The Centers for Medicare & Medicaid Services (CMS) recently revised its guidance to states on standards for citing “immediate jeopardy” during surveys of all provider and supplier types and laboratories, including health, emergency preparedness, and life safety code surveys.  CMS Administrator Seema Verma observed in a blog post that the changes were made in response to stakeholders who “have voiced concerns that the guidance needs to be clearer and more consistent to identify serious quality concerns across states.”  Administrator Verma added that the updated policy “is just the beginning of upcoming efforts to strengthen oversight of healthcare settings.”

Under the new policy, which is set forth in an update to Appendix Q to the State Operations Manual (SOM), surveyors must identify the following “key components” in order to cite immediate jeopardy:

Noncompliance: An entity has failed to meet one or more federal health, safety, and/or quality regulations. CMS removed a previous requirement of culpability to cite immediate jeopardy. 


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.  In its guidance to state survey agency directors, CMS points out that the potential for that level of harm does not constitute immediate jeopardy.


Need for Immediate Action: The noncompliance creates a need for immediate corrective action by the provider/supplier to prevent serious injury, serious harm, serious impairment or death from occurring or recurring.

CMS created a new “Immediate Jeopardy Template” that must be used by surveyors to document evidence of each component of immediate jeopardy.  CMS also clarifies that each immediate jeopardy citation must be decided independently (i.e., there are no automatic immediate jeopardy citations).  Additionally, the updated guidance addresses determinations of whether noncompliance has caused or made likely serious mental or psychosocial harm to recipients.  CMS drafted separate subparts to Appendix Q focusing on nursing homes and clinical laboratories, since those provider types have specific policies related to immediate jeopardy.

CMS issued the Appendix Q update on March 5, 2019; the changes are effective immediately.