Three different places a concern can go
The home itself has to take a grievance. 42 CFR 483.10(j) says a resident may voice grievances without discrimination or reprisal, including grievances about care that was furnished and care that was not, about the behavior of staff and of other residents, and about other concerns with the stay. The facility has to make prompt efforts to resolve them. It has to make information on how to file a grievance or complaint available. The grievance policy has to tell residents they may file orally or in writing, and anonymously. It has to name a grievance official, with a mailing address, an email address, and a phone number, and it has to give a reasonable expected time for finishing the review. A resident can ask for a written decision. That decision has to include the date the grievance was received, a summary of the concern, the steps taken to investigate, the findings, whether the grievance was confirmed, any corrective action, and the date of the decision. The home keeps evidence of the result for at least three years.
The same policy has to list independent entities a person can go to, including the pertinent state agency, the state survey agency, and the state long-term care ombudsman. A grievance filed inside the building is the home investigating itself under that policy. It does not, by itself, start a federal survey.
The Long-Term Care Ombudsman is the resident advocate. The Administration for Community Living administers the program. Ombudsmen are not the inspectors, and they are not employed by the home. 42 CFR 483.10(k) says a facility must not prohibit or discourage a resident from communicating with federal or state surveyors, other health-department employees, or representatives of the Office of the State Long-Term Care Ombudsman, whether or not the matter is in some other kind of proceeding. Call the ombudsman when you want an advocate. Call the survey agency when you want the compliance office to look at the home.
What the survey agency is deciding
42 CFR 488.332 requires the state survey agency to have procedures and enough staff to investigate complaints of violations of the federal participation requirements. The agency has to take appropriate precautions to protect a complainant's anonymity and privacy, if possible. If another part of state government helps with investigations, the survey agency still keeps responsibility for the process. If the investigation gives the state reason to believe an identifiable person neglected or abused a resident, or misappropriated a resident's property, the agency has to act under 42 CFR 488.335.
Chapter 5 of the State Operations Manual defines a complaint as an allegation of noncompliance with federal or state requirements. Reports can come from residents, family members, health care providers, other citizens, public agencies, or news reports. They can be spoken or written. The surveyor's job, the manual says, is not to validate whether every event in the allegation occurred. It is to determine whether the facility is in compliance with the federal requirements. If the concern also belongs to someone else, the agency refers it. The examples in the manual include law enforcement for a possible crime, a state licensing board for a practitioner, and the Medicare Administrative Contractor for a billing issue. A referral does not erase the survey agency's duty to assess federal compliance, and it does not change the investigation clock.
What to have ready, and what they should tell you
Section 5010.1 of the manual lists the information the agency collects so it can set a priority. Have these pieces if you know them. You do not need all of them to start the call.
- Your name, address, and telephone number, if you are willing to give them.
- The people involved and the people affected.
- What happened, including the date and time.
- How often you believe it happens, and how widely.
- The name of the nursing home and where in the building it happened, such as a unit, room, or floor.
- Why you think it happened.
- Whether you have already talked with the home, the ombudsman, or another agency, and what came of that.
- What you want to happen, if you know.
You can ask that your name be kept out of it. The manual says a complainant may request anonymity, and that the survey agency and the CMS regional office ensure the privacy and anonymity of every complainant. The agency generally discloses the complainant's identity only to people who need it in order to investigate and who are acting in an official capacity. The posted survey report has a matching limit. The facility is not allowed to release identifying information about complainants or residents.
Section 5010.2 says the intake should give you something back, not only take the story. The agency provides its policies for handling intakes, including the scope of its authority and any confidentiality limits. It tells you the course of action it or the CMS regional office will take, and the anticipated time frames. It tells you about other agencies that could help, with a name and phone number when it has one. And it gives you a contact name and number at the survey agency so you can follow up.
CMS publishes contact information for each state survey agency. The home is also supposed to post that kind of contact information with its grievance instructions. Use the CMS list if the posting in the lobby is missing or out of date. If a state's own deadline is stricter than the federal deadline, the manual says the agency uses the state's time frame.
