Harmony Healthcare International (HHI) Blog

Immediate Jeopardy: Scope and Severity

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C.A.R.E.

Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency


Risks Concept. Colored Document Folders Sorted for Catalog. Closeup View. Selective Focus..jpegFirst and foremost, this blog post is spurred by the recent modification of two forms used for the survey process.  

Both forms were revised after the Requirements of Participation (RoP) Phase II implementation in November 2017.  The Scope and Severity Grid is below and the CE Pathway for Resident Council is below as a download.  

Download the Resident Council Interview Form

The purpose of a nursing home survey is to detect deficits (actual and potential) related to the services provided to the patients and residents within the facility.  The inspection entails a review of the entire span of clinical and operational components with the common goal of safeguarding quality care. 

The survey process entails on-site observations, interviews with staff, family and patients as well as data analysis and medical record reviews.  Exploration of aspects delve into: 

  • Administration
  • Admission Transfer/Discharge Rights
  • Dental Services
  • Dietary Services
  • Infection Control
  • Nursing Services
  • Pharmacy Services
  • Physical Environment
  • Physician Services
  • Quality of Care
  • Quality of Life
  • Resident Assessment
  • Resident Behavior/Facility Practice
  • Resident Rights
  • Specialized Rehabilitative Services 

The seriousness of the deficiency (F-Tag) is determined by the Scope and Severity of the issue. The below grid depicts the range of deficiencies and the interpretation of substantial compliance, substandard care to immediate jeopardy. 

Scope (Isolated, Pattern, Widespread) 

The term Scope refers to the number of residents who are impacted by the deficiency. 

Isolated typically means the deficiency included a very small number of residents or a limited number of staff are involved or that the situation occurred only occasionally. 

Pattern.  This column is chosen when more than a few residents are affected, more than a limited number of staff are involved, or there are repeat occurrences.  The rule of thumb for this column is 75%.  If a deficient practice affects more than 3 residents but less than 75% of the nursing home population, it generally will be considered a “Pattern.” 

Widespread. A problem affects many residents or if there is systemic failure in a facility. 

Severity (Level 1, 2, 3 and 4) 

The term Severity refers to the how serious the issue is or what the potential for harm. 

Level

Letter

How Serious and Potential for Harm

Level 1

A, B, C

Not Serious
Not Actual Harm
No potential for harm

Level 2

D, E, F

These tags are cited when there is noncompliance that is not actual harm but results in minimal discomfort to the resident or has the potential to cause harm.  These are very common citations in nursing home surveys.

Level 3

G, H, I

They represent actual harm has occurred to a resident.  Please note, a bruise, skin tear, or upsetting a resident can be considered actual harm.

Level 4

J, K, L

These are the highest level tags a facility can receive on survey. This is Immediate Jeopardy terrain, and shortened to ‘IJ’.  It is important to distinguish that an ‘IJ’ is an abbreviation for Immediate Jeopardy. “IJ” does not correspond to the I or J on the Scope and Severity Grid.  It characterizes the organization of the row of letters J, K, and L, only.  Therefore, 

  • J is an ‘IJ’ tag
  • K is an ‘IJ’ tag
  • L is an ‘IJ’ tag.

No actual harm must occur to receive an IJ tag.

 

Immediate Jeopardy citations are often accompanied by a fine.  This is known as Civil Monetary Penalty (CMP). The dollar amount ranges from $3,050 per day up to $10,000 per day.  No to mention, a CMP’s may be retroactive to the date of the incident. 

Substandard Quality of Care is any deficiency in 42 C.F.R. 

  • 42 C.F.R. §483.13, Resident Behavior and Facility Practices
  • 42 C.F.R. §483.15 Quality of Life, or
  • 42 C.F.R. §483.25, Quality of Care, 
    that constitutes: 
    • immediate jeopardy to resident health or safety;
    • or a pattern of or widespread actual harm that is not immediate jeopardy;
    • or a widespread potential for more than minimal harm that is not immediate jeopardy, with no actual harm. 

It is prudent to review the definitions: 

  • 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.” (See 42 CFR Part 489.3.) 
  • Abuse: “The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.” (See 42 CFR Part 488.301.) 
  • Neglect: “Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.” (See 42 CFR Part 488.301.) 

