Immediate Jeopardy Control Panel Access

THINKING LIKE A SURVEYOR

IMMEDIATE JEOPARDY

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THINKING LIKE A SURVEYOR

IMMEDIATE JEOPARDY

Surveyor

How many of you would like to know what

Surveyors are thinking when they enter your

facility to conduct a survey?

?

INTRODUCTION

Focus of this presentation includes:

•

Immediate Jeopardy (IJ);

•

Triggers;

•

Determining Factors;

•

Decision Making;

•

Avoiding an IJ; and

•

Removing an IJ.

THE GOAL

Today, you will:

•

explore the ramifications of an Immediate

Jeopardy (IJ) being called in your facility;

•

consider ways to avoid having an IJ called; and

•

review steps to take if an IJ is called in your facility.

APPENDIX Q

Find Appendix Q at:

https://www.cms.gov/Regulation

s-and-Guidance/Guidance/

Manuals/ downloads/som107

ap_q_immedjeopardy.pdf

The 

State Operations Manual

(SOM) 

 is available at:

https://www.cms.gov/Regulation

s-and-Guidance/Guidance/

Manuals/Internet-Only-Manuals-

IOMs-Items/CMS1201984.html

State Operations

Manual

Appendix Q –

Guidelines for

Determining

Immediate

Jeopardy

REQUIREMENTS OF

PARTICIPATION

REQUIREMENTS OF PARTICIPATION

Requirements

of Participation

refer to a broad

range of topics.

REQUIREMENTS OF PARTICIPATION

Immediate

Jeopardy

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 or patient

42 CFR Part 489.3

Appendix Q, Section II

REQUIREMENTS OF PARTICIPATION

An IJ is a form of noncompliance that is especially

serious.

When an IJ is called, "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."

(SOM §3010A)

REQUIREMENTS OF PARTICIPATION

POSSIBLE CAUSES

POSSIBLE CAUSES

People

In your facility,

who could be

responsible

for an IJ?

POSSIBLE CAUSES

Appendix Q,

Section III 

Individuals must not be

subjected to abuse by 

anyone

including, but not limited to,

entity staff, consultants or

volunteers, family members or

visitors.

POSSIBLE CAUSES

A failure in one or more of these areas usually causes

most IJs:

•

managing operations and staff;

•

planning delivery of services;

•

implementing care plans correctly;

POSSIBLE CAUSES

Poll Question

How might managing operations

and/or Staff fail to comply with the

Requirements of Participation?

A. failing to conduct a background

check on a new Employee

B.  running out of time-sensitive

medications before they are

delivered

C. not providing specialized care

and services to Residents

D. All of the above.

POSSIBLE CAUSES

More areas where failures occur that could cause IJs

are:

•

monitoring and evaluating staff performance;

•

ensuring contractors honor their contracts ; or

•

ensuring staff’s knowledge base is current or

updated.

LUCILLE

POSSIBLE CAUSES

Case Study #1

On 9/3/15, staff determined that Lucille was at high

risk for pressure ulcers.

On 12/29/15, Lucille fractured her right leg. At the

hospital an immobilizer was placed on her leg from

her knee to the ankle.

POSSIBLE CAUSES

Case Study #1

Lucille’s 1/3/16 care plan identified “skin breakdown” as a

problem and stated, “Check under immobilizer brace

every shift for breakdown.”

On 1/4/16, her physician ordered a weekly skin assessment

for Lucille.

However, from 1/4/16 until 1/20/16, staff only checked

Lucille’s exposed skin around the edges of the immobilizer.

POSSIBLE CAUSES

Case Study #1

On 1/21/16, an orthopedic physician removed the

immobilizer and discovered a Stage IV pressure ulcer

on Lucille’s Achilles tendon and above her right

ankle.

pressure ulcer

POSSIBLE CAUSES

Chat

Question

Given only the information we have

here, what questions do you think the

Surveyor would ask?

POSSIBLE CAUSES

Chat

Question

(follow up)

How could the facility have

prevented this situation from being

called an IJ?

LUCILLE

POSSIBLE CAUSES

Unexpected Changes

Unexpected changes that could contribute to an IJ

include but are 

not

 limited to:

•

a Resident accidentally falling when walking to the

dining room;

•

management changing a policy and failing

effectively to monitor staff; and

•

two roommates who previously got along starting to

curse at and hit each other.

