Immediate Jeopardy

 

This message is being sent out to all Program Approved Service Agencies (PASA) providers. CDPHE, in collaboration with Health Care Policy and Financing (HCPF), would like to emphasize the importance of “Immediate Jeopardy” situations found during surveys conducted by CDPHE. Immediate Jeopardy is defined as a situation in which noncompliance by providers (referred to as "entities") has caused, or is likely to cause, serious injury, harm, impairment, or death to an individual member. The following definitions may be used during an immediate jeopardy investigation: IJ Template: Standardized form completed by surveyors to document the basis for an IJ determination, and to formally notify the provider agency of the IJ determination. Likely/Likelihood: the nature and/or extent of the identified noncompliance creates a reasonable expectation that an adverse outcome resulting in serious injury, harm, impairment, or death will occur if not corrected. Recipient at Risk: a member who, as a result of noncompliance, and in consideration of the recipient’s physical, mental, psychosocial or health needs, and/or vulnerabilities, is likely to experience a serious adverse outcome. Noncompliance: failure to meet one or more federal or state health, safety, and/or quality regulations. Serious injury, serious harm, serious impairment or death: adverse outcomes which result in, or are likely to result in: death; or a significant decline in physical, mental, or psychosocial functioning (that is not solely due to the normal progression of a disease or aging process); or loss of limb, or disfigurement; or avoidable pain that is excruciating, and more than transient; or other serious harm that creates life-threatening complications/conditions. *NOTE: IJ does not require serious injury, harm, impairment or death to occur. It is sufficient that non-compliance makes serious injury, harm, impairment or death likely to occur to one or more members IJ Removal Plan: A written, time-limited plan from the agency identifying immediate actions taken to remove the immediate jeopardy. Plan of Correction (POC): A separate plan from the IJ Removal Plan that addresses all cited deficiencies, which may include long-term preventive actions. Agency Responsibilities After Declaration of an Immediate Jeopardy The agency must immediately begin corrective actions and submit an IJ Removal Plan within the timeframe established by CDPHE (typically within 45 minutes). Written IJ Removal Plan Must Include: Affected [Member(s)]: Identify who has suffered or may suffer serious harm. Immediate Correction: Step-by-step actions to resolve the issue and protect health, safety, and welfare. System/Process Fix: Actions to prevent recurrence, including completion dates. Responsible Staff: Provide the title of staff accountable for each action. Investigation: Method for determining the cause of the noncompliance. Staff Training: Trainer title, content, and completion dates. Documentation: How actions will be recorded and implemented. Ongoing Monitoring: Monitoring steps, frequency, and staff responsible to prevent future issues. Submission Instructions: The plan must be on the agency letterhead, or have agency name and contact information listed at the top of the removal document.  Must be signed and dated by the administrator or designee. Provide the plan to the surveyor who sent the IJ template and the IDD supervisors at cdphe_hfems_idd_sups@state.co.us CDPHE will review the plan and request revisions as needed. Final acceptance requires supervisory approval. The agency's plan must address all immediate actions outlined in the IJ Template’s “Need for Immediate Action” section.