HCFA's New Guidelines for Determining Immediate Jeopardy.

The Health Care Financing Administration (HCFA) recently released "Appendix Q, Guidelines for Determining Immediate Jeopardy," which became effective September 25. The stated goal of these new regulatory guidelines is that "crisis situations, in which the health and safety of individuals are at risk, (should be) accurately identified, thoroughly investigated and resolved as quickly as possible." The guidelines are intended to standardize the definitions of Immediate Jeopardy and to describe the process surveyors use in determining it, including preparation, investigation, decision making and implementation. Most importantly for providers, the guidelines clarify that potential harm, as well as actual harm, might constitute Immediate Jeopardy.

Several key terms were defined in this release and are detailed below:

* Immediate Jeopardy: "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: "The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish."

* Neglect: "Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness."

HCFA has identified several principles as a foundation for the new guidelines:

1. "Only one individual needs to be at risk." HGFA believes that identifying Immediate Jeopardy for one individual will prevent risk to other individuals.

2. "Serious harm, injury, impairment or death does not have to occur before considering Immediate Jeopardy." HCFA further states that "The high potential for these outcomes to occur in the very near future also constitutes Immediate Jeopardy."

3. "Individuals must not be subjected to abuse by anyone including, but not limited to, entity staff, consultants or volunteers, family members or visitors."

4. "Serious harm can result from both abuse and neglect."

5. "Psychological harm is as serious as physical harm."

6. "When..an individual...was harmed by a cognitively impaired individual due to the entity's failure to provide care and services to avoid physical harm, mental anguish or mental illness, this should be considered neglect."

7. "Any time a team cites abuse or neglect, Immediate Jeopardy should be considered."

8. After determining that Immediate Jeopardy exists, the team must consider whether:

A. "The entity 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."

B. "The entity had an opportunity to implement corrective or preventive measures.

The new guidelines spell out triggers associated with issues that could cause Immediate Jeopardy. The triggers describe situations that will cause surveyors to consider if further investigation is needed to determine the presence of Immediate Jeopardy. HCFA states, "The listed triggers do not automatically equal Immediate Jeopardy," and that "these triggers are general examples and are not all-inclusive." I have listed in the sidebar ("Triggers Associated With Immediate Jeopardy Issues") triggers that apply to Medicare- and Medicaid-certified nursing facilities.

Surveyors are instructed to conduct an investigation asking "Who?" "What?" "When?" "Where?" and "Why?" "Who was involved in the Immediate Jeopardy situation?" "What harm has occurred, is occurring or most likely will occur?" "When did the situation first occur?" "Where did the potential/actual harm occur?" "Why did the potential/actual harm occur?"

Facility managers must be prepared for this more rigorous, detailed investigation of incidents that could be characterized as Immediate Jeopardy under the new guidelines, and be proactive in constructing quality assurance activities that self-investigate these matters before surveyors arrive.

Beth A. Klitch, FACHCA, is president of Survey Solutions, Inc., Columbus, Ohio.

Triggers Associated With Immediate Jeopardy Issues

Issue: Failure to protect from abuse

Triggers:

1. Serious injuries such as head trauma or fractures

2. Nonconsensual 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

7. Suspicious injuries, e.g., black eyes, rope marks, cigarette burns, unexplained bruising

Issue: Failure to prevent neglect

Triggers:

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. Nonfunctioning 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

15. Inadequate supervision to prevent physical altercations

Issue: Failure to protect from psychological harm

Triggers:

1. Application of chemical/physical restraints without clinical indications

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

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

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

Triggers:

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

6. Lack of timely and appropriate monitoring for drug titration 

Issue: Failure to provide adequate nutrition and hydration to support and maintain health

Triggers:

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

2. Failure to provide adequate nutrition and hydration resulting in malnutrition, manifested by severe weight loss and/or abnormal laboratory values

3. Withholding nutrition and hydration without advance directive

4. Lack of a potable water supply

Issue: 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

Triggers:

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

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

Issue: Failure to correctly identify individuals

Trigger:

1. Administration of medication or treatments to wrong individual

Issue: Failure to provide safety from fire, smoke and environmental hazards and/or failure to educate staff in handling emergency situations

Triggers:

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 unapproved space heaters, such as kerosene or 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

13. Unsafe dietary practices resulting in high potential for foodborne illnesses