CMS found 'immediate jeopardy' at your hospital. Now what?

An immediate jeopardy designation by CMS represents "the most severe and egregious threat to the health and safety of recipients, as well as carries the most serious sanctions" — but, even if a hospital is cited for such an event it may not affect your hospital's safety grade. 

Out of several hospitals that received immediate jeopardy citations in the last year, when analyzed against the recently released 2023 safety rankings from The Leapfrog Group, many of these hospitals were given As, Bs or Cs — nothing lower.

Even still, the penalty carries weight and the possibility of losing CMS funding can severely hurt a hospital's operating capabilities, so correcting immediate jeopardy and finding a way back into compliance is key. But where should you start? What should you avoid? How can you make the process as seamless as possible? 

Becker's connected with a CMS spokesperson to get the answers for you.

Becker's: For hospitals that are cited for immediate jeopardy situations, what are the first steps they should take to correct the matter?


CMS spokesperson: Create a removal plan. A removal plan documents the immediate action an entity will take to prevent serious harm from occurring or recurring. Following verification of [immediate jeopardy] with the State Agency, the [CMS] survey team must notify the entity immediately that [immediate jeopardy] has been identified. 

A removal plan will be required and must be provided to the [state agency] as soon as the entity has identified the steps it will take to ensure that no recipients are suffering or are likely to suffer serious injury, serious harm, serious impairment or death as a result of the entity’s noncompliance. 

The removal plan identifies all actions the entity will take to immediately address the noncompliance that has resulted in or made serious injury, serious harm, serious impairment, or death likely by detailing how the entity will keep recipients safe and free from serious harm or death caused by the noncompliance. 

Unlike a plan of correction, it is not necessary that the removal plan completely correct all noncompliance associated with the [immediate jeopardy], but rather it must ensure serious harm will not occur or recur. The removal plan must include a date by which the entity asserts the likelihood for serious harm to any recipient no longer exists.

Q: If a hospital is cited for immediate jeopardy and is in the process of trying to correct things, but another adverse situation occurs, what should they do?


A: If the plan is not fully implemented, the [immediate jeopardy] will continue until the removal plan is fully implemented and the likelihood of serious injury, serious harm, serious impairment, or death no longer exists. 

If the harm cannot be remedied (e.g., death or serious harm has already occurred), the removal plan must address how additional serious harm will be prevented.

If the removal plan cannot be implemented prior to the exit conference of the original survey in which [immediate jeopardy] was cited, the [immediate jeopardy] continues until an onsite revisit verifies the date that [immediate jeopardy] was removed. 

During onsite revisit surveys, surveyors should verify that all elements of the removal plan have been implemented and that the actions taken were completed in a manner that eliminates the likelihood of serious injury, serious harm, serious impairment or death.

Removing the [immediate jeopardy] does not ensure that substantial compliance has been achieved. Once [immediate jeopardy] has been removed, the [state agency] will issue a completed Form CMS-2567 and request a plan of correction that achieves substantial compliance.

Q: What is the average timeline between when a hospital is cited for immediate jeopardy and when they are deemed back in compliance after corrections are made?


A: When an immediate jeopardy to patient health or safety is documented, the [state agency] and [regional office] complete termination procedures within 23 calendar days. 

Processing times given here are the maximum allowed. Do not postpone or stop the procedure unless compliance is achieved and documented through onsite verification. 

If there is a credible allegation that the threat or deficiency has been corrected, the [state agency] conducts a revisit prior to termination if possible

Q: What is something CMS would like hospitals and health system leaders to know about the process of correcting a situation after a citation or fine?

A: CMS works closely with state survey agencies and accrediting organizations to routinely survey facilities and take action when noncompliance is identified. Most facilities take these findings seriously and take corrective actions to come into compliance with the Medicare Conditions of Participation. Generally, a facility may be given the opportunity to submit a plan of correction to correct deficiencies.

Additional information about the answers referenced by the agency can be found here.

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