Has your psychiatric hospital been cited by CMS for an Immediate Jeopardy situation? If so, “Immediate Jeopardy” can be a somewhat frightening term. What exactly does it mean and what are the implications?

Most importantly, how should you respond? In this article, we provide important information on CMS Immediate Jeopardy and your response strategy. In our next article, we’ll discuss how best to prepare for your CMS resurvey.

Immediate Jeopardy: Definition

CMS 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.” The Core Guidelines for Determining Immediate Jeopardy are in the CMS State Operations Manual Appendix Q. The State Survey Agency surveys your psychiatric hospital on behalf of CMS. If the surveyors identify a potential Immediate Jeopardy situation, they notify CMS Regional Office. If CMS agrees, the surveyors call an Immediate Jeopardy and notify hospital leadership.

Be aware that effective March 2019, CMS revised its guidelines for surveyors citing Immediate Jeopardy. Under the new guidelines, surveyors must identify all of the following three components in order to cite Immediate Jeopardy:

1. Noncompliance
2. Serious adverse outcome or likely serious adverse outcome
3. Need for immediate action

For more info on this change, see our post CMS Immediate Jeopardy: Revised Guidelines for Surveyors.

Immediate Jeopardy Response

When surveyors notify you of Immediate Jeopardy, your response must be just as immediate. That is, you need to correct the deficiency right away. That means while the surveyors are still onsite.

Let’s say, for example, they cite the towel hooks in your patient bathrooms as an Immediate Jeopardy risk. You should proceed to immediately remove those hooks. Then show the surveyors they’ve been removed. Your goal is to have the surveyors clear the Immediate Jeopardy while they are still on site.

Immediate Jeopardy: Possible Outcomes

Scenario # 1: You correct the Immediate Jeopardy while surveyors are onsite and also correct any Condition level deficiencies associated with the IJ. In this case, the IJ is lifted. The surveyors include the IJ situation in the 2567 report.

Scenario # 2: You correct the Immediate Jeopardy while surveyors are onsite. But you’re still out of compliance with one of the CMS Conditions of Participation (CoPs.) In this case, the surveyors include the IJ situation in the 2567 report and place your hospital on a 90 day Medicare termination track. (This is the scenario most psychiatric hospitals experience when faced with Immediate Jeopardy.)

Scenario # 3:  You do not correct the Immediate Jeopardy while surveyors are onsite. In this case, the surveyors issue an IJ 2567 and place the hospital on a 23 day Medicare termination track.

Preparing the Plan of Correction

The State Survey Agency should issue its written report (2567 Report) within 10 workdays of the final date of your survey. You then have 10 calendar days to submit your 2567 response (aka Plan of Correction.) That’s a quick turnaround. So, you need to get started right away on your POC.

Preliminary Plan of Correction

We see too many psychiatric hospitals wait to receive their 2567 report before they get started on their POC. They think they need the detailed report before they can begin working on corrective actions. That’s a mistake. Especially if you have a Condition level finding related to your Immediate Jeopardy.

You should’ve gathered enough information during the survey to develop a Preliminary POC. That includes information from meetings with the surveyors. Also, questions they asked during staff interviews. And comments they made while reviewing records or policies. Lastly, the feedback they gave you in the exit conference. (Some hospitals tape the exit conference for clarity sake.)

Even though you don’t yet have the official report, you can begin to develop corrective actions based on the feedback surveyors have already given you.

For example, maybe they told you your informed consent process was not being consistently carried out and documented. So, even though you don’t have the official report, you can easily begin to address that deficiency. Look at your policy and review the records they looked at when they made this observation.

For each area of deficiency you’re aware of at this point, read the relevant CoP and standard in the State Operations Manual. Appendix A applies to all hospitals (including psychiatric hospitals. Appendix AA applies to psychiatric hospitals only. You need to understand all the requirements so you can draft a Preliminary Plan of Correction.

Official 2567 Plan of Correction

Once you receive the official 2567 Report, you now have 10 calendar days (from the date on the cover letter) to submit your Plan of Correction. That’s a quick turnaround. So, organization and efficiency are key.

Organizing your POC Effort

We recommend the following steps for developing your POC:

• Identify a single individual who will coordinate the POC.
• Convene a team of leaders and managers to work on the POC. They need to have content knowledge in the areas of deficiency cited. They also need sharp problem solving skills.
• Assign each citation in the 2567 Report to a team member to be responsible for drafting that response.
• Give everyone a template to follow for drafting their responses.
• Hold a team session to orient everyone to the template. Give them examples of how to complete it.
• Organize subgroups who will work on the different citations and brainstorm solutions and corrective actions.
• Provide timelines to team members for submission of their responses to the team coordinator.

