Immediate Jeopardy: Removal Plan & 23-Day Clock

An immediate jeopardy (IJ) citation is not primarily a definitional problem. By the time it matters to you, a surveyor has already handed your administrator a completed IJ Template, the finding has already been confirmed with the State survey agency, and a termination clock is already running. What you control from that point is two documents and their timing: the removal plan, which stops the jeopardy, and the plan of correction, which restores substantial compliance. They are different documents, judged against different standards, on different deadlines — and conflating them is the most common way a facility loses days it cannot get back.

This page is the procedure and the paperwork trail: what CMS requires a removal plan to contain, how surveyors decide it worked, and what happens on each day of the 23-calendar-day termination track that begins the day the survey ends.

Verified against the current text of 42 CFR parts 488 and 489 via the eCFR API (edition current to 1 August 2026), CMS State Operations Manual (SOM) Appendix Q — Core Guidelines for Determining Immediate Jeopardy, Rev. 228 (issued and effective 13 December 2024), and SOM Chapter 3 §§3010–3016. Civil money penalty dollar figures are inflation-adjusted annually and are date-stamped where quoted below. This page describes the federal floor for Medicare- and Medicaid-certified providers; State licensure consequences and accreditor consequences run separately and are not federal law.

The First Hour: What Actually Happens When IJ Is Called

Under Appendix Q §VI, once the survey team and the State agency (and, in some States, the CMS Regional Office) agree that IJ exists, the team must immediately do two things:

Notify the administrator — or another staff member with full authority to act for the entity — that IJ has been identified, and hand over a copy of the completed IJ Template.
Request a written removal plan.

The date and time the IJ Template was provided must be recorded on the template itself and on the Form CMS-2567. That timestamp is the anchor for everything that follows, so confirm it is accurate before anyone signs anything. In most cases the template is provided before the survey team exits.

The IJ Template is not the citation. Appendix Q is explicit that findings on the template are preliminary and do not represent an official finding against a Medicare provider or supplier; Form CMS-2567 is the only form that carries official survey findings. Surveyors use one template per tag being considered at IJ level, and it forces a yes/no answer plus a written fact analysis on each of the three key components of IJ:

Noncompliance — the entity failed to meet one or more federal health, safety, or quality regulations;
A serious adverse outcome, or the likelihood of one — serious injury, serious harm, serious impairment, or death has occurred, is occurring, or is likely to occur to one or more identified recipients at risk as a result of that noncompliance;
Need for immediate action — the noncompliance creates a need for immediate corrective action to prevent that outcome from occurring or recurring.

All three must be answered yes. Appendix Q also states plainly that harm need not have happened: it is sufficient that the noncompliance makes serious injury, harm, impairment, or death likely for one or more recipients. Only one recipient needs to be affected or at risk.

Two facts from Appendix Q are worth knowing before you argue the finding. First, a “rogue employee” defence does not work: CMS instructs that noncompliance is cited despite the entity’s training and monitoring efforts, because an entity cannot disown the acts of its employees, operators, consultants, contractors, or volunteers. Second, the duration of IJ does not automatically end when the affected patient leaves or dies — the team must determine whether the noncompliance still creates a likelihood of serious harm for anyone else.

The Removal Plan: What It Is, and What It Is Not

Appendix Q §VII defines the removal plan as the document setting out the immediate action the entity will take to prevent serious harm from occurring or recurring. The critical sentence for anyone drafting one is this: unlike a plan of correction, the removal plan does not have to completely correct all the noncompliance associated with the IJ. It has to ensure serious harm will not occur or recur.

That distinction is the whole job. A removal plan that tries to be a full corrective-action program is slower to write, slower to implement, and slower to verify — and every day of that delay is a day the IJ continues, which is a day of exposure on the termination clock and, for nursing facilities, a day of civil money penalty accrual in the upper range.

	Removal plan	Plan of correction (PoC)
Purpose	Remove the likelihood that serious injury, harm, impairment, or death will occur or recur	Achieve substantial compliance with the cited requirement
Trigger	Requested at the moment IJ is called	Requested after IJ is removed and the completed CMS-2567 is issued
Scope	Need not correct all associated noncompliance	Must address the full deficiency
Who approves	State agency, or the survey team in consultation with the SA	State agency / CMS Regional Office
How closure is proved	Onsite verification only — desk or telephone review is not permitted	Revisit survey; for non-LTC providers, ordinarily within 60 days of notification (42 CFR 488.28(d))

The Two Elements CMS Requires in the Document

Appendix Q states that the entity’s removal plan must:

Identify the recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and
Specify the action the entity will take to alter the process or system failure so a serious adverse outcome does not occur or recur, and when that action will be complete.

