The Guide to Mitigating Immediate Jeopardy Risks
When you operate a nursing home or long-term care facility, there’s so much riding on the subjective findings of one surveyor from the Centers for Medicare and Medicaid Services (CMS). An Immediate Jeopardy (IJ) ruling not only highlights the real risks to patients, it can also cut off your revenue and damage your institution's reputation in the healthcare community.
Noncompliance cited as IJ is one of the most severe survey findings that can be levied against certified Medicare and Medicaid providers—and such a citation can even cause you to lose your accreditation and certification. According to the CMS, IJ “represents a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death.”
That definition indicates that CMS surveyors have exacting standards when it comes to Conditions of Participation (CoP) and the related Quality Indicator Surveys (QIS). And it’s precisely those standards that you can use as a guide to identify the predictable, actionable practices to prevent IJ risk from gripping your healthcare institution.
How To Mitigate Immediate Jeopardy Risks
The previously mentioned subjective nature of CMS surveyors makes IJ a risk that’s in a constant state of flux. Surveyors are often given latitude to judge the situation as they see fit, making an IJ ruling depending on the specific situation they encounter. Which is why having a survey readiness checklist on hand is your first line of defense!
But even with the unknown factor of how the individual surveyor might assess deficiencies, there are still ways to reduce your chances of receiving an IJ citation. Here are some ways nursing homes and long-term care facilities can prevent such a detrimental label after immediate jeopardy citation.
- Close oversight of day-to-day activities. An involved hospital board and management team can do much of the legwork in avoiding Immediate Jeopardy. Their goal should be to catch and fix potentially serious problems before the CMS surveyor arrives.
- Review CMS guidelines. Standards can often change, so constantly reviewing the current standards set by CMS is a vital strategy.
- Hold staff accountable for monitoring compliance. Your entire team needs to be on the same page in order to avoid IJ. Each individual who is responsible for overseeing and reporting must understand the importance of their role.
- Oversight should be the primary focus for entity leaders. Decision makers should always search for ways to strengthen practice and policy. This means stepping in and closing the knowledge gap with education and training.
- Don’t fear technology. Mobile and desktop platforms can empower periodic inspections that cover the same issues that CMS surveyors will look for. Enable technology to help you examine real-time data in an effort to manage your operations.
Immediate Jeopardy Issues and Triggers
Even though CMS standards tend to shift, knowledge is power! In order to mitigate risks, it’s crucial that nursing homes and long-term care facilities understand the incidents that could trigger a surveyor's Immediate Jeopardy ruling. What’s important to remember is that both potential and actual harm is considered when reviewing Immediate Jeopardy triggers. The following situations will cause a surveyor to consider if further investigation is needed to determine the presence of Immediate Jeopardy.
Failure to Prevent Abuse
- Serious injuries (head trauma or fractures)
- Suspicious injuries (black eye, cigarette burns on skin)
- Bruises around breast or genital area
- Unexplained serious injuries not investigated
- Staff striking or roughly handling residents
- Staff yelling, swearing, gesturing or calling residents names
- Nonconsensual sexual interactions
Failure to Prevent Neglect
- Failure to adequately monitor & intervene for serious medical or surgical conditions
- Lack of supervision for individual with known special needs
- Lack of timely assessment after injury
- Failure to follow doctor’s orders
- Repeated occurrences (falls) without interventions
- Access to chemicals & physical hazards
- Hot water temperature too high
- Broken call system without alternatives
- Unsupervised smoking
- Failure to adequately monitor individuals with known severe self injurious behavior
Failure to Protect from Psychological Harm
- Use of chemical or physical restraints without clinical indications
- Threatening or demeaning behaviors from staff resulting in fearful residents
- Lack of interventions to prevent individuals from creating an environment of fear
Failure to Protect from Undue Adverse Medication Consequences
- Administration of medication to resident allergic to it
- Lack of monitoring to identify side effects
- Administration of contraindicated medications
- Lack of diabetic monitoring
- Lack of timely and appropriate monitoring for drug titration
Failure to Provide Adequate Nutrition & Hydration
- Inadequate food to meet nutritional needs
- Failure to provide adequate nutrition, resulting in malnutrition
- Withholding nutrition and hydration without advance directive orders
- Lack of potable water supply
Failure to Provide Safety from Fire, Smoke & Environmental Hazards
- Fire in resident’s room
- Nonfunctioning or lack of emergency equipment &/or power source
- Widespread lack of knowledge of emergency procedures by staff
- Smoking in high-risk areas
- Widespread infestation by insects or rodents
- Lack of functioning ventilation system
- Improper disposal of hazardous material, chemicals or waste
- Lack of maintenance of fire alarm systems
- Unsafe dietary practices
Failure to Protect from Widespread Nosocomial Infections
- Improper handling of body fluids
- High number of infections without appropriate reporting, intervention and care
- Ineffective infection control precautions
- High number of nosocomial infections from cross-contamination
Failure to Correctly Identify Individuals
- Administration of medication or treatments to wrong resident
Qsource Provides a Clear Path Away from Immediate Jeopardy
A quick response is the ultimate way to address Immediate Jeopardy. Qsource can deploy a team within 24-48 hours to implement a remediation plan. Our proven model includes an assessment of your current situation, actionable solutions, a full review of your systems, and continued monitoring to ensure you maintain compliance with CMS.
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