The Centers for Medicare and Medicaid Services (CMS) is “actively” reviewing federal rules on antipsychotic use for residents in nursing homes, aiming to support clinically appropriate use while discouraging misuse. The review follows a January update designed to improve reporting accuracy, and industry experts say the policy could also be simplified.

“CMS is actively reviewing the antipsychotic measure with the goal of supporting clinically indicated use while continuing to discourage inappropriate prescribing,” a CMS spokesperson told Skilled Nursing News in an emailed statement. “In this case, it is important to balance resident access to necessary treatment with the critical need to protect against inappropriate prescribing … CMS will remain committed to ensuring quality measures are evidence-based, clinically appropriate, and support transparency for residents and families.”

CMS’ review of the policy was first noted in a story in the Washington Post on Friday, the article noting that the review came at the urging of lawmakers, who directed CMS last month to distinguish between “appropriate” and “inappropriate” antipsychotic prescribing in nursing homes.

However, the CMS spokesperson said the federal agency’s internal review was already in progress.

“CMS’ review of the antipsychotic measure was already underway prior to the appropriations report. CMS continuously reviews its quality measures to ensure they are based on the best available evidence and reflect appropriate clinical care,” the spokesperson said. “CMS appreciates the congressional interest in this topic. We take very seriously our responsibility to promote safe, high-quality care in the nation’s nursing homes, including avoiding inappropriate prescribing of antipsychotics.”

CMS’ consideration to expand appropriate uses of antipsychotics would be a positive change for the quality measure, Joel Van Eaton, executive vice president of post acute regulatory affairs and education at Broad River Rehabilitation, told SNN.

“If CMS truly reevaluates this issue and begins to take into consideration other appropriate uses of this class of medication in the nursing home population then yes, it could, and frankly should, have some positive effects on how the antipsychotic quality measures for both long- and short-stay [residents] could be revised, along with the contributing MDS items,” said Van Eaton.

‘Complicated and confusing’ claims criteria

The last time CMS made a change to its guidelines on this front – changes which have been in effect since Jan. 1, 2026 – was in summer of 2025. The federal agency revised the Long-Stay Antipsychotic Quality Measure to include Minimum Data Set (MDS) and Medicare and Medicaid claims data – a process known as the “hybrid method” – to improve accuracy, the agency said in a memo issued at the time.

This guidance was also aimed at increasing use of non-pharmacological interventions, proper documentation, and gradual dose reduction (GDR) within the first year of antipsychotic use.

These changes were meant to capture the use of antipsychotics at nursing homes more accurately, but came with flaws that could adversely – and unfairly – impact a facility’s star ratings on the CMS Nursing Home Care Compare website, said Van Eaton.

“The current measures are too restrictive, the long-stay measure is too complex and complicated to be used practically/actionably and the MDS is not currently equipped to accommodate specifics when it comes to making this useful information,” he said.

Moreover, nursing homes already had tools in the MDS for documenting a physician’s clinical rationale and for tracking antipsychotic use from admission or reentry in order to ensure proper use and auditing, Van Eaton said, arguing that the new claims-based rules made things unnecessarily complex and confusing.

“There are ways to record that already in the MDS,” he said. “It would be great to get rid of the new complicated and confusing claims criteria.”

Change building for a decade

For more than a decade, the federal government has sought to reduce antipsychotic use in nursing homes by factoring prescribing rates into facilities’ star ratings. High use of these drugs – sometimes described as “chemical restraints” because they can sedate residents – can lower a facility’s rating. The policy helped cut use by one-third since 2011, with the reported national rate for nursing home residents being about 17%, according to CMS figures.

CMS has made some significant changes in phases in the last five years: 2022 marked an initiation of survey regulations with new F-tags introduced, and 2023, CMS led an MDS focus audit of schizophrenia diagnosis. In 2025, CMS consolidated and updated F-tags tied to antipsychotic medication.

