How Home-based Care Providers Can Survive An Immediate Jeopardy Citation

Immediate jeopardy (IJ) is the most serious regulatory citation a home-based care provider can receive. It’s not reserved for problematic providers — even the best can find themselves under IJ scrutiny. 

The right approach can mean the difference between recovery and disaster, experts told Home Health Care News. By responding quickly, engaging the right advisors and maintaining thorough documentation, home-based care providers can navigate IJ scenarios, avoid the most severe consequences and reset their reputations. 

“There is a misconception that immediate jeopardies occur only with ‘bad providers,’” Matthew Murer, department chair of public policy and government investigations at Polsinelli Law Firm, told Home Health Care News. “It happens to the best providers in the world. You can have the most sterling history of compliance. You can be mission-driven and offer the gold standard of care, but things happen.”

Polsinelli operates from coast to coast in the U.S., with offices in 24 major cities in 17 states and the District of Columbia.

The IJ designation, outlined by the Centers for Medicare & Medicaid Services (CMS), triggers urgent responses from organizations facing conditions that may lead to serious harm or death. Potential sanctions include hefty daily fines and rapid termination of service agreements, making it crucial for health care providers to address IJ situations swiftly and effectively.

According to The Joint Commission, an organization may receive an IJ citation if it fails to protect patients from abuse or neglect, psychological harm, or inadequate nutrition and hydration, among other forms of serious negligence. Failing to comply with CMS requirements following IJ  carries the most serious sanctions, according to Rolf Martin Lang LLP, based in Cleveland, Ohio.

Acting on behalf of CMS, state health agency inspectors identify IJ situations, typically during inspections prompted by complaints. Surveyors assess deficiencies and categorize each violation into one of three categories: standard, condition or IJ. IJ “represents the most severe and egregious threat” to patient health and safety, a CMS spokesperson told HHCN.

“When looking at immediate jeopardy, it’s usually about medications, wound care or fall issues,” Murer said. “When you have an issue involving an injury, death or an upset family member, assume the following: they’re going to file a complaint; you’re going to have a survey and you’re going to get immediate jeopardy. If you assume those things, you will be in great shape regardless of what happens. It’s when we don’t assume those things that bad things happen.” 


One example of an IJ citation, Murer said, is an instance in which a home health patient did not receive prescribed medication for several days following a discharge from a hospital.

The patient was discharged from the hospital on July 9, Murer said with an order to receive an anticoagulant twice a day by injection. The home health agency sent a nurse the same day as discharge. However, the patient’s medication was not delivered from the pharmacy until July 13. 


“There was a dispute about what happened in between, and the agency said they called the hospital to urge them to send over the medication,” Murer explained. “Regardless of what happened, [the agency is] responsible for the plan of care, which was that this person was supposed to receive this anticoagulant twice a day; they didn’t do it. The plan of care wasn’t followed.”

Murer said that when an agency is presented with a worsening situation, it must act immediately. The agency must show that it contacted the physician and document the care provided. Once the patient is in the agency’s care, blame cannot be shifted to another party. 


“[The agency’s] duty is always to follow policies and the care plan,” Murer stated. “If you can’t meet the plan of care, you’re going to have liability.”

Immediate jeopardy clarifications

In late November 2024, CMS provided revised guidance for surveyors and health care providers regarding IJ. The original guidance was drafted in 2004 and updated in 2019. The 2024 revisions were meant to “clarify and increase consistency in identifying immediate jeopardy,” CMS said in a memo.

The memo outlines four key guidance changes.

To issue an IJ in situations where individuals have not already experienced serious harm, there must be a “likelihood” that serious injury, harm, impairment or death will occur if the identified noncompliance is not corrected. According to CMS, “likelihood” refers to a “reasonable expectation” that serious harm will occur. This represents a shift from the 2019 update, which suggested that the “potential” for serious harm could warrant an IJ.