How fast a visit is required
An intake is prioritized by someone the manual describes as professionally qualified to judge the allegation against the federal requirements and current clinical practice. The clocks below are the maximum times in section 5075.9 for nursing home complaints. The manual says the agency is not barred from going sooner. A complaint received after business hours counts as received on the next business day. The manual's example is a complaint that arrives on Saturday when the office is closed for the weekend: Monday is the day the clock uses.
| Priority | What the manual is describing | Nursing home complaints |
|---|---|---|
| Immediate jeopardy | Serious injury, harm, impairment, or death, or the likelihood of it, and an immediate risk unless action is taken. The manual also puts abuse here when it is uncertain the resident is protected, and, for nursing homes, an allegation that a resident was evicted to an unsafe location. | Start the onsite survey within 3 business days of receipt. |
| Non-immediate jeopardy, high | The alleged noncompliance may have caused actual physical or psychosocial harm. | Start the onsite survey within an annual average of 15 business days of receipt, and no later than 18 business days. |
| Non-immediate jeopardy, medium | No actual physical or psychosocial harm, but a potential for more than minimal harm. | Start the onsite survey within 45 calendar days of receipt. |
| Non-immediate jeopardy, low | No actual harm, with a potential for minimal harm. | Track the allegation for the next onsite survey, or start a complaint survey if the agency sees a pattern. |
The manual quotes 42 CFR 489.3 for immediate jeopardy: a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. That label is the agency's triage decision. It is not a finding that the home has already been cited. Letters J, K, and L on a later survey are the citation-level version of immediate jeopardy. The deficiency-tag guide explains those letters. The discharge-rights guide explains the notice rules that sit behind an allegation of an unsafe eviction.
Facility-reported incidents, which the home itself sends in, use a related schedule in the same section. For an incident the agency treats as immediate jeopardy, the onsite survey starts within 3 business days if resident protection is inadequate, and within 7 business days if protection may already be adequate. A family complaint uses the complaint column, not that 7-day incident rule.
Not every intake becomes a visit. The manual says an alleged event more than 12 months before the intake date generally would not require a complaint investigation. The agency may still investigate current compliance based on those concerns. Section 5075.8 uses a "no action necessary" priority when the agency is certain that no further investigation is needed. The examples include an allegation that is not about a federal requirement, the same event already investigated, and an event from before the last standard survey when there is sufficient evidence the home does not have continuing noncompliance. For nursing homes, section 5070 also says an onsite survey may not be required in that last situation. A pattern of similar medium or low complaints can be raised to a higher priority. Ask the contact you were given which priority your intake received, and what the time frame is. That question is one of the things section 5010.2 says the agency should be able to answer.
What you get back
Section 5080.1 says the survey agency or CMS location provides the complainant a written report of the investigation findings, as a summary. The principles for that letter include acknowledging the concern, stating the agency's authority and any limits on it, summarizing the methods used, giving the investigation dates, and explaining the decision. CMS tells agencies to avoid the words "substantiated" and "unsubstantiated." The letter should say whether noncompliance was identified. It should not, if the agency can avoid it, include details that would identify a person who asked for anonymity. It should say where to find the statement of deficiencies and plan of correction: posted at the nursing home, on Nursing Home Care Compare, or by requesting Form CMS-2567 from the survey agency. The inspection-report guide explains how to read that form. The letter should also say how to request a copy of the investigation report under the disclosure rules, including 42 CFR 488.325, and should point to other agencies that may be involved.
A written report that says noncompliance was not identified will not produce a new citation row. The Health Deficiencies file marks a complaint deficiency when surveyors found the deficiency on a complaint inspection. It does not list every complaint that was filed, and it does not include an investigation that ended with no citation. On a facility page, reached from the state list or search, a later complaint survey shows up as citation rows grouped by survey date, with a complaint flag under the description. Compare shows counts, not the narrative of the complaint.
This site cannot take the complaint
A message to this website about a resident's care is not a complaint to the survey agency, and it does not start an investigation. The corrections process is for a page that does not match the CMS file for the processing date printed on that page. Send the home's name, what happened, and the dates to the state survey agency on the CMS contact list, and send a copy of the story to the long-term care ombudsman if you want an advocate involved. Keep your own notes of the date you called, the name of the person who took the intake, and any priority or time frame they gave you.
Sources
- 42 CFR 488.332, investigation of complaints, and 42 CFR 488.335.
- State Operations Manual, Chapter 5, sections 5010 through 5010.2, 5070, 5075.1 through 5075.9, and 5080.1.
- 42 CFR 489.3, immediate jeopardy.
- 42 CFR 483.10(j) and (k), grievances and contact with outside offices.
- CMS contact information for state survey agencies.
- Long-Term Care Ombudsman Program, Administration for Community Living.
- Medicare Care Compare.