Some of the changes came about after the Office of Inspector General (OIG) issued a report in 2021 that found nursing homes underreported antipsychotic use, with 12,000 cases missing from self-reported data, and flagged that one-third of residents reported as having schizophrenia – used to exempt prescriptions from quality measures – lacked supporting Medicare claims.

Antipsychotics are primarily approved for conditions such as schizophrenia and bipolar disorder. However, physicians often prescribe them as “off-label” for dementia-related agitation or aggression when residents pose risks to themselves, staff or other residents. The drugs can sometimes help control severe behavior, but they also carry significant risks, including falls, strokes and death.

Industry-backed advocacy groups argue the current rating system unfairly penalizes facilities for appropriate prescribing and may discourage treatment for residents who genuinely need the medications.

Jodi Eyigor, vice president of health policy at LeadingAge, the association of nonprofit providers of aging services, including nursing homes, told SNN that the organization doesn’t support misuse, but would welcome more clarity on any changes to policy.

LeadingAge is part of the Project PAUSE coalition, which has been working with Congress and advocating to CMS on the issue of antipsychotic usage in nursing homes.

“LeadingAge absolutely does not support the use of antipsychotics as chemical restraints or any other inappropriate prescribing practices. However, we know that there are residents who can benefit from appropriate use of antipsychotic medications to lessen the distress caused by neuropsychiatric symptoms in dementia,” Eyigor said. “While CMS continues its work to reduce the use of antipsychotic medications in nursing homes, we urge them to reconsider ways to more appropriately distinguish between appropriate and inappropriate use of the medications.

Leaders at the American Health Care Association and National Center for Assisted Living (AHCA/NCAL), the nation’s largest nursing home provider association, called attention to certain missing features of the current policy.

“The current CMS quality measure causes concern, as it does not account for the use of antipsychotic medications for conditions that are FDA approved. We will continue to work with CMS on improving this quality measure so every resident is supported in receiving the specific medications that are necessary and appropriate for their care,” Holly Harmon, senior vice president of quality, regulatory and clinical services, told SNN.

Administering the medicines is after all an exact science, Harmon noted.

“Long-term care providers continue to support the delivery of the right medications at the right time and for the right reasons based on each resident’s unique medical needs. Long-term care is highly regulated with extensive oversight, and providers have been active partners in a national effort to reduce the unnecessary use of antipsychotics in nursing homes while also recognizing these medications are necessary and beneficial to certain residents,” she said.

Resident advocates warn that relaxing the rules could reverse progress made in reducing unnecessary drug use in nursing homes, telling the Post that some facilities rely on medications to compensate for lack of training of workers and labor shortages, which push staff away from non-drug approaches such as redirection, social activities, therapy or investigating underlying medical issues like infections or pain.

“It’s such a reflex when there’s behavior problems. It’s so much easier to give people a drug,” Michael Steinman, a doctor who specializes in geriatrics and internal medicine at the University of California at San Francisco medical school told the Washington Post.

Steinman co-chaired a panel that developed the American Geriatrics Society’s guidelines for alternative approaches to drugs,”

“There are definitely people who need antipsychotics. Their behavior can’t be managed in other ways, and it poses threats to safety and well-being,” he said. “But it’s substantially less than the number of people getting them currently.”

If CMS now relaxes its policy on antipsychotic use in nursing homes, it will reopen a long-running debate over safety, quality of care and appropriate treatment. And aside from regulatory implications, any shift could also impact financial penalties and impact on facility ratings.

“This is an opportunity for CMS to collaborate with the provider community shape this quality initiative in a way that would put the onus on the nursing home not only to monitor more carefully for inappropriate use, i.e., be required to document the evidence-based criteria used in prescribing these meds – we do this for UTIs after all – but to reshape these quality measures into actionable data that would truly accomplish what should be the purpose of this whole initiative, positive outcomes for the resident,” Van Eaton said.