Critical Element Pathways

Lisa Volk in Clinical & Quality

How do I begin to prepare for the new survey process? The newly released CMS Critical Element Pathways are a perfect place to start. These tools can help manage quality in healthcare settings and standardize care processes. The new survey method is a blend of traditional and QIS survey. The critical pathways are included in this new process. Each pathway provides detailed information for the surveyor to follow during survey. Some of the areas for review are: resident records, staff and family interviews, as well as observations. Use these critical pathways as a helpful resource, review the sections below and educate the staff to ensure compliance in each of these areas. Additionally, the last section of the pathway includes the critical element decision making related to citing of deficiencies. All the critical pathways can be found at: 

Here are some examples of what to look for under the critical element accidents. See full critical element pathway in the above link.


Is the resident supervised if required?
Does the resident have oxygen on while smoking?
Does the resident have a smoking apron or other safety equipment if needed?
Does the resident have difficulty holding or lighting a cigarette?
Are there burned areas in the resident’s clothing/body?
Does the resident keep his/her cigarettes and lighter?

Resident-to-Resident Altercations (also being reviewed under the Abuse pathway)

Did the resident have any altercations (e.g., verbal or physical) with any residents?  If so, how did staff respond?

How does staff supervise/respond to a resident with symptoms such as anger, yelling, exit seeking, rummaging/wandering behaviors, targeting behaviors, inappropriate contact/language, disrobing, pushing, shoving, and striking out?

Wandering and elopement:

Where is wandering, behavior observed?
What interventions are implemented to ensure the resident’s safety?
If the resident is exit seeking, what interventions are implemented to prevent elopements? 

Safety/Entrapment (e.g., physical restraints, bed rails).

If the resident requires assistance with transfers, does staff implement care-planned interventions for transfers?
Does the equipment appear to be in good condition, maintained, and used per manufacturer’s instructions?
If bed rails are used:

Are they applied safely; and
Are there areas in which the resident could become entrapped (i.e., large openings or gaps), or become injured, such as exposed metal, sharp, or damaged edges?

For a resident with a physical restraint:

Does the resident attempt to release/remove the restraint, which could lead to an accident? If so, describe;
Who applied the restraint, how was it applied, and how was the resident positioned; and How does the resident request staff assistance (e.g., access to the call light)?
How do staff respond to resident requests, and how often is monitoring provided? 


Lisa Volk, RN, B.P.S., LNHA
Director, Clinical & Quality Services
518-462-4800 x15