Separately, the plan “must include a date by which the entity asserts the likelihood for serious harm to any recipient no longer exists.” Treat that date as the single most consequential number in the document. It is the date you are asking the surveyor to accept as the IJ removal date, and it will be tested against what is actually observable on site.

Where the harm cannot be undone — a death, or serious harm that has already occurred — Appendix Q directs that the removal plan address how additional serious harm will be prevented. There is no expectation that you unwind an irreversible outcome.

What a Removal Plan Should Actually Contain

CMS does not publish a mandatory removal-plan form. The following structure maps to what Appendix Q says the plan must do and to what surveyors must verify on the revisit; adapt it to your State agency’s preferred format, which varies.

The tag and the deficient practice, stated in your own words, matching the tag on the IJ Template. Use one plan section per tag cited at IJ level, mirroring the one-template-per-tag rule.
Identification of recipients at risk — named or otherwise specifically identified, including the affected individual and the wider population exposed to the same system failure. A plan that identifies only the index patient invites the finding that the jeopardy continues for everyone else.
The immediate protective action: what changed today, physically or operationally. Removing a device from service, suspending a practice, one-to-one observation, reassignment of an individual pending investigation, a hard stop in the EHR.
The system or process change that prevents recurrence, distinguished from the protective action above. Surveyors are directed to verify that the actions “alter the process or system failure,” not merely that a single patient is now safe.
Education and competency validation: who was trained, by whom, when, with what verification of competence — and, critically, what happens to staff who have not yet been trained when they next report for duty.
Monitoring: what is being audited, by whom, at what frequency, with what threshold, and what escalation occurs on a failed audit.
The asserted removal date and time.
Evidence attached or available on site — sign-in sheets, competency checklists, audit tools, revised policy with an effective date, work orders, staffing schedules.

Because surveyors verify removal through observation, interview, and record review, every claim in the plan should have a corresponding artefact and a corresponding person who can describe it. A plan asserting that all staff were educated fails on interview if the night-shift aide cannot explain what changed.

Approval Is Not Removal

This is the single most frequently misunderstood step. Appendix Q is unambiguous: “Approving the written removal plan does not mean the IJ is removed.” To remove IJ, the entity must implement the plan, and the survey team must verify through observation, interview, and record review that the actions actually removed the likelihood of serious harm.

Consequences that follow from that rule:

Surveyors must be on site to verify removal. Offsite desk or telephone review for removal of IJ is not permitted.
If the plan is not fully implemented, the IJ continues until it is, and until the likelihood of serious harm no longer exists.
The removal date is the surveyor’s determination, not yours. Appendix Q instructs surveyors not to automatically use the revisit date or the date the entity asserted in its removal plan. IJ is removed on the date it is determined that all elements of the plan were implemented and were effective.
There is no federal requirement that surveyors stay on site continuously until IJ is removed, and no requirement that IJ be removed before the exit conference. The State agency may delay the team’s exit until a removal plan is accepted and IJ is determined removed, if the entity is capable of removing it while surveyors are still there. Where that is achievable, it is almost always worth pursuing — it collapses the removal date to the survey date rather than to a later revisit.

Removing the IJ does not mean you are in substantial compliance. Once IJ is removed, the State agency issues the completed Form CMS-2567 and requests a plan of correction that achieves substantial compliance. Even where IJ was removed before the exit conference, an onsite revisit is still required to determine substantial compliance.

The Post-Citation Timeline: The 23-Day Track

SOM Chapter 3 §3010B sets the enforcement schedule for immediate jeopardy for Medicare providers and suppliers other than SNFs and NFs (long-term care runs on the separate track described below). The processing times given are maximums, and CMS instructs that the procedure is not postponed or stopped unless compliance is achieved and documented through onsite verification.

