I. Executive Summary: DRR as a Cornerstone of LTC Quality

The implementation of the Drug Regimen Review (DRR) mandate stands as a defining moment in the history of quality assurance within United States long-term care facilities (LTCFs). Instituted primarily through the Omnibus Budget Reconciliation Act of 1987 (OBRA-87), the DRR was a critical legislative response to widespread reports of medication misuse, excessive polypharmacy, and the routine reliance on pharmacologic agents, particularly psychotropic drugs, as chemical restraints. The mandate established a necessary external audit function performed by licensed consultant pharmacists.

The DRR required a fundamental shift in pharmaceutical governance, moving the standard of care from facility-centric compliance—merely managing drug supplies and basic dispensing—to resident-centric outcomes, focusing on the appropriate use and minimization of adverse consequences.¹ This paradigm shift, codified under federal regulations (currently 42 CFR ) and enforced through the Centers for Medicare & Medicaid Services (CMS) F-tags (specifically F756 and F757), remains the foundational mechanism for ensuring pharmaceutical safety in nursing homes today. While initially designed as a necessary retrospective compliance measure, the DRR has since spurred the development of more proactive, clinically integrated models of medication management, underscoring its role as the essential regulatory baseline from which all subsequent quality improvements have developed.

II. The Pre-Regulatory Landscape and the Catalyst for Reform

The environment of long-term care prior to 1987 was characterized by significant regulatory gaps and documented failures in quality of care, setting the stage for radical legislative intervention.

A. Nursing Home Quality Standards Before 1987

Before the passage of OBRA-87, federal standards governing nursing home operations were demonstrably deficient. Regulatory efforts at the time focused heavily on administrative and procedural adherence—a system commonly described as “paper compliance”.² This approach often lacked meaningful measures of actual resident health, safety, and quality of life. The consequence of this narrow focus was that compliance mechanisms were frequently ineffective, failing to curb widespread poor practice because enforcement was either difficult or habitually ignored by facilities.²

This flawed framework contributed to institutional inertia, where the focus remained on process documentation rather than clinical outcomes. The failure of pre-OBRA oversight to enforce standards related to care quality meant that practices detrimental to the resident’s well-being, such as excessive sedation or the routine use of restraints, were permitted to persist unchallenged at a systemic level.

B. Documented Deficiencies in Medication Management

The most significant driver for the OBRA reforms, particularly the DRR, was the crisis related to medication use. High rates of inappropriate drug prescribing, especially concerning psychotropic drugs, were documented widely and highlighted the danger of unrestrained institutional prescribing.² These medications, intended to manage psychiatric symptoms, were frequently misused as chemical restraints for the convenience of staff, rather than as therapeutic interventions based on clinical necessity.

This endemic problem indicated that inappropriate medication use was not an isolated issue but a systemic failure of prescribing and oversight. The intensity and specificity of the drug mandates introduced in OBRA-87, later codified in regulations concerning “unnecessary drugs” (42 CFR (d)) and specialized rules for psychotropic agents (42 CFR (e)) ³, explicitly targeted this pre-existing crisis. The DRR was legislated as the mandatory systemic check—an external safeguard designed to identify and force the correction of these widespread failures in care management.²

III. The Genesis of the Mandate: OBRA-87 and the Institutionalization of DRR

The 1987 Omnibus Budget Reconciliation Act (OBRA-87) fundamentally reformed the regulation of nursing homes, placing the DRR at the core of its pharmaceutical services requirements.