POSSIBLE CAUSES

Chat

Question

What other examples of unexpected

changes can you think of?

POSSIBLE CAUSES

A Resident accidentally falls when walking to the

dining room.

POSSIBLE CAUSES

culpable

meriting condemnation or

blame esp. as wrong or harmful

syn. blameworthy

Webster’s Ninth New

Collegiate Dictionary

1989

PRINCIPLES OF IJ

PRINCIPLES OF IJ

One Person

A condition could exist that threatens many

Residents, or just one.

One person is the extent by which protection is

measured for all Residents in similar situations.

Appendix Q, Section III

PRINCIPLES OF IJ

High Potential

Serious harm, injury, impairment and/or death do

  not

actually have to occur before a Surveyor will

consider calling an IJ.

If conditions exist with a high potential for these

outcomes to occur in the very near future, these

conditions could be regarded as a component of an

Immediate Jeopardy.

PRINCIPLES OF IJ

Universal Protection

Residents must 

not

 be subjected to abuse by 

anyone

including, but not limited to:

•

entity Staff;

•

Consultants or Volunteers;

•

other Residents;

•

Family Members; or

•

Visitors.

PRINCIPLES OF IJ

Nature of Serious Harm

Serious harm can result from both abuse and neglect.

PRINCIPLES OF IJ

Nature of Psychological Harm

Psychological harm can be as serious as physical

harm.

PRINCIPLES OF IJ

Neglect

Neglect is failure to provide a Resident the care and

services necessary to avoid physical harm, mental

anguish or mental illness.

PRINCIPLES OF IJ

neglect

failure to provide goods and

services necessary to avoid

physical harm, mental anguish,

or mental illness

(42 CFR Part 488.301)

(Appendix PP, F224)

PRINCIPLES OF IJ

Poll

Question

Neglect should be considered an

Immediate Jeopardy because

A. some Residents are unable to

protect themselves.

B.  it could be a potentially

dangerous situation.

C. the Staff must learn the full

ramifications of neglect.

PRINCIPLES OF IJ

abuse

willful infliction of injury,

unreasonable confinement,

intimidation, or punishment with

resulting physical harm, pain, or

mental anguish

(42 CFR Part 488.301)

(Appendix PP, F223)

IJ PARAMETERS

IJ PARAMETERS

Immediate

Jeopardy

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

42 CFR Part 489.3

Appendix Q, Section II

IJ PARAMETERS

The serious harm, injury, impairment or death may

have occurred in the past, may be occurring at

present, or may be likely to occur in the very near

future as a result of the jeopardy situation.

IJ PARAMETERS

After determining that a situation is harmful, the

Surveyor(s) will consider the following points

regarding the entity’s compliance:

• The entity either created a situation or allowed a

situation to continue which resulted in serious harm

or a potential for serious harm, injury, impairment or

death to individuals.

• The entity had an opportunity to implement

corrective or preventive measures.

IJ PARAMETERS

If a Surveyor(s) recognizes a situation that may

constitute IJ, he/she must investigate the condition

until he/she confirms or rules out the immediacy of

the situation and whether the facility is culpable.

interview

observation

record review

TRIGGERS

TRIGGERS

TRIGGERS

TRIGGERS

Trigger

a critical situation with a

Resident that will cause the

Surveyor to consider if further

investigation is needed to

determine the presence of

Immediate Jeopardy

TRIGGERS

TRIGGERS

TRIGGERS

TRIGGERS

TRIGGERS

TRIGGERS

TRIGGERS

TRIGGERS

TRIGGERS

Chat

Question

What questions do you think the

Surveyors would ask about the

Resident who was burned?

MARIA

TRIGGERS

Case Study #2

While living in the long-term care facility, Maria had a diagnosis

of advance dementia with a documented history of refusal to

eat.

Maria was often confused and debilitated because of her

continued weight loss and dehydration related to her refusal to

eat or drink.

The staff Primary Care Physician wrote orders to discontinue all

of Maria’s nutrition and hydration support.

She died three days later. 

TRIGGERS

Case Study #2

During the investigation, the Surveyor found that

Maria’s chart did not include a copy of an advance

directive.

Nor did the progress notes contain documentation of

her ever expressing a wish to have nutrition and

hydration withdrawn at the end of her life.

TRIGGERS

Case Study #2

Lupe, Maria’s daughter, who actively participated in

her mother’s care, was identified in the social service

notes as Maria’s legal representative and her closest

living family member.

