Effective February 1, 2024, through April 30, 2024, the Bureau of Nursing Home Resident Care (BNHRC) will implement a pilot program by temporarily expanding DQA’s current Immediate Jeopardy (IJ) call process. his program will be for incidents identified during an onsite survey that are so serious that BNHRC needs to determine if the incident meets the IJ requirements located in Appendix Q of the State Operations Manual.

Currently, DQA holds IJ calls as needed, where DQA personnel, including DQA leadership, regional leaders, and the involved survey team confer on a call to discuss the circumstances surrounding a suspected IJ deficiency, and ultimately determine if an IJ-level deficiency does or does not exist. Currently, providers are not involved in the call.

DQA’s new pilot program will provide an opportunity for an involved facility’s NHA or DON to participate at the onset of the IJ call to provide additional information to DQA staff on the call. DQA has said it is engaging in this pilot to ensure facility leadership is provided ample opportunity to present additional or mitigating information to the survey team, or information that supplements what has already been provided to the survey team.

Please see below for more information on the new pilot program.

WHCA/WICAL wants to hear from YOU how these calls are going. Please reach out to Rick Abrams or Jim Stoa to share your experience participating in these calls.

Pilot program

Pre-IJ determination call

The BNHRC Regional Field Operations Director (RFOD) or Regional Field Operations Supervisor (RFOS) will notify the NHA or DON that DQA has identified an incident that warrants a review as to whether an immediate jeopardy deficiency exists. The NHA or DON will be invited to the call for the first seven minutes to provide any additional information about the identified issue. Questions about the incident should be discussed with the RFOD or RFOS during the pre-IJ determination call.

DQA is including this additional step on a Pilot basis into the process to give the facility an opportunity to provide important, mitigating evidence or to provide important context for consideration by DQA.

Conducting the IJ Call

The DQA lead will provide the expectations for the call:

1. The NHA or DON will be provided seven minutes at the onset of the call to provide information they wish to be included for consideration. The NHA or DON will then exit the call.
2. The IJ call will proceed. Attendees will take into consideration any information the facility just presented.
3. Surveyor and survey issues will not be discussed during the call. This should be addressed with the RFOD in a separate conversation during or after the survey.
4. DQA staff will not engage in a discussion on the call.

DQA reserves the right to end the call if the facility deters from the above process.

Evaluation

DQA will collect information from all IJ calls held during the pilot to determine whether the program has been effective. Once the pilot has ended, the information collected will be evaluated and a decision made on whether a permanent change will be made to the process.