• Skip to main content
  • Skip to header right navigation
  • Skip to site footer
  • (888) PHC-INC1

HBS logo family- Patton

Patton Healthcare Consulting

  • Products & Services
    • Survey Prep & Support
      • Survey Readiness
      • Survey Preparation
      • CMS Compliance Support
      • Patient Safety System Support
      • Joint Commission International
      • Remote Survey Technology
    • Adverse Decision Response & Recovery
    • Disease-Specific Care Support
      • Stroke Certification Assistance
      • Orthopedic Certification Assistance
    • Continuous Accreditation Support (CAS) Program
    • Interim Healthcare Leaders
    • Tracer Team Boot Camp
    • Healthcare Building Solutions
  • About Us
    • About Patton
    • Our Parent Company
    • Patton Principals
    • Patton Professionals
    • Testimonials
    • Patton FAQs
  • Resources
    • Patton Post Newsletter
    • Patton Blog
    • Additional References
  • Client Login (CAS)
  • Careers
  • CONTACT

Immediate Jeopardy Determination

You are here: Home / Preliminary Denial of Accreditation / Immediate Jeopardy Determination
April 23, 2019
The word "Jeopardy" in a blurred page in a book

CMS issued a new QSO memo this past month, QSO 19-09. It details the dreaded subject of immediate jeopardy determination. Appendix Q of the State Operations Manual describes the IJ process. In fact, this may be a step in the right direction. The memo suggests that there will be more consistency and structure used to determine immediate jeopardy.

Immediate Jeopardy Determination

CMS describes three key components which must be present for an immediate jeopardy determination. These include:

  • Noncompliance
  • Caused harm or created a likelihood of serious harm, impairment or death to patients. “Likelihood” is further defined as “a reasonable expectation that harm would occur”
  • Immediate corrective action is necessary

In addition, the prior concept of culpability has been removed.

CMS states that the term culpability is not in the underlying regulations. So, they removed it. Also, in our opinion, the concept of blame worthiness is likely not pertinent at a hospital level. Since the patient is in your care, if something goes wrong you own the issue, regardless of culpability.

In section V of the memo, CMS further clarifies non-compliance. To avoid an organization’s finding of noncompliance, hospitals may not claim that properly trained and supervised individuals acted as rogue employees and violated a regulation. CMS also discusses psychosocial harm as one of the forms of harm that could rise to the immediate jeopardy level.

CMS describes that it is difficult to make this determination in some instances. For example, when the patient has cognitive impairments and the surveyor cannot interview family or a representative of the patient. In such circumstances CMS advises that surveyors should apply a “reasonable person approach.”

We will refrain from any editorial commentary on this concept. But, we assume readers may have their own opinions.

Additional Structure Guides The Process

To add structure to the process, Section VI describes the procedures that surveyors should undertake to declare an immediate jeopardy situation. On the last page of the transmittal, CMS provides a template for surveyors to use that documents the noncompliance. It includes the injury or likely risk of injury and the need for immediate action to be taken. This will enable the surveyors to think through the details. And then, CMS requires the on-site surveyors to call their respective state agency for authorization to declare the immediate jeopardy situation. CMS notes that some state agencies require consultation with the CMS regional office, while other states make this determination themselves.

Furthermore, CMS states that the team should identify the IJ while onsite at the organization. But, CMS also notes that in “rare” instances, the state or regional office may identify the IJ after the survey team has left the organization.

Removing Immediate Jeopardy

Section VII discusses removal of the IJ. CMS requires that the survey team should confirm the IJ with the state agency or regional office, if required by the state and inform the organization immediately. CMS calls for a “removal plan” from the organization. This describes the steps they will take to ensure that no patients are suffering or likely to suffer serious harm, serious impairment or death as a result of the noncompliance. Unlike a plan of correction, CMS further states that it’s not necessary to eliminate all noncompliance before removal of the IJ. But, the steps must ensure that serious harm or likelihood of harm will not occur. Furthermore, the removal plan must include a date by which the organization states it will eliminate the likelihood for harm.

As is often the case, if implementing a removal plan isn’t possible for the exit conference, the IJ will continue. Instead, verifying elimination of the IJ will occur on a revisit date. And, the onsite follow up surveyors will verify implementation of all steps in a manner that eliminates the likelihood for harm.

