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Breaking Down a Nursing Home’s Immediate Jeopardy: Pt. 1

As we posted last week, CMS Compliance Group will be defining an Immediate Jeopardy situation for our readers in Part 1 of our series on nursing homes and these potentially costly situations. Read last week’s post here.

Part 1: What is an Immediate Jeopardy?

The purpose of a survey of your nursing home is to identify potential deficiencies across the entire gamut of nursing facility practices for the purposes of ensuring quality care. These areas include: Resident Rights, Admission Transfer/Discharge Rights, Resident Behavior/Facility Practice, Quality of Life, Resident Assessment, Quality of Care, Nursing Services, Dietary Services, Physician Services, Specialized Rehabilitative Services, Dental Services, Pharmacy Services, Infection Control, Physical Environment, and/or Administration.

While the surveyors are inspecting your facility, they may identify areas of potential concern that could lead to an Immediate Jeopardy. This type of citation is problematic not only because it shows that the facility has substandard quality of care, but also because of the monetary penalties that can be assessed by the Centers for Medicare and Medicaid (CMS).

Immediate jeopardy situations can also be identified when a State surveyor is reviewing an incident that has been self-reported by a facility, such as an elopement, death related to side rail entrapment, an injury related to unsafe smoking or a choking incident that results in death.

Appendix Q of the State Operations Manual provides you with the most crucial information regarding what is considered an Immediate Jeopardy.  Let’s take a look at some relevant federal definitions related to Immediate Jeopardy:

  • 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.” (42 CFR Part 489.3.)
  • Abuse – “The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.” (42 CFR Part 488.301.)
  • Neglect – “Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.” (42 CFR Part 488.301.)

The SOM also cites the three components of Immediate Jeopardy – Harm, Immediacy and Culpability. These components will guide the surveyors through the process of deciding if a situation should result in an Immediate Jeopardy. With proper systems, training and care planning, your facility can prevent these situations from occurring. The three components are:

Harm – This component can be divided into “Actual Harm” and “Potential” Harm. Actual Harm relates to situations where the issue at the facility caused serious harm or injury, impairment or in the worst case, death of a resident. Potential Harm refers to situations where the facility’s practices could likely cause serious harm, impairment, injury or death to a resident.
Immediacy – This component identifies harm or potential harm that could occur in the very near future for the resident in question or for multiple residents at the facility if immediate action is not taken to correct the problem.
Culpability – This component addresses knowledge of the harm or potential harm by looking at the following:

  • Was the situation known? If yes, when was the facility first made aware?
  • Should the facility have known about the situation?
  • Was a thorough investigation of the issue completed?
  • Were proper corrective measures implemented by the facility?
  • Has a re-evaluation been completed to ensure that the corrective measures accurately corrected the situation?

In our next post, we will review the end-to-end process of how an Immediate Jeopardy is identified and how you and your team will need to formally address it.

 

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