23 Days to Fix Everything: Responding to Immediate Jeopardy Findings Before It’s Too Late

So your hospital has just received a notice of Immediate Jeopardy. Now what?

Actual termination from Medicare is relatively rare, but as surveys by the Centers for Medicare and Medicaid Services (CMS) have become more thorough, an increasing number of hospitals are being forced to deal with findings of Immediate Jeopardy and subsequent termination procedures. Responding to termination procedures is inevitably stressful and confusing. To help you navigate the process, here are a couple of basic tips on what to expect and how to respond to prevent Immediate Jeopardy findings from turning into Medicare termination.

Act quickly.
The most serious of regulatory deficiencies will result in 23-day Termination Procedures. This means that the hospital will have 23 days from the final day of survey to prove that it has come into compliance with CMS Conditions of Participation. Hospitals should be equipped to react within the timeline set by CMS, while leaving extra time for the realities that accompany the process. For example, CMS estimates that hospitals will be notified of Immediate Jeopardy and the related non-compliance by Day 2. In reality, this information could arrive as late as Day 10. So, clinical and quality leaders should be prepared to act quickly, aiming to resolve the Immediate Jeopardy by Day 19, at the latest. This leaves a four-day grace period, in case of complications.

Create plans you can complete.
One way to ensure a quicker response is to develop simple, reasonable action plans. Create plans that address deficiencies quickly and that can be validated. Wide-reaching strategies for addressing problems on a large scale are wonderful, but often take significant time and effort to execute. Since the action plan has to show how the organization has become compliant by the date the plan is submitted, it is better to aim for smaller, achievable solutions, than grand plans that look great on paper but have a low probability of succeeding.

Respond to CMS, not The Joint Commission.
While the expectations of The Joint Commission (TJC) and CMS overlap to some extent, it is important to understand the differences in the way that these organizations approach compliance. TJC supports progress toward bigger patient safety goals, while CMS expects 100% compliance with basic practices, 100% of the time. So when responding to Immediate Jeopardy, action plans and verbal responses during survey should reflect the CMS perspective on quality. For example, hospitals should craft action plans that ensure full compliance with the minimum standards. Such plans are much more likely to be followed, allowing hospitals to pass their first follow-up surveys, and avoid the necessity of re-survey.

Once is enough.
If your hospital is facing termination, the last thing you want to do is lengthen the recovery process by requiring multiple re-surveys. After an action plan is submitted, your hospital will undergo a follow-up survey to verify that Immediate Jeopardy no longer exists. If the hospital doesn’t pass, it is highly unlikely that the 23-day timeframe will permit a second survey. So, it’s important to pass the first time. Also remember that the longer the hospital goes without resolving Immediate Jeopardy, the greater the likelihood that the story will hit the press.

For more information on responding to Immediate Jeopardy and avoiding Medicare termination, download “Hospital Near-Death Experience: How Medicare Termination Can Push Your Hospital to the Brink of Closing.”