by Jay Luxenberg, MD

Although it's been said many times, many ways, there are still going to be many questions from our residents about the implications of the looming implementation of California’s decriminalization of the recreational use of marijuana for adults. Under state law, adults will be allowed to possess and use up to an ounce of marijuana starting January 1^st. Facilities that rely on federal dollars will have little choice - Section 1819(d)(4) of the Social Security Act (42 U.S.C. 1395i-e(d)(4)) provides that "[a] skilled nursing facility must operate and provide services in compliance with all applicable Federal, State, and local laws and regulations . . . ." Marijuana is a Schedule I controlled substance under the Controlled Substance Act (CSA), 21 U.S.C. 801, 812. The manufacture, distribution, or possession of marijuana a criminal offense, CSA sections 841(a)(1), 844(a). Clearly at this time a skilled nursing facility would not be in compliance with those federal laws if marijuana was stored or distributed to a resident. It will be interesting to see how facilities will handle requests from residents that purchase edible marijuana products, for example. Would they be allowed to store personally purchased products in their rooms like they currently store candy or other snacks? Will we be thinking about this possibility as we analyze falls or changes in cognitive function? We live in interesting times!

by Flora Bessey, PharmD, BCGP

As many of you already know, on November 24th CMS put a moratorium on civil monetary penalties associated with Phase 2 implementation of some of the new Requirements of Participation for nursing homes.

Good news, right? Not so fast…There is still a real possibility of deficiencies and citations during the survey process, even with this moratorium. The main result of this moratorium is that the harshest penalties (i.e. withholding of payment and decertification) has been put on hold.

Returning to the main topic: What can you expect from your consultant pharmacist and your pharmacy at this point?

As I reflect on the recent CALTCM "Propeller Learning" teaching format for our Northern California Fall CME meeting, I was struck by the apocalypse of destructive fire in Santa Rosa, with the not-so-visible but equally destructive power of diabetes in our society and facilities.  As a teacher on this subject at our annual meeting, I enjoyed the ability to change the emphasis of my presentation on the basis of our attendees’ response to what was presented. In turn, their individual responses seemed to resonate with others and generate more questions. I do believe this is the way of the future. I also believe that the best way to improve diabetes care is to challenge our workforce and patients to keep up with the many new changes in our understanding of diabetes, and what to emphasize in an individualized care plan.

by Frank Randolph, MD

Many nursing home admission forms ask physicians to address patient decisional capacity. I am unsure how this came to be a part of the admissions forms. I could not find references to it in California’s Title 22 regulations. Title 22 (§ 72303) states that physician services shall include but are not limited to: “Patient evaluation including a written report of a physical examination within 5 days prior to admission or within 72 hours following admission; an evaluation of the patient and review of orders for care and treatment on change of attending physicians; patient diagnoses; advice, treatment and determination of appropriate level of care needed for each patient; written and signed orders for diet, care, diagnostic tests and treatment of patients by others; health record progress notes and other appropriate entries in the patient's health records; provision for alternate physician coverage in the event the attending physician is not available.”  Also, federal regulations (§483.40 Physician Services) make no mention of capacity assessment.