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In the previous post we started talking about Immediate Jeopardy. There are some triggers which, when seen, should clue the hospital and nursing home surveyor or survey team into looking further to see if there is an IJ situation. Although CMS doesn’t consider the triggers to be all inclusive, they are a good starting point. CMS has placed the issues and triggers into a chart for the surveyors. I have copied that chart here for your perusal. The chart and other information can be found in the SOMAppendix Q.

 

Issues

Triggers

A. Failure to protect from abuse.

1. Serious injuries such as head trauma or fractures;

2. Non-consensual sexual interactions; e.g., sexual harassment, sexual coercion or sexual assault;

3. Unexplained serious injuries that have not been investigated;

4. Staff striking or roughly handling an individual;

5. Staff yelling, swearing, gesturing or calling an individual derogatory names;

6. Bruises around the breast or genital area; or Suspicious injuries; e.g., black eyes, rope marks, cigarette burns, unexplained bruising.

B. Failure to Prevent Neglect

1. Lack of timely assessment of individuals after injury;

2. Lack of supervision for individual with known special needs;

3. Failure to carry out doctor’s orders;

4. Repeated occurrences such as falls which place the individual at risk of harm without intervention;

5. Access to chemical and physical hazards by individuals who are at risk;

6. Access to hot water of sufficient temperature to cause tissue injury;

7. Non-functioning call system without compensatory measures;

8. Unsupervised smoking by an individual with a known safety risk;

9. Lack of supervision of cognitively impaired individuals with known elopement risk;

10. Failure to adequately monitor individuals with known severe self-injurious behavior;

11. Failure to adequately monitor and intervene for serious medical/surgical conditions;

12. Use of chemical/physical restraints without adequate monitoring;

13. Lack of security to prevent abduction of infants;

14. Improper feeding/positioning of individual with known aspiration risk; or

15. Inadequate supervision to prevent physical altercations.

C. Failure to protect from psychological harm

1. Application of chemical/physical restraints without clinical indications;

2. Presence of behaviors by staff such as threatening or demeaning, resulting in displays of fear, unwillingness to communicate, and recent or sudden changes in behavior by individuals; or

3. Lack of intervention to prevent individuals from creating an environment of fear.

D. Failure to protect from undue adverse medication consequences and/or failure to provide medications as prescribed.

1. Administration of medication to an individual with a known history of allergic reaction to that medication;

2. Lack of monitoring and identification of potential serious drug interaction, side effects, and adverse reactions;

3. Administration of contraindicated medications;

4. Pattern of repeated medication errors without intervention;

5. Lack of diabetic monitoring resulting or likely to result in serious hypoglycemic or hyperglycemic reaction; or

6. Lack of timely and appropriate monitoring required for drug titration.

E. Failure to provide adequate nutrition and hydration to support and maintain health.

1. Food supply inadequate to meet the nutritional needs of the individual;

2. Failure to provide adequate nutrition and hydration resulting in malnutrition; e.g., severe weight loss, abnormal laboratory values;

3. Withholding nutrition and hydration without advance directive; or

4. Lack of potable water supply.

F. Failure to protect from widespread nosocomial infections; e.g., failure to practice standard precautions, failure to maintain sterile techniques during invasive procedures and/or failure to identify and treat nosocomial infections.

1. Pervasive improper handling of body fluids or substances from an individual with an infectious disease;

2. High number of infections or contagious diseases without appropriate reporting, intervention and care;

3. Pattern of ineffective infection control precautions; or

4. High number of nosocomial infections caused by cross contamination from staff and/or equipment/supplies.

G. Failure to correctly identify individuals.

1. Blood products given to wrong individual;

2. Surgical procedure/treatment performed on wrong individual or wrong body part;

3. Administration of medication or treatments to wrong individual; or

4. Discharge of an infant to the wrong individual.

H. Failure to safely administer blood products and safely monitor organ transplantation.

1. Wrong blood type transfused;

2. Improper storage of blood products;

3. High number of serious blood reactions;

4. Incorrect cross match and utilization of blood products or transplantation organs; or

5. Lack of monitoring for reactions during transfusions.

I. Failure to provide safety from fire, smoke and environment hazards and/or failure to educate staff in handling emergency situations.

1. Nonfunctioning or lack of emergency equipment and/or power source;

2. Smoking in high risk areas;

3. Incidents such as electrical shock, fires;

4. Ungrounded/unsafe electrical equipment;

5. Widespread lack of knowledge of emergency procedures by staff;

6. Widespread infestation by insects/rodents;

7. Lack of functioning ventilation, heating or cooling system placing individuals at risk;

8. Use of non-approved space heaters, such as kerosene, electrical, in resident or patient areas;

9. Improper handling/disposal of hazardous materials, chemicals and waste;

10. Locking exit doors in a manner that does not comply with NFPA 101;

11. Obstructed hallways and exits preventing egress;

12. Lack of maintenance of fire or life safety systems; or

13. Unsafe dietary practices resulting in high potential for food borne illnesses.

J. Failure to provide initial medical screening, stabilization of emergency medical conditions and safe transfer for individuals and women in active labor seeking emergency treatment (Emergency Medical Treatment and Active Labor Act).

