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Hospital Accreditation

Immediate Jeopardy
Posted by
on 6/13/2017 10:00:00 AM
There are fewer terms more dreaded in the world of accreditation than “immediate jeopardy”. Hospitals reel, governing bodies tremble, regulators frown in concern, and it only gets worse from there. Chances are your hospital has never been found in immediate jeopardy. If that’s the case, it means you’re good, or you’re lucky, or (most likely) a mixture of both.
What is immediate jeopardy?
CMS defines immediate jeopardy “as a crisis situation in which the health and safety of patients is at risk.”
Generally, it is a deficient practice that indicates a hospital’s inability to furnish safe care and services, although it may not have resulted in actual harm. The threat of probable harm is real and important and could be perceived as something that will result in potentially severe temporary or permanent injury, disability, or death.
Therefore, it must be perceived as something that is likely to occur in the very near future. If the patients are not protected effectively from the threat, or if the threat is not removed, there is a high probability that serious harm or injury could occur at any time or already has occurred and may occur again.
What comprises immediate jeopardy?
There are four components that are evaluated by CMS in determining if an immediate jeopardy exists:
  • Actual - Was there an outcome of harm? Does the harm meet the definition of Immediate Jeopardy, e.g., has the hospital’s noncompliance caused serious injury, harm, impairment, or death to an individual?
  • Potential - Is there a likelihood of potential harm? Does the potential harm meet the definition of Immediate Jeopardy; e.g., is the hospital’s noncompliance likely to cause serious injury, harm, impairment, or death to an individual?
  • Immediacy - Is the harm or potential harm likely to occur in the very near future to an individual or others in the hospital, if immediate action is not taken?
  • Culpability - Did the hospital know about the situation? If so when? Should the hospital have known about the situation? Did the hospital thoroughly investigate the issue and implement corrective actions? Did the hospital evaluate corrective actions to ensure the situation was corrected?
It’s important to note that the stated lack of knowledge by a hospital about a particular situation does not excuse it from knowing and preventing Immediate Jeopardy. The key factor in issuing an immediate jeopardy is, as the name implies, limited to immediate and serious situations. The threat must be present when surveyors are onsite and must be of such magnitude as to seriously jeopardize a patient’s health and safety.
What are some examples of immediate jeopardy?
Although the possible scenarios that can lead to a finding of immediate jeopardy are seemingly endless, CMS has published a list of issues that surveyors key in on:
  • Failure to protect a patient from abuse
  • Failure to prevent patient neglect
  • Failure to protect a patient from psychological harm
  • Failure to protect a patient from undue adverse medication consequences and/or failure to provide medications as prescribed
  • Failure to provide adequate nutrition and hydration to support and maintain a patient’s health
  • Failure to protect a patient from widespread nosocomial infections
  • Failure to correctly identify a patient when providing care and treatment
  • Failure to safely administer blood products
  • Failure to provide safety from fire, smoke and environment hazards
What should my hospital do if we’re found to be in Immediate Jeopardy?
CMS will expect your hospital to take immediate corrective action. We’d recommend the following:
  • Work closely and take direction from the survey team on-site
  • Immediately put measures in place to eliminate the deficient practice and protect all patients.
    • If at all possible, this needs to be done before the end of the survey and in the presence of the survey team
  • Provide assurance to your CMS State Agency and Regional Office prior to exit by the survey team that the deficient practice has been corrected and will remain corrected
  • Describe in writing the steps your hospital will take to maintain compliance. Also known as the Plan of Correction (POC)
  • Notify senior leadership and your governing body as soon as possible
  • Be prepared to address the issue when public notice is posted. This type of thing is likely to garner media attention
  • Conduct an intensive assessment to determine how/why the issue occurred in the first place
    • The key is to show that the hospital has looked beyond the proximal cause and has revised systems and processes that contributed to the event
How will CMS respond?
Only onsite confirmation of implementation of your hospital’s corrective action justifies a determination that the immediate jeopardy can be removed.
  • If your hospital is able to remove the immediate jeopardy and correct associated deficient practices before the survey team exits, the issue will be cited as a condition-level deficiency on the Form CMS-2567.
  • If your hospital is unable or unwilling to remove the immediate jeopardy before the survey team’s exit, the CMS Regional Office and procedures to terminate your hospital from the Medicare program will be initiated.
The reality, is that bad things can happen to good hospitals. When they do, understanding the issue and knowing how to respond can help your hospital learn from the experience and emerge as a stronger and safer organization.
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About the Author

Traci Burgkwist RCP, HACP

Traci Burgkwist is the Executive Director of Survey Operations for CIHQ. Traci has more than 15 years of experience in hospital survey preparation.
Traci's past positions include Chief Quality Officer for a multi-hospital community based health system where she was responsible for accreditation and regulatory compliance. Prior to joining CIHQ, Traci served as the Executive Director of Quality for a large regional medical center, providing executive management oversight in the areas of quality, risk, medical staff credentialing, and patient relations.
Traci received her degree in education from Pima in Tucson Arizona. She is nationally certified in healthcare accreditation, and serves on the Board of Examiners for the Healthcare Accreditation Certification Program.
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