Point in the clock	What happens
Date of survey	The date the entire survey is completed, regardless of when the exit conference is held. This is day zero — not the exit date, not the CMS-2567 date.
By the 2nd working day	The State agency telephones the CMS Regional Office to certify noncompliance and IJ, and notifies the provider (overnight mail, fax, or email) of the deficiencies and that it is recommending termination. The notice states the provider’s due-process rights, the expected termination schedule, and that the deficiency must be corrected and verified by the SA to halt termination. If the provider also participates in Medicaid, the State Medicaid Agency is notified.
3rd working day	SA forwards all supporting documentation to the RO (statement of deficiencies, correspondence, contact reports, Form CMS-1539) by overnight mail so the RO can meet the 5-working-day deadline.
5th working day	The RO notifies the provider and the public of the proposed termination by the most expeditious means available. A radio or television press release is acceptable if a newspaper notice cannot be arranged in time. Public notice must be made at least 2 calendar days before the effective date of termination.
10th working day	If the SA’s day-2 notice covered only the IJ deficiencies, it must now issue a second CMS-2567 covering the non-IJ condition- and standard-level deficiencies, to the provider, the RO, and the State Medicaid Agency.
23rd calendar day	Termination takes effect — unless compliance is achieved or the threat is removed.

The Branch at Day 23: Removed IJ, Remaining Condition-Level Deficiencies

If the threat has been removed but deficiencies still exist at the condition level, SOM §3010B gives the provider up to 67 more calendar days — 90 calendar days in total (23 plus 67) — to reach compliance. These are maximums; participation may be terminated earlier if processing allows, but the RO must still honour both the provider and public notice timeframes.

This is the practical reason to treat removal of IJ as a separate, faster workstream from correction. Removing the jeopardy converts a 23-day exposure into a 90-day one and, for facilities subject to per-day civil money penalties, shifts the penalty out of the upper range.

For Comparison: The Non-IJ 90-Day Track

Where condition-level noncompliance exists without immediate jeopardy, SOM §3012 runs a different schedule: a warning letter and CMS-2567 on the 10th working day with a recommended termination effective within 90 calendar days of the survey; 10 calendar days for the provider to complete and return the plan of correction; a revisit within 45 calendar days if a credible allegation of compliance is received; certification of continued noncompliance at day 55; RO review at day 65; and an official termination notice at day 70, with at least 15 calendar days’ notice. Only two revisits are permitted — one within 45 days, one between the 46th and 90th day, with the second subject to RO approval.

SOM §3016C is the trapdoor: the SA switches from the 90-day procedure to the accelerated 23-day procedure at any point when an immediate threat to patient health and safety arises. A non-IJ track can become an IJ track mid-correction.

Credible Allegation of Compliance

SOM §3016A defines a credible allegation as a statement or documentation that is realistic in terms of the corrective action being accomplishable between the exit conference and the date of the allegation, and that indicates resolution of the problems. It triggers a revisit — it does not, by itself, stop anything. The manual’s summary is four words: “Only compliance can stop a termination action.”

What Does Not Stop the Clock

Informal hearings and meetings. SOM §3016B states the process may not be postponed to accommodate them or to give the provider additional time to achieve compliance.
Disagreeing with the deficiency. SOM §3016E advises a provider that disagrees to annotate its position on the plan of correction and specify why the citation is not correct. That information does not interrupt the termination process — and it is publicly disclosable, and is included in the documentation considered during any later reconsideration.
A change of ownership. SOM §3016D: a CHOW does not affect completion of a termination action, the SA does not solicit a plan of correction from the new owner, and court-appointed receivership is not a basis for stopping the process.

Where the 23 Days Is Actually Codified

It is worth being precise about this, because it is commonly overstated. The 23-day figure in SOM §3010B is CMS survey-and-enforcement policy applied across provider types. In the regulations, the 23-day preliminary-notice rule for hospitals appears specifically in the EMTALA context: 42 CFR 489.53(d)(2)(i) provides that where CMS finds a hospital in violation of §489.24(a)–(f) and determines the violation poses immediate jeopardy, CMS gives a preliminary notice that the provider agreement will be terminated in 23 days if the hospital does not correct the deficiencies or refute the finding, followed by a final notice to the hospital and the public at least 2 but not more than 4 days before the effective date. The general rule at 42 CFR 489.53(d)(1) is 15 days’ notice; for SNFs and home health agencies with IJ-level deficiencies, 42 CFR 489.53(d)(2)(ii)–(iii) requires only 2 days’ notice before termination takes effect.

The practical implication: the short notice periods in the regulation are not the same thing as the 23-day correction window in the manual. The manual gives you 23 days to remove the jeopardy; the regulation may give you as little as two days’ notice that the agreement is ending.

