Immediate Jeopardy in CMS Survey

What happens when CMS arrives at your doorstep for an allegation survey?  After you notify key people and get the surveyors settled, how do you address their concerns?  Sometimes their review triggers a standard in a Condition of Participation, and you know a corrective action plan will be required within 10 days.  If they cite a Condition Level Deficiency, you know they will revisit to review the implementation of your corrective actions.  But, when they start speaking to “Immediate Jeopardy” all your systems go on alert as you attempt to make sense of the finding and what to do to abate the situation.

Immediate Jeopardy 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)

When Immediate Jeopardy (IJ) is triggered, organizations must act to immediately stop or remove the risk that is or may cause harm to the patient.  Triggers alert CMS surveyors that some circumstances may have the potential to be identified as situations that would or could threaten the health and safety of patients. Surveyors then must follow the steps necessary to carefully analyze and accurately determine whether IJ exists.  These steps include: preparation, Investigation, decision-making and implementation.

CMS interprets IJ as a crisis that must be addressed to preserve the health and safety of the individuals served by the healthcare entity.  “Guidelines for Determining Immediate Jeopardy” are found in the State Operations Manual, Appendix Q.  The guidelines apply to all certified Medicare/Medicaid entities, except CLIA, and apply to all types of surveys and investigations:  certifications, recertifications, revisits and complaint surveys.  The primary goal of IJ guidelines is to identify unsafe situations to prevent serious injury, harm, impairment or death to patients.  (CMS State Operations Manual, Appendix Q – Guidelines for Determining Immediate Jeopardy, Rev.102, Issued: 02-14-14).   When questions arise about Immediate Jeopardy and CMS, contact us and we’ll assist you with the necessary actions to get your organization back on track.

Next month learn more in Part II – CMS Immediate Jeopardy Series: What Circumstances Trigger Immediate Jeopardy?

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