Regulations and Guidelines on Antipsychotic Use in Long-Term Care

Antipsychotic medication use continues to be one of the most closely scrutinized areas in long-term care. Surveyors, regulators, and families expect facilities to demonstrate thoughtful clinical decision making, strong documentation, and a clear commitment to person-centered care. While these medications may be appropriate in limited circumstances, inappropriate or unsupported use places residents at risk and exposes facilities to serious regulatory consequences.

CMS has maintained a sustained focus on reducing unnecessary antipsychotic use for more than a decade, and enforcement expectations remain firm. Facilities are expected to show not only that regulatory boxes are checked, but that systems are in place to support safe prescribing, ongoing reassessment, and alternatives to medication whenever possible.

Antipsychotic oversight is primarily evaluated under F758 (Unnecessary Psychotropic Meds), with supporting expectations related to gradual dose reduction, adverse consequences, and when staffing or competency gaps contribute to inappropriate medication use.

Why Antipsychotic Oversight Remains a Priority

Antipsychotic medications are not FDA approved for the treatment of dementia-related behaviors, yet they have historically been used to manage agitation, aggression, and other behavioral expressions. Research has consistently shown increased risks, including falls, stroke, cognitive decline, and mortality. These risks, paired with concerns about quality of life, continue to drive CMS oversight.

Noncompliance in this area can result in:

• Survey citations and enforcement actions
• Civil monetary penalties and directed plans of correction
• Declines in Five-Star Quality Ratings
• Increased liability exposure
• Loss of trust with residents and families

Strong antipsychotic management is no longer viewed as a pharmacy issue alone. It reflects the facility’s overall clinical leadership, interdisciplinary collaboration, and commitment to resident-centered care.

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CMS Expectations for Antipsychotic Use

National Partnership to Improve Dementia Care

CMS launched the National Partnership to Improve Dementia Care to reduce unnecessary antipsychotic use and promote non-pharmacological approaches. Facilities are expected to actively monitor prescribing patterns, implement behavioral interventions, and demonstrate measurable efforts to reduce reliance on medications when clinically appropriate.

Antipsychotic use remains publicly reported and directly impacts Five-Star Quality Ratings, keeping this issue visible to consumers, referral partners, and regulators.

Psychotropic Medication Requirements and Survey Focus

Surveyors evaluate whether residents are free from unnecessary psychotropic medications unless there is a clear clinical justification. During surveys, facilities are expected to demonstrate:

• A documented diagnosis that supports antipsychotic use
• Evidence that non-pharmacological interventions were attempted and evaluated
• Clear informed consent from the resident or representative
• Ongoing monitoring for effectiveness and adverse effects
• Compliance with gradual dose reduction requirements

Surveyors often review clinical records, interview staff, and speak with residents or families to confirm that documentation reflects actual practice.

CMS recognizes that antipsychotics may be clinically appropriate for residents with specific psychiatric diagnoses or severe behavioral symptoms that pose a danger to the resident or others. In these cases, facilities must clearly document the diagnosis, clinical rationale, risk-benefit analysis, and failure of non-pharmacological interventions.

Gradual Dose Reduction Expectations

Facilities must routinely assess whether antipsychotic medications can be reduced or discontinued. CMS expects:

• Two gradual dose reduction attempts within the first year of treatment unless clinically contraindicated
• Annual attempts after the first year
• Clear physician documentation when dose reduction is not appropriate

Failure to attempt or properly document gradual dose reduction remains a frequent survey citation.

Informed Consent and Resident Rights

Informed consent is a critical component of antipsychotic compliance. Facilities must ensure residents and their representatives understand why the medication is prescribed, potential risks, and available alternatives. Surveyors often validate this through interviews, not just chart review. Documentation must reflect ongoing communication, not a one-time signature.

Quality Measures and Public Reporting

Antipsychotic use continues to influence quality measure calculations and Five-Star Ratings. Higher rates of use can negatively affect public perception, referral patterns, and reimbursement opportunities. Reducing unnecessary use supports both regulatory compliance and long-term sustainability.

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State-Level Oversight

Many states have implemented additional requirements related to psychotropic medication use. These may include enhanced pharmacist reviews, additional behavioral documentation, or staff training requirements. Facilities are expected to understand both federal and state-specific expectations and integrate them into daily practice.

Building a Sustainable Compliance Approach

Facilities that perform well in this area tend to share common practices:

• Routine internal audits of psychotropic use and documentation
• Strong interdisciplinary involvement, including nursing, pharmacy, medical providers, and social services
• Staff education focused on behavior tracking and non-drug interventions
• Consistent care planning that reflects resident preferences and needs

Qsource works with facilities to strengthen these systems through mock surveys, targeted audits, documentation reviews, and practical guidance that reflects real survey outcomes. Support is designed to help teams move beyond reactive compliance and build sustainable processes that protect residents and reduce regulatory risk through QAPI intiatives.

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Moving Forward with Confidence

Antipsychotic oversight is not a passing regulatory trend. It remains a core measure of quality, safety, and person-centered care in long-term care settings. Facilities that prioritize documentation integrity, interdisciplinary collaboration, and meaningful alternatives to medication are better positioned for survey success and improved resident outcomes.

With the right structure, education, and support, compliance in this area becomes a strength rather than a vulnerability.