Nursing Facilities: A Different Enforcement Regime

SNFs and NFs are enforced under 42 CFR part 488 subpart F rather than the Chapter 3 procedures above, and the mechanics differ materially.

Termination or Temporary Management

Under 42 CFR 488.410(a), where there is immediate jeopardy to resident health or safety, the State must (and CMS does) either terminate the provider agreement within 23 calendar days of the last date of the survey or appoint a temporary manager to remove the jeopardy. If the facility refuses to relinquish control to the temporary manager, termination follows within the same 23 calendar days, and State monitoring may be imposed pending termination. If the facility does relinquish control, it is notified that unless it removes the immediate jeopardy the agreement terminates within 23 calendar days of the last day of survey. The State must provide for the safe and orderly transfer of residents on termination.

Civil Money Penalties

42 CFR 488.438(a)(1)(i) sets the upper (IJ) range of per-day civil money penalties at a statutory $3,050–$10,000 per day, “as adjusted annually under 45 CFR part 102.” The non-IJ range at §488.438(a)(1)(ii) is $50–$3,000 per day, and the per-instance range at §488.438(a)(2) is $1,000–$10,000. Penalties are set in $50 increments.

The figures in the regulation are base amounts, not current amounts. The operative numbers are in the table at 45 CFR 102.3. As that table appeared in the eCFR edition current to 1 August 2026, the most recent adjusted column was labelled 2025, and showed, for 42 CFR 488.438(a)(1)(i), a per-day upper range of $8,351 minimum to $27,378 maximum; for §488.438(a)(1)(ii), a lower range of $136 to $8,211 per day; and for §488.438(a)(2), $2,739 to $27,378 per instance. Because these are adjusted annually, check 45 CFR 102.3 for the current year before relying on any figure, including these.

Three accrual rules drive the arithmetic:

Under 42 CFR 488.440(a)(1), the per-day CMP may start accruing as early as the date the facility was first out of compliance — not the survey date. This is why Appendix Q instructs surveyors to determine when the IJ began, which may predate the incident that exposed it.
Under 42 CFR 488.438(c)(1), if IJ is removed but the noncompliance continues, the per-day penalty shifts to the lower range. Removing the jeopardy therefore changes the daily rate, even where correction is incomplete.
Under 42 CFR 488.440(b), the per-day penalty runs until the facility achieves substantial compliance or, if applicable, the date of termination.

The 50% self-reporting reduction at 42 CFR 488.438(c)(2) is expressly unavailable where the noncompliance constituted a pattern of harm, widespread harm, immediate jeopardy, or resulted in a resident’s death. The separate 35% reduction for waiving the right to a hearing under §488.436 cannot be combined with the 50% reduction.

The Administrator’s Licence and the Attending Physician

This is the consequence that reaches an individual rather than the entity, and it is a real regulatory mechanism, not a rumour.

Under 42 CFR 488.410(e), if the immediate jeopardy is also substandard quality of care, the State survey agency must notify the attending physicians and the State board responsible for licensing the facility administrator, as specified in 42 CFR 488.325(h). Section 488.325(h) sets the deadline: not later than 20 calendar days after the State complies with §488.325(g), it must give written notice of the noncompliance to the attending physician of each resident with respect to whom a finding of substandard quality of care was made, and to the State board responsible for licensing the facility’s administrator.

Two qualifications matter. First, this pathway attaches to substandard quality of care, a defined term at 42 CFR 488.301 covering deficiencies in specified paragraphs of 42 CFR 483.10 (resident rights), 483.12 (freedom from abuse, neglect, and exploitation), 483.24 (quality of life), 483.25 (quality of care), and specified paragraphs of 483.40, 483.45, and 483.70 — not to every IJ. Second, the federal requirement is a notification to the licensing board. What the board then does is a matter of State administrator-licensure law, which varies by State; the federal regulations do not impose any sanction on the individual. Anyone facing this should get State-specific advice rather than reason from the federal text.

Past Noncompliance

Appendix Q’s LTC subpart recognises past noncompliance (PNC): a citation at a specific tag where (1) the facility was not in compliance at the time the situation occurred, (2) the noncompliance occurred after the exit date of the last standard survey and before the current survey, and (3) there is sufficient evidence that the facility corrected it and is in substantial compliance at the time of the current survey. PNC at the IJ level means the facility both removed the jeopardy and fully corrected the noncompliance before the survey started. Where PNC applies, no plan of correction and no revisit are required, because the facility is already in substantial compliance — but the Regional Office retains discretion to impose enforcement remedies. Surveyors must independently verify the corrective action through observation, interview, and record review; the facility’s assertion is not enough.

