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The Use of Critical Element Pathways to Identify Noncompliance

On June 29, 2022, the Centers for Medicare and Medicaid Services (CMS) released updates to the surveyor guidance in Appendix PP of the State Operations Manual. Highlights of the updates can be found in the AAPACN article “Appendix PP Revisions in the State Operations Manual: Breaking Down Key Changes,” which also synthesizes the F-tag changes.

Surveyors will begin to investigate noncompliance by following the updated guidance on October 24, 2022. To assist with the investigation of many of the federal tags, surveyors will use critical element (CE) pathways. CMS released an advance copy of updates to 23 of the CE pathways on September 6, 2022, aligning the CE pathways with updates to the guidance in Appendix PP. Given the breadth and depth of changes facilities are expected to implement, nurse leaders should be proactive and take advantage of the information available by following the methods of investigation the CE pathways include. Nurse leaders can put into practice today the same methods surveyors will use. This article will summarize three of those key methods of investigation.

Review of Policies and Procedures

The CE pathways instruct surveyors to review the facility’s policies and procedures for specific content the regulations require. For example, the Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) Plan Review CE Pathway instructs surveyors to “review the policies and procedures (P&P) for feedback, data collection, and monitoring, including adverse event monitoring” (CMS, 2022). Then, surveyors are to determine if each component is included in the facility’s policies and procedures:

  • Does the facility have written P&P for feedback, data collection systems, and monitoring (including adverse events)?
  • Do the P&P include how the facility obtains and uses feedback from residents, resident representatives, and staff to identify high-risk, high-volume, or problem prone issues as well as opportunities for improvement?
  • Do the P&P include how the facility will maintain effective systems to identify, collect, use and monitor data for all departments, and based on the facility assessment (F838)?
  • Do the P&P describe how the facility will identify, report, track, investigate and analyze adverse events, and high risk, high volume, and/or problem-prone concerns?
  • Does the facility have P&P for developing, monitoring and evaluating performance indicators, which include the frequency and how the facility develops, monitors, and evaluates its performance indicators?
  • Do the P&P describe how the facility uses systematic approaches (such as root cause analysis, reverse tracker methodology, or health-care failure and effects analysis) to assist in determining underlying causes of problems impacting larger systems? (CMS, 2022, p. 1)

Just as a surveyor would, nurse leaders can review the facility’s policies and procedures and answer the questions contained on the CE pathways. Does the facility fall short of what the regulations require? If policies and procedures are noncompliant, corrective action will be necessary—but by initiating the review internally, the facility may be able to correct the issue before surveyors arrive or issue citations for the deficiency.


Almost all the CE pathways include observations of staff providing care and services to residents. Furthermore, CMS expects surveyors to spend most of the survey observing staff. The CE pathway for Sufficient and Competent Nurse Staffing Review instructs surveyors to conduct observations of staff throughout the survey to determine their availability to meet resident needs. Examples of observations in this CE pathway include, on page 2:

  • Do staff rush when providing resident care?
  • Do staff explain to residents what they are doing when assisting or providing services to the resident?
  • Are residents provided timely assistance with eating during meals and are nursing staff monitoring the dining area during meals?
  • If concerns about staff responsiveness exist, the surveyor should monitor when the resident’s call device is activated and record the response time of the staff.
  • When observing care or services provided to residents by nursing staff, determine if they demonstrate competency. Such as, their abilities to provide care according to professional standards in the following areas: Refer to other regulations and IGs as appropriate.
    • Inability for staff to identify any obvious signs of residents’ change in condition;
    • Transfers and Positioning (e.g., use of mechanical lifts, bed to chair);
    • Infection Control Techniques, including wound care and residents on isolation precautions;
    • Tracheostomy, Ventilator care, or Tube feeding; and
    • Incontinence, including Catheter care.

Nurse leaders can incorporate into many of their activities observations of care delivery that are included in the CE pathways. Activities such as daily rounds, staff evaluations of competency, surveillance of infection control and prevention practices, and assisting staff to care for residents provide opportunities to observe staff competency. During these observations, nurse leaders should note any problems that may indicate noncompliance and investigate the situation further with additional observations. If noncompliance is found, corrective action will be necessary.


Most of the CE pathways also instruct surveyors to interview staff, residents, and families as part of their investigation. For example, the Unnecessary Medications, Psychotropic Medications, and Medication Regimen Review Critical Element Pathway instructs surveys to interview residents and/or their family members, as well as staff including the consulting pharmacist. From page 4 of the CE pathway, interview questions for residents, family, or resident’s representatives include:

  • What medications do you get and why do you need to take them?
  • What are your goals for your medications?
  • What information on the risk, benefits, and potential side effects of medications were you provided?
  • What changes in your medications have occurred, including gradual dose reductions for psychotropic medications?

These are a few of the questions the surveyor will ask staff. Pages 4 – 5 of the unnecessary medications CE pathway include additional questions.

  • What, when, and to whom do you report changes in the resident’s status (e.g., indications of distress or pain)?
  • How do you learn what the resident’s daily care needs are?
  • What non-pharmacological approaches are used?
  • What is the clinical indication for the medication?
  • How does the facility monitor the medication?
    • What monitoring tools or systems are used?
    • How did the interdisciplinary team (IDT) determine what should be monitored?
    • For psychotropic medications, how did you determine what behavior to monitor?
    • How do you assure orders for medication monitoring are implemented (e.g., HbA1c, PT/INR)?
    • How do you communicate relevant information regarding medication monitoring for this resident to other team members?
  • How do you assess whether each medication is effective?
  • How does the facility ensure a review of medications for GDRs?
  • If the resident is on a psychotropic medication: When did you attempt to reduce the medication and what were the results?

Nurse leaders should interview staff as part of a formalized scheduled compliance activity. Mock surveys or monthly focused compliance review provide opportunities to select interview questions to raise during daily rounds and at team meetings. If responses are questionable, nurse leaders should seek further clarification from the person providing the answer, particularly if any concerns of noncompliance have been noted for corrective action.


The CE pathways are available for nurse leaders to use and conduct a self-evaluation of compliance. By investigating these areas before survey, nurse leaders can correct concerns and improve processes to avoid citations. The AAPACN Survey Readiness: Critical Element Pathway, Observations, Reviews, and Policy Calendar guides nurse leaders through using the CE pathways to develop a plan and investigate compliance in their facilities throughout the year.

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