CMS Issues Revised Appendix Q, Guidance on Immediate Jeopardy

PUBLISHED: Aug 6, 2019
Relevant to: Clinical Lab, Critical Access Hospitals, Hospitals, Long Term Care

The U.S. Centers for Medicare and Medicaid Services (CMS) recently updated their memorandum on Immediate Jeopardy, reinserting language to Appendix Q about referring criminal acts to local law enforcement.

According to the updated guidance, if a survey team verifies noncompliance and determines that the noncompliance was “…caused by, or has led to a criminal act, reporting must be made to local law enforcement.” CMS further outlines that, if the entity refuses to report, or the surveyor cannot verify that a report was made to local law enforcement, the surveyor must consult with his/her supervisor immediately, and the State Agency must report the potential criminal incident to law enforcement immediately.

While this guidance is specific to State surveyors, it underscores for organizations the seriousness and importance of reporting suspected or actual criminal activity to local law enforcement. Further, organizations should be prepared to demonstrate to a surveyor that a report has been made.

Make sure your organization:

  • Has a clear process and written policy addressing response to actual or suspected criminal activity that includes reporting to local law enforcement.
  • Requires documentation of any reports made to local law enforcement.

Included with today’s notice are example policies addressing security processes for reporting actual or suspected criminal activity.

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