Critical Element Pathways (CEPs) are tools in the Long-Term Care State Operations Manual (SOM) that are developed by Centers for Medicare and Medicaid (CMS) and utilized by surveyors along with interpretive guidance to evaluate each facility’s adherence to specific Federal Tag (F-tag) requirements. To evaluate resident care, each CEP is formatted to explain the purpose of investigation, with directions about which records to review – including Minimum Data Set (MDS) and care plans. Each CEP also guides specific resident observations, along with interviews to be completed with the resident and family/resident representative. Finally, each CEP provides surveyor guidance for staff interviews.
CMS updates CEPs to align with changes in CMS regulations and provide guidance as F-tag language changes. The most recent regulatory updates in April 2025 include the CEP for Unnecessary Medications, Chemical Restraints/Psychotropic Medications, and Medication Regimen Review. Using this CEP, surveyors identify residents and review records to determine potentially unnecessary medication use and evaluate prescribed psychotropic medication use. This CEP specifically addresses F757 Unnecessary Drugs and F605 Right to Be Free from Chemical Restraints by guiding the surveyor in determining if the facility has practices in place to identify, evaluate, and intervene for potential or actual unnecessary medications and/or chemical restraints. This CEP is also used to evaluate the facility’s medication regimen review (MRR) process. If a surveyor – using this CEP and interpretive guidance in the SOM – has identified insufficient facility practices in place to identify, evaluate, and intervene for potential or actual unnecessary medications and/or chemical restraints, CMS has imbedded guidance for additional areas to investigate – including additional F-tags and CEPs, to determine compliance with specific regulations.
The Inderdisciplinary Team
Involving the interdisciplinary team in medication management is critical for successful resident outcomes. Pharmacist consultants are experts at reviewing medications and identifying potential medication interactions, specific medication side effects, and opportunities to reduce medication burden. Pharmacist consultants can also help direct care staff connect the dots when residents are having adverse outcomes related to medications. Changes in mood and behavior, weight loss or gain, skin problems, lab results, and even mobility issues and falls should be brought to the attention of the pharmacist consultant when residents are receiving psychotropic medications. Therapy may need to evaluate changes in mobility, fine motor skills, and even cognition or swallow safety when psychotropic medications are utilized. The dietician may need to implement specific dietary changes and weight monitoring recommendations based on specific medication changes. Social Services may need to initiate referrals for additional services such as counseling, psychology, or psychiatry. Activities may need to implement specific resident-centered activities to support successful medication implementation or reduction.
The direct care staff – even nursing assistants and medication aids – need to be notified when psychotropic medication changes are implemented. Direct care staff see changes in symptoms and changes in the resident’s cognition, mood, and/or participation in activities of daily living often much more quickly than most other team members, and their prompt reporting may reduce the risk for negative resident outcomes. Licensed nursing documentation should include clear symptoms and behaviors the resident is experiencing, as well as specific side effects that are being monitored for. When PRN psychotropic medication is implemented, staff need to be educated that the PRN is only to be used for specific prescribed reasons. For example, a PRN psychotropic prescribed to treat hallucinations and delusions that are causing resident distress cannot be given at HS for insomnia, and the order cannot be extended beyond 14 days without provider documentation to do so.
Care Planning for PRN and Long-Term Use of Psychotropic Medications
Care planning for PRN psychotropic medication use might be an acute/short-term or temporary care plan, developed when the order is written. Managing PRN psychotropic medications as orders are written and implemented would be care planning “in real time,” with goals that are short term due to the nature of PRN psychotropic medication requirements for 14-day order limits. If a PRN psychotropic medication order is extended beyond 14 days with provider rationale and duration documented (as in the need for seizure rescue medications), the care plan may be created with long term goals. Residents who are stable on scheduled psychotropic medications should have a long-term care plan implemented, with updates “in real time” as those medications are titrated, and/or adverse interactions or side effects are noted, in addition to scheduled periodic reviews.
Integrating the CEP into Facility Practice
A specific risk meeting to evaluate PRN psychotropic medication use on a weekly basis can be helpful in monitoring for inappropriate use and mitigate negative outcomes. This meeting could also incorporate reviews of residents who had a recent gradual dose reduction or increase, with the focus on ensuring any complications those residents are experiencing are addressed and appropriate consent has been obtained in the case of dose increase. Acute/temporary/short term plans could be reviewed and updated at this meeting. The CEPs that CMS surveyors utilize for surveys can be used by the IDT as audit tools to evaluate how internal facility processes are functioning and supporting each resident’s highest practicable level of function while maintaining each resident’s safety. Critical Element Pathways can serve as guidance for building and revising processes and policies that ensure facilities attain and remain in compliance with each federal regulation in the long-term care setting.
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