This comment is being made regarding changes to 18VAC110-20-240 subsection C clarifying that chart order used in long term care facilities must include a quantity or duration of therapy.  As a general rule, the current pharmacy practice for the skilled nursing setting uses chart orders in the form of 1) admission order/MD Plan of Care, or 2) individual chart orders (verbal orders). Most often the nurse contacts the Physician verbally to receive admission orders.

When the pharmacy dispenses the medications, the qty is generally driven by the payor source; shortened days supply for Medicare Part A Skilled residents and a full month supply for Medicare Part D or third party payer residents.  Continual clinical oversight for medications is routinely occuring in the skilled facility settings.  The skilled facility resident has licensed nursees monitoring the patients and there is a Consultant RPh reviewing medications monthly.  The Physician also performs routine reviews through the recertification process (which could be monthly, every 3 or every 6 months) which are sent to the pharmacy with the physician signature once he has completed the review.  The medication order is considered an active order until the pharmacy receives an order to modify or discontinue the order, or the patient is discharged from the LTC setting.

If this revision is adopted, admission orders received in the pharmacy without a qty or duration stipulated, will result in a delay of processing the medications until the requirements are met.  The same would be true for ongoing orders or if new or changed orders were sent to the pharmcy without requirements.  This has the potential to significantly delay therapy to residents, whom may have just been discharged from the hospital.  This not only has the potential for significant harm to the patients, but it also has implications for the facility in regards to Federal CMS regulations specifically the following Federal Tags:  F425 (Medication Availability is a recurring issues), F332 (Charting omissions/Med Errors per documetation/audit).  This may also effect the CMS reimbursement and Five-Star Quality program ratings for the facility.

I would request that the board continue to allow Long Term Care pharmacies the use of chart orders without the requirement of quantity or duration of therapy, like hospitals and hospice programs, whom we are currently not facing this change.  If you have any additional questions, please do not hesitate to contact me.