07/24/2025

Survey Tip of the Week: Safe Medication Administration 

F-tag 880 (Infection Prevention & Control) remains the most frequently cited deficiency in Ohio, and improper injection practices is one area of noncompliance contributing to this citation. Surveyors will cite facilities when injectable medications are not prepared or administered according to infection control best practices. The Centers for Disease Control and Prevention (CDC) and CMS emphasize the importance of safe injection practices as a critical component of infection control practices. 

During medication pass observations, surveyors will be watching closely for proper technique and compliance with the following requirements. According to CMS guidance in the State Operations Manual Appendix PP, failure to comply with any of these practices may lead to additional investigation or result in a citation: 

• Injections are prepared using aseptic technique in a clean area, free from potential sources of contamination (e.g., blood, body fluids, contaminated equipment). 
• Needles and syringes are used for only one resident (this includes manufactured prefilled syringes and cartridge devices such as insulin pens).
• Medication containers are entered with a new needle and a new syringe, even when obtaining additional doses for the same resident. If noncompliance is found, further investigation is warranted. 
• Single dose (single-use) medication vials, ampules, and bags or bottles of intravenous solution are used for only one resident. 
• Medication administration tubing and connectors are used for only one resident. 
• Multi-dose vials to be used for more than one resident are kept in a centralized medication area (e.g., medication room or cart) and do not enter the immediate resident treatment area (e.g., resident room). If multi-dose vials enter the immediate resident treatment area, they should be discarded immediately after use. 

Surveyors will observe for compliance with these requirements during medication administration. Facilities should ensure staff are trained, competent, and consistently using proper technique to avoid F880 citations and, more importantly, protect residents from avoidable harm.  

Facilities should also routinely monitor compliance using the surveyor guidance outlined in the State Operations Manual Appendix PP.  Additionally, the survey pathways can be found in the Survey Resources zip file on the CMS Nursing Home webpage and under the downloads section on this CMS webpage. LeadingAge Ohio has provided survey tips to help navigate the changes in the revised QSO-25-14- NH memo.  The previously provided survey tips can be accessed on the LeadingAge Ohio webpage under the Communications tab, then The Source tab. CMS has updated the survey resources on the CMS Nursing Home webpage in accordance with the revised QSO-25-14- NH memo. LeadingAge has developed webinars and resources on the requirements of participation which are located on the LeadingAge learning hub. LeadingAge continues to add QuickCasts on the regulatory groups. Updated resources have also been added on the Nursing Home RoP Tools and Resources webpage.  

For more information about the requirements of participation and citations occurring in Ohio, please join us on the monthly STAT: Survey Tips and Tactics call. Register now for the August 13 call at 11:00AM. LeadingAge Ohio is sharing tips to assist members during the survey process. Send questions you would like addressed in future Tips of the Week to Stephanie DeWees at sdewees@leadingageohio.org.