In a recent update, we discussed Immediate Jeopardy and some other key terms you need to know, and now in we will review the Immediate Jeopardy process in nursing homes and how you need to respond to it.
Part 2: The Process
CMS requires that all nursing home surveys are unannounced, so after the surveyors walk into your facility, they will begin either the traditional or Quality Indicator Survey process (depending on your State) or initiate a complaint survey. If a situation is identified that constitutes an Immediate Jeopardy, the clock begins ticking for your nursing home. When an IJ is identified, the Regional Office needs to take action itself or notify your State Medicaid Agency to take action. The facility will face termination of their Provider Agreement and/or the appointment of a temporary manager to remove the IJ situation. A facility only has 23 days after the last day of the survey to remove the IJ.
According the SOM, here are some key items you need to know:
- Within 2 days: The Regional Office or State Medicaid Agency will provide your facility with written notification that your facility has been identified as being eligible for termination and/or temporary management. One of the 2 days needs to be a working day.
- As soon as you have removed the IJ situation: Your facility will have to submit a written allegation of how the Immediate Jeopardy has been removed, referred to as the Immediate Plan. Your Immediate Plan must provide documentation of the actions taken to remove the IJ and date of removal.
- State monitoring: Does not require a notice.
- Enforcement Remedies: Category 3 remedies are required – termination or temporary management with Civil Money Penalties (CMPs) being optional. Category 1 and category 2 remedies can also be imposed and often are.
- Within 5 days: The State must provide all documentation to the Regional Office and/or State Medicaid agency. This documentation includes the notice letter defining the Immediate Jeopardy situation findings, Form CMS-1539, contact reports and the deficiencies.
- Within 10 days of last day of survey: The CMS-2567 must be sent out to your facility.
- Within 10 days of receipt of the 2567: Your Plan of Correction must be received no later than 10 calendar days after you receive your 2567. Your POC for addressing the deficiencies found during survey should be deferred until your Immediate Plan has submitted and the surveyors revisit your facility to determine that the IJ has been removed. It’s important to note that the IJ must be removed within 23 days to prevent termination, but it is acceptable that the underlying deficiencies have not yet been corrected (SOM 7308.1). If you provide the State with a full POC for review, it may take longer to have the Immediate Jeopardy removed, so focus on your immediate plan first.
- If your facility’s Immediate Jeopardy constitutes Substandard Quality of Care: the State will also provide notification to the attending physician for each resident impacted and will also notify the State Board that licenses your administrator.
- Substandard quality of care means one or more deficiencies related to participation requirements under 42 CFR 483.13, resident behavior and facility practices, 42 CFR 483.15, quality of life, or 42 CFR 483.25, quality of care, that constitute either immediate jeopardy to resident health or safety (level J, K, or L); a pattern of or widespread actual harm that is not immediate jeopardy (level H or I); or a widespread potential for more than minimal harm, but less than immediate jeopardy, with no actual harm (level F). (42 CFR 488.301)
- On the 23rd day: Medicaid termination will go into effect unless your facility’s Immediate Jeopardy situation has been removed and the surveyors have revisited to ensure the IJ no longer exists. If the surveyors find that your Immediate Jeopardy has been removed, but your facility is still not within compliance, you may be given additional time to get back into compliance (SOM 7316 includes key dates).
In our next update, we’ll give you relevant information on some specific requirements that can come out of an Immediate Jeopardy situation, including your Plan of Correction, Directed Plan and Directed InService.