Federal and state agencies can rely on Healthcare Management Solutions, LLC (HMS) to provide services and help when danger presents itself in healthcare facilities in the form of Immediate Jeopardy situations. In this video, Nadine Renbarger, Senior Advisor at HMS, provides valuable insights on Immediate Jeopardy situations, the urgency these cases carry and the best ways to respond to them.
What is an Immediate Jeopardy Situation?
An Immediate Jeopardy situation occurs when the non-compliance of providers, suppliers or laboratories causes or is likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy is the most serious type of citation to be issued, and it also carries the most severe sanction.
Why is it Critical to Act on Identifying Immediate Jeopardy Situations?
In these situations, someone has either already been harmed or will likely be in harm’s way in the near future. By definition, that makes these situations incredibly dangerous, and it’s imperative that they are acted on urgently.
Surveyors must identify the Immediate Jeopardy situation as quickly as possible and notify the provider immediately for rapid corrective action.
What is the Time Frame for Investigating an Immediate Jeopardy Situation?
The time frame varies depending on when the situation is identified. When a state survey agency gets a complaint or a Facility Reported Incident (FRI), the agency will review it, and if they determine that someone is at risk of serious injury, harm or death, they are required to initiate a complaint investigation within two business days of the complaint or FRI.
However, CMS is currently working with each state to change this. The new time frames will be three days for those complaints and FRIs, and seven days if the FRI shows that the facility put safeguards in place.
If surveyors are on site and identify an Immediate Jeopardy situation, however, they need to gather information on an Immediate Jeopardy template and present it to their supervisor for approval before submitting it to the facility Administrator. The surveyors should complete this as soon as possible so that corrections can be made right away and the Immediate Jeopardy situation can be removed.
What is an Immediate Jeopardy Template?
The Immediate Jeopardy template has to document three components and prove they are all in play in the situation in order for it to be classified as an Immediate Jeopardy. These components are:
There is non-compliance.
There is a serious risk of injury, harm, impairment or death.
There is a need for immediate action.
What is the Step-by-step Process for Dealing with an Immediate Jeopardy Situation?
The surveyor or survey team identifies concerns related to the health and safety of individuals.
They gather as much information as they can to rule in or rule out Immediate Jeopardy. If they believe it is an Immediate Jeopardy, they notify the supervisor and prepare an Immediate Jeopardy template.
When the Immediate Jeopardy template is approved by the supervisor, the Immediate Jeopardy is confirmed.
The Immediate Jeopardy template is then provided to the administrator, who should take immediate action to remove the Immediate Jeopardy.
The surveyor will ask for a removal plan. If they get one before they leave the facility, they can verify whether or not the Immediate Jeopardy has been removed while they’re on site. If they depart while the Immediate Jeopardy is still ongoing, the state survey agency will notify the provider that they have 23 calendar days to remove the Immediate Jeopardy.
In that case, the surveyor will go back on site to verify removal.
How Does HMS Support State Agencies with Responding to Immediate Jeopardy Situations?
HMS works with surveyors and state agency staff on how to identify an Immediate Jeopardy, how to document the situation, and what to include on Immediate Jeopardy templates. HMS has hypothetical scenarios surveyors they use to practice identifying Immediate Jeopardy situations in comparison to other severity levels. HMS can also provide items like sample Immediate Jeopardy templates as well as quality review tools that can be used by managers.
HMS also employs a pool of highly skilled, trained surveyors, so when states need additional help, HMS can assist. HMS surveyors can either accompany the state survey team and supplement it, or the HMS surveyor can actually conduct the survey for the state.
If HMS is on site and identifies an Immediate Jeopardy situation, we have developed a process for review and approval of the Immediate Jeopardy prior to communicating with the state agency. We assign a Quality Assurance (QA) Analyst to work with the HMS survey team on site to make sure they’ve gathered information before it gets submitted to the state.
What is the Role of a QA Analyst in Immediate Jeopardy Situations?
The QA Analyst is an employee of HMS. They work closely with the rest of the HMS team when the team is on site.
When the team believes they have enough information to call an Immediate Jeopardy situation, they will convene with the QA analyst. The analyst will then ask questions and make sure they have enough observations, interviews, and record reviews to complete the IJ template and to call the situation an Immediate Jeopardy.