On November 21, 2024, CMS published its latest QSO memo outlining the changes that have been made to the Immediate Jeopardy Criteria. Highlights of the revisions are:
- For surveyors to cite an immediate jeopardy there either has to be a situation, created by non-compliance, in which an individual has been harmed OR there must be the “likelihood” that serious harm, injury, impairment or death will occur if the identified non-compliance is not immediately corrected.
- Likelihood is referenced as a “reasonable expectation” that serious harm will occur. This is a shift from the previous guidance used by surveyors that the “potential” for serious harm was sufficient to trigger an Immediate Jeopardy.
- This new guidance does not include reference to a previous requirement related to “ culpability” and shifts the focus to whether noncompliance caused, or is likely to cause, serious harm.
- Last but not least, with the new guidance, surveyors must determine if deficiencies have “caused or made likely serious mental or psychosocial harm”. Surveyors have been instructed to utilize the reasonable person concept in making this determination. The reasonable person approach encourages persons to consider how a reasonable person in the recipient's position would be impacted by the noncompliance.
Additionally- CMS has provided an Immediate Jeopardy Template that must be used by surveyors with gathering and documenting the information that was considered when determining that an Immediate Jeopardy situation exists. CMS has also advised surveyors that there are no automatic immediate jeopardy citations or situations. Each individual situation needs to be evaluated.
To read more on this QSO memo or to access the Immediate Jeopardy template Click here.
Please contact Courtemanche and Associates for questions at 704-573-4535 or info@courtemanche-assocs.com.
