Responding to an Immediate Jeopardy - Training
The LeadingAge PA Foundation is pleased to offer this virtual training series to members this fall in partnership with Proactive LTC Consulting!
This 5-week intensive series offers long-term care professionals an in-depth understanding of the regulatory requirements and process involved when an Immediate Jeopardy (IJ) has been cited. Tips and strategies will be shared for writing an IJ Removal Plan and subsequent PoC, and for preparing for the IJ removal and revisit surveys that will follow. Sessions 3 through 5 will focus on the most commonly cited IJ issues: Abuse, Infection Control, and Accidents/Incidents with best practices for risk reduction in these areas.
Who Should Attend:
- Nursing Home Administrators
- Directors of Nursing
- Nursing Leadership
- QA Directors
- Compliance Staff
Training Dates:
All virtual training sessions will take place on Wednesdays from 12:30 - 1:30 pm starting October 14 through November 11, 2026.
CEU info:
One (1) contact hour each session (5.0 total) for Nursing Home Administrators and Nursing professionals; NAB approved through Proactive LTC Consulting.
Price:
We are pleased to offer training series to our members at the price of $215 per person. (Members-only event offers)
Session Descriptions:
Session 1: October 14
Writing the Immediate Jeopardy Removal Plan
- Understand the differences between a Plan of Correction and Immediate Jeopardy Removal Plan
- Identify the essential elements of an Immediate Jeopardy Removal Plan
- Recognize the critical components and timeframes for IJ Removal Plans to improve SA approval and expedite the revisit process
- Become aware of vital information for developing an IJ Removal Plan to prove Past Jeopardy
Session 2: October 21
Preparing for the Immediate Jeopardy Revisit and the Plan of Correction
Removal of Immediate Jeopardy is only the first step. Facilities must then demonstrate that corrective actions have been fully implemented, sustained, and are effective before the revisit survey. This session will guide participants through preparing for the IJ revisit, developing a credible and compliant Plan of Correction (PoC), organizing supporting evidence, and demonstrating lasting systemic change. Learn practical strategies to avoid common pitfalls, ensure survey readiness, and build confidence that your facility is prepared to successfully close out the Immediate Jeopardy.
- Differentiate between the Immediate Jeopardy Removal Plan and the Plan of Correction (PoC).
- Identify the documentation and evidence surveyors expect during an IJ revisit survey.
- Develop a comprehensive PoC that addresses root cause, corrective actions, monitoring, and systemic changes.
- Organize documentation and prepare staff to effectively demonstrate sustained compliance during the revisit survey.
- Implement ongoing monitoring and QAPI strategies to reduce the risk of recurring Immediate Jeopardy deficiencies.
Session 3: October 28
Addressing IJs Related to Abuse
- Identify the essential elements of an Abuse Immediate Jeopardy Removal Plan
- Recognize the critical components and timeframes for Abuse IJ Removal Plans to improve SA approval and expedite the revisit process
- Become aware of vital information for developing an Abuse IJ Removal Plan to prove Past Jeopardy
Session 4: November 4
Addressing IJs Related to Infection Control
- Identify the essential elements of an Infection Control Immediate Jeopardy Removal Plan
- Recognize the critical components and timeframes for Infection Control IJ Removal Plans to improve SA approval and expedite the revisit process
- Become aware of vital information for developing an Infection Control IJ Removal Plan to prove Past Jeopardy
Session 5: November 11
Addressing IJs Related to Accidents/Incidents
- Identify the essential elements of an Accident/Incident Immediate Jeopardy Removal Plan
- Recognize the critical components and timeframes for Accident/Incident IJ Removal Plans to improve SA approval and expedite the revisit process
- Become aware of vital information for developing an Accident/Incident IJ Removal Plan to prove Past Jeopardy
Presenters:
Janine Lehman, RN, RAC-CT, CLNC
Janine Lehman, RN, RAC-CT, CLNC
Director of Clinical & Legal Nurse Consulting
Janine is a Registered Nurse with over 30 years’ experience in long term care, working in all nursing capacities. She is MDS Certified through AAPACN and is a Certified Legal Nurse Consultant. Her background includes serving as a Corporate Nurse Consultant, and the Director of Clinical Services for a multi-facility, multi-level of care organization. She has extensive experience in the RAI process, clinical documentation, legal nurse consulting, restorative nursing programs, fall management, QAPI, and infection control, and has provided training on these topics for State and National organizations.
Shelly Maffia RN, MSN, MBA, LNHA, QCP, CHC, CLNC, CPC
Shelly Maffia RN, MSN, MBA, LNHA, QCP, CHC, CLNC, CPC
Vice President of Quality & Compliance
Shelly Maffia is a Registered Nurse and licensed Nursing Home Administrator with extensive experience in the long-term care setting. She specializes SNF regulatory compliance and nursing home quality improvement. Shelly provides frequent consultation and training to nursing facilities across the nation on regulatory compliance, reimbursement compliance, and quality improvement. She has presented extensively on survey preparedness, QAPI, Achieving 5-Star QMs, Infection Prevention and Control, PDPM, and ICD-10-CM coding.
All education and training programs are provided by the LeadingAge PA Foundation.