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Monitor staff adherence to key hospital policies to avoid IJ

In the September issue, we told you about a hospital that responded quickly to threats posed after the nation learned of the 2019 novel coronavirus, but still faced a finding of immediate jeopardy (IJ) to patients and staff from CMS officials.

Such findings can not only threaten a hospital’s ability to bill Medicare, but also involve key resources to write and implement a Plan of Correction (POC) sufficient to satisfy CMS surveyors and remove the IJ.

We asked Gayle Nash, RN, MPH, CEO of Nash Healthcare Consulting, to review the CMS report and offer her input on the deficiencies and a plan of correction.

The CMS Form-2567 “Statement of Deficiencies” was among those posted recently by CMS on its online database of hospitals surveyed within the last few months that were cited for “substantial deficiencies.” Find the Quality, Certification and Oversight Reports (QCOR) group database at

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