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Minimum standards for which 100% performance is expected are communication of advance directives, attention to pain control, and attention to relief of dyspnea. Performance indicators for medical care guidelines and options in terminal care of nursing home patients are also described.

Both physicians and consultant pharmacists have a longstanding role in nursing home care. The physician role was emphasized in 1974, when medical directors were required in all skilled nursing facilities. It was intensified in 1987, when the Omnibus Budget Reconciliation Act of 1987 (OBRA '87) regulations required all nursing facilities to have a medical director and reinforced that each resident should have an attending physician who visits the resident at specified intervals. In 1974, the Medicare Conditions of Participation first mandated a quarterly drug regimen review (DRR) by a consultant pharmacist in nursing facilities, which was later increased to monthly. Subsequently, the State Operations Manual (SOM) has expanded its guidance to surveyors regarding the required elements of a DRR, to help them determine if an effective DRR was occurring.

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