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Are you up to speed on how CMS is instructing its surveyors to cite Immediate Jeopardy? Effective March 5, 2019, CMS revised its surveyor guidelines for citing cases of Immediate Jeopardy.

The goal is to make decisions about Immediate Jeopardy more consistent across different states and regions of the country. Immediate Jeopardy is “a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death.” 

Key Components for CMS Immediate Jeopardy

Under the new guidelines, surveyors must identify all of the following three key components in order to cite Immediate Jeopardy:

Noncompliance: The provider has failed to meet one or more federal health, safety, and/or quality regulations. (The change here is that CMS removed the previous requirement for “culpability.”)


Serious Adverse Outcome or Likely Serious Adverse Outcome: As a result of the identified noncompliance, serious injury, serious harm, serious impairment or death has occurred, is occurring,or is likely to occur to one or more identified recipients at risk. (Note: The potential for that level of harm does not constitute Immediate Jeopardy.)


Need for Immediate Action: The noncompliance creates a need for immediate corrective action by the provider/supplier to prevent serious injury, serious harm, serious impairment or death from occurring or recurring. 

New CMS Immediate Jeopardy Template

CMS has developed a new Immediate Jeopardy Template. Surveyors must use this template to document their evidence for each of the three components of Immediate Jeopardy. Essentially, they must supply evidence from record reviews, interviews, and observations to support their conclusion of Immediate Jeopardy.

Communicating Immediate Jeopardy to Hospital Leadership

CMS has instructed its surveyors to use the Immediate Jeopardy template to communicate their findings to hospital leadership. They must also provide a copy of the completed template to the hospital administrator.

We saw this in action this week when a hospital was put in Immediate Jeopardy for an inappropriate use of restraint. The surveyor documented her findings on the new template and gave a copy to hospital leadership.

Removal of Immediate Jeopardy

After surveyors communicate the Immediate Jeopardy finding to hospital leadership, they request a written Immediate Jeopardy Removal Plan. This is a description of the immediate action(s) the hospital will take to address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely. Surveyors expect to see this Removal Plan before they exit the hospital. 

To view the full content of the updated guideline and the IJ Template, see the CMS State Operations Manual, Appendix Q – Core Guidelines for Determining Immediate Jeopardy, issued 3/5/19

You can also view CMS Administrator Seema Verma’s blog post Protecting the Health and Safety of all Americans which provides the context for the updated guidelines.

Avoiding Immediate Jeopardy

For psychiatric hospitals, paying close attention to the CMS Conditions of Participation is the best way to avoid adverse findings on CMS surveys. That includes both the A Tags which apply to all hospitals (including psychiatric hospitals) and the B Tags which apply only to psychiatric hospitals. Barrins & Associates’ CMS Compliance Support Services can help you achieve that goal. We offer an array of services including training, mock surveys, and post-survey support. They’re designed to support your ongoing compliance with CMS requirements and help you avoid adverse findings and re-surveys.