The revised guidance also eliminates “culpability” as a required element for IJ citations. Surveyors must now focus on whether noncompliance caused or is likely to cause serious harm. According to CMS, this aligns with regulatory definitions emphasizing the role of noncompliance over assigning blame.

An IJ citation can also be issued for concerns beyond physical health conditions.

According to the revised guidance, surveyors also must assess whether an agency has “caused or made likely serious mental or psychosocial harm.” In cases where it may be challenging to determine whether individuals have suffered serious psychosocial harm, surveyors should apply the reasonable person concept when making that determination, according to CMS.

“The reasonable person approach considers how the noncompliance would impact a reasonable person in the recipient’s position,” a CMS spokesperson said.

The revision specifies that no automatic IJ citations exist; each citation must be decided independently.

According to CMS, home health agencies might encounter IJ for issues such as insufficient staff training, improper supervision or problems with specific equipment.

Following IJ citations, CMS may require actions including fast-track termination, which requires the facility to return to substantial compliance within six months of the issue date, otherwise, its provider agreement will be terminated. In IJ cases, termination may occur in as few as two days, but must be enforced no later than 23 days after the issue date.

When an organization receives a citation, daily fines, ranging from $50 to $3,000, may be imposed. For an IJ citation fines start at a minimum of $3,050 and can escalate to $10,000 per day.

Aside from the state’s immediate monitoring of the agency, regulators can take enforcement actions with only two days’ notice. These actions include temporary management, denial of payment for new admissions, in-service training and a directed plan of correction.

Worst-case scenario

Swift and decisive action to address non-compliant standards is crucial if an organization has been cited for IJ, according to Patton Healthcare Consulting, a consultant group based in Langhorne, Pennsylvania.

Patton’s recommendations for managing an IJ scenario include engaging experts, keeping meticulous records and crafting a comprehensive corrective plan.

The primary focus should be on eliminating the at-risk situation, a Patton representative said. CMS provides agencies with a concise IJ worksheet to plan corrective actions. Once this worksheet is received, the home-based care provider’s leadership team should be briefed on the areas of deficiency and develop an action plan. Patton recommends assigning a senior leader to oversee each area of deficiency.

Next, Patton suggests that leadership create an executive summary to formally record the organization’s regulatory or accreditation status. This summary should include a list of non-compliant standards, the corrective actions taken and a timeline for completing those actions.

Agencies should also secure legal counsel and a regulatory compliance consultant to address any legal concerns related to the citation, according to Patton. These consultants can help develop a comprehensive plan to address deficiencies, monitor compliance and document actions taken.

Conducting a root cause analysis enables organizations to identify deficiencies and develop effective preventive action plans. Organizations should change policies and procedures as necessary, track versions before and after the citation, educate staff on any policy or facility changes and maintain records of actions taken.

Home-based care providers should also develop a monitoring plan to track the effectiveness of corrective actions and report results to leadership, according to Patton. Once resolved, they must notify CMS to verify that corrective actions have been implemented.

A facility remains certified unless noncompliance issues persist. Facilities can resolve IJ situations and comply with federal requirements to maintain their certification as Medicare or Medicaid providers. However, if a facility remains noncompliant, CMS can issue a notice of involuntary termination, which means the agreement for CMS to pay for services provided to Medicare or Medicaid beneficiaries will be terminated. Involuntary termination of a provider agreement is typically a last resort after all attempts to resolve the facility’s noncompliance deficiencies have been exhausted.

“If you receive a citation, it’s not the end of the world; you can rebound,” Murer said. “Understanding the process and having a clear plan is most important. Before a surveyor walks back through the door, discuss the action plan, conduct the training and document everything. When the surveyor returns to conduct their survey, hand them a folder that says, ‘Here’s our policy, here’s documentation of our training, here’s all the things that we’ve done.’ It’s powerful in resetting the surveyors’ view of the agency, which resets the narrative. Show you understood the issue, addressed it and were thorough.”

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