Clinical & Medical Care
Clinical & Medical Care
MANDATORY
5 criteria
| Standard 4.1 NON-NEGOTIABLE · Standard 4: Clinical & Medical Care Monthly Pharmacist Medication Review Actually Catches Unnecessary Drugs |
ASSESSMENT ASF-LTC-STD4-v3.0 |
| CR ADAPTED | TR FULL | SM FULL | ST FULL |
| 4.1 NON-NEGOTIABLE L1 |
THE STANDARD Monthly Pharmacist Medication Review Actually Catches Unnecessary Drugs A licensed pharmacist reviews every resident's complete drug regimen at least monthly, with any irregularity — excessive dose, excessive duration, inadequate monitoring, inadequate indication — specifically reported to the attending physician and acted upon, not a review that occurs on schedule but produces no real consequence. |
| FACILITY SELF-ASSESSMENT Tick YES, PARTIAL, or NO for each question. |
| 1 | Does a licensed pharmacist review every resident's complete drug regimen at least monthly? A genuine, complete review, not a partial check or one that lapses under pressure. Doc: Monthly pharmacist review record |
YES | PARTIAL | NO |
| 2 | Are identified irregularities specifically reported to the attending physician, medical director, and director of nursing? Specific, documented reporting to the right people, not an informal or incomplete escalation. Doc: Irregularity reporting record |
YES | PARTIAL | NO |
| 3 | Is there real evidence that reported irregularities are actually acted upon, not just noted and filed? Genuine action resulting from the report, not a report that produces no real consequence. Doc: Irregularity resolution record |
YES | PARTIAL | NO |
ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.
| WHAT THE ASSESSOR DOES ON SITE no surprises, no hidden checks |
| DOCUMENT Monthly review record check |
Reviews pharmacist review records for consistent, complete monthly coverage of every resident. |
| DOCUMENT Irregularity reporting review |
Reviews evidence that identified irregularities are specifically reported to the correct individuals. |
| ASK Resolution outcome interview |
Asks staff for a real example of an irregularity that was identified and what actually happened as a result. |
REFERENCES
- [16] Established long-term care regulatory principles, recognized in various forms across many countries' care standards, require regular licensed pharmacist review of each resident's complete drug regimen, with identified irregularities reported to the attending physician, medical director, and director of nursing, and acted upon.
| Standard 4.1 · Standard 4: Clinical & Medical Care Guidance & Learning |
GUIDANCE ASF-LTC-STD4-v3.0 |
| WHY THIS STANDARD EXISTS |
An unnecessary drug — one given at excessive dose, for excessive duration, or without adequate ongoing indication — can cause real harm that accumulates quietly over time, and a monthly pharmacist review exists specifically to catch this systematically, not leave it to be noticed only if something visibly goes wrong.
| WHAT GOOD LOOKS LIKE ✓ Every resident receives a genuine, complete monthly pharmacist review. ✓ Irregularities are specifically reported to the attending physician, medical director, and director of nursing. ✓ Real evidence shows reported irregularities are genuinely acted upon. |
WHAT FAILURE LOOKS LIKE ✗ Pharmacist review is inconsistent, partial, or lapses for some residents. ✗ Irregularities are identified but not specifically reported to the required individuals. ✗ Reports produce no documented action or resolution. |
| MOST COMMON REASONS FACILITIES SCORE PARTIAL |
1 Review happens monthly but doesn't consistently cover every category of potential irregularity.
A review that misses a category of concern provides only partial protection.
2 Reporting happens but response time from the attending physician is inconsistent.
A report without a prompt, genuine response doesn't provide the real protection this process is meant to ensure.
3 Irregularities are resolved for individual cases but patterns across residents aren't reviewed collectively.
A pattern across multiple residents can reveal a systemic issue that individual case review alone would miss.
| HOW TO IMPLEMENT IF YOU ARE STARTING FROM ZERO |
Week 1 Review current pharmacist review practice for consistency and completeness.
Week 2 Establish clear reporting pathways to the attending physician, medical director, and director of nursing.
