IMMEDIATE JEOPARDY AND PLAN OF REMOVAL

Lisa Thomas RN-BC

OLTC

State Training Coordinator

OBJECTIVES What constitutes Immediate Jeopardy

Review the process Surveyors implement to determine Immediate Jeopardy

Review potential civil money penalties and sanctions imposed on the facility by the State Agency or CMS due to Immediate Jeopardy

Immediate Jeopardy Immediate Jeopardy is interpreted as a crisis

situation in which the health and safety of resident(s) are at risk.

“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.

Immediate JeopardyThe identification and removal of Immediate Jeopardy,

either psychological or physical, are essential to prevent serious harm, injury, impairment, or death for individuals.

Only one individual needs to be at risk

Serious harm, injury, impairment or death does NOT have to occur

Serious harm can result from either abuse and neglect

Psychological harm is as serious as physical harm

Immediate Jeopardy

Any time abuse or neglect is identified, you should consider whether it is Immediate Jeopardy.

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.

Issues/Triggers for Immediate Jeopardy

Failure to protect from abuse Failure to prevent neglect Failure to protect from psychological 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 Failure to provide safety from fire, smoke and environment

hazards and/or failure to educate staff in handling emergency situations

Determining Immediate Jeopardy The surveyors will gather information to address:

Who: who was involved in the immediate jeopardy situation: staff, individuals receiving care and services and others?

What: what harm has occurred, is occurring or most likely to occur?

When: when did the situation first occur?

Where: where did the potential/actual harm occur?

is it an isolated incident or an entity wide problem?

Why: why did the potential/actual harm occur?

Immediate Jeopardy Identified

When immediate jeopardy is identified the provider is to be terminated within 23 calendar days from the last date of the survey if corrective measures are not immediately implemented.

However termination can be taken more quickly with as little as a two day notice per the State Operations Manual Appendix Q.

In any case, the immediate jeopardy must be removed no later than 23 days from the last day of the survey to avoid termination.

Immediate action is required to remove the immediate jeopardy and to

subsequently correct the deficiencies.

Facility allegation that the immediate jeopardy has been

removedThis allegation must include:

A plan of sufficient detail to demonstrate how and when the

immediate jeopardy has been removed.

(The plan of removal does not mean that the deficiencies are corrected; the facility still has to develop and implement a plan of correction.)

Plan of RemovalPlans of removal are the facility’s plans to remove the level of severity (IJ) of the failed practice from resident(s) in the facility; it is not a plan of correction.

The information required for the Plan is:

Identification of total number of residents at risk for same failed practice.

Assessments required to determine what immediate actions are necessary to remove the IJ situation

Training of staff to ensure all have knowledge of care/actions required until POC is implemented

Plan of Removal continued Monitoring by supervisory personnel to ensure staff

are following the Plan of Removal.

Documentation of facility’s actions until POC is implemented (in-service records, logs etc)Plan can be handwritten or typed. However it must have the facility’s name, “Plan of Removal for IJ” and it needs to be signed/dated by the Administrator/designee.

The plan should document for each applicable area: Date/time action began and when completed (unless ongoing), who performed the action, and estimated date/time of completion

Plan of Removal Should include at least:

1. actions taken to remove the immediacy of the failed practice (e.g.: remove the perpetrator, remove chemicals, immediate assessment of appropriate medical intervention, staff education)

2. actions taken to prevent recurrence of the failed practice

3. date and time the immediacy was removed

4. monitoring implementation of plan

Level Four-J- IsolatedDefinition:

Only one or a very limited number of residents were affected and/or a very limited number of staff is involved, and/or the situation has occurred only occasionally or in a very limited number of locations.

Level Four-K-PatternDefinition:

More than a limited number of residents are affected, and/or more than a very limited number of staff are involved, and/or the situation has occurred in several locations, and/or the same resident(s) have been affected by repeated occurrences of the same deficient practice.

Level-Four-L-WidespreadDefinition:

Problems causing the deficiency are pervasive throughout the facility and have affected or have the potential to affect all or a large portion of the facility’s residents. The facility does not have an adequate system or policies in place to prevent the deficiency from recurring.

Level-Four-J,K or L Immediate Jeopardy to Resident Health or Safety: The

deficiency has resulted in noncompliance and immediate action is necessary. An event has caused or is likely to cause serious harm, injury, impairment or death to the resident(s).

Deficiencies cited at this level in Resident Behavior and Facility Practices (483.13), Quality of Life (483.15) and Quality of Care Regulatory Groupings (483.25) are designated by HCFA as Substandard Quality of Care Citations.

Any deficiency cited at this level is considered an Immediate Jeopardy citation.

RESOURCESThe State Operations Manual Appendix Q

The State Operations Manual §7307-7309

Lisa.Thomas@dhs.arkansas.gov

501.320.6396