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Scope Severity Grid

This document provides guidance on assessing the seriousness of deficiencies found during surveys of nursing homes. It outlines a matrix for determining the scope and severity of deficiencies based on whether they resulted in actual harm, immediate jeopardy, or the potential for harm. Scope can be isolated, a pattern, or widespread, depending on how many residents, staff, or locations are affected. Severity levels range from no actual harm with potential for minimal harm to immediate jeopardy. Factors like resident impact, number of staff/locations involved, and whether issues are pervasive in the facility are used to determine the scope and severity of deficiencies.

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144 views2 pages

Scope Severity Grid

This document provides guidance on assessing the seriousness of deficiencies found during surveys of nursing homes. It outlines a matrix for determining the scope and severity of deficiencies based on whether they resulted in actual harm, immediate jeopardy, or the potential for harm. Scope can be isolated, a pattern, or widespread, depending on how many residents, staff, or locations are affected. Severity levels range from no actual harm with potential for minimal harm to immediate jeopardy. Factors like resident impact, number of staff/locations involved, and whether issues are pervasive in the facility are used to determine the scope and severity of deficiencies.

Uploaded by

Richard Hsu
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Assessment Factors Used to Determine the Seriousness of Deficiencies Matrix

Isolated Pattern Widespread


J K L
Immediate jeopardy
to resident health or PoC Required PoC Required PoC Required
safety

G H I
Actual harm that is
not immediate PoC Required PoC Required PoC Required

No actual harm with


D E F
potential for more
than minimal harm PoC Required PoC Required PoC Required
that is not immediate
jeopardy

A B C
No PoC Required PoC Required PoC Required
No actual harm
with potential for No remedies
minimal harm
Commitment to Correct
Not on CMS-2567

Substandard quality of care means one or more deficiencies related to participation requirements
under §483.10 “Resident rights”, paragraphs (a)(1) through (a)(2), (b)(1) through (b)(2), (e) (except
for (e)(2), (e)(7), and (e)(8)), (f)(1) through (f)(3), (f)(5) through (f)(8), and (i) of this chapter;
§483.12 of this chapter “Freedom from abuse, neglect, and exploitation”; §483.24 of this chapter
“Quality of life”; §483.25 of this chapter “Quality of care”; §483.40 “Behavioral health services”,
paragraphs (b) and (d) of this chapter; §483.45 “Pharmacy services”, paragraphs (d), (e), and (f) of
this chapter; §483.70 “Administration”, paragraph (p) of this chapter, and §483.80 “Infection
control”, paragraph (d) of this chapter, which constitute either immediate jeopardy to resident health
or safety; a pattern of or widespread actual harm that is not immediate jeopardy; or a widespread
potential for more than minimal harm, but less than immediate jeopardy, with no actual harm.

Substantial compliance

04/12/2018
Guidance on Severity Levels
Level 1 - No actual harm with potential for minimal harm: A deficiency that has the potential for
causing no more than a minor negative impact on the resident(s).

Level 2 - No actual harm with a potential for more than minimal harm that is not immediate
jeopardy: Noncompliance with the Requirements for Participation that results in the potential for no
more than minimal physical, mental, and/or psychosocial harm to the resident and/or that result in
minimal discomfort to the residents of the facility, but has the potential to result in more than minimal
harm that is not immediate jeopardy.

Level 3 - Actual harm that is not Immediate Jeopardy: Noncompliance with the Requirements for
Participation that results in actual harm to residents that is not immediate jeopardy.

Level 4 - Immediate Jeopardy to resident health or safety: Noncompliance with the Requirements for
Participation that results in Immediate Jeopardy to resident health or safety in which immediate corrective
action is necessary because the provider’s noncompliance with one or more of those requirements has
caused, or is likely to cause, serious injury, harm, impairment or death to a resident receiving care in a
facility. (See Appendix Q)

Guidance on Scope Levels


Scope is isolated when one or a very limited number of residents are affected and/or one or a very limited
number of staff are involved, and/or the situation has occurred only occasionally or in a very limited
number of locations.

Scope is a pattern when more than a very limited number of residents are affected, and/or more than a
very limited number of staff are involved, and/or the situation has occurred in several locations, and/or the
same resident(s) have been affected by repeated occurrences of the same deficient practice. The effect of
the deficient practice is not found to be pervasive throughout the facility.

Scope is widespread when the problems causing the deficiencies are pervasive in the facility and/or
represent systemic failure that affected or has the potential to affect a large portion or all of the facility’s
residents. Widespread scope refers to the entire facility population, not a subset of residents or one unit of
a facility. In addition, widespread scope may be identified if a systemic failure in the facility (e.g., failure
to maintain food at safe temperatures) would be likely to affect a large number of residents and is,
therefore, pervasive in the facility.

04/12/2018

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