Week 3 Build a tracking process confirming irregularities lead to genuine action.
Ongoing Review irregularity patterns across residents for systemic issues.
| FOR SURVEYORS — WHAT IS NOT OBVIOUS |
Ask for a real, recent example of an irregularity and trace it through to its actual resolution.
A real, traced example reveals whether the process genuinely functions, not just exists on paper.
Ask the attending physician how quickly they typically respond to a pharmacist-identified irregularity.
A specific, confident answer reveals genuine, prompt engagement with the process.
| E-LEARNING academy.gmj.ge/ltc-std4-1-pharmacist-review — 30 min · complete before self-assessment |
| Standard 4.2 NON-NEGOTIABLE · Standard 4: Clinical & Medical Care Psychotropic Medications Require a Documented, Specific Diagnosis, Not General Behavior Management |
ASSESSMENT ASF-LTC-STD4-v3.0 |
| CR ADAPTED | TR FULL | SM FULL | ST FULL |
| 4.2 NON-NEGOTIABLE L1 |
THE STANDARD Psychotropic Medications Require a Documented, Specific Diagnosis, Not General Behavior Management A resident is never started on a psychotropic medication without a specific, diagnosed, clinically documented condition justifying its use — never as a general response to behavior, agitation, or the convenience of managing a resident who is difficult to care for. |
| FACILITY SELF-ASSESSMENT Tick YES, PARTIAL, or NO for each question. |
| 1 | Is every psychotropic medication tied to a specific, diagnosed condition documented in the clinical record? A specific, documented diagnosis, not a general behavioral rationale. Doc: Psychotropic medication diagnosis documentation |
YES | PARTIAL | NO |
| 2 | Are non-pharmacological, behavioral approaches genuinely tried first, before psychotropic medication is started? Real, attempted alternatives, not psychotropic medication as the default first response. Doc: Behavioral intervention documentation |
YES | PARTIAL | NO |
| 3 | Can staff describe the specific diagnosed condition behind a particular resident's psychotropic medication? Specific, genuine knowledge, not a general sense that the medication helps with behavior. Doc: N/A — tested directly |
YES | PARTIAL | NO |
ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.
| WHAT THE ASSESSOR DOES ON SITE no surprises, no hidden checks |
| DOCUMENT Diagnosis documentation review |
Reviews psychotropic medication orders for a specific, documented diagnosed condition, not general behavior rationale. |
| DOCUMENT Behavioral intervention review |
Reviews documentation of non-pharmacological approaches genuinely attempted before medication initiation. |
| ASK Staff knowledge interview |
Asks staff to describe the specific diagnosed condition behind a particular resident's psychotropic medication. |
REFERENCES
- [17] Established long-term care regulatory principles, recognized in various forms across many countries' care standards, prohibit psychotropic drug use unless necessary to treat a specific condition that is diagnosed and documented in the resident's clinical record.
| Standard 4.2 · Standard 4: Clinical & Medical Care Guidance & Learning |
GUIDANCE ASF-LTC-STD4-v3.0 |
| WHY THIS STANDARD EXISTS |
Using psychotropic medication as a general behavior management tool, rather than treatment for a specifically diagnosed condition, is one of the most well-documented and serious patterns of harm in long-term care — it can leave a resident over-sedated, at higher fall and mortality risk, and chemically restrained in substance if not in name.
| WHAT GOOD LOOKS LIKE ✓ Every psychotropic medication is tied to a specific, documented diagnosis. ✓ Non-pharmacological approaches are genuinely tried first. ✓ Staff can describe the specific condition behind a resident's medication. |
WHAT FAILURE LOOKS LIKE ✗ Psychotropic medication is used as a general response to behavior or agitation. ✗ No genuine attempt at non-pharmacological approaches precedes medication. ✗ Staff describe the medication's purpose only in general behavioral terms. |
| MOST COMMON REASONS FACILITIES SCORE PARTIAL |
1 New psychotropic orders have specific documented diagnoses but older, long-standing orders lack the same clarity.
Every psychotropic medication deserves the same documented justification, regardless of when it was originally started.
