Attn: Nursing Home Providers
DQA Pilot Program Expanding Immediate Jeopardy
The Division of Quality Assurance is sending this message as part of our commitment to Collaboration, Innovation and Quality.
Program Overview
Effective February 1, 2024, through April 30, 2024, the Bureau of Nursing Home Resident Care (BNHRC) will implement a pilot program by temporarily expanding the Immediate Jeopardy (IJ) call. This 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. The facility Nursing Home Administrator (NHA) or Director of Nursing (DON) will be invited to provide additional information to Division of Quality Assurance (DQA) staff on the call.
DQA 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.
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 we have 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.
We are temporarily including this additional step 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:
- 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.
- The IJ call will proceed. Attendees will take into consideration any information the facility just presented.
- 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.
- 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.
Questions
If you have questions about this memo, please contact Ann Angell, Director of the Bureau of Nursing Home Resident Care at Ann.Angell@dhs.wisconsin.gov or Jessica Radtke, Deputy Director of the Bureau of Nursing Home Resident Care at Jessica.Radtke@dhs.wisconsin.gov.
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