CMS Alert: Determining Immediate Jeopardy

CMS Announces Major Revision in
Determining Immediate Jeopardy

It’s been 15 years since the last major revision to State Operations Manual Appendix Q – Guidelines for Interpreting Immediate Jeopardy. This week, CMS announced four key changes in the determination of Immediate Jeopardy (IJ) situations:

  1. The potential for harm has been changed to the likelihood of harm.
  2. Culpability is no longer a required component for this determination of IJ situations.
  3. Surveyors are instructed to consider whether the non-compliance caused or made likely serious mental or psychosocial harm to recipients.
  4. Each IJ citation must be decided independently, as there are no automatic IJ citations.

The advanced copy of Appendix Q contains a new “Core,” which is applicable to all provider, supplier types, and laboratories. Subparts of the manual are devoted to provider types that have specific polices related to IJ, such as nursing homes and laboratories. Surveyors now have an IJ template to use when identifying an IJ situation to provide a framework for identifying serious patient health and safety problems.

At TiER1 Healthcare, we are seeing an increase in hospitals and laboratories being cited for non-compliance to the CMS Conditions of Participation. According to the CMS release, “Today’s guidance is just the beginning of upcoming efforts to strengthen oversight of healthcare settings.”

“CMS’ increased oversight of accrediting organizations and improved framework for Immediate Jeopardies highlights patient safety as the focus of healthcare,” said Lisa Prytula, Associate Managing Director of TiER1 Healthcare. “To prevent harm to patients and healthcare workers, leaders must build a culture that is continuously committed to zero harm.”

TiER1 Healthcare consultants have extensive experience and up-to-date knowledge of CMS Conditions of Participation. We partner with healthcare organizations to immediately mitigate risk, implement corrective actions and sustainable solutions, and develop plans of correction. In fact, 100% of our Medicare revocation (termination) clients have been successfully reinstated through Systems Improvement Agreements.

We urge healthcare organizations to get ready for CMS surveys—which means 100% compliance with the standards, 100% of the time, and more comprehensive survey methods designed to find non-compliance.

Is your organization ready for increased scrutiny by CMS? Consider an external validation, mock survey, or assessment of patient safety to assess your compliance and readiness. Let’s talk.

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