2 Behavioral approaches are documented as considered but the actual attempt isn't clearly described.
Considering an alternative isn't the same as genuinely attempting it before resorting to medication.
3 Diagnosis documentation exists but isn't consistently reviewed for continued accuracy over time.
A diagnosis justifying ongoing medication should remain genuinely accurate, not simply carried forward indefinitely.
| HOW TO IMPLEMENT IF YOU ARE STARTING FROM ZERO |
Week 1 Review current psychotropic medication orders for specific, documented diagnostic justification.
Week 2 Establish or strengthen non-pharmacological intervention practice and documentation.
Week 3 Train staff on the specific diagnosed conditions behind each resident's psychotropic medications.
Ongoing Review long-standing psychotropic orders for continued diagnostic accuracy.
| FOR SURVEYORS — WHAT IS NOT OBVIOUS |
Ask about a specific, long-standing psychotropic order, not only recently started ones.
This is where documentation most commonly grows stale or unclear over time.
Ask a front-line staff member, not only a nurse, what the medication is specifically for.
This reveals whether specific understanding genuinely extends through the care team.
| E-LEARNING academy.gmj.ge/ltc-std4-2-psychotropic-diagnosis — 30 min · complete before self-assessment |
| Standard 4.3 NON-NEGOTIABLE · Standard 4: Clinical & Medical Care Gradual Dose Reduction Is Genuinely Attempted for Psychotropic Medications |
ASSESSMENT ASF-LTC-STD4-v3.0 |
| CR ADAPTED | TR FULL | SM FULL | ST FULL |
| 4.3 NON-NEGOTIABLE L1 |
THE STANDARD Gradual Dose Reduction Is Genuinely Attempted for Psychotropic Medications Residents on psychotropic medication receive genuine, documented gradual dose reduction attempts combined with behavioral interventions, unless a specific clinical reason makes this genuinely contraindicated — not medication continued indefinitely without any real attempt to reduce or discontinue it. |
| FACILITY SELF-ASSESSMENT Tick YES, PARTIAL, or NO for each question. |
| 1 | Does every resident on psychotropic medication have a genuine, documented gradual dose reduction attempt? A real, documented attempt, not medication continued indefinitely by default. Doc: Gradual dose reduction documentation |
YES | PARTIAL | NO |
| 2 | Where gradual dose reduction is considered clinically contraindicated, is the specific clinical reason documented? A specific, documented clinical justification, not contraindication assumed without real basis. Doc: Contraindication documentation |
YES | PARTIAL | NO |
| 3 | Are behavioral interventions combined with dose reduction attempts, not medication reduction alone? Genuine combined approach, not dose reduction attempted in isolation. Doc: N/A — tested directly |
YES | PARTIAL | NO |
ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.
| WHAT THE ASSESSOR DOES ON SITE no surprises, no hidden checks |
| DOCUMENT Dose reduction attempt review |
Reviews documentation of genuine, attempted gradual dose reduction for residents on psychotropic medication. |
| DOCUMENT Contraindication justification review |
Reviews the specific, documented clinical reasoning behind any contraindication determination. |
| ASK Combined approach interview |
Asks staff whether behavioral interventions are genuinely combined with dose reduction attempts. |
REFERENCES
- [18] Established long-term care regulatory principles, recognized in various forms across many countries' care standards, require residents using psychotropic drugs to receive gradual dose reduction and behavioral interventions, unless clinically contraindicated, in a genuine effort to discontinue these drugs.
| Standard 4.3 · Standard 4: Clinical & Medical Care Guidance & Learning |
GUIDANCE ASF-LTC-STD4-v3.0 |
| WHY THIS STANDARD EXISTS |
A psychotropic medication that was genuinely needed at one point may not remain needed indefinitely, and without a real, ongoing effort to reduce dose where clinically appropriate, a resident can remain on medication — and its real risks — far longer than actually necessary, simply because no one made the effort to check.
