High levels of citation could increase as new requirements for transfers and discharges came into effect on April 28th.
For example, immediate danger (IJ) quotations are feared by nursing home operators and are often the result of many benign and avoidable ways in which facility staff can misinterpret the quotation, which can increase with an additional layer of complexity.
The more stringent scrutiny also raises concern that the survey process, which is subjective, depending on the surveyor and state, will become even more contradictory.
This is according to Michelle Stuarkke, chief clinical officer of transition care management, and Jody O'Mara, chief nursing officer for Indiana-based operator Journey.
If surveyors admit that discharge or rejection is inappropriate and that there is evidence of physical and psychosocial harm, lower levels of violations can become more severable, Omara and Stuarch told skilled nursing news.
Furthermore, commonly triggered IJs can be attributed to harmless things like meal tags investigated to pose an immediate threat of harm, says Brent Willett, CEO of the Iowa Healthcare Association. Food is not refreshing to small enough pieces and can cause future harm, he said.
To make the issue even more complicated, Stuart Lindeman, CEO of Florida's Mission Health Community, says there is a tendency to be inconsistent with the lines of states that make up IJ.
“IJs in one state may not be IJs in another state. I think that in itself creates a lot of problems for both providers and regulators,” Lindemann said.
Additionally, the various ways in which IJs can be issued can be confusing for staff, and past compliance issues guarantee IJ based on IJs or self-reported patient or family complaints compared to IJs issued for what happened during the investigation.
In some cases, IJs may be attributed to self-reports already revised by the time the surveyor arrives, but these remain on facility records.
Therefore, it is important for the facility staff to keep all this straight.
“I don't want IJ either way, but a lot of people come in and a lot of people happen on self-reports (residents). “It could be a month or a few weeks later, and it was fixed immediately. It could be in danger right away, but it's already been fixed.”
Common misconceptions and pitfalls around IJ
If the purpose of issuing an IJ is based on a flag of serious harm or possibility of death, another common misconception that could lead to an IJS that could lead to an IJS is attributed to the assumption that such quotations are linked only to serious harm or death.
This can lead to a lack of preparation if staff believes that IJ quotes can only arise from actual death or harm rather than the possibility.
Therefore, it is necessary to make it clear to staff that acknowledging an IJ is based on the possibility of serious harm or death, not on actual harm or death.
In one case, staff were surprised that the IJ was issued when the patient was fine, but because the patient was compromised, the facility was given a quote because it was busy, and staff didn't realize that the patient was not gone until the patient was halfway from the block.
Experts also pointed out that if the facility is flagged for a past violation, staff should identify the issue prior to the complaint investigation in which such violations grew. This issue, as Lindemann said, is reflected in the blurry lines between how and when IJ is issued.
Journey's O'Mara said it is essential that the problem be resolved before the next investigation.
“It has to be completely tempered, so education, immediate revisions, all those components need to be made functional and undo before the start of that investigation,” O'Mara said.
This does not mean that surveyors cannot cite the facility for fines by citing the facility, even if they believe it is fully compliant, Heather Haberhern says he is senior vice president of the Health for Health Dimensions group.
In many cases, this can be attributed to the subjective nature of the process. This is as subjective as individual surveyors and depends on the state.
“We did everything that needed to be done and the surveyors didn't feel the same,” Harbor Hearn said of past non-violation citations. “There is a certain degree of subjectivity in quotations. I think the state is different as to who is willing to review past violations.”
Harbor Hearn said that while the investigation may be helpful in providing additional information while it is still happening, it may be useful before an exit meeting is called between surveyors and staff to review the findings.
Still, even if the surveyor has obtained additional documents, it can be a difficult battle. Otherwise, staff will be approached about the fact that information is still being collected in the incident.
“Usually, by the time they call the supervisor, it's already a decision,” she said.
Harbor Hearn is extremely important to provide surveyors with as much information as possible during the survey, so don't wait until the state and operator exit meeting. Or the facility could be approaching because the facility is still trying to gather information, Harbor Hearn said.
O'Mara agreed that when they called IJ to their supervisors it would be too late for them to overturn it, especially in states where state travel is active.
In some cases, surveyors say they came to the facility to write an IJ before they saw anything, Stuercke said. She sometimes feels like a “innocent” situation, she said.
“If they don't find enough, they'll mostly work for them. They have to prove to their condition, their boss that IJ doesn't exist. That's even more difficult for them at times.”
How to prepare for IJ and state behavior
If the facility had not received an IJ previously, it is difficult to write a reduction plan that is achievable, achievable and state-approved. Hiring a consultant may be the right move for IJ, the first time, according to Harbor Hearn.
Nursing homes are something that should not be missed by trained staff ready to manage surveyors, as staff can be threatened if they pass through the door. The workforce knowing what to do when a state surveyor comes in is very important to investigate success, as checking the halls of residents.
In addition to preparing the facility, more can be done in terms of national industry cooperation, in addition to the end of the facility through education and consultants.
“I think it should be about collaboration. Surveyors have found something, and the nurses and the managers and directors of the nursing community staff can rebut and add to the patient and what's going on with their systems,” O'Mara said.
Iowa law seeks to do something similar to give nursing homes a second chance by challenging the violation before IJ is issued. This was a technical amendment that passed the law passed by the state Senate in 2024, allowing reviews and additional context at the time only after the citation was issued.
From a provider's perspective, the law helps ensure that operators provide opportunities to present new evidence that may not have been part of the original IJ discovery, Willett said.
“If we really deploy this at the core level, there are immediate and serious circumstances in nursing homes and by their nature require immediate action, so this meeting (between the facility and the state) allows providers to provide the additional evidence they need, but they can quickly identify what the surveyor finds,” Willett said.
Rather than waiting for a surveyor to report, facilities can respond to the situation in real time and create revision plans.
So far, IJS has declined slightly within the state, Willett said. However, that's not because of the 2024 law, and it may often be that you have a better understanding of what your provider is looking for when it comes to IJ.
