Determining Health Severity and Scope of Deficiencies

7203.3.2 Determining Health Severity and Scope of Deficiencies (Rev. 244; Issued: 06-26-26; Effective: 06-26-26; Implementation: 06-26-26) Guidance on Severity: After the survey team decides to cite a deficiency(ies), evaluate the deficient practice’s impact on the resident(s) and the prevalence of the deficient practice. Review deficiency statements, and results of team discussions for evidence on which to base these determinations. The team may base evidence of the impact or prevalence for residents of the deficient practices on record reviews, interviews and/or observations. Whatever the source, the evidence must be credible. NOTE: The survey team must always assess the level of severity of noncompliance beginning with the highest level of harm, and if the outcome doesn’t reach that level of harm, to proceed to review the other levels in consecutive order until a determination of severity has been made. Assessment Factors Used to Determine the Seriousness of Health Deficiencies Matrix Isolated Pattern Widespread Immediate jeopardy to resident health or safety (Level 4) J PoC Required SQC K PoC Required SQC L PoC Required SQC Actual harm that is not immediate jeopardy (Level 3) G PoC Required H PoC Required SQC I PoC Required SQC No actual harm with potential for more than minimal harm that is not immediate jeopardy (Level 2) D PoC Required E PoC Required F PoC Required SQC No actual harm with potential for minimal harm (Level 1) A No PoC Required Substantial compliance No remedies Commitment to Correct Not on CMS-2567 B PoC Required Substantial compliance C PoC Required Substantial compliance Substandard quality of care Substantial compliance There are four severity levels which are defined accordingly: • Level 4 - Immediate Jeopardy to resident health or safety: Noncompliance with the Requirements for Participation that results in Immediate Jeopardy to resident health or safety in which immediate corrective action is necessary because the provider’s noncompliance with one or more of those requirements has caused, or is likely to cause, serious injury, harm, impairment or death to a resident receiving care in a facility. (See Appendix Q) • Level 3 - Actual harm that is not Immediate Jeopardy: Noncompliance with the Requirements for Participation that results in actual harm to residents that is not immediate jeopardy. • Level 2 No actual harm with a potential for more than minimal harm that is not immediate jeopardy: Noncompliance with the Requirements for Participation that results in the potential for no more than minimal physical, mental, and/or psychosocial harm to the resident and/or that result in minimal discomfort to the residents of the facility, but has the potential to result in more than minimal harm that is not immediate jeopardy. • Level 1 - No actual harm with potential for minimal harm: A deficiency that has the potential for causing no more than a minor negative impact on the resident(s). Guidance on Scope: After determining the severity level of a deficient practice, determine the scope of the noncompliance which reflects the number of residents actually or potentially affected by the provider’s noncompliance Scope is isolated when one or a very limited number of residents are affected and/or one or a very limited number of staff are involved, and/or the situation has occurred only occasionally or in a very limited number of locations within the facility. Scope is a pattern when more than a very limited number of residents are affected, and/or more than a very limited number of staff are involved, and/or the situation has occurred in several locations of the facility, and/or the same resident(s) have been affected by repeated occurrences of the same deficient practice. The effect of the deficient practice is not found to be pervasive (affect many locations) throughout the facility. Scope is widespread when the problems causing the deficiencies are pervasive in the facility and/or represent systemic failure that affected or has the potential to affect a large portion or all of the facility’s residents. Widespread scope refers to the entire facility population, not a subset of residents or one unit of a facility. In addition, widespread scope may be identified if a systemic failure in the facility (e.g., failure to maintain food at safe temperatures) would be likely to affect a large number of residents and is, therefore, pervasive in the facility. NOTE: If the evidence gathered during the survey for a particular requirement includes examples of various severity or scope levels, surveyors should generally classify the deficiency at the highest level of severity. For example, if there is a deficiency in which one resident suffered a severity 3 while there were widespread findings of the same deficiency at severity 2, then the deficiency would be classified as severity 3, isolated. In these situations, the survey team should expand the sample to rule out the presence of SQC. When Immediate Jeopardy (IJ) Exists: Identification of IJ triggers additional survey tasks and should be determined while the team is onsite. IJ as defined at §488.301, means 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. At any time during the survey, if one or more survey team members identify possible IJ, the survey team leader must be immediately notified so that the survey team can gather to discuss the IJ concern and, if