A. The Omnibus Budget Reconciliation Act of 1987 (OBRA-87) Reforms

OBRA-87 introduced sweeping, comprehensive reforms across the long-term care industry, specifically designed to ensure the well-being and safety of frail, elderly residents.² The law achieved a paradigm shift by elevating patient rights and the quality of life to equal standing with the quality of medical care.² Central to this regulatory overhaul was the mandate for facilities to ensure the “maximum possible functioning” for each resident, setting an outcome-oriented standard for care delivery.² Beyond clinical standards, OBRA-87 also instituted enforcement laws, providing regulatory bodies with mechanisms for swiftly dealing with facilities found to be non-compliant.²

B. Statutory Implementation and Codification

The specific requirements regarding pharmaceutical services, including the DRR, were formally codified in federal law as conditions of participation for the Medicare and Medicaid programs, primarily located under 42 CFR  (Pharmacy Services).³ While the OBRA provisions became federal law on October 1, 1990, delays in issuing the necessary regulations meant the actual implementation of the required standardized assessment system, the Resident Assessment Instrument (RAI), and related DRR processes occurred during the spring of 1991.⁶

C. Defining the Scope, Frequency, and Professional Obligation

The core requirement of the DRR mandate is explicitly defined: the drug regimen of every resident must be reviewed at least once a month by a licensed pharmacist (F756).¹ The objective of this mandatory review is clinical—to minimize or prevent adverse consequences (defined as unpleasant symptoms or events associated with a medication, including adverse drug reactions and interactions) and to prevent residents from receiving unnecessary drugs.¹

The pharmacist fulfills this role by reviewing the resident’s comprehensive assessment information, identifying irregularities, potential adverse drug consequences, and syndromes potentially related to medication therapy.¹ Crucially, the mandate enforces accountability by requiring the licensed pharmacist to report any identified irregularities in writing to three key figures within the facility: the attending physician, the facility’s medical director, and the director of nursing.¹ This written report necessitates follow-up action by the facility leadership.

Furthermore, the DRR is intrinsically linked to the overall resident assessment process. A comprehensive assessment must be conducted promptly upon admission (within 14 days), following any significant change in the resident’s physical or mental condition, and in no case less often than once every  months.⁷ The pharmacist leverages the comprehensive assessment data to inform their monthly review, ensuring the drug regimen aligns with the resident’s current clinical status and care plan.⁶

The immediate legislative reaction to quality failure was to impose this mechanism of external monitoring—the consultant pharmacist’s monthly review and mandatory reporting. This regulatory design acknowledged the potential for internal conflicts of interest or institutional inertia to lead to poor prescribing practices. By requiring a review by an external, licensed professional ⁵ and demanding that written reports of problems be delivered to the facility’s key medical and nursing leadership ¹, the law structurally outsourced oversight. This process ensured a mandatory paper trail existed to force accountability and decision-making by the facility’s administration regarding identified medication irregularities.⁸

Table 1: Key Legislative Milestones Governing Drug Regimen Review

Legislation/Regulation	Year Enacted	Primary DRR Requirement	Impact/Significance
Pre-OBRA Standards	Prior to 1987	Focus on dispensing, minimal clinical oversight	Led to systemic quality failure, focus on paperwork 2
OBRA 1987 (P.L. 100-203)	1987 (Effective 1990/91)	Mandatory monthly DRR by licensed pharmacist for every resident	Revolutionized quality standards; foundational for all subsequent requirements 2
42 CFR	Post-1987	Codifies monthly DRR (F756), unnecessary drug standards (F757), and psychotropic control (F605/F757)	Federal condition of participation for Medicare/Medicaid 3
OBRA 1990 (ProDUR)	1990	Mandates Prospective Drug Use Review (ProDUR) and patient counseling (Retail/Medicaid)	Established the superiority of prospective review outside LTC 9
CMS Mega Rule Revisions	2016	Reorganized F-Tags (F428  F756/F757/F605) and updated surveyor guidance (CEP)	Increased regulatory specificity and heightened scrutiny on unnecessary drugs 11

IV. The Initial Impact and Practice Evolution (1990s)

Following its implementation, the DRR, combined with other mandates of OBRA-87, demonstrated immediate and measurable positive effects on resident care quality.

