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What Happens After an Immediate Jeopardy Citation?

When your facility receives an Immediate Jeopardy (IJ) citation, it’s crucial that you and your team act as quickly as possible to mitigate the damage and correct the deficiencies to reduce the amount of fines and prevent denial of new admission payment.

The Centers for Medicare & Medicaid Services (CMS) will hit you with an Immediate Jeopardy charge when your nursing home or long-term care facility’s noncompliance to regulations leads to injury, harm, impairment, or death; this includes physical harm and/or psychosocial/mental harm. Only one resident needs to have suffered or be likely to suffer for IJ to exist. CMS could also tag you with Immediate Jeopardy should surveyors observe the potential for such incidents to occur.

In this blog, we review what you should do next if your facility is labeled with an Immediate Jeopardy citation.

What’s the first thing I should do when tagged with Immediate Jeopardy?

If your facility is cited with Immediate Jeopardy, your first priority should be to have that citation removed as quickly as you can. CMS clarifies that action must be taken even if the resident is no longer in the facility or has passed. Immediate Jeopardy can ruin your reputation, lead to hefty fines, and even result in the closure of your facility.

Removing the jeopardy tag is known as “abating the jeopardy.” In order to achieve this, you will need to submit a written Allegation of Compliance that the Immediate Jeopardy has been removed. Your submission must include a detailed plan of action recounting how and when the citation was removed. Try to do this before the surveyor leaves your facility. A full plan of correction still has to be completed and implemented.

As such, once the immediate and serious threat has been removed and poses no more risk to the residents, then you can allege that the Immediate Jeopardy has been removed.

Can I appeal the Immediate Jeopardy citation?

Appeals are appropriate in cases of Immediate Jeopardy. You can appeal the underlying deficiency named in the citation, just as you would any other deficiency through the informal dispute resolution process, and also through the formal appeal process to an administrative law judge. In addition, when an Immediate Jeopardy is cited, you are allowed to dispute the severity level as well through the appeals process.

What should I do if an incident occurs that I think could potentially be cited as an Immediate Jeopardy?

When you take into account the potential severity of penalties that come with Immediate Jeopardy, the best thing you can do is fix the problem in short order. Fixing the problem puts you in the position to qualify the deficiency for past noncompliance, which essentially means that your facility corrected the noncompliance and is currently operating under compliance; the facility would then not be required to submit a Plan of Correction (POC) in cases of past noncompliance.

What is an Immediate Jeopardy Removal Plan?

A removal plan is required by CMS. It identifies all actions the entity will take to immediately address the noncompliance that has resulted in the Immediate Jeopardy by detailing how your facility will keep recipients safe and free from serious harm or death caused by the noncompliance.

Your removal plan must:

  • Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance.
  • Then specify the action taken for those residents to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring and specify when the action will be complete.

Is the Removal Plan the same as a Plan of Correction?

No. Your removal plan does not need to completely correct all noncompliance issues. Instead, it addresses and ensures that the serious harm will not occur or reoccur. Your removal plan must include a date for the serious harm to no longer exist.

What is a Plan of Correction?

A Plan of Correction outlines the specific steps you will take to bring your facility to full compliance. The plan must be approved by CMS and include dates by which the corrections will be implemented.

Your facility’s Plan of correction must answer:

  • How corrective action will be accomplished for those residents found to have been affected by the deficient practice.
  • How the facility will identify other residents having the potential to be affected by the same deficient practice.
  • What measures will be put into place or systemic changes made to ensure that the deficient practice will not repeat.
  • How the facility plans to monitor its performance to make sure that solutions are sustained and reviewed.
  • When corrective action will be completed. The corrective action completion dates must be acceptable to the state.

If your Plan of Correction is deemed unsatisfactory for any reason, you will receive written notification from the state. If the plan is accepted, the state will likely notify you via phone or email. What’s more, the Plan of Correction will serve as the facility’s Allegation of Compliance.

What is Qsource's primary role in a facility's reaction to Immediate Jeopardy?

“Qsource deploys a team onsite within 24-48 hours to assist with the immediate removal plan, completes systems review, identifies remediations, and creates a sustainment plan,” says Ann Lewis, Qsource Vice President of Business Development. “Qsource can complete the remediations onsite with the team, work with the state surveyors, assist with writing the Plan of Correction and Allegation of Compliance, and provide additional support needed to achieve compliance such as complete competency based training, Root Cause Analysis and interventions.”