Nursing Home Survey: Submitting a Removal Plan for Immediate Jeopardy

Request a written Immediate Jeopardy (IJ) removal plan, which is the immediate action(s) the entity will take to address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely.

Removal Plan

A removal plan documents the immediate action an entity will take to prevent serious harm from occurring or reoccurring. 

Following verification of IJ with the state agency (SA) and/or the CMS regional office (RO), the survey team must notify the entity immediately that IJ has been identified. A removal plan will be required and must be provided to the SA as soon as the entity has identified the steps it will take to ensure that no recipients are suffering or are likely to suffer serious injury, serious harm, serious impairment, or death as a result of the entity’s noncompliance. 

The removal plan identifies all actions the entity will take to immediately address the noncompliance that has resulted in or made serious injury, serious harm, serious impairment, or death likely by detailing how the entity will keep recipients safe and free from serious harm or death caused by the noncompliance. 

Unlike a plan of correction, it is not necessary that the removal plan completely correct all noncompliance associated with the IJ, but rather it must ensure serious harm will not occur or recur. The removal plan must include a date by which the entity asserts the likelihood for serious harm to any recipient no longer exists.

The entity’s removal plan must:

• Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance.
• Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete.

The removal plan must be on your facility’s letterhead.

Your removal plan typically should include an assessment of the residents, an update to the care plan, education of staff, and review of policies as appropriate.

Please provide the team leader (TL) with your removal plan as soon as possible. The TL and survey team will review the removal plan to assure all components are included. When the team identifies the plan is acceptable, it will be forwarded to appropriate MDH staff for review. MDH will work with you until the IJ removal plan is acceptable. 

After your removal plan is accepted, the survey team will verify your removal plan has been fully implemented through interviews with staff and/or residents, review of documentation, and observations.

IJ Removal

Surveyors shall confirm that IJ has been removed by onsite verification after the entity’s removal plan, (or allegation of compliance (AoC) for CLIA) is approved and has been implemented. Removal of IJ means that immediate action has been taken by the entity to prevent a serious adverse outcome from occurring or recurring. This is not synonymous with the Plan of Correction, which documents steps the entity will take to come into substantial compliance.

IJ is removed when surveyors verify that the approved removal plan is fully implemented, and no recipient is currently experiencing serious injury, serious harm, or serious impairment, and/or serious injury, serious harm, serious impairment, or death is not likely. If the plan is not fully implemented, the IJ will continue until the removal plan is fully implemented and the likelihood of serious injury, serious harm, serious impairment, or death no longer exists.

NOTE: If the harm cannot be remedied (e.g., death or serious harm has already occurred), the removal plan must address how additional serious harm will be prevented.

MDH will notify you after verifying the IJ has been removed.

Surveyors will follow guidance consistent with the State Operations Manual, Appendix Q, Guidance on Immediate Jeopardy: Medicare State Operations Manual