A. Documented Improvements in Clinical Outcomes

The implementation of OBRA-87’s nursing home regulations was directly associated with significant, positive clinical changes across the long-term care industry.² The legislation was highly effective in achieving its primary target: reducing the use of specific drug classes.¹³ Notably, the use of psychotropic drugs and physical restraints declined substantially.² Furthermore, objective measures indicated broader quality improvement, including decreased hospitalization rates and improved physical functioning among residents.² Beyond these direct benefits, the legislative action served as a potent, though unanticipated, stimulus to research in geriatric pharmacotherapy and nursing home care.¹³

B. Integration of DRR and Standardized Assessment

A critical component of the early success was the regulatory requirement for the mandatory use of the standardized, comprehensive Resident Assessment Instrument (RAI).⁶ This system was designed to assist in objective assessment and care planning. The DRR process relies heavily on this comprehensive assessment information ¹, ensuring the pharmacist’s review is directly linked to objective clinical data collected via the Minimum Data Set (MDS).

The effectiveness of the DRR mandate cannot be viewed in isolation; its success was derived from its necessary synergy with the other comprehensive OBRA reforms. By requiring standardized data collection (RAI/MDS) ⁶ and combining that with an explicit mandate for improved resident outcomes (“maximum possible functioning”) ², a crucial closed loop was created: assessment identifies needs, the DRR ensures medication aligns with those needs, and facility staff are compelled to comply with the outcome goal. This combination drove holistic quality improvement.

C. The Challenge of Retrospective Review and OBRA-90

The foundational structure of the federally mandated DRR dictates that it is a retrospective review of a patient’s medications, focusing on identifying problems that have already occurred.⁹ While effective in correcting historical prescribing failures, this design presented a limitation when contrasted with evolving standards of community pharmacy practice.

In 1990, the separate Omnibus Budget Reconciliation Act of 1990 (OBRA-90) expanded the pharmacist’s role in the retail and institutional (non-LTC) settings, particularly through the Medicaid program.⁹ OBRA-90 mandated that pharmacists perform prospective drug use review (ProDUR), offer patient counseling, and maintain detailed patient medication records (PMRs).⁹ ProDUR involves actively examining the PMR to determine if potential conflicts—such as over/under utilization, therapeutic duplication, drug-drug or drug-allergy interactions, or incorrect dosage—exist before the prescription is dispensed or refilled.¹⁰

This simultaneous development of separate mandates—OBRA-87 imposing a mandatory, retrospective review in LTC and OBRA-90 establishing a prospective, preventative model in the community—created a structural dichotomy in pharmaceutical quality assurance. The DRR came to be seen as a necessary compliance barrier, whereas the ProDUR model (and its descendants, MTM) represented an optimal clinical strategy, highlighting the inherent limitation of the LTC retrospective model.

V. Regulatory Enforcement: The Evolution of CMS F-Tags

The enforcement of the DRR mandate relies on the federal survey process conducted by CMS, which identifies deficiencies using the F-tag system. The evolution of these tags reflects a growing regulatory sophistication and an increased focus on clinical outcomes.

A. The CMS Survey Process and Deficiency Identification

Federal regulations governing nursing homes are identified and enforced through the F-tag system, where “F” designates the federal standard.¹⁴ Surveyors utilize these assigned numbers to document when a facility fails to meet a given standard on the Statement of Deficiencies.¹⁴ Historically, the primary tag encompassing all aspects of pharmacy services and the monthly DRR compliance was F428.

B. The 2016 CMS Mega Rule Revisions: Enhanced Specificity

The implementation of the comprehensive revision of the Requirements of Participation (known as the Mega Rule) in 2016 resulted in a significant reorganization of 42 CFR Part 483, leading to the strategic disaggregation of the F428 requirements into more specific tags.¹² This reorganization targeted the core components of the DRR, allowing for more nuanced citations:

1. F756 (Drug Regimen Review): This tag addresses the adherence to the monthly review process as mandated by 42 CFR (c)(1).³ A citation here typically signifies a failure to ensure the licensed pharmacist conducts the review with the required frequency or adequacy.
2. F757 (Unnecessary Drugs—General): This tag addresses the clinical outcome of the review process, enforcing the standard that “Each resident’s drug regimen must be free from unnecessary drugs,” as detailed in 42 CFR (d).³ Critically, the guidance for F757 was subsequently revised to focus primarily on non-psychotropic medications, indicating a segregation of investigative elements based on drug class.¹¹
3. F605 (Right to be Free from Chemical Restraints): This tag enforces the rules against using psychotropic medications for chemical restraint (42 CFR (a)(2)).¹⁶ Given the historical context of OBRA-87, this remains a high-severity citation area and is intrinsically linked to the DRR, often triggering a specific investigation alongside F757 concerning psychotropic agents.