Content of the POC

Your cover letter from the CMS Regional Office lists the elements you must include in your POC. The wording varies a bit among Regional Offices but the key required elements are as follows:

1. The plan for correcting the specific deficiency. It’s important here to include two types of actions. First, the immediate actions you took during the survey. Second, the longer term actions you took in follow-up to the survey.
2. The plan for improving the process that led to the deficiency. Here, you must describe improvements you’ve made to processes and systems to prevent the likelihood of recurrence of the deficient practice. (This is particularly critical when the deficiency relates to Immediate Jeopardy.)
3. The procedures for implementing the POC for each deficiency. Implementation procedures typically include education/training, revised policies, changes to forms and templates, and committee approval for these actions.
4. A completion date for implementation of the POC for each deficiency. This should be the date when all corrective actions were fully implemented.
5. The monitoring and tracking procedures to be implemented to ensure the POC is effective and the deficiency remains corrected. Describe the performance measures you’ll use to monitor implementation of the corrective action. Include who’s responsible for monitoring, the frequency, where results are reported, and the process for responding to the results. Also, describe how you will integrate this monitoring into your hospitalwide QA/PI process.
6. The title of the person responsible for implementing the POC for each Tag cited. This should be a senior leader. Don’t list more than one person. It only causes confusion around ultimate

It’s critical to include each of these six elements in your POC. So, be sure to list them as headings in the response template you provide to the team.

We’ve seen POCs rejected because they were missing one of the required elements. Frequently, it’s element # 2 which requires you to address underlying systems issues and how these were resolved.

Example of POC Response

The following is an example of an inadequate POC response and an adequate POC response including the six key elements of a complete response:

Deficiency cited in 2567 Report: In 10 medical records reviewed, there was no documentation that nursing staff followed hospital policy and evaluated the patient’s response to medication administered for pain.

Inadequate Response: The Pain Management Policy was revised to be more specific about how nursing staff should evaluate the patient’s response to pain medication.

Adequate Response:

Immediate Corrective Action: When this deficiency was identified during the survey, the Chief Nursing Officer met with the nursing staff whose records were reviewed to clarify with them the proper procedure for evaluating the patient’s response to pain medication in keeping with hospital policy.

Long Term Corrective Actions: After the survey ended, the hospital took the following corrective actions:

• The Nursing Council reviewed the Pain Management Policy (# …) on (date.) They revised the policy to be more specific regarding the timeline for assessing the patient’s response to medication. They also added specifics regarding how to document the patient’s response in the medical record. The Medical Executive Committee approved the revised policy on (date.)
• The revised policy was emailed to all nursing staff on (date) with a Read and Sign requirement and return date of (date.)
• Nurse Managers reviewed the revised policy in person with all nursing staff the week of (date.)
• A module on Pain Assessment and Management was added to nursing orientation.

Process Improvement: Hospital leadership determined that a contributing factor to this deficiency was that the specific requirements for evaluating a patient’s response to pain medication had not been adequately emphasized during nursing orientation. Thus, this component was added to nursing orientation.

Completion date: … (Must be prior to POC submission date.)

Monitoring Procedure: The CNO and Nursing Council developed a Pain Management Audit Checklist. It includes the requirements for timely documentation of the patient’s response to pain medication. On a weekly basis, the Nurse Managers complete a 25% sample of medical records for patients who received pain medication. The results of the audits are aggregated and reviewed by Nursing Council on a monthly basis. Re-education with individual nurses is conducted as indicated. The results are also reviewed in QA/PI Committee monthly.

Person Responsible: Chief Nursing Officer

Timeline for Correction of Deficiencies

Keep in mind that your POC must describe the actions you have taken to correct the deficiency. Not the actions you plan to take to correct the deficiency. Your goal is to complete all corrective actions by the time you submit your POC to CMS.

So, what if there are long term corrective actions that simply cannot be completed by the submission of the POC? For example, the installation of new hardware on 75 doors in the hospital.

In this case, describe each corrective action that has been taken along the way (toward the long term fix) and the date it was completed. For example:

• The Director of Plant Operations researched the best ligature resistant hardware for doors and reviewed this with the Environment of Care Committee on (date.)
• The order for replacement hardware was sent to the vendor on (date.)
• The vendor confirmed that the shipment will be sent to the hospital on (date.)
• The Director of Plant Operations developed a schedule for replacing door hardware starting on (date.)
• Replacement of all door hardware will be completed by (date.)

This way, you take credit for each action step completed prior to the POC submission date. The only date that’s beyond the POC submission date is the final step.

Submission of the POC

Keep in mind that when you submit your POC, your goal is to show you’ve corrected all the deficiencies and are ready for re-survey. As the 2567 cover letter states, CMS wants you to provide them with “a credible allegation of compliance.” That’s what you’ve described in the POC you’re submitting.

Next step is for CMS to review (and hopefully approve) your POC. Depending on your State Survey Agency, you may or may not get an official response to your POC. Either way, one thing’s for sure. They will be back to re-survey you within 45 days of your survey.

Barrins & Associates CMS Compliance Support

Barrins & Associates’ CMS Compliance Support Services can help your psychiatric hospital achieve ongoing compliance with the CMS CoPs. And avoid Immediate Jeopardy or adverse decisions. We provide training, mock surveys, and post-survey support. We’ve also been approved by CMS as the Independent Consultant for Systems Improvement Agreements.

In our next article, we’ll cover how to prepare for a successful CMS re-survey. That includes preparing evidence of POC implementation, staff preparation, and survey management strategies.