SMQT Study Guide With Complete Solutions 2023.

Appendix Q Contains what information?
Determining Immediate Jeopardy

What are the three components of IJ?

1. Harm
   a. Actual – was there an outcome of harm?
   b. Potential – Is there the likelihood of potential harm?
2. Immediacy – Is the harm or potential harm likely to occur in the very near future?
3. Culpability –
   a. did the entity know about the situation? If so, when did they first become aware?
   b. Should the entity have known about the situation?
   c. Did the entity thoroughly investigate the circumstances?
   d. Did the entity implement corrective measures?
   e. Has the entity re-evaluate the measures to ensure the situation was corrected?

Failure to protect from abuse triggers?

1. Serious injuries such as head trauma or fractures
   2.non-consensual sexual interactions
   3.unexplained serious injuries that have not been investigated
2. staff striking or roughly handling an individual
3. staff yelling, swearing, gesturing or calling an individual derogatory names
4. bruises around the breast or genital area or suspicious injuries

Failure to prevent neglect triggers?

1. lack of timely assessment of individuals after injury
2. lack of supervision for individual with known special needs
3. failure to carry out dr orders
4. repeated occurrences such as falls which place the individual at risk of harm without intervention
5. access to chemical and physical hazards by individuals who are at risk
6. access to hot water of sufficient temperature to cause tissue injury
7. non functioning call system without compensatory measures
8. unsupervised smoking by an individual with a known safety risk
9. lack of supervision of cognitively impaired individuals with known elopement risk
10. failure to adequately monitor individuals with known severe self-injurious behavior
11. failure to adequately monitor and intervene for serious medical/surgical conditions
12. use of chemical./physical restraints without adequate monitoring
13. improper feeding/positioning of individual with known aspiration risk
14. inadequate supervision to prevent physical altercations

Failure to protect from psychological harm triggers?

1. Application of chemical/physical restraints without clinical indication
2. Presence of behaviors by staff such as threatening or demeaning resulting in displays of fear, unwillingness to communicate and recent or sudden changes in behavior by individuals
3. Lack of interventions to prevent individuals from creating an environment of fear

Failure to protect from undue adverse medication consequences and/or failure to provide medications as prescribed triggers

1. Administration of medication to an individual with a known history of allergic reaction to that medication
2. Lack of monitoring and identification of potential serious drug interaction, side effects, and adverse reactions
3. Administration of contraindicated medications
4. Pattern of repeated medication errors without intervention
5. Lack of diabetic monitoring resulting or likely to result in serious hypoglycemia or hyperglycemic reaction
6. Lack of timely and appropriate monitoring required for drug titration

Failure to provide adequate nutrition and hydration to support and maintain health triggers?

1. Food supply inadequate to meet the nutritional needs for the individual
2. Failure to provide adequate nutrition and hydration resulting in malnutrition; eg severe weight loss, abnormal lab values
3. withholding nutrition and hydration without advance directives
4. lack of potable water supply

Failure to protect from widespread nosocomial infections triggers?

1. pervasive improper handling of bodily fluids or substances from an individual with an infectious disease
   2.high number of infections or contagious diseases without appropriate reporting, intervention and care
2. pattern of ineffective infection control precautions
3. high number of nosocomial infections caused by cross contamination from staff and/or equipment/supplies

Failure to correctly identify individuals triggers?

1. blood products given to wrong individual
2. surgical procedure/treatment performed on wrong individual or wrong body part
3. administration of medication or treatment to wrong individual
4. discharge of infant to wrong individual

Failure to safely administer blood products and safely monitor organ transplantation triggers?

1. wrong blood type infused
2. improper storage of blood
3. high number of serious blood reactions
4. incorrect cross match
5. lack of monitoring

Failure to provide safety from fire, smoke and environment hazards and/or failure to educate staff in handling emergency situations triggers?

1. nonfunctioning or lack of emergency equipment and/or power source
2. smoking in high risk areas
3. incidents such as electrical shock, fires
4. ungrounded/unsafe electrical equipment
5. widespread lack of knowledge of emergency procedures by staff
6. widespread infestation by insects/rodents
7. lack of functioning ventilation, heating, or cooling system placing individuals at risk
8. use of non-approved space heaters in resident or patient areas
9. improper handling/disposal of hazardous materials, chemicals and waste
10. locking exit doors in a manner that does not comply with NFPA 101
11. obstructed hallways and exits preventing egress
12. lack of maintenance of fire or life safety systems
13. unsafe dietary practices resulting in high potential for food borne illnesses

Failure to provide initial medical screening, stabilization of emergency medical conditions and safe transfer for individuals and women in active labor….not really applicable to the long term care side so I chose not to include it.

What is the definition of Immediate Jeopardy?
a situation in which the providers noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident

What is the definition of abuse?
the WILLFUL infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish

What is the definition of neglect?
failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness

Principals of Immediate Jeopardy

1. only ONE INDIVIDUAL needs to be at risk
2. SERIOUS HARM, INJURY, IMPAIRMENT, OR DEATH does NOT HAVE TO OCCURE BEFORE CONSIDERING immediate jeopardy. Requires HIGH potential for those outcomes.
3. Individuals must not be subjected to abuse by ANYONE…staff, family, visitors, volunteers
4. Serious harm can result from both abuse and neglect
5. Psychological harm is as serious as physical harm
6. When a cognitively impaired individual harmed another individual receiving care from the entity due to the entity’s failure to provide care and services to avoid physical harm, mental anguish, or mental illness, this should be considered neglect.
7. any time a team cites abuse or neglect, it should consider IJ

What points should be considered regarding entity compliance in regards to immediate jeopardy?

1. the entity either created a situation or allowed a situation to continue which resulted in serious harm or a potential for serious harm, injury, impairment, or death to individuals
2. the entity had an opportunity to implement corrective or preventive measures

Key components to prevent abuse and neglect?

1. screening
2. training
3. prevention
4. identification
5. investigation
6. protection
7. reporting/response

Principles of Documentation #1
Entity compliance and noncompliance
-When an entity complies with the requirements applicable to the survey conducted, the form CMS-2567 should consist of an explicit statement that the entity is in compliance.

• If an entity does not comply with one or more applicable requirements, the form CMS-2567 includes corresponding citations of noncompliance

Principles of Documentation #2
Using Plain Language

• The deficiency citation is written clearly, objectively and in a manner that is easily understood.

Principles of Documentation #3
Components of a Deficiency Citation

• regulatory reference
• deficient practice statement
• relevant findings

Principles of Documentation #4
Relevant onsite correction of findings

• if during the survey the entity corrects the situation that resulted in the deficiency, a determination of “not met” must be documented on the 2567. The entity may indicate its corrections in the right-hand column of the 2567. During IJ, if the facility initiates corrective actions that abate a finding for IJ, follow the guidance in appendix Q

Principles of Documentation #5
Interpretive Guidance

• the deficiency citation explains how the entity fails to comply with the regulatory requirements, not the interpretation of those requirements.

Principles of Documentation #6
Citation of State or Local Code Violations

• state code are not cited on the 2567

Principles of Documentation #7
Cross-References

• Cross referencing from one citation to another is acceptable, but each deficiency must stand by itself

Principles of Documentation #8
Condition of Participation Deficiencies

• COP (requirements with which an entity must comply in order to participate in the programs) citation includes deficient practice statements and findings to support the determination of noncompliance with a condition level requirement. The finding may be incorporated either by cross references to those which must be corrected to find the COP in compliance or by narrative description of the individual findings