Skip to content

How to Avoid CMS Survey Deficiencies & Immediate Jeopardy

Nursing homes and long-term care facilities that participate in Medicare and Medicaid programs are subject to regular annual surveys by the Centers for Medicare & Medicaid Services (CMS) to ensure compliance with federal regulations and standards. 

Any failure to meet these requirements can result in serious consequences, including fines, legal action, or even loss of certification. This all falls under the umbrella of Immediate Jeopardy—a phrase that can strike fear into the heart of any healthcare provider. Some of the most common CMS survey deficiencies include infection control, accidents, quality of care/life, medication management, resident assessment, and staffing. 

However, by implementing evidence-based practices, providing proper training to staff, and regularly evaluating policies and procedures, healthcare providers can take steps to avoid these deficiencies and provide the best possible care to their patients.

 Check out our guide to mitigating immediate jeopardy risks! 

How is Immediate Jeopardy Linked to CMS Surveys?

Immediate jeopardy citations result from the most dire and serious findings in a CMS survey. Essentially, it means that a healthcare provider's noncompliance with CMS regulations has placed patients in immediate danger of serious physical and/or psychological injury, harm, impairment or death.

During a CMS survey, an official surveyor evaluates a healthcare provider's compliance with CMS regulations, policies, and standards. If the surveyors identify an issue that poses an immediate threat to patient safety, they may issue an immediate jeopardy citation. This citation requires healthcare providers to take immediate corrective action to remedy the issue and prevent further harm or potential further harm to patients. 

Without a serious and proactive approach to resolving your facility’s issues, you will face fines, legal action, or even loss of Medicare or Medicaid certification. But by prioritizing patient safety and implementing training along with policies and procedures that comply with CMS regulations, healthcare providers can minimize the risk of immediate jeopardy citations and provide high-quality care to their patients.

The Most Common CMS Survey Deficiencies 

Here are some of the most common CMS survey deficiencies and how to avoid them:

Infection Control Deficiencies

To avoid deficiencies in this area, make sure your staff are trained in proper hand hygiene and follow standard precautions, such as wearing gloves and gowns when necessary. Ensure that all medical equipment is properly cleaned and disinfected after each use.

Accident Deficiencies

Facilities must ensure they mitigate an environment free from accident hazards they can control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes individual resident hazards risk assessment including: identifying, evaluating/analyzing, implementing interventions, monitoring effectiveness and modifying interventions when necessary to prevent any unexpected or unintentional accidents.

Quality of Care Deficiencies

A critical component of healthcare, CMS surveys often assess whether providers are meeting established quality standards. Implement evidence-based clinical protocols and guidelines, use performance metrics to measure outcomes, and see that all staff are trained in quality improvement methodologies and are actually implementing them on the floor.

Medication Management Deficiencies

Medication errors can have serious consequences for patients. As such, it’s vital to have robust medication management policies in place. Medication orders must be accurately recorded and verified, medication dispensing and administration practices must be followed correctly, and staff must be trained in identifying and reporting adverse medication events.

Resident Assessment Deficiencies

For long-term care facilities, CMS surveys often focus on resident assessment and care planning. To avoid deficiencies in this area, ensure that all residents are accurately assessed and that care plans are developed and routinely revised based on individual needs and preferences; this ensures that they remain appropriate and effective.

Staffing Deficiencies

Adequate staffing levels are critical to ensure quality care and patient safety. Staffing levels must always be at an appropriate level for patient acuity/needs, and staff should be properly trained and supervised. Regularly evaluate staffing levels and adjust as necessary to ensure that patient needs are being met.

Maintaining compliance with CMS regulations is essential to delivering high-quality care and avoiding survey deficiencies. By implementing evidence-based clinical protocols and guidelines, providing proper training to staff, and regularly evaluating and adjusting policies and procedures, healthcare providers can minimize the risk of deficiencies and provide the best possible care to their patients.

Enlist Qsource to Attend to CMS Survey Deficiencies 

CMS survey deficiencies can seriously hamper your facility’s ability to not only meet the needs of your patients, but also merely keep your doors open. Qsource is a certified Quality Improvement Organization. Our reliable and fully vetted processes can help you:

  • Identify the problem: The first step is to identify the issue that led to the immediate jeopardy citation. This may involve reviewing the CMS survey report and conducting additional assessments and investigations to identify the root cause of the problem.
  • Develop a corrective action plan: A corrective action plan outlines the specific steps that will be taken to address the issue. This plan should include specific timelines, staff responsibilities, and measures for evaluating the effectiveness of the corrective action.
  • Implement the corrective action plan: The plan should be implemented as quickly as possible to address the immediate jeopardy and prevent further harm to residents. This may involve making changes to policies, procedures, or practices, providing additional staff training, or making physical changes to the facility.
  • Monitor and evaluate progress: Continuously gauge the effectiveness of the corrective action plan on an ongoing basis. This involves conducting follow-up assessments, reviewing data and outcomes, and making additional adjustments as needed based on the effectiveness or ineffectiveness of each intervention.
  • Communicate with residents, families, and staff: This is essential to addressing CMS survey deficiencies and regaining trust in the facility. Regular updates and transparent communication can help to ensure that everyone is informed and involved in the corrective action process.

By taking these steps, nursing homes and long-term care facilities can address CMS survey deficiencies and overcome immediate jeopardy citations. Contact Qsource and let’s start a conversation.


More Information on Immediate JeopardyPartner with QsourceBook a Consultation