that. But if we keep the process person-centered and individual, we know that separately crushed meds may not be appropriate for all. So let patient safety, needs and preferences and functional ability drive the process.

At Consonus, this is an opportunity we’re using to help our clients identify areas where nurses can save time. For instance, we’ve been pointing out for several years that the use of sliding scale insulin is no longer best practice. It takes a lot of extra time to do finger sticks four times a day, so we work with them to do better diabetes better management, which yields efficiencies.

This is also a great opportunity to get rid of unnecessary meds, and med pass consolidation can be another big time-saver. If meds are now given three times a day, is there a formulation for once a day? Are some of the meds being crushed available in liquid formulations?

New survey process

There’s a new survey process now that applies to all states, and at least two key areas relate especially to pharmacy—the med pass and unnecessary medications. There is particular focus on high risk medications, which include anticoagulants, diabetic meds, cardiac meds and opioids for pain, so make sure you have a system around safety with these medications. This is where the survey is dialed in, and for good reason—to prevent adverse drug events around high-risk meds.


Finally, as you put processes into place to deal with the pharmacy implications of Phase II, it’s also a great time to go back and reevaluate systems that were developed for Phase I. Gather your team, (along with your consultant pharmacist, of course) and ensure these processes are working as intended, making fine-tuning adjustments where necessary. Two areas should get particular attention:

1. Pharmacist reports

Starting in Phase I, facilities needed to have policies in place to identify time frames for the different steps in the Medication Regimen Review (MRR) process, including follow-up on medication irregularities. Since we’re now in Phase II, that system should be reevaluated to make sure it’s working like a well-oiled machine.

2. Interim medication review process

Also emphasized in Phase I was the importance of having an interim MRR process, so this is a good time for facilities to ensure they know what that process is and are using it. When a new admit comes in or a current resident has a change of condition, what’s the process for notifying the pharmacy that they need a review in between consultant visits?


That’s my quick Pharmacy Implications 101 overview of the new RoP, and Consonus is working with our clients to navigate the uncertainty. We’re helping them update their Policies and Procedures, and refine and monitor the MRR process. We’re making sure consultant pharmacists are included in QAPI meetings, and as part of antimicrobial stewardship teams. We’re acting as a trusted adviser to everybody, across the board—from physicians and nurses to residents and families.

Most importantly, your surveys are our surveys. Our clients call us when the survey team is in the building, and through our knowledge and depth of experience we’re able to offer critical support. With every phase of the RoP, the challenge for facilities becomes greater, and they’re looking to Consonus as their pharmacy partner even more. It’s exciting and gratifying to be able to lift some of their burden.


Terri Fagan is a certified geriatric pharmacist with more than 20 years of long-term care pharmacy experience. She’s director of clinical services at Consonus Pharmacy, where she leads a team of 25 consultant pharmacists serving 325 facilities in five states.