Accreditation

Quick look: Immediate Jeopardy

Briefings on Accreditation and Quality, September 1, 2017

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Why this finding can be disastrous to your facility

In healthcare, the words “Immediate Jeopardy” carry roughly the same meaning as “my brakes aren’t working,” “why is the tiger enclosure empty?” and “Vesuvius is rumbling really loudly today.”
In other words, something has already gone wrong and you have to move very quickly to stop it before it gets exponentially worse.

The CMS State Operations Manual defines Immediate Jeopardy (IJ) as “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.” Once a hospital or healthcare organization gets an IJ rating, it’s given a time frame to fix the deficiency. If not, CMS will terminate the facility’s Medicare and Medicaid funding. Since the government tends to be a facility’s largest payer, losing accreditation can be devastating. In addition, it can also negatively impact a hospital’s insurance rates, among other things.

 "[You] lose community support because you are no longer certified/accredited," says Victoria Fennel, PhD, RN-BC, CPHQ, director of accreditation and clinical compliance at Compass Clinical Consulting. "You start seeing some effects with physicians who may not want to send their patients to that hospital because [it] may affect their payments as well. Then you start to see staff leaving the organization. It really erodes the whole infrastructure if an organization loses its accreditation/certification."

Richard Curtis, RN, MS, HACP, CEO of the Center for Improvement in Healthcare Quality (CIHQ) and a nationally recognized expert on the CMS Conditions of Participation (CoP) and Certification & Survey process, says there are multiple reasons that a hospital can receive an IJ finding, he says.

“If you look at the CMS survey and certification procedures, there are literally dozens of situations that can cause an IJ,” he says. “The most common that we’ve seen involve failure to maintain a fire safe environment (e.g., an inoperable monitoring system), failure to protect a patient from abuse or neglect (e.g., staff physically or verbally abusing a patient), failure to adequately monitor a patient (e.g., a patient in restraint), and failure to assure RN supervision of care.”

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on Accreditation and Quality.

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