Lupe

TRIGGERS

Case Study #2

The Primary Care Physician documented a discussion

with Lupe about Maria’s poor prognosis for a

meaningful recovery.

Even though death was not imminent as a result of

the dementia, everyone concerned did expect

Maria’s death sometime in the near future.

TRIGGERS

Case Study #2

Maria’s chart at the facility did not include any

documentation that Lupe or Maria had expressed a

wish to have nutrition and hydration support

withdrawn.

When the Surveyor contacted Lupe about her

mother, Lupe became very upset and said, “I didn’t

know that food and water were stopped.”

TRIGGERS

Case Study #2

The facility’s Social Worker was unable to confirm that

Maria or Lupe had expressed such a wish. So the

Social Worker was uncertain why Maria’s nutrition

and hydration had been discontinued.

The Surveyor discovered a discrepancy between the

written order for withdrawal of support, and Lupe and

the Social Worker’s knowledge of the situation.

TRIGGERS

Case Study #2

In an interview with the Director of Nursing (DON), the

Surveyor learned that the DON was unaware of

Maria’s Doctor’s orders.

DON

TRIGGERS

Case Study #2

The Surveyor could not find in Maria’s plan of care

any evidence that the facility had discussed the

Doctor’s orders in a care plan meeting.

Nor could the Surveyor locate documentation

supporting the facility’s investigation or the

implementation of corrective measures following

Maria’s death.

MARIA AND LUPE

TRIGGERS

Poll Question

Did actual harm occur to Maria?

TRIGGERS

Poll Question

Does the harm meet the definition of

Immediate Jeopardy, e.g., serious

injury, harm, impairment, or death?

TRIGGERS

Poll Question

Was the harm likely to occur in the

very near future, if immediate action

was not taken?

TRIGGERS

Poll Question

Did the facility have knowledge of

the situation or should they have

known Maria refused to eat?

TRIGGERS

Poll Question

Did the facility thoroughly investigate

the circumstances?

TRIGGERS

Poll Question

How do we know the facility did not

thoroughly investigate the

circumstances?

A. There was no documentation in the

files and nothing was revealed during

the interviews.

B. The DON revealed this information

during an interview.

C. A Staff member showed the Surveyor

the documentation explaining why

there was no investigation.

TRIGGERS

Poll Question

Did the facility implement corrective

measures?

TRIGGERS

Poll Question

Does this situation meet the definition

of Immediate Jeopardy?

DETERMINING FACTORS

DETERMINING FACTORS

Failure to meet the Requirements of Participation can

cause a wide range of negative effects.

In some situations, these effects are minimal.  In other

situations, a deficiency can cause or have the

potential to cause the Resident:

•

serious injury;

•

harm;

•

impairment; or

•

death.

DETERMINING FACTORS

As soon as a facility becomes aware of a critical

situation that could result in an IJ, the administration

must 

immediately

 put a plan of action/intervention

into place and monitor its effectiveness.

plan of removal

DETERMINING FACTORS

Think like a Surveyor.

Surveyor

DETERMINING FACTORS

Five Senses

In your practice of thinking like a Surveyor, use your

five senses.

DETERMINING FACTORS

Five Ws

Another tool  to use when thinking like a Surveyor is

the 5 Ws:

•

who?;

•

what?;

•

when?;

•

where?; and

•

why?

DETERMINING FACTORS

Who?

Who was involved in the potential IJ situation:  Was it

Staff, Family Members or others? Which Resident was

involved?

Examples questions 

•

Which Resident was missing?

•

Which Staff Member administered the medication?

•

Who should have tested the generator?

DETERMINING FACTORS

What?

What harm has occurred, is occurring, or most likely

will occur?

Examples questions 

•

What was the sequence of events?

•

What did your facility do to avoid the situation in

the first place?

•

What was the hazard?

•

What was the outcome?

DETERMINING FACTORS

When?

When did the situation first occur? How long has the

situation existed? Has a similar occurrence happened

before? If so, when did it happen? Is there a pattern or

trend?

Examples questions 

•

When did the situation (or each event) occur?

•

How long did it take for your facility to notice the

situation?

•

When did the local Fire Marshal do his/her last

inspection?

DETERMINING FACTORS

Where?

Where did the potential or actual harm occur? Where is

the facility located (urban or rural)?

