Immediate Jeopardy (IJ) is a situation in which a recipient of care has suffered or is likely to suffer serious injury, harm, impairment or death as a result of a provider’s noncompliance with one or more health and safety requirements. Immediate jeopardy represents the most severe and egregious threat to the health and safety of recipients, as well as carries the most serious sanctions for providers.
Florida skilled nursing centers have received IJ citations for issues with CPR, infection control, abuse and failure to supervise. CPR citations have been issued because of failure to initiate CPR when there is no Do Not Resuscitate Order (DNRO) or initiating CPR when there is a DNRO. The center should have good education and a communication system for all staff about the resident’s code status. Good practice would be to conduct code blue drills. Infection control citations have been issued for improper cleaning of glucose monitoring devices. The center must follow the manufacturer guidelines for the device and use the proper cleaning product. The abuse citations are from injuries or negative outcomes from failure to monitor a resident who has been identified as a risk. Failure to supervise may have been an elopement or an injury or choking incident when the resident was a known risk.
Many of the IJs cited are questioned as to whether they were really an IJ. The word “potential” in the definition of Immediate Jeopardy makes it broad for interpretation. Further guidance and understanding are needed about what an Immediate Jeopardy really is, as there is a lack of consistency on the Immediate Jeopardy citations from state to state.
The Centers for Medicare and Medicaid Services (CMS) has developed the guidance to surveyors for citing Immediate Jeopardy in Appendix Q of the State Operations Manual (SOM). The version of Appendix Q that is being replaced was drafted in 2004 and is being updated to clarify and increase consistency for identifying Immediate Jeopardy. QSO-19-09-ALL includes the updates and explanations of the IJ changes.
The revision to the appendix creates a Core Appendix Q that will be used by surveyors during surveys. To cite Immediate Jeopardy, the surveyor will need to determine: 1) noncompliance; 2) the facility caused or created a likelihood that serious injury, harm, impairment or death to a recipient would occur or recur; and 3) immediate action is necessary to prevent the occurrence or recurrence of serious injury, harm, impairment or death to one or more recipients.
The Core Appendix Q contains several key changes from the previous version of Appendix Q. Those changes include:
Likelihood instead of potential
The previous version of Appendix Q suggested that a potential for serious harm might constitute Immediate Jeopardy. The survey guidance now makes it clear that to cite Immediate Jeopardy in situations where recipients have not already suffered serious injury, harm, impairment or death, the nature and/or extent of the identified noncompliance creates a likelihood (reasonable expectation) that such harm will occur if not corrected, not simply the potential for that level of harm to occur.
Culpability has been removed
The previous version of Appendix Q made culpability a required component to cite Immediate Jeopardy. Because the regulatory definitions of Immediate Jeopardy do not require a finding of culpability, that requirement has been removed and has been replaced with the key component of noncompliance, since the definitions Of Immediate Jeopardy require noncompliance to be the cause of the serious injury, harm, impairment or death, or the likelihood thereof.
Core Appendix Q includes a section instructing surveyors to consider whether noncompliance has caused or made likely serious mental or psychosocial harm to recipients. In situations where the psychosocial outcome to the recipient may be difficult to determine or incongruent with what would be expected, the guidance instructs surveyors to use the reasonable person concept to make that determination. The reasonable person approach considers how a reasonable person in the recipients’ position would be impacted by the noncompliance (i.e. consider if a reasonable person in a similar situation could be expected to experience a serious psychosocial adverse outcome as a result of the same noncompliance).
No automatic Immediate Jeopardy citations
Core Appendix Q makes it clear that each Immediate Jeopardy (IJ) citation must be decided independently, and there are no automatic IJ citations.
CMS has established a notification process for surveyors to follow when Immediate Jeopardy is identified. This process will ensure the provider is notified as soon as possible of an IJ finding. This should increase transparency and improve timeliness and clarity of communication to providers.
Online basic training for Core Appendix Q is available on the Integrated Surveyor Training Website at the following link: https://surveyortraining.cms.hhs.gov/.
If a skilled nursing center receives an IJ, they must immediately develop a removal plan. The removal plan should document the immediate action the center will take to prevent serious harm from occurring or recurring. Unlike a plan of correction, it is not necessary that the removal plan completely correct all noncompliance associated with the IJ, but rather it must ensure serious harm will not occur or recur. The removal plan must include a date by which the entity asserts the likelihood for serious harm to any recipient no longer exists. The center’s removal plan must identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome because of the noncompliance. It must also specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete.
There is no requirement that IJ be removed prior to conducting the exit conference. To remove the IJ, the facility must implement the removal plan, and the survey team must verify through observation, interview and record review, that all actions the center took were effective in removing the likelihood that serious injury, serious harm, serious impairment or death would occur or recur. Surveyors shall confirm that the IJ has been removed by onsite verification after the center’s removal plan is approved and has been implemented. If the removal plan cannot be implemented prior to the exit conference of the original survey in which the IJ was cited, the IJ continues until an onsite revisit verifies the date that IJ was removed.
Appendix Core Q should assist the provider and surveyor in understanding what is truly an Immediate Jeopardy and the path to immediately correct the situation.