What Ends Up on the CMS-2567

Appendix Q §VIII requires the State agency to document, on the Form CMS-2567:

the date the IJ began — the date the noncompliance caused, or made likely, a serious adverse outcome — if known;
the date the entity was notified;
the specific requirement violated, with a description of the noncompliance and the serious adverse outcome that occurred or was likely;
identification, within the deficient practice statement, of the recipients affected or identified at risk;
the date the IJ was removed, as confirmed by onsite verification; and
a statement of the seriousness of any remaining noncompliance — condition, standard, or element level, or scope and severity.

Read those six items as an audit checklist against your own record before you sign the plan of correction. Two of them — the IJ start date and the IJ removal date — determine the number of days at issue for any per-day remedy, and both are contestable on the evidence.

Note also the reverse scenario Appendix Q contemplates: during the review or enforcement process, the SA or RO may determine that IJ exists based on survey results already collected, even though IJ was never conveyed on site. In that case the entity must be notified immediately by provision of the IJ Template, and the notice or CMS-2567 must be delivered within the timeframes in SOM Chapter 3 §3010. An IJ can therefore arrive by post, weeks after a survey that felt uneventful.

Where the Cost of an IJ Tag Actually Comes From

There is no single published price for an IJ citation, and any figure presented as one should be treated sceptically. The exposure is structural and comes from several separate mechanisms, each with its own authority:

Per-day or per-instance civil money penalties for SNFs and NFs, under 42 CFR 488.438, accruing potentially from the first date of noncompliance (§488.440(a)(1)).
Denial of payment for new admissions and other alternative remedies under 42 CFR part 488 subpart F.
Temporary management costs where a manager is appointed under 42 CFR 488.410(a).
Revisit user fees. 42 CFR 488.30 establishes a revisit user fee for revisit surveys; the fee amount and its applicability are set through that section and CMS guidance rather than being a fixed figure in the regulation.
Loss of Medicare and Medicaid payment on termination, subject only to the narrow post-termination payment exceptions at 42 CFR 489.55 (up to 30 days for inpatient services for a beneficiary admitted before the effective date).
The public notice itself, which under SOM §3010B is issued to the media on the 5th working day, well before any appeal is resolved.

Accreditation consequences run in parallel and are set by each accrediting organisation’s own rules rather than by CMS. We were unable to retrieve The Joint Commission’s current published policy text directly — jointcommission.org blocks automated retrieval — so this page does not state what TJC’s current response to an IJ-equivalent finding is. Confirm that with your accreditor directly. What is federally grounded is that deemed status does not insulate a hospital from this process: SOM Chapter 3 §3010B cross-references Chapter 5 §5110.2 for the procedures and timelines that apply when a State agency validation survey identifies immediate jeopardy in a deemed provider or supplier.

A Working Checklist for the Cited Facility

Confirm the timestamp. Verify the date and time recorded on the IJ Template as the moment it was provided to you.
Get the tag list. One template per tag cited at IJ level; make sure you have all of them, and read each fact analysis.
Split the work immediately. One team drafts the removal plan against the two mandatory elements; a separate team starts the root-cause and correction work. Do not merge them.
Ask whether removal is achievable before exit. The SA may hold the team on site to verify removal. If you can implement while they are there, the removal date becomes the survey date.
Name the population, not just the patient. Identify everyone at risk from the same system failure.
Attach the evidence. Every assertion in the plan needs an artefact and a person who can describe it on interview.
Diary the working days. Days 2, 3, 5 and 10 are working days; day 23 is calendar. Public notice can issue on working day 5.
Track two dates for the record — the date IJ began and the date it was removed. Both drive any per-day remedy, and both are evidence questions.
Annotate disagreement on the PoC (SOM §3016E) rather than relying on an informal hearing to buy time — and understand the annotation is publicly disclosable.
Do not treat removal as the end. A revisit for substantial compliance is still required, and the plan of correction is still due.

Immediate Jeopardy: Writing the Removal Plan and Working the 23-Day Clock

Ask about Immediate Jeopardy: Writing the Removal Plan and Working the 23-Day Clock