Department of Health and Human Services

OFFICE OF 

INSPECTOR GENERAL 

N H
URSING  OME 

C I
OMPLAINT  NVESTIGATIONS

Daniel R. Levinson

Inspector General 

July 2006

OEI-01-04-00340
 Office of Inspector General 

http://oig.hhs.gov 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, 
as amended, is to protect the integrity of the Department of Health and Human Services 
(HHS) programs, as well as the health and welfare of beneficiaries served by those 
programs.  This statutory mission is carried out through a nationwide network of audits, 
investigations, and inspections conducted by the following operating components: 
Office of Audit Services 
The Office of Audit Services (OAS) provides all auditing services for HHS, either by 
conducting audits with its own audit resources or by overseeing audit work done by others. 
Audits examine the performance of HHS programs and/or its grantees and contractors 
in carrying out their respective responsibilities and are intended to provide independent 
assessments of HHS programs and operations. These assessments help reduce waste, 
abuse, and mismanagement and promote economy and efficiency throughout HHS. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide 
HHS, Congress, and the public with timely, useful, and reliable information on 
significant issues.  Specifically, these evaluations focus on preventing fraud, waste, or 
abuse and promoting economy, efficiency, and effectiveness in departmental programs.  
To promote impact, the reports also present practical recommendations for improving 
program operations. 
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative 
investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries 
and of unjust enrichment by providers.  The investigative efforts of OI lead to criminal 
convictions, administrative sanctions, or civil monetary penalties. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to 
OIG, rendering advice and opinions on HHS programs and operations and providing all 
legal support in OIG's internal operations. OCIG imposes program exclusions and civil 
monetary penalties on health care providers and litigates those actions within HHS. 
OCIG also represents OIG in the global settlement of cases arising under the Civil False 
Claims Act, develops and monitors corporate integrity agreements, develops compliance 
program guidances, renders advisory opinions on OIG sanctions to the health care 
community, and issues fraud alerts and other industry guidance.    E X E C U T I V E   S U M M A R Y  