What hazards are present in the vicinity of the facility?

Examples questions 

•

Where did the incident occur?

•

Where does the Resident reside?

•

Does the situation impact only a wing or the entire

facility?

DETERMINING FACTORS

Why?

Why did the potential or actual harm occur?

Examples questions 

•

Was the care plan followed? If so, why did it fail?

•

Why did Staff not notice the elopement?

•

Were Staff put in a position where they would fail?

•

Why was there only one exit?

MARIA

DETERMINING FACTORS

5W Questions – Who?

Chat

Question

What Who questions do you think the

Surveyor would ask about Maria’s

case?

DETERMINING FACTORS

5W Questions – What?

Chat

Question

Which, What questions would the

Surveyor ask?

DETERMINING FACTORS

5W Questions – When?

Chat

Question

What about the When questions?

What would the Surveyor ask?

DETERMINING FACTORS

5W Questions – Where?

Chat

Question

What Where questions would the

Surveyor ask?

DETERMINING FACTORS

5W Questions – Why?

Chat

Question

And finally, what Why questions

would the Surveyor ask for Maria?

DECISION MAKING

DECISION MAKING

Before Surveyors conclude that there is an IJ, they

collect evidence of the three components of an IJ.

Surveyors ask, “Was there:

•

harm (actual or potential);

•

immediacy; and

•

culpability?”

DECISION MAKING

Immediate

Jeopardy

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 or patient

See 42 CFR Part 489.3

Appendix Q, Section II

DECISION MAKING

Immediate

Jeopardy

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

42 CFR Part 489.3

Appendix Q, Section II

DECISION MAKING

Actual

Harm

“

Was there an outcome of

harm? Does the harm meet the

definition of Immediate

Jeopardy, e.g., has the

provider’s noncompliance

caused or is likely to cause

serious injury, harm, impairment,

or death to an individual?”

DECISION MAKING

Potential

Harm

“

Is there a likelihood of potential

harm? Does the potential harm

meet the definition of

Immediate Jeopardy; e.g., is the

provider’s noncompliance likely

to cause serious injury, harm,

impairment, or death to an

individual?”

DECISION MAKING

Harmed Resident

DECISION MAKING

Immediate

Jeopardy

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 or patient

42 CFR Part 489.3

Appendix Q, Section II

DECISION MAKING

Immediacy

“

. . . has caused or is likely to

cause . . . “

DECISION MAKING

Immediacy

As soon as a facility becomes

aware of a critical situation, it

must 

immediately

 put a plan of

action into place.

DECISION MAKING

Chat

Question

Do you have a question about DADS’

decision-making process?

DECISION MAKING

Immediate

Jeopardy

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

42 CFR Part 489.3

Appendix Q, Section II

DECISION MAKING

Culpability

A lack of knowledge about a

particular situation does 

not

excuse a facility from knowing

about and preventing an IJ.

A crisis situation without early

warning signs or indications of

potential serious harm, are 

very

rare

.

42 CFR Part 489.3

Appendix Q, Section II

DECISION MAKING

documentation

Culpability

DECISION MAKING

Awareness of the Situation

Culpability

DECISION MAKING

Assessment

Culpability

DECISION MAKING

Implementation

Culpability

DECISION MAKING

Outcome

Culpability

DECISION MAKING

Chat

Question

Do you have a question about

Culpability?

DECISION MAKING

Strategy for corrective action

Plan of

Removal

DECISION MAKING

How the corrective action

will be accomplished for

individuals found to have

been affected by the

deficient practice;

Corrective

Action for

Individual

DECISION MAKING

How the facility will identify

other individuals who have

the potential to be affected

by the same deficient

practice, and how the facility

will act to protect individuals

in similar situations;

Identify all

Individuals

DECISION MAKING

What measures will be put

into place or systemic

changes made to ensure

that the deficient practice

will not recur;

Measures/

Changes

DECISION MAKING

How the facility will monitor its

corrective actions/

performance to ensure that the

deficient practice is being

corrected and will not recur;

i.e., what program will be put in

place to monitor the continued

effectiveness of the system

change to ensure that solutions

are permanent; and

Monitoring

System

DECISION MAKING

When corrective action must

be accomplished.

Final Date

DECISION MAKING

Writing Acceptable PoCs for Nursing Facilities

http://www.dads.state.tx.us/providers/training/

jointtraining.cfm

PRINCIPLES OF IJ

Poll

Question

An effective Plan of Removal includes:

A.

a description of how to accomplish

the corrective action.