Scope and Severity Matrix.jpg

Health Inspection Descriptors: Definitions 

Substandard Quality of Care means one or more deficiencies related to participation requirements under: 

  • 483.10 “Resident Rights”
  • 483.12 “Freedom from Abuse, Neglect, and Exploitation”
  • 483.24 “Quality of Life”
  • 483.25 “Quality of Care”
  • 483.40 “Behavioral Health Services”
  • 483.45 “Pharmacy Services”
  • 483.70 “Administration”
  • 483.80 “Infection Control” that constitutes: 
    • immediate jeopardy to resident health or safety;
    • or a pattern of or widespread actual harm that is not immediate jeopardy;
    • or a widespread potential for more than minimal harm that is not immediate jeopardy, with no actual harm. 

Immediate Jeopardy 

Whether you are new to the industry or a seasoned player, you must really pause and contemplate the meaning of immediate jeopardy. 

The State Operations Manual references the three components of Immediate Jeopardy: 

  • Harm
  • Immediacy
  • Culpability 

Surveyors utilize these three elements to determine wither the situation warrants a citation of Immediate Jeopardy. 

  1. Harm can be separated into “Actual Harm” and “Potential Harm. Actual Harm relates to situations where the issue at the facility caused serious harm or injury, impairment or in the worst case, death of a resident. Potential Harm refers to situations where the facility’s practices could likely cause serious harm, impairment, injury or death to a resident.
    • Actual: Was there an outcome of harm?  Does the harm meet the definition of Immediate Jeopardy, e.g., has the provider’s noncompliance caused serious injury, harm, impairment, or death to an individual?
    • Potential: 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? 
  1. Immediacy: Is the harm or potential harm likely to occur in the very near future to this individual or others in the entity, if immediate action is not taken?  (Refer to the SOM §3010(B)(6) for timelines during normal termina) 
  1. Culpability: This component addresses knowledge of the harm or potential harm by looking at the following:
    • Did the entity know about the situation? If so when did the entity first become aware?
    • Should the entity have known about the situation?
    • Did the entity thoroughly investigate the circumstances?
    • Did the entity implement corrective measures?
    • Has the entity re-evaluated the measures to ensure the situation was corrected? 

Immediate Jeopardy 

  • Immediate Jeopardy is interpreted as a crisis in which the health and safety of individual(s) are at risk (see SOM §3010). 
  • The primary goals of these Immediate Jeopardy guidelines are to identify and to prevent serious injury, harm, impairment, or death. 
  • Only One Individual needs to be at risk. Identification of Immediate Jeopardy for one individual will prevent risk to other individuals in similar situations. 
  • Serious harm, injury, impairment, or death does NOT have to occur before considering Immediate Jeopardy. The high potential for these outcomes to occur in the very near future also constitutes Immediate Jeopardy. 
  • Individuals must not be subjected to abuse by anyone including, but not limited to, entity staff, consultants or volunteers, family members or visitors. 
  • Serious harm can result from both abuse and neglect. 
  • Psychological harm is as serious as physical harm. 
  • Abuse or neglect, consider Immediate. 
  • 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 because of the jeopardy situation. 
  • Immediate Jeopardy procedures must not be used to enforce compliance quickly on more routine deficiencies. 

Immediate Jeopardy Triggers 

The listed triggers do not automatically equal Immediate Jeopardy. The team must investigate and use professional judgment to determine if the situation has caused or is likely to cause serious harm, injury, impairment or death. 

Download Immediate Jeopardy Triggers

Harm does not have to occur before considering Immediate Jeopardy. 

Triggers describe situations that cause the surveyor to consider if further investigation is needed to determine the presence of immediate jeopardy.  The listed triggers do not automatically equal Immediate Jeopardy. The team must investigate and use professional judgement to determine if the situation has caused or is likely to cause serious harm, injury impairment or death.

Harmony Healthcare International (HHI) is available to assist with any questions or concerns that you may have. You can contact us by clicking here.  Looking to train your staff?  Join us in person at one of our our upcoming Competency/Certification Courses.  Click here to see the dates and locations. 


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Topics: Immediate Jeopardy


Kris Mastrangelo, OTR/L, LNHA, MBA

WRITTEN BY

Kris Mastrangelo, OTR/L, LNHA, MBA
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