The phrase “immediate jeopardy” is as foreboding as it sounds.
A designation levied upon nursing homes and long-term care facilities by the Centers for Medicare & Medicaid Services (CMS), Immediate Jeopardy (IJ) means you are on the brink of losing your accreditation for Medicare in the very near future. It also means you will be subjected to hefty fines and incredibly bad publicity.
In other words, you never want to see those dreaded words on a CMS survey report. In this blog, we’ll reveal simple tips you can use to mitigate the risk of IJ.
But first ….
What is Immediate Jeopardy?
CMS defines Immediate Jeopardy (IJ) as “a situation in which the provider’s noncompliance with one or more conditions of [Medicare/Medicaid] participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.”
As outlined in the Core Guidelines for Determining Immediate Jeopardy in the CMS State Operations Manual Appendix Q, all Medicare- and Medicaid-certified senior living providers, including nursing homes, skilled nursing facilities (SNFs) and assisted living communities, must undergo compliance surveys and can find themselves in crisis if a CMS surveyor declares IJ.
Appendix Q is the resource used by surveyors when determining when to cite Immediate Jeopardy, and that handbook also offers specific key components of IJ. These include:
- Noncompliance: An entity has failed to meet one or more federal health, safety, and/or quality regulations.
- Serious Adverse Outcome or Likely Serious Adverse Outcome: As a result of the identified noncompliance, serious injury, serious harm, serious impairment or death has occurred, is occurring, or is likely to occur to one or more identified recipients at risk.
- Need for Immediate Action: The noncompliance creates a need for immediate corrective action by the provider/supplier to prevent serious injury, serious harm, serious impairment or death from occurring or recurring.
When CMS surveyors determine that all three of the above criteria exist, it will impose a ruling of Immediate Jeopardy.
The CMS State Operations Manual (SOM) outlines three contributing factors that can result in Immediate Jeopardy: Harm, Immediacy, and Culpability. What’s more, it’s important to remember these crucial SOM factors as well:
- Serious harm, injury, impairment, or death does not have to occur before considering Immediate Jeopardy.
- Psychological harm is considered to be as serious as physical harm.
- Individuals must not be subjected to abuse by anyone including, but not limited to, staff, consultants, volunteers, family members or visitors.
- Only one individual needs to be at risk. Identification of Immediate Jeopardy for one individual will prevent risk to other individuals in similar situations.
Even the best-run facilities with extremely high-quality healthcare can be hit with IJ findings. However, the subjective nature of the surveyor’s assessment can often lead to frustration and anger among hospital leaders. This reaction is completely valid. However, once an IJ ruling is handed out, it’s vital for you to focus on achieving compliance rather than what you may perceive as a gross overreaction by the surveyor.
How to Avoid Immediate Jeopardy
The old adage, “an ounce of prevention is worth a pound of cure” certainly applies to Immediate Jeopardy. While there are steps you can take to correct IJ after the fact, it's easier to stop something from happening in the first place than to repair the damage after it has happened.
Here are steps you can take to avoid an Immediate Jeopardy ruling altogether:
1. Educate staff on the organization’s policies and procedures
When your staff fully understands the guiding principles of your organization, they are better equipped to avoid making mistakes that lead to IJ. Make sure all of the members of your team are up-to-date on your policies and procedures, as well as the compliance standards of CMS. Compliance education and training provides crucial resources for your team, preparing them for shifts in compliance standards, while also bridging knowledge gaps and strengthening potential weaknesses.
2. Hire skilled staff that can perform tasks required for safe patient care
Oftentimes, CMS compliance is fostered during the hiring process. Any team members you bring on board to your facility must have the ability to perform their duties at the top of their field. This means following protocols that ensure patient safety, having the ability to correctly operate a range of instruments, understanding the needs of patients and their families, and identifying shortfalls in care before a situation becomes untenable.
3. Follow instructions for products and equipment
A CMS surveyor can impose an IJ ruling for improperly used medical products or equipment. This is one of the most unfortunate instances of IJ, mainly because it is also one of the most avoidable compliance errors. Healthcare staff should be continuously trained to use all manner of medical equipment, with special attention paid to instructions at all times. For example, your organization must strictly follow a manufacturer’s instructions for cleaning and disinfecting medical devices.
4. Deploy proactive risk assessment
You can get ahead of potential immediate jeopardy by assessing the possibility that such a ruling could be handed down by a CMS surveyor. Avoiding legal issues, monetary fines, and damage to your reputation are huge incentives for including risk assessment in your healthcare compliance program. What’s more, when potential problems are identified and corrected, patient safety is positively impacted.
5. Understand Immediate Jeopardy inside and out
There’s a well-known legal principle that states: “Ignorance of the law is no excuse.” This means that a person who is unaware of the existence of a law cannot escape liability simply because they didn’t know the law existed. In other words, you shouldn’t expect your CMS surveyor to cut you some slack on a violation you didn’t know you were committing. As a provider of healthcare, you are expected to possess a full understanding of the standards governing nursing homes and long-term care facilities. Become a student of CMS standards—a deep well of knowledge can keep your facility in good compliance.
Qsource Equips Immediate Jeopardy Mitigation Tactics
Should a CMS surveyor deem an Immediate Jeopardy judgment necessary, Qsource can implement a plan of action. This includes current state assessment, immediate remediations, systems review, root-cause analysis, and sustainment interventions to assure compliance is achieved.
When you are tagged with Immediate Jeopardy, there is no time to waste. Connect with Qsource today.
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