IMMEDIATE JEOPARDY
(IJ)
Determination in the Acute Care Setting
To determine Immediate Jeopardy, always refer to Appendix Q
Objectives
Define Immediate Jeopardy
Discuss the investigation process
Review decision making for compliance
Review documentation expectations
DEFINITION
CFR 489.3 - Immediate Jeopardy
• “...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.”
Principles of Immediate Jeopardy
Interpreted as a crisis situation which
threatens the health & safety of individual(s)
Applicable to all certified Medicare/Medicaid
entities (excluding CLIA)
IJ is called based upon information gathered
onsite- but MAY be called by SA/RO offsite
based upon document reviews
Principles (cont.)
May have occurred in the past
May be occurring in the present
May be very likely to occur in the future
That is serious harm, injury, impairment or
death
Recognizing Immediate Jeopardy
Focus is on:
Timing: how imminent the danger appears
and
Severity: seriousness of the potential
consequences
Recognizing Immediate Jeopardy
(cont.)
Harm does NOT have to occur before
Immediate Jeopardy can be considered
Only ONE individual needs to be at risk
Principles
 Serious psychological harm is considered
as significant as serious physical harm
 Individuals must not be subjected to
abuse by anyone, including staff,
volunteers, other patients or visitors
INVESTIGATION
The investigation process must
proceed until Immediate Jeopardy is
 confirmed
or
 ruled out
Components of Immediate Jeopardy
 Harm
 Immediacy
 Culpability
Consider a stool with three legs
All 3 components must be applied to the
situation in order for the IJ to “stand”
Decision Making
Component # 1: Harm
Actual
Was there an outcome of harm
Potential
Is there likelihood of potential harm
Is it likely to occur in the very near future
Does that harm meet the definition of IJ
Decision Making
Component # 2: Immediacy
 How imminent is the danger
 What is the likelihood of it happening again
 Does the situation need to be “immediately
addressed”
Decision Making
Component # 3: Culpability
Did the entity know about the situation
Should they have known
 If so when did they first become aware
 Includes but is not limited to neglect,
indifference or disregard for resident care,
comfort or safety
Culpability
Otherwise known as avoidability
Are remarkably consistent across all care tags
Are common sense
Congruent with basic nursing practice
Examples of failure to assess
Failure to develop
Failure to implement
Failure to change unsuccessful interventions
Example Culpability
 Failure to provide supervision to ensure medication is
administered in accordance with physician’s order
 Patient died due to administration of medication not
intended to the patient
Investigation of IJ
 Who- patient/staff at risk due to failures of
entity
 What- did not do something that was
necessary or did something not acceptable
within standards of care
 When- currently or in the past*
 Where- service area, patient unit
 Why- policy support, interview support
Principles
Can only cite current noncompliance
For example, when initial identifying event, such
as a death, is the underlying cause, actions,
inactions, etc that led to, or that was associated
with the death still present? If the answer is
YES, then evaluate the present status of the
issue(s) as current noncompliance
Evaluate the components of IJ to determine if
IJ is currently present
Principles (cont.)
 IJ may have been present in the past, but the hospital truly
“fixed” the problem that led to the adverse situation prior to
the survey
 The surveyor must determine if the “fix” is complete
 Or is there some level of noncompliance that currently exists
 If current noncompliance exists, the hospital is currently noncompliant and would be cited
 If the situation does not meet IJ definition, then the team
must determine whether the noncompliance is condition level
or standard level
Principles (cont.)
 Remember we can only cite current
noncompliance (hospitals)
 No past IJ except for EMTALA
 We cite only noncompliance that is found
during the survey
Therefore we DO NOT cite past IJ
Reminders to Staff
Copying of documents is allowed:
– Obtain copies of the records which show the
deficient practice
– Surveyors have access even to QA and Peer
Review if needed
– Ensure they speak with the person most
knowledgeable about the situation
– Gather information NEEDED
– Their investigation must continue until IJ is
confirmed or ruled out
Access to Records 489.53
(Termination by CMS)
“(a) Basis for termination of agreement with any
provider. CMS may terminate the agreement
with any provider if CMS finds that any of the
following failings is attributable to that
provider: …
Access to Records 489.53
(Termination by CMS) (cont.)
• (5) It refuses to permit examination of its fiscal
OR OTHER RECORDS by, or on behalf of CMS,
as necessary for the verification of information
furnished as a basis for payment under
Medicare
• This requirement does not apply to
information protected as Patient Safety Work
Product (PSWP)
Access to Records 489.53
(Termination by CMS) (cont.)
