Immediate Jeopardy (for Nursing Homes, Deemed and Non-

5075.1 - Immediate Jeopardy (for Nursing Homes, Deemed and Non- Deemed Non-Long Term Care Providers/Suppliers, and EMTALA) (Rev. 243; Issued: 06-12-26; Effective: 06-12-26; Implementation: 06-12-26) General Provisions The regulations at 42 CFR 489.3 define immediate jeopardy 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.” Appendix Q contains the Guidelines for Determining Immediate Jeopardy. Intakes are assigned this priority if the alleged noncompliance indicates there was serious injury, harm, impairment or death of a patient or resident, or the likelihood for such, and there continues to be an immediate risk of serious injury, harm, impairment or death of a patient or resident unless immediate corrective action is taken. In addition, for nursing homes, facility-reported incidents are assigned this priority if immediate jeopardy may have occurred, regardless of whether an immediate risk may continue to exist. Examples of intakes that are assigned this priority include, but are not limited to, the following: • All intakes alleging abuse of a resident/patient/client that involve serious injury, harm, impairment, or death of a resident/patient/client or likelihood for such, and it is uncertain that they are adequately protected. • For nursing homes, all intakes where a resident was discharged to an unsafe setting, or in a manner that place the resident at risk for serious harm (e.g. the resident still has medical needs but they cannot be supported in the setting they were discharged to). • Intakes alleging EMTALA noncompliance may also be assigned this priority. • Any hospital self-reported incident of patient death associated with use of restraint or seclusion which the CMS location determines requires an on-site investigation is also assigned this priority. When the SA or CMS location makes the determination that a complaint or incident report suggests an immediate jeopardy may be present, the investigation is to be initiated in accordance with Section 5075.9. See also Section 5310.2A for additional guidance related to nursing home facility- reported incidents. (Note: Please see Section 5075.9 for maximum time frames related to Federal onsite investigation of complaints/incidents.) Fires Resulting in Serious Injury or Death Fires resulting in serious injury or death are prioritized as “immediate jeopardy”. The following actions are taken when a report of a fire resulting in serious injury or death in a Medicare/Medicaid certified facility is received from any source: The SA • Enters the complaint or self-reported incident into the CMS system (Priority = IJ, Allegation Category = Life Safety Code); • Informs the appropriate CMS location of fire resulting in serious injury or death no later than one working day after receipt of the intake; • Compiles information as needed to present a comprehensive picture of the situation surrounding the fire; • Takes appropriate action necessary to assist the Medicare/Medicaid- certified provider/supplier to protect and/or relocate residents or patients from further harm; and • Performs the Life Safety Code investigation. The CMS location • Informs CMS Central Office (CO) Division of Emergency Preparedness and Life Safety Code (DEPL) of the fire and planned actions, sending a copy of the alert to the Life Safety Code specialist; • Consults with the CO DEPL to determine whether there is an indication for CO DEPL participation in the survey for program evaluation purposes; • Reports any findings and actions taken by the SA to the CO DEPL at the end of the on-site survey; and • At its discretion, may accompany the SA during the on-site survey. The CO • Consults with the CMS location to determine whether or not issues are present that indicate further investigation to determine the adequacy of current standards and their application; and • In certain cases, CO DEPL staff may accompany CMS location and/or state personnel on the on-site survey.