OBJECTIVES 
(1) To assess whether State agencies investigate nursing home 
complaints in accordance with program requirements. 
(2) To determine the extent to which the Centers for Medicare & 
Medicaid Services (CMS) monitors State agency performance of nursing 
home complaint investigations. 
BACKGROUND 
The nursing home complaint process is the front-line response system 
for addressing problems raised by residents, their families, and nursing 
home staff.  However, in recent years various Government reports have 
documented vulnerabilities in nursing home complaint investigations.   
CMS, in conjunction with the State agencies, oversees Medicare- and 
Medicaid-funded nursing homes to ensure that they meet Federal 
standards.  State survey agencies investigate nursing home complaints 
on behalf of CMS.  CMSs State Operations Manual (SOM), which is 
binding on Medicare-certified and Medicare-Medicaid dually certified 
nursing homes, provides State agencies with procedural guidelines for 
nursing home complaint investigations.  These guidelines include a 
detailed protocol for the complaint investigation process, including 
directions on complaint intake, triage and prioritization, and followup.  
CMS annually evaluates each State agencys nursing home complaint 
investigation process according to criteria set forth in the State 
Performance Standards that address complaint prioritization, 
investigation timeframes, and other procedural requirements.  
Beginning in 2004, CMS required all State agencies to enter all 
complaint investigation information into the ASPEN 
Complaints/Incidents Tracking System (ACTS).  CMS uses the ACTS to 
evaluate complaint investigations nationwide. 
This report draws on various data from all 50 States and the District of 
Columbia. We analyzed calendar year 2004 ACTS data, State agencies 
written policies, data from a file review of selected complaints, State 
agency survey data, and CMS regional office interviews to evaluate 
State agency complaint investigation performance and CMSs oversight 
of that performance. Pennsylvania and Washington had waivers 
exempting them from using ACTS; therefore, we collected their data 
  OEI-01-04-00340  NURSING HOME COMPLAINT INVESTIGATIONS  i  E X E C U T I V E   S U M M A R Y  
separately. For these two States, we were unable to distinguish which 
nursing homes were certified only for Medicaid. 
FINDINGS 
State agencies did not investigate some of the most serious nursing 
home complaints within the SOM-required timeframes.  In calendar 
year 2004, State agencies did not investigate 7 percent of complaints 
alleging immediate jeopardy, the most serious complaint category, in 
the required 2-day timeframe.  Furthermore, State agencies did not 
investigate 27 percent of complaints alleging actual harm (high), the 
second most serious complaint category, within the required 10-day 
timeframe. CMS regional offices and State agencies report that staff 
shortages and insufficient training limit State agencies ability to 
investigate complaints within the 10-day required timeframe.  
While the ACTS shows potential for managing complaints, State 
agencies have not taken full advantage of this system.  State 
agencies use of their own data systems in addition to the ACTS, 
technical problems with the ACTS, and lack of training have hindered 
its use as a complaint management tool. 
Most State agencies written policies and procedures generally 
incorporate the SOM; however, those policies and procedures do 
not incorporate all of the SOMs guidelines.  Several of the 42 State 
agencies policies and procedures we reviewed do not incorporate 
guidelines pertaining to intake, triage and prioritization, and followup.  
For example, only 19 State agencies policies and procedures incorporate 
the SOM requirement that agencies prioritize all nonimmediate 
jeopardy complaints within 2 days. 
In a five-State file review, State agencies followed protocols for 
complaint intake and triage; however, many follow-up letters to 
complainants lacked meaningful information.  Although 86 and 
92 percent of the complaint files included letters to the nursing homes 
and complainants, respectively, letters to complainants often lacked 
comprehensive information about the complaints such as acknowledging 
the complainants concern and summarizing the investigation methods. 
CMS oversight of nursing home complaint investigations is limited. 
We identified four limitations to CMS oversight of nursing home 
complaint investigations. First, the State Performance Standard for 
complaints alleging actual harm (high) measures whether State 
agencies investigate all of these complaints within an average of 
  OEI-01-04-00340  NURSING HOME COMPLAINT INVESTIGATIONS  ii  E X E C U T I V E   S U M M A R Y  
10 working days, with all complaint investigations completed within   
20 working days.  This standard is more lenient than the SOMs 10-day 
investigation timeframe for these complaints.  Second, CMS conducts 
few Federal Oversight and Support Surveys (FOSS).  The FOSS allows 
CMSs regional offices an opportunity to observe a State agencys 
complaint investigation process.  However, the SOM states that State 
survey agencies should provide CMS with at least 2 weeks advance 
notice, thus limiting the use of the FOSS for the most serious nursing 
home complaints.  Third, CMS regional offices do not usually follow up 
on State Performance Standard failures until a year after the failure 
occurs.  Finally, CMS regional offices lack sufficient expertise in the 