• (13) It refuses to permit photocopying of any
records or other information by, or on behalf
of CMS, as necessary to determine or verify
compliance with participation requirements.”
As a Surveyor
Be familiar with the contents of Appendix Q
Notify the team leader IMMEDIATELY if you
suspect an Immediate Jeopardy situation
An IJ investigation becomes the FIRST
PRIORITY for the team
Where Does the Surveyor Now go
Gather the evidence
Determine the facts based on the evidence
Draw the conclusions or findings from your
facts
Investigate accordingly
The 3 Sources of Data
 Documents- logs/reports, records, policies, procedures
as well as incidents , QA, Peer Review that we review
and gather in the conduct of the survey
 Interview- informal is best with open ended questions
 Speak with knowledgeable persons r/t the subject
matter; carefully record the responses to questions
asked
 Observations- what we saw/heard/smelled/tasted or
felt
 Careful- felt as with actual touch & not felt in your gut!
Implement the Investigation
What does the team need to know based
upon the identified concerns
Carefully review the language of the
regulation and the IG
Can’t investigate without the SOM regardless
of how seasoned you are
Your Concern
What about the regulation
Is there an actual regulatory requirement
Is there a deficient practice- regardless of
adverse outcomes
Use IJ triggers in Appendix Q- identifies facility
failures as core issues for the TEAM to
consider
Do the 3 legs of your stool hold your concern
“up”
Temptation
Our job is difficult- easy outs are tempting
Survey process is thorough & thought out for
a reason
We must resist the temptations- checklists are
not thorough
Survey is not just a set of protocols
Go with the evidence
Is the requirement met - yes or no
Your Survey Finding Facts
 Based upon verified evidence
 Was it an event that happened that shouldn’t
have or was it an event that should have
happened that didn’t
 Was it a situation that existed or does not exist
AND that, alone or in company with other facts,
proves or disproves a violation of a regulatory
requirement
 Was the requirement violated
REMEMBER!
An Immediate jeopardy can present
itself on any tag at any point during a
survey. It is up to the surveyors to
determine whether or not an IJ
situation is present and to investigate
it using Appendix Q.
Immediate Jeopardy
What Happens Next
Documentation Expectations
Immediate Jeopardy- Process
Surveys cannot be conducted in isolation
It leads to an inadequate investigation
This may allow a dangerous situations to be
missed so evaluate all pertinent info
If a citation written is flawed & can not standbeneficiaries may remain at risk
Accurate level of citation(s) is critical to health
& safety protection
Immediate Jeopardy Is Present
 Team and information sharing using Appendix Q
and triggers
 Verify information is sufficient and meets
definition of IJ
 All components are addressed- 3 legs of the stool
 Follows state agency procedures with RO
notification
 Team notification to entity administration of the
identified circumstances that constitute IJ
After Informing the Facility
• Facility has opportunity to make corrections
• Should submit to team a “credible allegation
of compliance”
• Refer to SOM 3016A
• Facility needs to identify steps taken to
remove the IJ
• Removal of IJ is NOT a system wide fix
Language Has Meaning
• Term “removal” of IJ and “abated” often used
interchangeably
• Removing IJ means the immediacy of the
situation has been addressed
• Term should be “removal” to be consistent
with Appendix Q
• There is a difference in facility “removing” IJ
and “correcting” IJ
Immediate Jeopardy:
Removal vs. Correction
Removal of IJ situation by hospital
Removing the beneficiaries at risk
Removing the direct threat
Reducing the immediacy of the threat
Reducing the severity of the threat
Immediate Jeopardy:
Removal vs. Correction (cont.)
Correction
IJ is corrected when the facility implements all actions to
fix the system breakdown
 Surveyors must validate that the actions taken have been
implemented facility wide
 Does remaining non-compliance meet definition of IJ
 If 3 legs of the stool are not present the IJ would be
corrected
Immediate Jeopardy
Removed or Not
 Surveyors must be onsite to validate IJ has been
removed
 Surveyors must verify the implementation of the
actions indicated by the provider
 This does not mean the “system issues have been
corrected” just immediacy has been mitigated
 Example- firing the nurse does not fully address a
situation with a fatal medication error
CMS 2567 Documentation
Official document of CMS findings
Must be written in accordance with the
Principles of Documentation
IJ now tracked for payment purposes
All IJ’s must be recorded on the CMS 2567
even if IJ removed while team is onsite
In initial comment section write the scenario
that constitutes IJ
DOCUMENTATION- IJ
REMINDERS
Clearly state the time and date that the IJ was
identified during the survey
State the date the IJ began
Document the date and specific persons
notified of the IJ
Include the justification for the determination
of an ongoing IJ
Documentation- IJ (cont.)
