There are few things that raise the alarm quicker during a facility survey than the mention of possible Immediate Jeopardy. This level of deficiency scope and severity has a significant impact on the facility staff and residents in the present and going into the future for a minimum of 3 years as part of the Health Survey 5-star calculation.

Immediate Jeopardy (IJ) is defined by CMS in Appendix Q of the State Operations Manual as “a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death”.  IJ does not exist when non-compliance creates only a potential for harm. IJ is determined to exist when a facility’s noncompliance has caused or is likely to cause serious harm, injury, impairment, or death.

As outlined in CMS Appendix Q, the survey team must verify that all three of the following components of IJ have been established in order to determine that an IJ exists.

  1. Harm—Was there an outcome of harm? Is there a likelihood of potential harm?
  2. Immediacy—ls the harm or potential harm likely to occur in the very near future if immediate action is not taken?
  3. Culpability—Did the entity know about the situation? Should the entity have known about the situation? Did the entity thoroughly investigate the circumstances? Did the entity implement corrective measures?

As noted in #3 above, as part of the IJ investigation process, the surveyors will determine if the facility has already implemented corrective actions to address the Immediate Jeopardy circumstances.  As soon as the facility becomes aware of the potential for an IJ, hopefully before the survey is conducted, it must develop and implement a plan of action as quickly as achievable. The goal is to have the IJ identified as past non-compliance if at all possible, or to shorten the period of time that the surveyors determine that the IJ, and therefore the CMP fines, still exist.

CMS Appendix Q tells us that

Past noncompliance (PNC) at the IJ level refers to situations where the facility has taken sufficient corrective actions prior to the survey to both remove the immediate jeopardy and fully correct the noncompliance before the start of the survey.

     PNC must be considered when the facility has taken all necessary action to achieve substantial compliance at the time of the current survey.


     Past Noncompliance means a deficiency citation at a specific survey data tag (F-tag or K-tag), that

     meets all of the following three criteria:

  1. The facility was not in compliance with the specific regulatory requirement(s) (as referenced by the specific -tag) at the time the situation occurred;
  1. The noncompliance occurred after the exit date of the last standard (recertification) survey and  before the survey (standard, complaint, or revisit) currently being conducted, and
  1. There is sufficient evidence that the facility corrected the noncompliance and is in substantial compliance at the time of the current survey for the specific regulatory requirement(s), as referenced by the specific tag.

 If Past Noncompliance (PNC) is determined to exist, no plan of correction or revisit is required because the facility is in substantial compliance at the time of the current survey. It, therefore, becomes critical that the facility correct the IJ situation as rapidly as possible, and performs ongoing audits as part of the QAPI process to ensure the corrective measures remain consistently in place and effective.

If the facility suspects that a deficient practice has occurred that may meet the IJ criteria, the following steps should be taken immediately:

  1. Complete a thorough investigation into the circumstances.
      • Determine if there has been any actual or likely harm to any residents, and address the immediate resident needs.
      • Determine all possible residents involved and any possible staff involved.
      • Determine if the situation meets the “reportable” criteria, and if so, report to all of the required State Agencies within the required timeframes.
  1. Develop and implement a plan of action to address the identified deficient practice(s)
      • Address how you identified the resident(s) affected (i.e., audits, observations, interviews, record reviews etc.)
      • Address how you will correct the identified deficient practice for the resident(s) affected. Is staff disciplinary action indicated? Do facility policies or procedures need to be revised?
      • Address the training/in-service education for staff to prevent recurrence of the deficient practice. Will this need to be included in future orientation for staff? How will it be provided to agency staff, staff on LOA, etc.?
      • Address how you will monitor the implemented interventions to ensure that the deficient practice has been corrected and will be prevented going forward. How will this be incorporated into your QAPI process?
  1. Conduct an adhoc QAPI meeting with the facility QAPI team, including the medical director, to review the circumstances that were identified and the plan of action being implemented.


While an Immediate Jeopardy can have a substantial effect on the facility, the impact can be significantly reduced if the facility takes quick and decisive substantive action.


Contact Proactive to schedule a mock survey or for assistance in survey management including PoC or Directed PoC support. Make plans to join the monthly Survey Success: Avoiding Top Citations webinar series which includes examples of Immediate Jeopardy citation case studies and access prior webinars on demand!



Janine Lehman, RN, RAC-CT, CLNC
Director of Legal Nurse Consulting

Learn more about the rest of the Proactive team.