ACTS to use it for oversight or to help State agencies use it. 
RECOMMENDATIONS 
Our review found that:  (1) many State agencies did not meet 
investigation timeframes for serious complaints, (2) State agencies do 
not incorporate some CMS guidelines for complaint investigations,  
(3) oversight by CMS regional offices is limited, and (4) State agencies 
are not fully utilizing the ACTS despite its potential for complaint 
management.  To address these problems, we recommend that CMS: 
Strengthen the oversight of nursing home complaint investigations by: 
Requiring State agencies to meet the 10-day timeframe for 
investigating complaints alleging actual harm (high).  CMS uses the 
State Performance Standards to hold State agencies accountable for 
the timeliness of their complaint investigations, yet the performance 
standard for complaints alleging actual harm (high) is more lenient 
than the 10-day standard required by the SOM. CMS should make 
the State Performance Standard timeframe consistent with the 
SOM. This would strengthen the State Performance Standards 
emphasis on complaints alleging actual harm (high) in nursing 
homes by requiring State agencies to investigate 100 percent of 
these complaints within 10 working days.   
Conducting additional followup to the State Performance Standard 
Reviews.  Many CMS regional offices reported that they generally do 
not follow up on State Performance Standard failures until the next 
performance review, a year later.  CMS regional offices should 
increase oversight of the State Performance Standards, which 
include the timely investigation of complaints alleging both 
immediate jeopardy and actual harm (high) and the proper 
  OEI-01-04-00340  NURSING HOME COMPLAINT INVESTIGATIONS  iii  E X E C U T I V E   S U M M A R Y  
prioritization and investigation of complaints.  This could be 
accomplished by following up throughout the year, either through 
onsite visits or regular checks of ACTS data. 
Eliminating the 2-week advance notice for the FOSS required in the 
SOM to allow regional offices the option of overseeing complaint 
investigations for the most serious nursing home complaints. The 
FOSS provides CMS regional offices with a valuable oversight tool 
for nursing home complaint investigations.  Pursuant to the SOM, 
State survey agencies should provide CMS with at least 2 weeks 
notice of all scheduled surveys.  Because of this provision, it is 
unlikely that CMS can conduct the FOSS for complaints alleging 
immediate jeopardy and actual harm (high) because of their 
respective 2- and 10-day investigation timeframes.  CMS should 
eliminate this advance notice requirement to allow its regional 
offices to more fully oversee State agencies investigations of the 
most severe complaints.  
Offer additional ACTS training to its regional offices, as well as to State 
agencies.  The ACTS has the potential to improve complaint management 
and oversight at the State agencies and CMS regional offices.  However, 
both groups reported insufficient ACTS training to use the system to its 
full potential. CMS should offer the State agencies further training 
targeted to complaint management.  In addition, CMS should continue to 
train its regional office staff on the ACTS functions specifically related to 
overseeing State agencies.   
To help minimize the time State agencies spend manually entering 
complaint information into both ACTS and State-specific complaint 
tracking systems, CMS should provide specific training regarding how 
State agencies can use ACTS features designed to download information 
into a State system or capture State-required information. 
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
In its comments on the draft report, CMS concurred with three of our 
four recommendations. The agency concurred with our recommendation 
to strengthen the oversight of nursing home complaint investigations. 
CMS also concurred with our recommendations to conduct meaningful 
followup to the State Performance Standards and to offer additional 
  OEI-01-04-00340  NURSING HOME COMPLAINT INVESTIGATIONS  iv  E X E C U T I V E   S U M M A R Y  
training to CMS regional offices and State agencies.  CMS outlined 
specific steps it will take to address each of these recommendations. 
CMS did not concur with our recommendation to eliminate the 2-week 
advance notice for the FOSS set forth in the SOM to allow regional 
offices the option of overseeing complaint investigations for the most 
serious nursing home complaints.  CMS does not consider this advance 
notice to be an important barrier to conducting a FOSS survey and 
indicated it could not assume the added administrative costs and 
challenges under the current resource constraints.  CMS also notes that 
regional offices have the authority to conduct onsite visits at nursing 
homes at any time and for any reason. 
With respect to our third recommendation, we remain concerned that 
the 2-week advance notice hinders CMSs ability to conduct FOSS for 
complaints alleging immediate jeopardy or actual harm (high).  The 
2-week advance notice requirement limits the effectiveness of CMS 
oversight of State agencies investigations of nursing homes. We 
encourage CMS to develop a policy that balances the resource 
constraints and the logistical challenge of scheduling surveys in a tight 
timeframe with the need for CMS to monitor State agency 
investigations of the most serious nursing home complaints. 
  OEI-01-04-00340  NURSING HOME COMPLAINT INVESTIGATIONS  v    T A B L E   O F   C O N T E N T S  

EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i

I N T RO DUC T IO N  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1

F I N D IN G S  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  8

State agencies did not investigate somecomplaints timely  . . . . . .  8

ACTS implementationremains limited. . . . . . . . . . . . . . . . . . . . .  11

State agencies policies do not address all SOM guidelines. . . . . .  12

In five-State file review,follow-up letters lack information . . . . .  13

CMS oversight is limited  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  14

R E C O MMEN D A T ION S  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  17

Agency Comments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  18

Office of Inspector General Response. . . . . . . . . . . . . . . . . . . . . . .  19

E N D NO T ES  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  21

APPENDIXES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  24

A:  Methodology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  24

B: 2004 State ACTS Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  28

C:  AgencyComments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  29

A C K NO WL E D G M E N T S  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  34
   I N T R O D U C T I O N  

OBJECTIVES 
(1) To assess whether State agencies investigate nursing home 
complaints in accordance with program requirements. 
(2) To determine the extent to which the Centers for Medicare & 
Medicaid Services (CMS) monitors State agency performance of nursing 
home complaint investigations. 
BACKGROUND 
The nursing home complaint process is the front-line response system to 
address problems and concerns raised by residents, their families, and 
nursing home staff.  However, recent studies have shown that 
weaknesses exist in survey and complaint investigation activities 
performed by CMS and the State survey agencies (State agencies) that 
oversee nursing homes.1 
Nursing Home Oversight 
CMS, in conjunction with the State agencies, oversees nursing homes to 
ensure that they meet Federal standards.  The State agencies, among 
other functions, conduct certification surveys on behalf of CMS.  State 
agencies must conduct certification surveys, which evaluate the quality 
of care nursing homes provide, on average every 12 months but no less 
frequently than every 15 months.2  In addition to certification surveys, 
State agencies conduct complaint investigations.  While complaint 
investigations primarily serve as a response system for health and 
safety concerns, they also allow State agencies to evaluate the quality of 
care the nursing homes provide between certification surveys. 
Complaint Investigations 
Sections 1819(g)(4)(a) and 1819(g)(5)(a) of the Social Security Act 
require each State to maintain procedures and adequate staff to 
investigate and report on the nursing home complaints they receive.   
CMSs State Operations Manual (SOM) outlines the process that State 
agencies must follow when managing complaint investigations.3 As part 
of the agreements with CMS under which State survey agencies 
operate, SOM requirements are contractually binding on  
Medicare-certified and Medicare-Medicaid dually certified nursing 
homes.4  In November 2003, CMS issued a program memorandum to 
provide State agencies with additional direction and guidelines for 
nursing home complaint management.5  This memorandum, which CMS 
  OEI-01-04-00340  NURSING HOME COMPLAINT INVESTIGATIONS  1  I N T R O D U C T I O N  
has since incorporated into the SOM, provides a detailed protocol for 
State agencies to follow throughout the complaint investigation process, 
including guidelines for complaint intake, triage and prioritization, and 
followup.6 
Intake. The SOM instructs State agencies to collect comprehensive 
information from complainants. This information includes, but is not 
limited to, information about the complainant, the nursing home, the 
individuals involved and affected, a narrative of the allegation, how and 
why the complainant believes the problem leading to the allegation 
occurred, and the complainants expectation for resolution.7  The SOM 
also directs State agencies to offer information to complainants during 
intake. This information includes, at a minimum, the State agencys 
policies and procedures, the course of action the State agency will take 
and the anticipated timeframes, relevant referral information, and a 
contact name and phone number for followup by the complainant.8 
Triage and prioritization.  The SOM requires that a qualified professional, 
who has knowledge of current clinical standards and Federal 
requirements, prioritize each complaint.  Complaints alleging 
immediate jeopardy must be prioritized and investigated within   
2 working days of receipt, while all nonimmediate jeopardy complaints 
must be prioritized within 2 working days of receipt.  The priority 
category that the State agency assigns to a complaint is critical because 
it determines the action and timing of the investigation.  The priority 
categories are: 
 	 Immediate jeopardy:  The SOM defines immediate jeopardy, the most 
serious allegation category, as a situation in which the providers 
noncompliance with one or more requirements of participation has 
caused, or is likely to cause, serious injury, harm, impairment, or 
death to a resident.9  If the State agency determines that 
immediate jeopardy may be present and ongoing, the SOM requires 
the agency to investigate these complaints onsite within 2 working 
days of receipt. 
 	 Actual harm (high): The State agency assigns the highest level of 
actual harm, which is the second most serious allegation category, 
when a providers alleged noncompliance with one or more 
requirements or conditions may have caused harm that negatively 
impacts the individuals mental, physical, and/or psychosocial status 
and is of such consequence to the persons well being that a rapid 
response by the State agency is indicated.10  The SOM directs State 
  OEI-01-04-00340  NURSING HOME COMPLAINT INVESTIGATIONS  2  I N T R O D U C T I O N  
agencies to investigate complaints alleging actual harm (high) onsite 
within 10 working days of complaint receipt.  
 	 All others: For complaints less serious than immediate jeopardy and 
actual harm (high), the State agency decides, based on the intake 
information, whether to investigate onsite, perform a desk review of 
the complaint, or refer the complaint to a more appropriate agency.   
Followup. After investigating the allegation, the State agency must 