B.

ways of identifying affected

Residents.

C.

actions to take to prevent the

deficient practice from happening

again.

D.

 ways of monitoring the changes.

E.

a deadline for accomplishing the

corrective action.

F.

 All the above.

DECISION MAKING

The occurrence of an IJ could be the result of:

•

intention; or

•

negligence.

Intentional or forgotten?

DECISION MAKING

Survey Team

DECISION MAKING

Program Manager

TEAM ACTIONS

TEAM ACTIONS

When the Survey Team and their PM decide that an

IJ exists, they will notify the facility’s Administrator of

the specific details, including the Resident(s) who are

at risk.

This verbal notification will be given to the

administration before the Survey Team leaves the

facility.

TEAM ACTIONS

Two Immediate Actions for the Facility

1. Immediate removal of the risk to Residents

2. Immediate implementation of corrective measures

to prevent repeated Jeopardy

TEAM ACTIONS

A notice describing the Immediate Jeopardy will be

delivered to the entity:

•

within two days of the end of the survey; or

•

on Form CMS-2567 on the tenth working day.

ENFORCEMENT

7 KEY COMPONENTS

7 KEY COMPONENTS

Find the Seven Key Components at

som107ap_q_immedjeopardy.pdf

7 KEY COMPONENTS

1. Prevent

The facility or system has the capacity to prevent the

occurrence of abuse and neglect and reviews

specific incidents for “lessons learned” which form a

feedback loop for necessary policy changes.

Regulation Authority:

42 CFR 483.13(b),

42 CFR 483.13(c),

42 CFR 483.13(c)(3)

Appendix PP, F226

7 KEY COMPONENTS

2. Screen

The facility or system provides evidence and

maintains efforts to determine if persons hired have

records of abuse or neglect.

Regulation Authority -

483.13(c)(1)(ii) (A)&(B)

Appendix PP, F226

7 KEY COMPONENTS

3. Identify

The facility or system creates and maintains a

proactive approach to identify events and

occurrences that may constitute or contribute to

abuse and neglect.

Regulation Authority –

42 CFR 483.13(c)(2)

Appendix PP, F226

7 KEY COMPONENTS

4. Train

The facility or system, during its orientation program,

and through an ongoing training program, provides

all employees with information regarding abuse and

neglect and related reporting requirements,

including prevention, intervention and detection.

Regulation Authority –

42 CFR 483.74(e)

Appendix PP, F226

7 KEY COMPONENTS

5. Protect

The facility or system must protect individuals from

abuse and neglect during investigation of any

allegations of abuse or neglect.

Regulation Authority –

42 CFR 483.13(c)(3)

Appendix PP, F226

7 KEY COMPONENTS

6. Investigate

The facility or system ensures, in a timely and

thorough manner, objective investigation of all

allegations of abuse, neglect, or mistreatment.

Regulation Authority

42 CFR 483.13(c)(2)(3)&(4)

Appendix PP, F226

7 KEY COMPONENTS

7. Report/ Respond

The facility or system must assure that any incidents of

substantiated abuse and neglect are reported and

analyzed, and the appropriate corrective, remedial

or disciplinary action occurs, in accordance with

applicable local, State or Federal law.

Regulation Authority

42 CFR 483.13(c)(1)(iii)

42 CFR 483.13(c)(2)

42 CFR 483.13(c)(4)

Appendix PP, F226

7 KEY COMPONENTS

Develop and implement written policies and

procedures that include:

•

prevention;

•

screening;

•

identification;

•

training;

•

protection;

•

investigation; and

•

reporting/response.

7 KEY COMPONENTS

Chat

Question

Do you have a question about the

Seven Key Components of avoiding

abuse and neglect?

REMOVAL OF AN IJ

REMOVAL OF AN IJ

Confirmation of Removal of

Immediate Jeopardy

REMOVAL OF AN IJ

Immediate Jeopardy Removed

Deficient Practice Corrected

REMOVAL OF AN IJ

Find 

CMS-2567B

 at

http://cms.hhs.gov/forms/cms2567b.pdf

REMOVAL OF AN IJ

Immediate Jeopardy Removed

Deficient Practice Present

REMOVAL OF AN IJ

Immediate Jeopardy Not

Removed

SUMMARY

Q/A