CMS Immediate Jeopardy: Part II

The goal of every CMS survey is to ensure the provision of quality care for all individuals receiving care or services from a Medicare or Medicaid entity.  Surveyors seek to identify and remove the harmful situation, whether psychological or physical to prevent harm to patients.

Immediate Jeopardy (IJ) is: “A situation in which the provider’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.” (See 42 CFR Part 489.3)   This definition includes concerns with abuse and neglect.

Abuse is defined as: “The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.” (See 42 CFR Part 488.301.)  While

Neglect is defined as: the “Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.” (See 42 CFR Part 488.301.)  Potential or actual circumstances are investigated to identify IJ.

Basic principles to keep in mind include:

  • One individual at risk can prompt Immediate Jeopardy (IJ). The assumption is that identification of one individual at risk will prevent risk to other individuals in the same situation.
  • Harm does not have to occur to trigger IJ. The potential for serious harm, injury, impairment or death to one or more individuals can trigger investigation.
  • Individuals must not be subjected to abuse by anyone. Consider staff, family, consultants, visitors, volunteers or others.
  • Abuse and neglect can result in serious harm
  • Psychological harm for individuals is as serious as physical harm.
  • When investigation establishes that a cognitively impaired individual harmed an individual receiving care, the entity’s failure to prevent harm would be considered neglect.
  • Whenever a surveyor cites abuse or neglect, it should consider IJ.

Once circumstances are identified that may constitute IJ, an investigation must be conducted to confirm or rule out IJ.  After determining that harm, whether past, present or likely to occur, is present, surveyors must address the entity’s compliance to determine if the entity created the situation or if the entity had opportunity to implement corrective or preventive actions.  When the investigation is complete, surveyors will choose the specific Federal regulation to address the deficient practice. Entities receive verbal notification at the time and written notification two days after survey.  When questions arise about Immediate Jeopardy and CMS, contact us at and we’ll assist you with the necessary actions to get your organization back on track.

Next month learn more in Part III – CMS Immediate Jeopardy Series:  What are the CMS Immediate Jeopardy Triggers?

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