provide the complainant and the nursing home with a written report of 
the investigation findings.  The SOM directs State agencies to draw 
upon the following information in these reports:  acknowledgment of the 
complainants concerns, the State agencys authority to investigate 
complaints, a summary of the investigation methods, an explanation of 
the decisionmaking process, a summary of the State agencys findings, 
any follow-up action to be taken, and referral of information to other 
agencies, when appropriate.11 
CMS Oversight of State Agency Complaint Investigations 
In October 2000, CMS began the State Performance Standard Reviews, 
which establish performance standards for State agencies.12  These 
annual reviews serve as CMSs primary oversight mechanism for State 
agencies. The 2004 performance standard for complaint investigations 
includes the following three conditions (referred to as emphases) 
pertaining to nursing homes: 
o Prioritization of complaintsFor 90 percent of randomly selected 
complaints, the CMS regional office must agree with the State 
agencys prioritization of the complaint. 
o Investigation of complaints 
o  Immediate jeopardy:  The State agency must investigate 
all immediate jeopardy complaints onsite within 
2 working days.   
o  Actual harm (high): The State agency must investigate all 
complaints alleging actual harm (high) onsite in an 
average of 10 working days, with all investigations 
completed within 20 working days.13 
o Complaint investigation proceduresThe State agency must follow 
CMS instructions for handling complaints for no less than 
80 percent of nursing home complaints.  These instructions include 
contacting complainants with investigation results and having 
  OEI-01-04-00340  NURSING HOME COMPLAINT INVESTIGATIONS  3  I N T R O D U C T I O N  
qualified surveyors complete the nursing home survey, among 
others.14 
The 2004 State Performance Standard reports show that many State 
agencies failed to meet performance standard timeframes for 
investigating nursing home complaints.  Of the 50 States and the 
District of Columbia, 21 State agencies failed to meet timeframes for 
investigating complaints assigned immediate jeopardy and 37 failed to 
meet timeframes for investigating complaints assigned   
actual harm (high). 
ASPEN Complaints/Incidents Tracking System 
Effective January 1, 2004, CMS requires State agencies to enter all 
complaint investigation information into the ASPEN 
Complaints/Incidents Tracking System (ACTS).15 CMS uses the ACTS 
to evaluate complaint investigations nationwide.  For each complaint, 
the ACTS contains information from the complaint intake through 
closure, including key dates, the prioritization level, overall findings, 
proposed action, and the reason the complaint was closed.  The ACTS 
includes more comprehensive complaint information than the previous 
repository for nationwide complaint data, the Online Survey 
Certification and Reporting system (OSCAR).  
Federal Oversight and Support Surveys 
Federal Oversight and Support Surveys (FOSS) provide CMS with 
valuable opportunities to observe a State agencys complaint 
investigation process in action.  CMS regional offices conduct the FOSS 
for State agency nursing home surveys, including complaint 
investigations. During a FOSS, regional office surveyors accompany 
State agency surveyors and review their performance in conducting the 
survey or complaint investigation. Regional office surveyors discuss the 
State agency surveyors performance with them following the survey; 
identify surveyor training needs, if appropriate; and provide the State 
agency with a numerical rating of the surveyors performance.16 
Concerns About Nursing Home Complaints 
In recent years, various Government reports and press articles have 
documented vulnerabilities in nursing home complaint investigations.  
Some of these reports have resulted in policy modifications and 
increased oversight by CMS.   
Two 1999 Government Accountability Office (GAO) reports documented 
problems with State agency complaint management and with CMSs 
oversight of the State agencies.  In one report, GAO found that CMS 
  OEI-01-04-00340  NURSING HOME COMPLAINT INVESTIGATIONS  4  I N T R O D U C T I O N  
provided minimal guidance to State agencies on prioritization and 
investigation timeframes for nonimmediate jeopardy complaints, 
resulting in varying timeframes for complaint investigations. 17 
Furthermore, GAO reported that CMS conducts very few oversight 
surveys for complaint investigations.  CMS addressed some of these 
concerns by instituting the State Performance Standards and the ACTS, 
both of which provide CMS with greater oversight capabilities. CMS 
created the actual harm triage category in response to another 
1999 GAO report that found that State agencies were understating the 
seriousness of complaints and were failing to investigate serious 
complaints promptly.18 
In July 2003, a GAO official testified before the Senate Finance 
Committee that timeliness of complaint investigations by State agencies 
remained problematic and that the State Performance Standards did 
not provide CMS with enough information to foster improvement.19 
Subsequently, in November 2003, CMS released a memorandum that 
addressed GAO recommendations to provide State agencies with 
additional guidelines for complaint investigations. 
Despite these policy changes and the provision of additional guidance in 
the SOM, accounts from individual States document continued problems 
with nursing home complaint investigations.  For example, an Office of 
Inspector General June 2004 report (A-04-03-07027) documented 
vulnerabilities in Alabamas survey agency relative to physical and 
sexual abuse complaints in nursing homes. 20 The State agency did not 
investigate these complaints within established timeframes, nor did it 
appropriately track and monitor complaints.  The review also found that 
the State agency did not have adequate policies and procedures for the 
intake of abuse complaints. 
Similarly, in August 2004, a series of articles in the Providence 
Journal highlighted a Rhode Island nursing home about which the 
State agency received multiple complaints.21  Despite numerous 
complaint investigations and a declaration of immediate jeopardy, the 
nursing home remained in operation.  Ultimately, one of the homes 
residents died of heart failure after suffering from severe pressure sores. 
In July, Rhode Island enacted the Long Term Care Reform Act of 2005 
to strengthen oversight of the States nursing homes.22 
  OEI-01-04-00340  NURSING HOME COMPLAINT INVESTIGATIONS  5  I N T R O D U C T I O N

