Immediate Jeopardy

In recent months, an increasing number of hospitals have received a notice of Immediate Jeopardy following a survey by the Centers for Medicare and Medicaid Services (CMS), usually conducted by the State Department of Health. Immediate Jeopardy is defined by CMS as “a crisis situation in which the health and safety of individual(s) are at risk (see §SOM 3010).” Commonly a finding from a for-cause (complaint) survey, the determination of Immediate Jeopardy carries with it a threat of termination procedures if conditions are not resolved within 23 days. In this short time, hospitals can (and will) lose the ability to bill Medicare.

As Goes CMS, So Goes The Joint Commission

In keeping with the long-held CMS definition of Immediate Jeopardy, The Joint Commission will adopt similar language for surveys beginning January 1, 2009. The Joint Commission (TJC) defines “Immediate Threat to Life” as a “situation, identified at the time of survey which has or may have a serious adverse effect on patient health and safety.” The examples given – inoperable fire alarms, high rate of infections, etc. – are reflective of the examples outlined in Appendix Q of CMS’s State Operations Manual.

In the past, the discovery of these findings resulted in RFIs and, sometimes, the activation of a particular decision ruling. In 2009, these findings will vault the organization directly to Preliminary Denial of Accreditation. The sequence of events is as follows:

1. Findings that support Immediate Threat to Life discovered on survey
2. Expedited decision of Preliminary Denial of Accreditation
3. On-site survey to validate implementation of corrective action
4. If corrected, accreditation status changes to Conditional Accreditation
5. Follow-up survey in four to six weeks

The initial determination of Immediate Threat to Life and Preliminary Denial of Accreditation may generate an immediate CMS survey. Joint Commission routinely notifies state survey agencies and CMS Regional Officers of any untoward accreditation decision, namely, Preliminiary Denial of Accreditation and Conditional Accreditation. This activates the CMS survey process, resulting in a range of events that may include a full review of the Conditions of Participation and activation of 23-Day Medicare Termination procedures. Once this process is activated by both organizations, it is not unusual to get two surveys a month, due to their heightened concerns.

Preventing Disaster Through a Combined Approach

Most organizations will admit that a proactive approach to Joint Commission readiness offers the best opportunity to avoid heightened scrutiny. The unpredictability of the survey process remains a threat to most organizations unfamiliar with the conditions that support Immediate Threat to Life or Immediate Jeopardy. Assuring that your readiness program combines activities that prepare the organization for both The Joint Commission and CMS surveys will provide the greatest protection against serious regulatory threats.

Key elements of your readiness program for managing Joint Commission and CMS surveys should include:

• Periodic education for all staff on changes to Joint Commission and CMS standards
• Establishing a readiness baseline through a comprehensive CMS mock survey conducted internally or by industry experts on the CMS survey process
• Tracer sessions that focus not only on Joint Commission hot topics, but also  common CMS findings
• Regular education on the differences between the approaches to survey and how management’s actions can make a difference in survey outcomes
• Adding a CMS “self-assessment” component to your continuous readiness program, either as an addendum to your PPR process, or as an activity that leads up to the process
• Periodic coaching of staff on how to answer a Joint Commission surveyor’s question, versus a CMS surveyor’s question

Finding Resources

The reality is that surveys are tougher now than they have been in the past. The call for greater accountability requires a move away from the mentality of “we’ve always done well,” into more vigilant efforts to assure full compliance. Finding ways to alter long-held ideas is vital to making changes “stick” in an organization.

When it comes to finding internal or external resources, it helps to be an informed consumer. The questions posed should be based on the reason for the activity – whether your goal is preventative, or in response to an actual adverse survey. TJC and CMS surveys, while having common goals, require different evidence of compliance. You must be sure that outside consultants understand the standards and the survey process, rather than just reading from a copy of the standards. Consider the following questions when seeking resources for your situation:

When seeking preventative services:

• How will the proposed approach address CMS and TJC? What percentage will be TJC-focused, and what portion will focus on CMS?
• How will you differentiate what is required by TJC versus what CMS requires?What resources are available to back me up if there are questions?
• What education will be provided? In what form?

When seeking response and recovery services (following a poor survey):

• How quickly can resources be made available? (Note: A 10-day turn-around is commonly required by regulators.)
• What experience have the individuals had with responding to TJC findings? With CMS findings?
• What success have you experienced in dealing with poor surveys?
• What guidance is available for dealing with public perception issues and avoiding disclosure of poor survey results in the media?