How to uncover immediate jeopardy citations — and how AHCJ can help

Every year dozens of hospitals violate federal safety regulations so severely that patients are in imminent danger of serious injury or death. Yet often these major infractions - which are referred to as immediate jeopardy - go unreported to the public.

Regulators and hospitals are not obliged to announce immediate jeopardy citations, which means journalists must be diligent about digging them up.

Promptly reporting immediate jeopardy citations enables people to make informed decisions about where to get care, Asheville Watchdog reporter Andrew Jones noted via email. "They are serious, difficult to completely remedy, and often point to managerial failures," he said.

Jones covered immediate jeopardy citations involving deficient care at HCA Healthcare's Mission Hospital in North Carolina during several years of reporting about problems at the hospital. According to his coverage, the conditions that triggered those citations contributed to four deaths and numerous injuries. (See more links to his stories, below.)

(AHCJ's HospitalInspections.org tool can help you learn about immediate jeopardy and other serious Medicare rule violations. More on that below.)

Here's a primer on what you need to know.

How is immediate jeopardy declared?

Inspectors for CMS or state health agencies acting on behalf of CMS identify immediate jeopardy situations, usually during an inspection generated by a complaint. The surveyors look for deficiencies in Medicare Conditions of Participation and assign each violation a level of severity: standard, condition or immediate jeopardy.

What constitutes immediate jeopardy?

According to CMS, of the three deficiency levels, immediate jeopardy "represents the most severe and egregious threat" to the health and safety of patients.

Key elements are:

• Noncompliance with one or more federal or state regulations.
• A likelihood to cause serious harm or death to patients.
• A need for immediate corrective action.

What happens after an immediate jeopardy citation?

An immediate jeopardy citation puts the hospital on track to lose its Medicare certification number after 23 days.

The hospital must produce a written removal plan outlining immediate actions it will take to stop or prevent harm to patients. For immediate jeopardy to be lifted, the survey team must approve the removal plan and verify that it's carried out. In many cases the process of removing the immediate threat takes just a few hours.

Note that a removal plan differs from a plan of correction, in which a hospital describes how it will correct other, less severe deficiencies. Often a hospital must execute both types of plans.

According to CMS, "it is not necessary that the removal plan completely correct all noncompliance associated with the [immediate jeopardy], but rather it must ensure serious harm will not occur or recur."

How common is immediate jeopardy?

More common than you might think. According to AHCJ's HospitalsInspections.org database, 46 hospital inspections resulted in immediate jeopardy during the first six months of 2024. They included a wide variety of serious deficiencies: inadequate nursing staff in an obstetrics unit, failure to protect patients from the use of abusive restraint, water leaking from a roof into multiple areas of a hospital, and improper screening of a patient's suicide risk, for example. Many of these incidents did not turn up in Google news searches.

How do I find out about immediate jeopardy citations?

You can search inspection reports for mentions of "immediate jeopardy" at hospitals on your beat using AHCJ's HospitalInspections.org tool, which is updated quarterly.

However, it's good to be more aggressive if you are investigating ongoing problems at a particular hospital. For example, develop sources within the hospital who can tip you off promptly when there is an inspection.

After an inspection, you can begin asking state and federal regulators for documents pertaining to any deficiencies that were identified. For example, with Mission Health the state health department sent a letter to the hospital outlining deficiencies, and CMS sent a notification of immediate jeopardy to the hospital.

A state health department typically has 10 calendar days following a survey to provide the hospital with a report detailing the deficiencies - called Form CMS-2567- which can be requested from the state or CMS.

What other reporting should I do?

CMS-2567 reports often provide rich details, and you can quote directly from them. However, they don't provide context about the hospital's culture, management or finances. "It is important to interrogate the report and discuss it with current hospital staff to understand the scope of the situation," Jones said.

Nor do they identify patients who were affected.

"A little bit of digging may help you find out who these patients are. Their stories are always more complex than the 2567's narrative," Jones added.

Here are his tips:

• Publish a story describing as many of the incidents as you can. At the end of that story, urge readers to reach out to you if they are a patient mentioned or if they know of someone.
• Get into local social media community groups (Facebook, Reddit, Nextdoor) and crowdsource.
• Find health care advocates in your community, people who embed themselves in the hospital and help patients navigate the complexities of healthcare. Build them as sources and they may create a bridge to patients mentioned in the 2567.

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