 Team will then cite the applicable CoP(s) that
contributed to the IJ at the Condition level of noncompliance
 Again with the POD- they are to write based upon
verified evidence
 Entity can have more that one IJ at the same time
CMS 2567 Documentation
IJ Not Removed
• Cite IJ at Condition Level
• Clearly state the time and date that the IJ was
identified during the survey
• State the date the IJ began
• Document the date and time specific facility
persons notified of the IJ
• Include the justification for the determination
of an ongoing IJ
Documentation
IJ Removed- Condition Level Exists
• Cite the IJ at the Condition level
• Deficient practice is no longer likely to cause
serious harm, impairment or death
• Facility is however non-compliant still at
Condition level
• Indicate date/time IJ was identified, date IJ
began
• Include date/time and specific title of those
informed of the IJ
Documentation
IJ Removed- Condition Level (cont.)
• Documentation will indicate subsequent
removal of IJ, date, time, actions taken that
removed the IJ
• Include your confirming evidence of removal
• Indicate although the IJ has been removed,
facility remains out of compliance at the
Condition level
• Cite remaining evidence of deficient practice
Documentation
IJ Removed and Corrected
• Deficient practice no longer likely to cause
serious harm, impairment of death
• Removal of IJ also achieved compliance at
Condition Level
• Cite date/time IJ identified and date it began
• Cite date/time IJ removed/corrected
Documentation (cont.)
• Include what facility did to remove IJ and
verification by survey team
• Cite anything remaining at appropriate
standard level
Documentation Example
A Validation Survey was conducted at Pleasant Valley Hospital
on 2/2/10 - 2/12/10. The Director of Compliance for the hospital
was notified on 2/11/10 at 5:55 p.m. that Immediate Jeopardy
(IJ) conditions existed. The determination was made related to
the failure of the facility to provide care in a safe setting and for
failure of nursing staff to respond to alarm indicators for Patient
#77 who required continuous cardiac rhythm and rate
monitoring. This failure resulted in the death of the patient on
1/4/10. At 9:56 a.m. on 1/4/10, the patient was asystole (without
a heart beat) and the staff did not respond to the alarm until
10:16 a.m.
Applicable CoPs
Nursing Services
Based on observations, review of clinical records, review of policies and
procedures, review of facility internal investigation reports, and interviews
with patients and staff, it was determined that the hospital failed to meet the
Condition of Participation for Nursing Services as evidenced by:
The nursing staff failed to respond to alarm on 1/4/2010 and evaluate patient
care needs for Patient #77 who required continuous cardiac and rhythm rate
monitoring when the heart rate decreased to asystole (without a heart
beat).
Please refer to A-0395
.
Example (cont.)
The facility provided a credible allegation of compliance with
their immediate corrective measures to address the IJ on 2/11/10
at 10:30 p.m. at that removed the immediacy of the situation.
This was done by stationing qualified staff at every central
monitoring display on each general care unit to ensure timely
response to alarms.
Based upon observations, interviews, hospital policy revisions,
and a review of nursing schedules, all corrective measures were
verified on 2/11/10.
Nursing staff provided a detailed schedule which confirmed
nursing coverage on each care unit at every central monitoring
display.
Example (cont.)
During a walk through of all general care units that utilized cardiac
monitors from 11:00 p.m. until 11:45 p.m., staff were verified to be
stationed at the display monitors. Interview with SP #6 and SP #9
confirmed at this time their schedules revised and a registered nurse had
been reassigned to be at each cardiac monitor display. It was further
stated this was their new assigned duty station until further notice.
Review of hospital policy HP #57 with a revision date of 2/11/10 noted
changes that all monitors would have qualified nursing personnel
stationed at display monitors until further notice.
The Director of Compliance and Nursing Executive Officer were
informed on 2/11/10 at 11:50 p.m. that the Immediate Jeopardy was
removed.
Immediate Jeopardy Not Removed
Notify the hospital’s administration that
termination procedures will be initiated
 23-day termination
The hospital will have to submit an allegation
that demonstrates its actions to correct the IJ
If not accepted the clock continues. The
hospital may submit a revised allegation.
 There must be another onsite survey after the
allegation is reviewed and accepted
23-Day Termination
 State Operations Manual §3010
 2nd working day: notice to hospital
 Notice to the provider and public notice: at least 15 days
prior to termination (EMTALA - at least 2, but not more
than 4 days prior to termination)
 23rd calendar day:
 Termination takes effect unless compliance is achieved or threat
removed
 If threat removed but deficiencies still present, allow up to 67
more days (90 days total) before termination
QUESTIONS?