C. Investigative Protocols and Surveyor Guidance

To ensure consistent enforcement, CMS utilizes specialized investigative tools, such as the Unnecessary Medications/Medication Regimen Review Critical Element Pathway (CEP).¹¹ The CEP is designed to guide surveyors in determining whether facility practices are robust enough to identify, evaluate, and appropriately intervene regarding potential or actual unnecessary medications.¹⁷

A crucial element of the surveyor investigation involves interviewing facility leadership. Surveyors routinely question the attending physician, medical director, and director of nursing regarding their compliance with F756 and F757. These interviews specifically address whether facility leadership received the pharmacist’s written report of irregularities and what actions, including attempts at gradual dose reduction (GDRs) for psychotropic medications, were taken in response.⁸ If a medication change was not made, the rationale must be documented.⁸

The shift from the singular F428 to the specialized tags F756, F757, and F605 represents a move toward a hyper-specific, audit-ready enforcement system. By decoupling the process of the monthly review (F756) from the resultant clinical outcome (F757/F605), CMS raised the standard of compliance. A facility can now be cited for F757 (unnecessary drugs persist) or F605 (chemical restraints used inappropriately) even if the F756 documentation is complete. This demands that facilities transition their quality assurance efforts from merely documenting the review to demonstrating tangible clinical action and effective resident outcome improvement.

Table 2: Evolution of CMS F-Tags Governing Pharmacy Services and DRR

Era/Regulation Set	Associated F-Tag(s)	Regulatory Focus	Current Status (Post-2016)
Pre-2016 (Traditional)	F428 (Primary Pharmacy Services)	General Pharmacy Services and monthly review	Replaced/Reorganized
Post-2016 (Revisions)	F756	Drug Regimen Review (Mandated Monthly Review Process) (483.45(c))	Active 3
Post-2016 (Revisions)	F757	Drug Regimen Free from Unnecessary Drugs (Non-Psychotropic) (483.45(d))	Active (Focus shifted specifically to non-psychotropics) 11
Post-2016 (Revisions)	F605	Right to be Free from Chemical Restraints/Psychotropic Medications (483.12(a)(2))	Active (Specific, high-severity citation often linked to F757 investigation) 16

VI. The Consultant Pharmacist and Interdisciplinary Dynamics

The consultant pharmacist is the agent designated by federal law to execute the DRR, making this role pivotal to facility compliance and quality assurance.

A. The Consultant Pharmacist Role Solidified

The mandate of OBRA-87 significantly intensified the professional responsibilities of the consultant pharmacist in nursing home care.¹⁸ While the federal mandate dictates a minimum of a monthly review ⁵, the modern role has expanded significantly beyond this retrospective compliance function.⁹ Today, consultant pharmacists frequently visit facilities more often than every 30 days. Their activities extend to proactive measures, including reviewing patient charts and meeting with residents to monitor their response to therapy, specifically aiming to preempt medication-related problems (MRPs) before they materialize.⁹

B. Challenges in Interdisciplinary Integration

While the DRR successfully ensures the identification of problems, the resolution of those problems requires the effective integration of the pharmacist’s findings into the interdisciplinary team (IDT) structure. Studies show that pharmacist-led reviews frequently identify critical issues such as missing clinical information, drug-age precautions, excessive duration alerts, and suboptimal regimens.¹⁹

However, the consultant pharmacist operates primarily as an external auditor, possessing advisory and compliance authority rather than primary prescribing authority. The core challenge in implementation is that successful resolution depends entirely on the willingness and capacity of the IDT—including the physician, medical director, and nursing staff—to implement the recommended changes. Research suggests that if the integration of the pharmacist is poor, and if collaborative case conferencing is lacking, up to half of identified drug-related problems (DRPs) may remain unsolved.¹⁹ Conversely, when a clinical pharmacist is successfully integrated into the healthcare team, marked improvements are observed in prescribing appropriateness and overall prescribing quality.¹⁹

