Advance Copy– Changes for Sub-Task 5E, Medication Pass Observation Protocol for Long Term Care (LTC) Facilities
Revisions to Appendix P of the State Operations Manual (SOM): Changes have been made to the Sub-Task 5E - Medication Pass
Observation Task in the Traditional Survey.
o The number of observations required to calculate the facility medication error rate is revised to a minimum of 25 medication
administration opportunities. A minimum number is specified because it is acceptable to include more than 25 observations
in a medication observation to capture multiple routes, times, and caregivers.
o This revision eliminates the current requirement to extend the medication pass for another 20-25 opportunities if errors
are detected in the first 20-25 observations.
o Form CMS–20056 (2/2013), Medication Administration Observation will be used; this form replaces Form CMS-677, Medication
o This change matches the Quality Indicator Survey (QIS) Medication Administration Observation protocol, thus standardizing
the medication error rate calculation for both the Traditional and QIS surveys.