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How to Respond to Immediate Jeopardy & CMS Surveys

An immediate jeopardy decision can hit a healthcare facility like a ton of bricks. Even when strict policies are faithfully followed by a nursing home or long-term care facility, a Centers for Medicare & Medicaid Services (CMS) surveyor can still uncover unexpected infractions. 

And if not dealt with quickly, these infractions could lead to the care facility losing its Medicare accreditation, being slammed with hefty fines, and taking a major hit to their reputation. All it takes for an immediate jeopardy ruling is a single deficiency slipping through the cracks or  noncompliance with one condition of participation (CoP)—with that, even the most top-notch facility can incur the dreaded negative survey report.  

Of course, the ideal scenario sees your facility avoiding an immediate jeopardy ruling altogether. But should you find yourself in the unenviable position of facing off with CMS surveyor’s immediate jeopardy findings, what should you do? What steps can you take to clear up the issues and mitigate the consequences?

But before talking about how to respond to immediate jeopardy on a CMS survey, let’s find out how and why you might receive an immediate jeopardy citation.

What Causes an Immediate Jeopardy Ruling?

The official definition of immediate jeopardy from CMS is as follows:

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 or patient. 

Most immediate jeopardy rulings are caused by a failing in one or more of these areas:

  • Managing operations and staff
  • Planning delivery of services
  • Implementing care plans
  • Monitoring and evaluating staff performance
  • Ensuring contractors honor contracts
  • Ensuring staff knowledge base, including but not limited to: infection control practices, appropriate use of lifts, keeping chemicals out of residents areas not secured, etc. current and up to date

More specifically, CMS might rule immediate jeopardy if your organization fails to:

  • Protect patients from abuse
  • Prevent patients from neglect
  • Protect patients from physical/psychological harm
  • Protect patients from undue medication consequences
  • Provide patients adequate nutrition and hydration
  • Protect patients from hospital-borne infections
  • Practice standard precautions
  • Maintain sterile techniques during invasive procedures
  • Identify, notify physicians of resident changes and treat infections
  • Correctly identify individuals
  • Safely administer blood products
  • Safely monitor organ transplants
  • Provide patients safety from fire, smoke, and other environmental hazards
  • Educate staff on how to handle emergency situations
  • Provide initial medical screening, stabilization of emergency medical conditions and safe transfer for individuals with emergencies and woman in active labor seeking emergency treatment (EMTALA)

Yes, a lot of circumstances can raise the immediate jeopardy red flag in the eyes of a CMS surveyor. Now, let’s discuss your best course of action in response to this ruling.

What is Your First Move When Facing an Immediate Jeopardy CMS Ruling?

For starters, your best course of action is to act fast

The first notification of immediate jeopardy does not come in the form of an official document. Instead, this ruling typically comes directly from the mouth of your CMS surveyor. When an infraction is pinpointed and judged to be enough to trigger immediate jeopardy, the CMS surveyor will notify the Administrator and the DON immediately. Do not wait for written notification of immediate jeopardy—this will only waste valuable time.

If a surveyor cites immediate jeopardy, your mission is to correct the problem as quickly as possible. CMS will require a written report that the jeopardy has been abated, but it is possible to do so even before the surveyors leave the facility that day. Remember that this does not require correcting all of the deficiencies related to the citation—you only have to eliminate the immediate threat to patient safety and health.

This means:

  • Reviewing/revising and/or writing a new policy and implementing corrective actions/in-services as soon as possible
  • Approving the policy and changes through the appropriate channels
  • Training staff on the policy changes and any new training required immediately

You can enlist the help of your facility’s CEO or president to direct staff and resources to this emergency effort of remediation. In more severe cases, the facility might have to halt performing particular procedures if a fix is not immediately available. In such scenarios, you must demonstrate to the CMS surveyor that residents and/or patients are no longer at risk because you are simply not doing the procedure in question.

What if You Need More Time to Fix Immediate Jeopardy?

When immediate jeopardy abatement is not possible on the day of the ruling, the CMS surveyors will visit your facility again to confirm improvement. This second visit counts as one of your two allowed re-surveys. However, you do not want to waste this revisit on merely confirming an immediate jeopardy abatement when the CMS survey highlights other deficiencies that must be addressed. 

In those scenarios when fixing your immediate jeopardy ruling on the spot is not possible, you need to take more targeted action—and that means partnering with an organization that specializes in clinical and quality improvement. 

The Qsource Response to Immediate Jeopardy

Should your nursing home or long-term care facility face an immediate jeopardy ruling on a CMS survey, Qsource is at the ready with a quick response. We deploy a team within 24-48 hours to implement a plan for remediation. The Qsource plan begins with a current state assessment, then transitions to immediate remediations to quickly address the major issues. From there, we conduct a thorough systems review as well as sustainment interventions to assure you achieve full compliance. 

Here’s the outline of our hands-on immediate jeopardy remediation process:

  • Systems Review
  • Plan of Correction Development
  • Immediate Interventions
  • Competency-Based Trainings
  • Policy and Procedure Optimization
  • Sustainment and Audit System
  • Representation with Social Security Administration (SSA) and CMS

Fix Your Immediate Jeopardy Citation Fast!

Qsource will help you create a plan of removal and a plan of correction to prepare for a resurvey as quickly as possible. Reach out to us right away!


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