necessary, conduct further investigation. The survey team must use its professional judgment and evidence gathered from observations, interviews, and record reviews to carefully consider each key component of IJ. Survey teams must use the IJ Template (found in Appendix Q) to document evidence of each component of IJ and to convey information to the entity. In order to determine that IJ exists, the team must verify that all three components of IJ have been established: 1. Noncompliance: An entity has failed to meet one or more federal health, safety, and/or quality regulations; AND 2. Serious Adverse Outcome or Likely Serious Adverse Outcome: As a result of the identified noncompliance, serious injury, serious harm, serious impairment or death has occurred, is occurring, or is likely to occur to one or more identified recipients at risk; AND 3. Need for Immediate Action: The noncompliance causes a serious adverse outcome or likely serious adverse outcome and creates a need for immediate corrective action by the entity to prevent serious injury, serious harm, serious impairment or death from occurring or recurring. Survey teams must use the IJ Template to determine if IJ exists and use the template to communicate the finding of IJ to the entity. When the surveyor/survey team determines the entity’s noncompliance has caused a serious adverse outcome, or has made a serious adverse outcome likely, and immediate action is needed to prevent serious harm from occurring or recurring, the survey team must consult with their SA for confirmation that IJ exists and seek direction. In some cases, it may be necessary for the survey team to stop all other investigations due to the need for additional investigation into the IJ situation. When there is agreement from the SA (and/or CMS Location) that IJ exists, the survey team must immediately: • Notify the administrator (or appropriate staff member who has full authority to act on behalf of the entity) that IJ has been identified and provide a copy of the completed IJ template to the entity; and • Request a written IJ removal plan, which is the immediate action(s) the entity will take to address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely. The administrator/designee should immediately begin to take action to remove the IJ. If the IJ is not removed prior to the end of the survey, an onsite revisit must be conducted for determination of removal of the IJ. The SA and/or CMS Location will invoke appropriate termination procedures. See Appendix Q for additional guidance regarding determination of IJ. When IJ is removed: Appendix Q states, “When IJ has been identified and removed during the current survey or the revisit, the SA must ensure the core components of IJ and the actions taken by the entity to remove the IJ are documented on the Form CMS- 2567. The documentation must identify and describe the following information: • The date the IJ began (the date entity’s noncompliance caused a serious adverse outcome, or made a serious adverse outcome likely), if known; • The date the entity was notified; • The specific requirement that has been violated, including a description of the noncompliance and the serious adverse outcome that occurred, or was likely to occur; • Identification of recipients that were affected or were identified at risk of serious injury, harm, impairment, or death within the deficient practice statement; • Date when the IJ was removed, as confirmed by an onsite verification by surveyor(s); and • A statement of the seriousness of the remaining noncompliance, if any (i.e. Condition/ Standard/Element-level, or scope/severity).” Lowering Severity when IJ is removed: As noted above, once IJ has been removed, surveyors must identify the level of severity any remaining noncompliance poses at the tag cited for IJ. When the facility has taken action to remove IJ, such that no further serious injury, serious harm, serious impairment, or death is occurring to the resident(s) involved and is not likely to occur to any other resident(s), any remaining noncompliance for that tag should be lowered to severity level 2 (No actual harm with potential for more than minimal harm that is not immediate jeopardy). If there are multiple occurrences of noncompliance at the same tag involving different residents with one cited at IJ and the other cited at harm, once IJ is removed, the remaining noncompliance is lowered to harm. Example at 483.25(d), Accidents and Supervision: During a recertification survey, IJ was determined to exist for Resident A who was seriously harmed when the facility failed to supervise this resident’s smoking break, resulting in Resident A being seriously burned. During the same survey, Resident B was found to have been harmed (not serious harm at IJ) when the facility failed to ensure the resident environment was free of accident hazards, resulting in Resident B sustaining a laceration which required sutures after slipping on spilled water near the water fountain. The IJ was removed when the facility put a plan in place to ensure all residents are supervised on their smoke breaks, but the plan did not address correction of the accident hazards. Once that IJ removal plan was implemented, and it was determined that no further residents were being seriously harmed or had the likelihood to be seriously harmed, the next remaining level of noncompliance would be actual harm at severity level 3 until substantial compliance is achieved.