| WHAT GOOD LOOKS LIKE ✓ Every resident on psychotropic medication has a genuine, documented reduction attempt. ✓ Contraindication, where determined, is backed by specific documented clinical reasoning. ✓ Behavioral interventions are genuinely combined with reduction attempts. |
WHAT FAILURE LOOKS LIKE ✗ Medication continues indefinitely with no documented reduction attempt. ✗ Contraindication is assumed or undocumented, without real clinical basis. ✗ Dose reduction, if attempted, happens without any behavioral intervention alongside it. |
| MOST COMMON REASONS FACILITIES SCORE PARTIAL |
1 Reduction attempts happen for some residents but not consistently across the full population on psychotropic medication.
Every resident on this medication deserves the same genuine, periodic reconsideration.
2 Contraindication documentation exists but doesn't specifically address why this particular resident's situation warrants it.
A generic contraindication rationale doesn't reflect the genuine, individual clinical judgement this requires.
3 Reduction is attempted but not systematically tracked to know whether it was ultimately successful.
Without tracking outcomes, a facility can't learn whether its reduction efforts are genuinely working.
| HOW TO IMPLEMENT IF YOU ARE STARTING FROM ZERO |
Week 1 Review current psychotropic medication population for documented reduction attempts.
Week 2 Establish a systematic process for periodic dose reduction consideration.
Week 3 Build genuine behavioral intervention practice alongside reduction attempts.
Ongoing Track reduction attempt outcomes to inform future practice.
| FOR SURVEYORS — WHAT IS NOT OBVIOUS |
Ask for a specific resident's dose reduction history over the past year.
A real, traceable history reveals whether reduction is genuinely attempted, not just theoretically required.
Ask what behavioral intervention accompanied a specific reduction attempt.
A specific, real answer reveals genuine combined practice, not medication-only reduction.
| E-LEARNING academy.gmj.ge/ltc-std4-3-gradual-dose-reduction — 30 min · complete before self-assessment |
| Standard 4.4 NON-NEGOTIABLE · Standard 4: Clinical & Medical Care PRN Psychotropic Orders Are Time-Limited and Re-Evaluated, Not Renewed Automatically |
ASSESSMENT ASF-LTC-STD4-v3.0 |
| CR ADAPTED | TR FULL | SM FULL | ST FULL |
| 4.4 NON-NEGOTIABLE L1 |
THE STANDARD PRN Psychotropic Orders Are Time-Limited and Re-Evaluated, Not Renewed Automatically As-needed psychotropic medication orders are limited to 14 days, with antipsychotic PRN orders specifically requiring a physician re-evaluation before any renewal — not extended or renewed automatically as a matter of routine. |
| FACILITY SELF-ASSESSMENT Tick YES, PARTIAL, or NO for each question. |
| 1 | Are all PRN psychotropic orders genuinely limited to 14 days, not extended automatically? A genuine, enforced 14-day limit, not a routine extension. Doc: PRN order duration record |
YES | PARTIAL | NO |
| 2 | Does any PRN antipsychotic renewal require a genuine physician re-evaluation, not automatic continuation? A real, documented re-evaluation specifically for antipsychotics, not a rubber-stamp renewal. Doc: Antipsychotic renewal re-evaluation documentation |
YES | PARTIAL | NO |
| 3 | Where a PRN order is extended beyond 14 days for a non-antipsychotic, is the physician's rationale specifically documented? A specific, documented clinical rationale, not an extension without real justification. Doc: Extension rationale documentation |
YES | PARTIAL | NO |
ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.
| WHAT THE ASSESSOR DOES ON SITE no surprises, no hidden checks |
| DOCUMENT PRN order duration review |
Reviews PRN psychotropic order records for genuine 14-day limit enforcement. |
| DOCUMENT Antipsychotic re-evaluation review |
Reviews documentation of genuine physician re-evaluation before any antipsychotic PRN renewal. |
| ASK Renewal practice interview |
Asks prescribing staff how PRN psychotropic renewal genuinely works in practice. |
REFERENCES
- [19] Established long-term care regulatory principles, recognized in various forms across many countries' care standards, limit as-needed psychotropic orders to a short, defined duration, with as-needed antipsychotic orders specifically prohibited from renewal unless the attending physician or prescribing practitioner evaluates the resident for continued appropriateness.
