CMS Releases Revisions to Guidance on Citing Immediate Jeopardy

Nancy Leveille and Lisa Volk in Clinical & Quality

This week, the Centers for Medicare & Medicaid Services (CMS) released a memorandum entitled "Revisions to Appendix Q, Guidance on Immediate Jeopardy" (QSO-19-09-ALL), which includes revisions to the guidance on citing immediate jeopardy (IJ) in Appendix Q of the State Operations Manual (SOM). These revisions to Appendix Q apply to all provider and supplier types and go into effect immediately. CMS intends for this guidance to increase clarity and consistency in identifying and citing IJ. 

The revised guidance includes a Core Appendix Q that will be used by surveyors to determine when to cite IJ for all provider types. It also includes a subpart with additional policy considerations for citing IJ in skilled nursing centers and clinical laboratories.

It is critical that members read the full guidance in detail, carefully review these changes, and discuss them with staff as appropriate. Below we highlight some of these changes.

The Three Components of IJ 

CMS has revised the criteria for determining IJ. The guidance specifies that to determine if IJ exists and to cite it appropriately, surveyors must verify and establish that the following three components of IJ are present:

  1. Noncompliance with one or more federal health, safety and/or quality regulations;
  2. Serious injury, harm, impairment, or death has occurred or is likely to occur as a result of the identified noncompliance; and
  3. The need for immediate action to prevent serious harm from occurring or recurring.

The guidance instructs surveyors to consider whether noncompliance has caused serious mental or psychosocial harm and to use the reasonable person concept in circumstances when it is difficult to determine the psychosocial outcome to the resident or when the outcome is "incongruent with what would be expected." 

The Use of IJ Template

Under this guidance, survey teams must use the new Immediate Jeopardy Template to both document and communicate to providers the evidence that IJ is present. Official survey findings of IJ will continue to be documented in the Form 2567. 

The guidance emphasizes the importance of timely and clear communication when surveyors identify IJ. Once the survey team has identified IJ and confirmed its findings in consultation with the State Agency and/or CMS Regional Office, the survey team must immediately notify the facility. It is expected that the identification of IJ be made while the survey team is onsite. In the rare circumstance that IJ may be identified after the survey team has exited, the survey team must return to the facility to validate the IJ finding using the IJ Template. 

The Long Term Care Subpart 

The long term care subpart to the Core Appendix Q includes guidance on citing IJ that meets the criteria for past noncompliance and lists possible resident outcomes or staff and facility actions that "trigger" the need for further investigation by surveyors.

CMS is providing online training on this new guidance that is available here. This training is required for State Agency and Regional Office staff and is available to providers and the public.

For questions related to Appendix Q, email with the subject line "Immediate Jeopardy Inquiry." 

AHCA will continue to monitor and assess the impact of these changes and advocate for policies that are clear, transparent, and focused on quality outcomes. If you have any questions or feedback, please contact Sara Rudow at


Nancy Leveille, RN, MS
Executive Director
518-462-4800 x20

Lisa Volk, RN, B.P.S., LNHA
Director, Clinical &Quality Services
518-462-4800 x15