Immediate Jeopardy requires an immediate response to avoid serious threats to the regulatory or accreditation status of the organization. This is a term that may confuse or intimidate organizations who are seeking to maintain regulatory and accreditation compliance, but who may not be aware of all the intricacies involved in what designates a finding or organization as being in Immediate Jeopardy. While Compass Clinical Consulting can help your hospital respond immediately to these situations, it is important to first understand the meaning of Immediate Jeopardy.

What is the official definition of Immediate Jeopardy?

The State Operations Manual, Appendix Q, defines Immediate Jeopardy as “A situation in which the provider’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.” (See 42 CFR Part 489.3.)

Immediate Jeopardy is interpreted as a crisis situation in which the health and safety of individual(s) are at risk (see SOM §3010). *

What are components of an Immediate Jeopardy situation?
  • Harm: actual or potential
  • Only one individual needs to be at risk
  • Immediacy – Is the harm or potential harm likely to occur in the very near future to this individual or others in the entity, if immediate action is not taken? (Refer to the SOM §3010(B)(6) for timelines during normal termination.)
  • Culpability…
  • Did the entity know about the situation? If so, when did the entity first become aware?
  • Should the entity have known about the situation?
  • Did the entity thoroughly investigate the circumstances?
  • Did the entity implement corrective measures?
  • Has the entity re-evaluated the measures to ensure the situation was corrected?
Who do the Immediate Jeopardy Guidelines apply to?

These guidelines apply to all certified Medicare/Medicaid entities (excluding CLIA) and to all types of surveys and investigations: certifications, recertifications, revisits, and complaint investigations.

What are “triggers” for Immediate Jeopardy situations?
  • Failure to protect from abuse.
  • Failure to prevent neglect
  • Failure to protect from psychological harm, which is as serious as physical harm
  • Failure to protect from undue adverse medication consequences and/or failure to provide medications as prescribed.
  • Failure to provide adequate nutrition and hydration to support and maintain health.
  • Failure to protect from widespread nosocomial infections; e.g., failure to practice standard precautions, failure to maintain sterile techniques during invasive procedures and/or failure to identify and treat Nosocomial Infections
  • Failure to correctly identify individuals.
  • Failure to safely administer blood products and safely monitor organ transplantation.
  • Failure to provide safety from fire, smoke and environment hazards and/or failure to educate staff in handling emergency situations.
  • Failure to provide initial medical screening, stabilization of emergency medical conditions and safe transfer for individuals and women in active labor seeking emergency treatment (Emergency Medical Treatment and Active Labor Act).
How is it determined if circumstances pose an Immediate Jeopardy to an individual’s health or safety?

For a complete list see the State Operations annual, Appendix Q, “Guidelines for Determining Immediate Jeopardy.”

What are questions to ask to determine if an Immediate Jeopardy situation exists?
  • Has actual harm occurred?
  • Is there a likelihood of potential serious harm?
  • Is the harm likely to recur in the very near future, if immediate action is not taken?
  • Did the facility have knowledge of the situation? If so, when did they first become aware?
  • Did the facility thoroughly investigate the circumstances?
  • Did they implement corrective measures?
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Hospital Leaders Like to Think that “Immediate Jeopardy Can’t Happen Here” — Until it Does

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*All answers are derived and excerpted from the State Operations Manual, Appendix Q – Guidelines for Determining Immediate Jeopardy.

If you need assistance in responding to findings of Immediate Jeopardy, or recovering Medicare certification, contact our office by phone at (513) 241.0142 or email for a confidential discussion of your needs. Our clinical experts work with your staff to resolve deficiencies and protect the organization’s regulatory status.

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