The mandate successfully forces the identification of irregularities through the monthly retrospective audit.¹ The critical barrier, however, lies in achieving clinical resolution. If the facility lacks robust systems for ensuring physician accountability and follow-up (the systems targeted by the F756/F757 compliance interviews ⁸), the monthly review risks becoming a documentation exercise that fails to translate into tangible quality improvement, leaving identified clinical problems unaddressed.¹⁹

VII. DRR in the Modern Clinical Context: Beyond Mandate

The success of the retrospective DRR in curbing major abuses of the 1980s has been proven, but the model’s compliance-centric design necessitates comparison with modern, proactive medication management strategies.

A. The Retrospective Limitation and the Call for Proactive Models

The nature of the traditional monthly DRR, focusing on catching errors that have occurred over the preceding month, has led to critiques that this model is insufficient for achieving optimal patient safety.⁴ The focus often remains on historical mistakes rather than implementing prophylactic strategies to prevent new medication-related issues in the complex environment of long-term care polypharmacy.

B. Emergence of Outcomes-Based Models: MTM and CMR

In response to the limitations of compliance-driven review, outcomes-based models have gained prominence, designed specifically to improve clinical results and enhance appropriate medication use.²⁰

1. Medication Therapy Management (MTM): This comprehensive framework aims to optimize medication outcomes and patient understanding.²¹
2. Comprehensive Medication Review (CMR): A core service within MTM, the CMR involves an individualized assessment of all medications taken by the patient, encompassing prescriptions, nonprescription drugs, alternative treatments, vitamins, and supplements.²¹ The goal is to ensure that every medication is appropriate for the condition, effective, safe given comorbidities, and able to be taken by the patient as intended.²¹
3. Targeted Medication Review (TMR): Defined interventions based on clinical rules used to identify specific, immediate medication-related problems (MRPs).²⁰

C. Policy Adoption and Effectiveness in LTC

The recognition of the clinical superiority of these proactive models has influenced policy. The Centers for Medicare and Medicaid Services (CMS) began requiring Medicare Part D plans to offer annual CMR services to their beneficiaries, an exemption which initially excluded those in Long-Term Care (LTC) settings. However, this exemption was officially changed in January 2013, requiring Part D plans to offer CMR services to LTC beneficiaries as well.²¹

Empirical evidence supports the value proposition of MTM services. Retrospective cohort studies comparing patients participating in MTM services found that the receipt of TMR interventions was associated with statistically significant reductions in acute inpatient admissions.²⁰ For instance, one study found 55.2 fewer acute admissions per 1,000 individuals receiving TMR in 2014.²⁰

The mandatory, retrospective DRR (OBRA-87) successfully addressed and curbed the most egregious abuses, such as the overuse of targeted psychotropics.² However, proactive, holistic models like MTM and TMR, which require active patient engagement and comprehensive review of all agents ²¹, offer demonstrable economic and clinical superiority through reduced acute care utilization (hospitalizations).²⁰ This evidence confirms that optimal pharmaceutical governance requires policy to shift beyond the minimum compliance standard (DRR) toward incentivizing or mandating Comprehensive Medication Management (CMM) systems within LTCFs, thereby aligning quality assurance with cost-saving measures.

Table 3: Comparison of Federally Mandated DRR vs. Modern Medication Management Models

Feature	Federally Mandated DRR (OBRA Model)	Comprehensive Medication Management (CMM/MTM)
Primary Driver	Compliance, Audit Readiness	Patient Outcomes, Optimized Therapy
Regulatory Basis	42 CFR  (Condition of Participation) 5	Medicare Part D Requirements/Professional Standards 21
Frequency (LTC)	Minimum monthly review 5	Annually (CMR); Event-driven (TMR) 21
Focus Scope	Reviewing physician orders, identifying irregularities and adverse consequences 1	Holistic review of all medications (Rx, OTC, supplements); patient understanding/adherence 21
Intervention Style	Retrospective identification and written reporting 1	Prospective risk assessment and intervention; active patient/prescriber counseling 10
Proven Impact	Reduction in targeted psychotropics 2	Reduction in acute inpatient admissions 20

VIII. Operational Challenges and Future Directions

Despite the regulatory framework established by OBRA-87 and refined by CMS, the effective execution of DRR and associated pharmaceutical services continues to face significant operational barriers.

