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“Immediate jeopardy” are words you never want to see on a CMS survey report for your facility because it means you are on the brink of losing your accreditation for Medicare in a very short time, and that is only the worst of the ramifications. Immediate jeopardy also means higher fines, less time to correct problems, and extremely bad publicity.
But this situation happens only to facilities that are in bad shape overall, where the administrators know that there are serious deficiencies that could lead to immediate jeopardy, right? Surely it can’t happen to facilities that are high quality and well-run.
It can happen to those top-notch facilities, experts say. It's possible for a serious deficiency to go unnoticed until a CMS surveyor makes a fateful note in the records.
Surveyors will declare immediate jeopardy when the facility is in noncompliance with at least one condition of participation (CoP) or condition for coverage (CfC) in a way that has caused or is likely to cause serious injury, harm, impairment, or death to a patient.
A wide range of situations can result in immediate jeopardy, but examples include failure to count instruments and supplies in surgery, medication safety failures, and patient-to-patient violence or sexual assault, says Susan G. Kratz, JD, shareholder and chair of the Healthcare Practice Group with the law firm Nilan Johnson Lewis in Minneapolis. CMS surveyors, or state surveyors acting on behalf of CMS, see the immediate jeopardy finding as a way to intervene in especially dangerous situations, she says.
“They’re looking for a problem in which a patient could come to immediate harm, not just a possibility sometime in the future,” Kratz says. “But it is important to remember that it is not necessary for a patient to have been harmed already.”
Failures with infection control also are a common prompt...