| Standard 4.4 · Standard 4: Clinical & Medical Care Guidance & Learning |
GUIDANCE ASF-LTC-STD4-v3.0 |
| WHY THIS STANDARD EXISTS |
An as-needed psychotropic order that simply keeps renewing without genuine re-evaluation can drift into de facto long-term, unmonitored use — the 14-day limit exists specifically to force a genuine clinical checkpoint, not to be treated as a paperwork formality that gets renewed without real reconsideration.
| WHAT GOOD LOOKS LIKE ✓ PRN psychotropic orders are genuinely limited to 14 days. ✓ Antipsychotic PRN renewal requires a real, documented physician re-evaluation. ✓ Any extension beyond 14 days carries specific, documented clinical rationale. |
WHAT FAILURE LOOKS LIKE ✗ PRN orders are routinely extended or renewed without genuine time limits. ✗ Antipsychotic renewal happens without real re-evaluation. ✗ Extensions lack specific clinical rationale. |
| MOST COMMON REASONS FACILITIES SCORE PARTIAL |
1 The 14-day limit is tracked for most orders but occasionally lapses during staff transitions.
Consistent tracking regardless of staffing changes is what makes this limit genuinely reliable.
2 Re-evaluation happens for antipsychotic renewals but isn't always documented with specific clinical detail.
Undocumented re-evaluation is difficult to distinguish from renewal without genuine reconsideration.
3 Extension rationale is documented but sometimes generic rather than specific to the individual resident's situation.
A specific, individual rationale is what distinguishes genuine clinical judgement from routine extension.
| HOW TO IMPLEMENT IF YOU ARE STARTING FROM ZERO |
Week 1 Review current PRN psychotropic order tracking for genuine 14-day limit enforcement.
Week 2 Establish a specific re-evaluation process required before any antipsychotic PRN renewal.
Week 3 Train prescribing staff on documentation requirements for any extension beyond 14 days.
Ongoing Audit PRN order duration and renewal documentation for continued compliance.
| FOR SURVEYORS — WHAT IS NOT OBVIOUS |
Ask for a specific, real example of an antipsychotic PRN renewal and its re-evaluation documentation.
A real, traceable example reveals whether re-evaluation is genuine practice, not a formality.
Check PRN order tracking during a period of staff transition or turnover.
This is where consistent enforcement of the time limit is most likely to lapse.
| E-LEARNING academy.gmj.ge/ltc-std4-4-prn-psychotropic-limits — 30 min · complete before self-assessment |
| Standard 4.5 NON-NEGOTIABLE · Standard 4: Clinical & Medical Care Infection Control Follows a Defined, Facility-Specific Program |
ASSESSMENT ASF-LTC-STD4-v3.0 |
| CR ADAPTED | TR FULL | SM FULL | ST FULL |
| 4.5 NON-NEGOTIABLE L1 |
THE STANDARD Infection Control Follows a Defined, Facility-Specific Program The facility maintains an infection prevention and control program specific to its own resident population and physical environment, with a designated, trained infection preventionist — not a generic infection control policy adopted without genuine adaptation to this facility's actual circumstances. |
| FACILITY SELF-ASSESSMENT Tick YES, PARTIAL, or NO for each question. |
| 1 | Does the infection control program genuinely reflect this facility's own resident population and physical environment? Facility-specific adaptation, not a generic policy adopted without genuine customization. Doc: Infection control program documentation |
YES | PARTIAL | NO |
| 2 | Is there a designated, trained infection preventionist with genuine responsibility for the program? A specific, trained, designated individual, not an informal or shared responsibility. Doc: Infection preventionist designation and training record |
YES | PARTIAL | NO |
| 3 | Is the program genuinely reviewed and updated based on the facility's own actual assessment, not left static? Real, ongoing adaptation, not a program written once and never revisited. Doc: Program review and update record |
YES | PARTIAL | NO |
ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.