A. Persistent Operational Constraints

The implementation of OBRA’s stringent regulations necessitated initial miscellaneous changes within facilities, including staff orientation and training on the various new provisions.⁷ This high threshold for documentation, medical recordkeeping, and resident assessment created an initial, and continuing, administrative burden.

More broadly, facilities consistently report challenges related to staffing and resource allocation, particularly during periods of high demand or public health emergencies.²² While these concerns often relate to emergency preparedness (such as ensuring proper staffing or transporting residents during evacuations) ²², these systemic resource constraints directly impact the quality and depth of required clinical activities. If nursing staff and physicians are overwhelmed, the comprehensive follow-up and effective implementation of the pharmacist’s monthly recommendations—the translation from DRR report to clinical resolution—is severely hampered. This reinforces the risk that the mandatory DRR becomes viewed purely as a documentation task rather than a dynamic clinical intervention tool.

B. Recommendations for Policy Enhancements

The primary direction for future policy must involve leveraging the clinical expertise of the consultant pharmacist to maximize proactive patient safety, moving beyond the baseline of retrospective compliance.

First, federal policy should evolve to actively mandate the implementation of integrated, prospective medication management practices (such as MTM/CMR) within LTC settings, rather than relying solely on the monthly retrospective DRR minimum. Second, financial mechanisms must be adjusted to support this enhanced clinical role. Policies should ensure that consultant pharmacists are adequately reimbursed for extensive interdisciplinary integration activities, case conferencing, and direct follow-up interventions.¹⁹ This economic shift would help solidify the pharmacist’s role as a consistent, integrated clinical team member, rather than an external compliance auditor paid merely to check the box for the monthly review, thereby addressing the implementation barrier of unsolved drug-related problems.

IX. Conclusion: Sustaining Quality Through Evolving Pharmaceutical Oversight

The history of the Drug Regimen Review (DRR) in long-term care facilities is a profound narrative of legislative response to systemic clinical failure. The mandate, born out of the Omnibus Budget Reconciliation Act of 1987, successfully achieved its primary objective: curbing egregious abuses, particularly the reliance on psychotropic drugs as chemical restraints, and establishing accountability for medication safety.

The regulatory evolution of the DRR, evidenced by the transition from the general F428 tag to the specialized enforcement of F756 (Process) and F757 (Outcome), demonstrates a necessary and increasing rigor in federal oversight. This hyper-specificity requires facilities to prove not only that the monthly review occurred, but that decisive clinical action was taken to eliminate unnecessary medications, raising the standard of compliance from mere documentation to demonstrable resident-centered outcomes.

However, the core retrospective nature of the DRR mandate remains its limitation. Optimal pharmaceutical governance requires integration of proactive clinical models. Evidence confirms that modern, holistic systems like Comprehensive Medication Management (CMM) and Targeted Medication Review (TMR) deliver superior clinical results, specifically by reducing costly acute care events. The future stability of quality assurance in long-term care depends on policy makers finding mechanisms to modernize the OBRA-87 mandate—incentivizing comprehensive, prospective medication management and providing appropriate reimbursement to overcome operational and resource barriers, thereby ensuring that problem identification translates consistently into effective clinical resolution.