1. Individuals turned away from ER without medical screening exam;

2. Women with contractions not medically screened for status of labor;

3. Absence of ER and OB medical screening records;

4. Failure to stabilize emergency medical condition; or

5. Failure to appropriately transfer an individual with an unstabilized emergency medical condition.

 

When determining if there is a finding of IJ, the nursing home and hospital surveyor or survey team must look for the components of IJ.

The first component of IJ is Harm, which is divided into actual and potential. To determine which one it is the nursing home and hospital surveyor or survey team asks the following questions:

  • ActualWas harm an outcome? Does the harm meet the definition of IJ? In other words, has the facility’s failure to comply with the requirements actually caused serious injury, harm, impairment, or death?
  • PotentialIs potential harm likely to occur? Does the potential harm meet the definition of Immediate Jeopardy? In other words, is the facility’s failure to comply with the requirements likely to cause serious injury, harm, impairment, or death to an individual?

The second component of IJ is Immediacy. The investigator looks to see if the harm or potential harm is likely to occur in the very near future to this particular person or to others in the facility, if immediate action is not taken.

The third component of IJ is Culpability. Here the surveyor or the survey team is looking to answer the following questions:

  1. Did the facility know about the situation? If so when did the facility first become aware?
  2. Should the facility have known about the situation?
  3. Did the facility thoroughly investigate the circumstances?
  4. Did the facility implement corrective measures?
  5. Has the facility re-evaluated the measures to ensure the situation was corrected?

The nursing home and hospital surveyor or survey team considers the facility’s response to any harm or potential harm that meets the definition of IJ. Just because the facilty’s staff  say they did not know about a particular issue or situation does not excuse that facility from knowing about and preventing IJ. The survey team or surveyor uses his or her experience and knowledge to determine if the circumstances could have been predicted. The nursing home and hospital surveyor or survey team should continue to investigate enough information has been gathered in order to evaluate any prior indications or warnings regarding the jeopardy situation and the facility’s response. The crisis situations in which a facility did not have any prior indications or warnings, and could not have predicted a potential serious harm, are very rare.

So what happens if a facility is found in Immediate Jeopardy? Do they get closed down? No, not immediately. The facility is given a period of time in which to correct the deficiency. CMS works with the state survey agency and tells them each next step to follow. There are many opportunities for the facility to correct situation, but when necessary, CMS will initiate termination from participation, meaning the facility will not be eligible to receive federal monies for the care of patients/residents.

Be safe and be informed!

JL

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The Centers for Medicare and Medicaid (CMS) have a classification for crisis situations in which the health and safety of individual(s) are at risk. This classification is called Immediate Jeopardy (IJ).

CMS developed guidelines for surveyors of nursing homes and hospitals to use to help determine if the circumstances they are seeing pose an Immediate Jeopardy to a patient or resident’s health and safety. The guidelines assist Federal and State Survey and Certification personnel and Complaint Investigators in recognizing situations that may cause or permit Immediate Jeopardy in a nursing home or hospital as well as to almost all other certified Medicare/Medicaid entities. The surveyors can apply these principles and guidelines to all types of surveys and investigations: certifications, recertifications, revisits, and complaint investigations. The main goal of having these guidelines is to help the surveyors and investigators identify and prevent serious injury, harm, impairment, or death.

CMS has provided some definitions for the surveyors.

Immediate Jeopardy is defined 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.

Abuse is defined as “The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.”

Neglect is defined as a “Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.”

In order to determine if there is an IJ situation, the nursing home and hospital surveyor or survey team will keep in mind that only one person needs to be at risk. They will also consider that serious harm, injury, impairment, or death does NOT have to occur before considering Immediate Jeopardy. Harm can come from both abuse and neglect and psychological harm is as serious as physical harm. 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 as a result of the jeopardy situation. In other words, a situation that can cause any of the problems above may or may not be currently happening, but if there is a potential for it to happen, that can constitute an IJ situation. Harm does not have to occur before the surveyor or survey team can consider or call IJ.

In order to call an IJ, the nursing home and hospital surveyor or survey team must also consider if the facility either created a situation or allowed a situation to continue which resulted in serious harm or a potential for serious harm, injury, impairment or death to individuals and if the facility had an opportunity to put corrective or prevention measures in place. During the investigation the surveyor/investigator will investigate and answer the following questions: Who was involved? What harm has occurred, is occurring, or most likely will occur? When did the situation first occur? Where did the potential/actual harm occur? Is it an isolated incident or a facility-wide problem? Why did the potential/actual harm occur?

In the next post I will discuss the triggers for IJ.