Learn More About The Process

Would you like to learn more about this IJ process? CMS created an online training website, intended for surveyors, but also open to organizations.

With this process conducted by 50 different state agencies, we assume there will be some variability in application of this memo. The training will help surveyors. But, we have already noticed some variation in the process since publication of the memo on March 5.

While the training is open to organizations, there is a downside to becoming more expert in the expected process. It depends on how you choose to “correct” the surveyors in the actual required process. In addition, the IJ situation is a situation more than 95% of our readers should never experience. And if you do, there will be further revisions to the process. Instead, spending more time on the top ten most frequently scored standards might be a better use of time.

Patton Healthcare Consulting

Immediate Jeopardy (IJ), Immediate Threat to Life (ITL) or Preliminary Denial Of Accreditation (PDA) notifications all require you to move swiftly, we will work with you to immediately mitigate risk,  implement corrective action plans and forge successful long term solutions. Patton Healthcare Consulting team members are experts at preparing your staff for a smooth, successful outcome in a follow up survey.

In addition, we provide Joint Commission Compliance Assistance and a full range of pre-survey and post survey services including support developing healthcare’s reporting culture.

Contact our office at 888-742-4621, via email or through our website contact page to schedule a discussion of your needs and learn more about our compliance and readiness expertise.

Category: Preliminary Denial of AccreditationTag: Immediate Jeopardy
Previous Post:GP sitting in office holding in hands big binderDay One Document Advice
Next Post:Joint Commission Scoring PatternsHospital control room with Medical Oxygen Tank

Reader Interactions

Leave a Reply Cancel reply

Your email address will not be published. Required fields are marked *

Sidebar

Enter your email address to follow this blog and receive notifications of new posts by email.

Loading

Archives

Categories

  • Company Announcements
  • COVID-19
  • Preliminary Denial of Accreditation
  • Q&A
  • Survey Readiness

Recent Posts

  • When is a History & Physical (H&P) Exam Required?
  • Which Patients Does NPSG 15 Apply To?
  • Safety Data Sheets in the Pharmacy
  • Surgical Tape On Instruments
  • Joint Commission Age-Specific Competencies

© 2021 – 2025 Patton Healthcare Consulting, an HBS Company.  All Rights Reserved

Privacy Policy | Cookie Policy

Manage Cookie Consent
We use cookies to optimize our website and our service.
Functional Always active
The technical storage or access is strictly necessary for the legitimate purpose of enabling the use of a specific service explicitly requested by the subscriber or user, or for the sole purpose of carrying out the transmission of a communication over an electronic communications network.
Preferences
The technical storage or access is necessary for the legitimate purpose of storing preferences that are not requested by the subscriber or user.
Statistics
The technical storage or access that is used exclusively for statistical purposes. The technical storage or access that is used exclusively for anonymous statistical purposes. Without a subpoena, voluntary compliance on the part of your Internet Service Provider, or additional records from a third party, information stored or retrieved for this purpose alone cannot usually be used to identify you.
Marketing
The technical storage or access is required to create user profiles to send advertising, or to track the user on a website or across several websites for similar marketing purposes.
Manage options Manage services Manage {vendor_count} vendors Read more about these purposes
View preferences
{title} {title} {title}
Manage Cookie Consent
We use cookies to optimize our website and our service.
Functional Always active
The technical storage or access is strictly necessary for the legitimate purpose of enabling the use of a specific service explicitly requested by the subscriber or user, or for the sole purpose of carrying out the transmission of a communication over an electronic communications network.
Preferences
The technical storage or access is necessary for the legitimate purpose of storing preferences that are not requested by the subscriber or user.
Statistics
The technical storage or access that is used exclusively for statistical purposes. The technical storage or access that is used exclusively for anonymous statistical purposes. Without a subpoena, voluntary compliance on the part of your Internet Service Provider, or additional records from a third party, information stored or retrieved for this purpose alone cannot usually be used to identify you.
Marketing
The technical storage or access is required to create user profiles to send advertising, or to track the user on a website or across several websites for similar marketing purposes.
Manage options Manage services Manage {vendor_count} vendors Read more about these purposes
View preferences
{title} {title} {title}