Works cited

1. Drug Regimen Review Policy – LeadingAge New York, accessed October 7, 2025, https://www.leadingageny.org/?LinkServID=D1B8C3B1-D7B5-356B-88D981FD25661EBC
2. Assuring Nursing Home Quality: The History and Impact of Federal Standards in OBRA-87, accessed October 7, 2025, https://www.commonwealthfund.org/publications/fund-reports/1996/dec/assuring-nursing-home-quality-history-and-impact-federal
3. 42 CFR 483.45 — Pharmacy services. – eCFR, accessed October 7, 2025, https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483/subpart-B/section-483.45
4. Nursing Home Care Quality Twenty Years After The Omnibus Budget Reconciliation Act of 1987 – Report – KFF, accessed October 7, 2025, https://www.kff.org/wp-content/uploads/2013/01/7717.pdf
5. 42 CFR § 483.45 – Pharmacy services. – Legal Information Institute, accessed October 7, 2025, https://www.law.cornell.edu/cfr/text/42/483.45
6. The OBRA-87 nursing home regulations and implementation of the Resident Assessment Instrument: effects on process quality – PubMed, accessed October 7, 2025, https://pubmed.ncbi.nlm.nih.gov/9256852/
7. Obra 1987 Requirements For Nursing Facilities – DHCS, accessed October 7, 2025, https://www.dhcs.ca.gov/formsandpubs/laws/Documents/Appendix%20A.pdf
8. Unnecessary Medications, Chemical Restraints/Psychotropic Medications, and Medication Regimen Review Critical Element Pathway, accessed October 7, 2025, https://leadingageny.org/sites/leadingageny/assets/qso-25-07-nh-combined-files-pages.pdf
9. CMS Review of Current Standards of Practice for Long-Term Care Pharmacy Services, accessed October 7, 2025, https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Reports/downloads/lewingroup.pdf
10. OBRA 1990 – Hawaii Medicaid, accessed October 7, 2025, https://medquest.hawaii.gov/content/medquest/en/plans-providers/pharmacy/produr/obra-1990.html
11. Revised Long-Term Care (LTC) Surveyor Guidance: Significant revisions to enhance quality and oversight of the LTC survey process – CMS, accessed October 7, 2025, https://www.cms.gov/files/document/revised-long-term-care-ltc-surveyor-guidance-significant-revisions-enhance-quality-and-oversight-ltc.pdf
12. State Operations Manual Appendix PP – Guidance to Surveyors for Long Term Care Facilities – CMS, accessed October 7, 2025, https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
13. The impact of OBRA-87 on psychotropic drug prescribing in skilled nursing facilities – PubMed, accessed October 7, 2025, https://pubmed.ncbi.nlm.nih.gov/9323748/
14. F-tags – NursingHome411, accessed October 7, 2025, https://nursinghome411.org/f-tags/
15. Revised Ftag of the Week – F757 Drug Regimen is Free from Unnecessary Drugs (Pt. 3), accessed October 7, 2025, https://cmscompliancegroup.com/ftag-of-the-week/revised-ftag-of-the-week-f757-drug-regimen-is-free-from-unnecessary-drugs-pt-3/
16. List of Revised FTags [Effective May 15, 2020] – CMS, accessed October 7, 2025, https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/List-of-Revised-FTags.pdf
17. Unnecessary Meds/Med Regimen Review Critical Element Pathway – CMS, accessed October 7, 2025, https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/CMS-20082-Unnecessary-Medication.pdf
18. The consultant pharmacist and the physician in the nursing home: roles, relationships, and a recipe for success – PubMed, accessed October 7, 2025, https://pubmed.ncbi.nlm.nih.gov/17367254/
19. Pharmacist services in nursing homes: A systematic review and meta‐analysis – PMC, accessed October 7, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC6955407/
20. Comparison of Medication Therapy Management Services and Their Effects on Health Care Utilization and Medication Adherence – PMC, accessed October 7, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC10397886/
21. Comprehensive Medication Management versus Comprehensive Medication Review, accessed October 7, 2025, https://www.nbmtm.org/mtm-reference/comprehensive-medication-management-versus-comprehensive-medication-review/
22. Nursing Homes Reported Wide-Ranging Challenges Preparing for Public Health Emergencies and Natural Disasters | Office of Inspector General, accessed October 7, 2025, https://oig.hhs.gov/reports/all/2023/nursing-homes-reported-wide-ranging-challenges-preparing-for-public-health-emergencies-and-natural-disasters/