| WHAT THE ASSESSOR DOES ON SITE no surprises, no hidden checks |
| DOCUMENT Program specificity review |
Reviews the infection control program for genuine, facility-specific content, not generic policy. |
| DOCUMENT Infection preventionist designation review |
Reviews the designation and training of the facility's infection preventionist. |
| DOCUMENT Program update review |
Reviews evidence that the program is genuinely reviewed and updated based on facility assessment. |
REFERENCES
- [20] Established long-term care regulatory principles, recognized in various forms across many countries' care standards, require facilities to establish and maintain an infection prevention and control program based on the facility's own assessment, with a designated infection preventionist holding specific training.
| Standard 4.5 · Standard 4: Clinical & Medical Care Guidance & Learning |
GUIDANCE ASF-LTC-STD4-v3.0 |
| WHY THIS STANDARD EXISTS |
Long-term care residents often have specific, elevated infection vulnerability — chronic conditions, close communal living, shared care staff across many residents — and a generic infection control policy that doesn't reflect this facility's actual population and physical environment misses the specific risks most likely to actually cause harm here.
| WHAT GOOD LOOKS LIKE ✓ The infection control program genuinely reflects this facility's specific population and environment. ✓ A designated, trained infection preventionist holds real responsibility for the program. ✓ The program is genuinely reviewed and updated, not static. |
WHAT FAILURE LOOKS LIKE ✗ A generic infection control policy is adopted without facility-specific adaptation. ✗ No specific, trained individual holds genuine responsibility for infection control. ✗ The program hasn't been reviewed or updated in a meaningful timeframe. |
| MOST COMMON REASONS FACILITIES SCORE PARTIAL |
1 An infection preventionist is designated but their specific training doesn't fully meet defined requirements.
The role's real protective value depends on genuine, adequate training, not designation alone.
2 The program addresses common infection risks but doesn't specifically reflect this facility's particular resident population.
Generic coverage of common risks can still miss what's specifically relevant to this facility's actual circumstances.
3 Program review happens but doesn't consistently incorporate genuinely current facility assessment data.
A review that doesn't use current, real data provides limited genuine improvement over a static program.
| HOW TO IMPLEMENT IF YOU ARE STARTING FROM ZERO |
Week 1 Review current infection control program for genuine facility-specific adaptation.
Week 2 Confirm or establish infection preventionist designation and training against defined requirements.
Week 3 Establish a genuine, scheduled program review process incorporating current facility assessment.
Ongoing Update the infection control program as facility circumstances genuinely change.
| FOR SURVEYORS — WHAT IS NOT OBVIOUS |
Ask the infection preventionist to describe a specific risk factor unique to this facility's population.
A specific, informed answer reveals genuine facility-specific engagement, not a generic role.
Ask when the program was last genuinely reviewed and what changed as a result.
A specific, real answer reveals whether review is genuine practice, not just a stated requirement.
| E-LEARNING academy.gmj.ge/ltc-std4-5-infection-control — 30 min · complete before self-assessment |
Long-Term Care Standards — overviewFacility Classification — Which Type of Facility Are You?Standard 1 — Admission & Resident RightsStandard 2 — Living Environment & SafetyStandard 3 — Personal Care & Daily LivingStandard 4 — Clinical & Medical CareStandard 5 — Cognitive & Behavioral CareStandard 6 — End-of-Life & Palliative CareStandard 7 — Governance & StaffingStandard 8 — Medical TourismStandard 9 — Health & MigrationReferences & Index
STANDARD 4Clinical & Medical Care4.1 Monthly Pharmacist Medication Review Actually Catches Unnecessary Drugs4.3 Gradual Dose Reduction Is Genuinely Attempted for Psychotropic Medications4.4 PRN Psychotropic Orders Are Time-Limited and Re-Evaluated, Not Renewed Automatically4.5 Infection Control Follows a Defined, Facility-Specific Program
Test your facility against this standard
Open self-assessment — no login, no fee.
Print to share.
