The Impact of Immediate Jeopardy on Accreditation and Certification

March 09, 2023 4 minute read female healthcare worker holding hands of senior man

When it comes to healthcare facilities, mitigating the risks of immediate jeopardy is a time-sensitive matter. The consequences of being found in immediate jeopardy can be severe, including fines (that multiply each day the IJ is in effect), loss of certification, or even closure. However, the impact of such a violation extends beyond just regulatory actions. It can have a lasting effect on the facility's reputation, and the trust that patients have in it.

So, let's delve into the influence that immediate jeopardy can have on healthcare facility accreditation and certification.

What is Accreditation and Certification in a Healthcare Facility?

Accreditation and certification are two essential components that define the quality of healthcare facilities in the U.S.

Accreditation: A voluntary process that assesses a facility's compliance with nationally recognized standards of quality and safety.
Certification: A mandatory process that requires facilities to meet specific requirements to receive funding from government programs like Medicare and Medicaid.

Healthcare facilities that successfully complete the accreditation process receive a seal of approval from accrediting organizations such as The Joint Commission or the Healthcare Facilities Accreditation Program (HFAP). This seal signifies to patients and stakeholders that the facility has met or exceeded stringent standards for patient care and safety.

Certification, on the other hand, is a legal requirement for healthcare facilities that wish to participate in federal healthcare programs like Medicare and Medicaid. These programs provide funding to healthcare facilities, and certification is necessary to ensure that they meet the requirements for participation. The Centers for Medicare and Medicaid Services (CMS) are responsible for initially certifying and recertifying healthcare facilities that participate in these programs.

Accreditation and certification are vital for healthcare facilities to grow and thrive. These “seals of approval” help to ensure that facilities meet or exceed the highest standards of quality and safety. Facilities that fail to obtain or maintain accreditation or certification can lose their reputation, patient trust, and ultimately their ability to continue operating.

How Does IJ Impact a Healthcare Facility’s Ability to Obtain Accreditation and Certification?

An IJ citation is the monkey wrench thrown into any nursing home or long-term care facility's ability to obtain accreditations and certifications. When a CMS surveyor drops the IJ label, it indicates a serious violation of regulations and standards, putting patients' immediate health and safety at risk.

Both The Joint Commission and the HFAP require healthcare facilities to be in compliance with their standards for accreditation. The presence of an IJ violation puts a healthcare facility at risk of losing its accreditation status. If the violation is not resolved, it can result in the facility's accreditation being revoked, which can be a serious blow to its reputation.

Similarly, certification from the CMS is required for healthcare facilities that participate in federal healthcare programs. An IJ violation can result in the loss of certification, which can be devastating for a healthcare facility. Loss of certification means that the facility can no longer receive funding from Medicare and Medicaid, which can have significant financial consequences, and can also halt admissions until compliance is reached.

Here are some examples of violations that can lead to an IJ citation and consequently make it nearly impossible for you to achieve any accreditations or certifications.

Failure to adequately monitor and assess patients, resulting in potential and/or actual harm or injury.
Failure to follow infection control protocols, resulting in the spread of infection among patients or staff.
Lack of appropriate staffing or insufficiently trained/incompetent staff, leading to potential and/or actual neglect or harm to patients.
Failure to properly store and administer medications, resulting in the potential for and/or actual harm or injury to patients.
Physical abuse or neglect of patients by staff or other patients.
Failure to maintain and ensure the safety of the facility's physical environment, such as fire safety violations, unalarmed doors resulting in elopement or hazardous conditions.
Failure to provide necessary medical treatment or procedures, resulting in the potential for and/or actual harm or injury to patients.
Failure to obtain informed consent for medical treatment or procedures, or failure to respect patient rights and preferences.

Remember: this is not an exhaustive list. IJ citations can be issued for a wide range of violations that pose a serious threat to patients’ health and safety.

Immediate jeopardy violations can also lead to additional inspections and surveys by accrediting organizations and regulatory agencies. These additional surveys can be burdensome for healthcare facilities, and if the violation is not resolved, it can lead to further consequences such as the suspension or revocation of the facility's license. Facilities also run the risk of surveyors citing other tags aside from the IJ while in the facility.

Violations that spark IJ can have a profound impact on a healthcare facility's ability to obtain or maintain accreditation and certification. Therefore, it’s essential for healthcare facilities to take immediate and effective corrective action to address the violation to residents health and safety to avoid long-term consequences.

Maintain Accreditation and Certification Status

Healthcare facilities must prioritize patient safety and comply with regulations and standards to maintain their accreditation and certification status.

From nursing homes to long-term care facilities, all healthcare institutions should develop comprehensive strategies to prevent and address IJ violations to ensure patient safety and prevent the potential loss of accreditation and certification. This may include implementing employee training and competency programs, regular safety checks/audits, and continuous quality improvement initiatives.

Qsource is here to help you take the necessary steps to prevent Immediate Jeopardy violations. Our services get to the source of the problem so that you can continue to provide high-quality care, maintain your reputation, and secure your accreditation and certification status.