Attachment T_IJ Template.pdf

This file is an Immediate Jeopardy (IJ) Template used for compliance assessment and enforcement purposes. The template is a standardized form designed to document and evaluate whether an entity has engaged in serious noncompliance with federal regulations that poses an immediate risk to recipients.

The template requires completion of three interconnected components, all of which must be satisfied with "Yes" responses to establish Immediate Jeopardy status. The first component addresses Noncompliance, requiring identification of specific federal health, safety, administration, fiscal, and/or quality regulations the entity has failed to meet, along with a detailed summary of the actions, errors, or lack of action constituting the violation and the extent of noncompliance across affected cases. The second component, connected by an "AND" requirement, addresses Serious Injury, Serious Harm, Serious Impairment or Death, requiring documentation of evidence that a serious adverse outcome has occurred or is likely to occur as a direct result of the identified noncompliance. The third component, also connected by "AND," addresses Need for Immediate Action, requiring explanation of why the entity must take immediate corrective measures to address the noncompliance and prevent serious injury, harm, impairment, or death. Each component includes a Yes/No column and narrative write-up space for preliminary fact analysis demonstrating whether the key component exists.