Keep safe and be informed!

JL

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For Federal surveys, hospitals and nursing homes have a different rating or grading system. In fact, nursing homes have a different system than all the other healthcare facility types. Nursing homes have a Severity and Scope level (from A through L). Hospitals and other healthcare provider types have standards and conditions of participation.

We will talk about Conditions of Participation and standards in the future. Today, let’s look at Severity and Scope, which is a system of rating the seriousness of deficiencies. A “deficiency” is a regulatory requirement that a facility fails to meet; or as it is officially put “is found not met” during the survey.

The Severity and Scope system is national and is used by all state survey agencies and the Centers for Medicare and Medicaid Services (CMS) when conducting nursing home Medicare and Medicaid certification surveys. For each deficiency, the survey team first determines the level of harm (severity) to the resident or resident(s) involved and then determines the scope of the problem within the nursing home. The team then assigns an alphabetical Severity and Scope value, A through L, to the deficiency. “A” is the least serious and “L” is one of the most serious ratings. It’s kind of like the grade on a report card except “A” doesn’t mean 100%; and “L” isn’t a grade any of us ever had on our report cards.

This is a visual representation:

Immediate jeopardy to resident health & safety

Level 4

J

K

L

Actual harm that is not immediate jeopardy

Level 3

G

H

I

No actual harm, with potential for more than minimal harm

Level 2

D

E

F

No actual harm, with potential for minimal harm

Level 1

A

B

C

Isolated

Pattern

Widespread

Here is how it is used.

First the team decides what “Level” the deficiency falls in.

Level 1 (the green row) means there was no actual harm but there was a potential for minimal harm. In other words there was no more than minor negative impact.

Level 2 (the yellow row) means there was no actual harm, but there was a potential for more than minimal harm that is not an immediate jeopardy. In other words there was no more than minimal physical, mental, and/or psychosocial discomfort as a result of the deficient practice. There is a potential to compromise the resident’s ability to maintain and/or reach his/her highest practicable physical, mental and/or psychosocial well being.

Level 3 (the orange row) means there was actual harm that is not immediate jeopardy. In other words there was a negative or bad outcome. The resident ended up being clinically compromised, or experienced deterioration or harm, or his/her ability to maintain &/or reach greatest practicable well-being was compromised.

Level 4 (the red row) means the facility’s deficient practice has caused or is likely to cause serious injury, harm, impairment, or death and therefore requires immediate action/correction. In this case the pattern of the facility’s practice establishes a reasonable degree of predictability of similar actions, situation, practices, or incidents occurring in the future if they don’t fix it right now. Anything in this row is called Immediate Jeopardy.

Once the team has made a determination of the severity they must then determine the scope. That means how many people, staff, or areas it affected, i.e. how prevalent or widespread the problem is.

Isolated (the first column) means:

  • One or a very limited number of residents are affected
  • One or a very limited number of staff are involved,
  • The situation had occurred only occasionally or in a very limited number of locations

 Pattern (the second column) means

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

Widespread (the third column) means

  • The problems causing the deficiencies are pervasive in the facility or
  • There is a systemic failure that has the potential to affect a large portion or all of the facility’s residents.

So taking all this together here is how you explain the scores (grades)

  • A – Isolated/Potential for minimal harm – Least serious rating and is isolated to the fewest number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor impact on the resident(s).
  • B– Pattern/Potential for minimal harm – Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than minor negative impact on the resident(s) and was not found to be throughout the facility.
  • C– Widespread/Potential for minimal harm – Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all of the residents. This deficiency has the potential to affect a large portion or all of the residents, but has the potential for causing no more than a minor negative impact on the resident(s).
  • D– Isolated/Minimal harm or potential for actual harm – This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential to negatively affect the resident’s ability to achieve his/her highest functional status.
  • E– Pattern/Minimal harm or potential for actual harm – This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident’s ability to achieve his/her highest functional status. This deficiency was not found to be throughout the facility.
  • F– Widespread/Minimal harm or potential for actual harm – This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the residents’ ability to achieve his/her highest functional status.
  • G– Isolated/Actual harm – This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident’s ability to achieve his/her highest functional status.
  • H– Pattern/Actual harm – This is a more serious deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident’s ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
  • I– Widespread/Actual harm – This is a more serious deficiency that was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency results in a negative outcome that has negatively affected the residents’ ability to achieve his/her highest functional status.
  • J– Isolated/Immediate Jeopardy – This is the most serious deficiency although it is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one which places the residents in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified.
  • K– Pattern/Immediate Jeopardy – This is the most serious deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one which places the residents in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified. This deficiency was not found to be throughout the facility.
  • L– Widespread/Immediate Jeopardy – This is the most serious deficiency and was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one which places the residents in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified.

There you go, a quick explanation of what those “grades” you see mean. Let me know if you have any questions and leave your comments. They will help me develop posts to answer questions you have.

JL

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