Paper narc books, efficiency, and OIG investigations

The following is an opinion piece by Dr. Michael Peppers, our in-house pharmacy consultant:

The Office of Inspector General has stated that an investigation examining possible opioid overuse, misuse, or diversion in nursing homes will begin in 2027. This investigation will probably use the CMS Survey process to begin increased scrutiny of opioid use in patients that are prescribed such.

This is consistent with broader federal enforcement priorities involving opioids, including diversion cases prosecuted by the Drug Enforcement Administration (DEA) and program integrity reviews affecting facilities reimbursed by the Centers for Medicare & Medicaid Services (CMS).

This may require multiple levels of oversight for controlled substance dispensing, receiving into the nursing home, storing, protecting against theft and diversion, documenting use with appropriate follow up after administration on the nursing side, and increased pharmacist oversight into the tracking from the point of dispensing to the point of patient administration. The following points are likely targets:

1. Prescribing patterns and duration of therapy

2. Documentation of indication and functional benefit

3. Pharmacy consultant oversight

4. Facility-level diversion prevention systems

5. State survey agency monitoring processes

6. Potential billing implications under Medicare and Medicaid

Additionally, the home and consultant pharmacist will need to assess for non-use as much as they assess for needed use. Doing so will require extreme efficiency. If using paper controlled substance logs, efficiency will become a major issue. Electronic tracking allows for multi-level oversight at each step along the path for controlled substance monitoring in real time vs only when a consultant pharmacist is in the building. Combining the online electronic monitoring of drug tracking and administration along with the electronic MAR, this process can become very efficient so that all potential diversion, misuse, abuse, and overprescribing can be minimized.