METHODOLOGY 
We based this review on 5 data sources:  (1) ACTS data, (2) a file review 
of 498 complaint records from 5 States, (3) a mail survey of the State 
agencies directors, (4) a review of State agencies policies and 
procedures for complaint investigations, and (5) interviews with CMS 
regional office survey and certification staff.  Appendix A contains a 
detailed description of our methodology. 
ACTS 
We analyzed ACTS data for calendar year 2004 to determine the 
percentage of complaints alleging immediate jeopardy and actual harm 
(high) in Medicare-certified nursing homes that State agencies 
investigated within the respective timeframes of 2 and 10 working days.  
We also used the ACTS to determine whether State agencies were using 
the system for required complaint data entry. Pennsylvania and 
Washington had waivers exempting them from using the ACTS; 
therefore, we collected and analyzed their complaint data separately.  
We were unable to distinguish which nursing homes in Pennsylvania 
and Washington were not Medicare-certified or Medicare-Medicaid 
dually certified; however, only 17 complaints for both States combined 
(out of a total of 3,197 immediate jeopardy and actual harm (high) 
complaints in these States) were not investigated within the   
2- and 10-day timeframes for immediate jeopardy and    
actual harm (high). 
We conducted onsite reviews of 498 nursing home complaint files in the 
State agencies of Florida, Illinois, Louisiana, Massachusetts, and 
Oklahoma to assess whether the State agencies followed SOM 
guidelines for complaint intake, triage and prioritization, and followup.  
We selected these States based on complaint volume in 2002 and 2003, 
State Performance Standard reports, and geographic considerations. 
We did not determine whether the State agency prioritized each 
complaint accurately. We calculated the time that elapsed between 
complaint receipt and investigation, assuming that the State prioritized 
the complaint correctly. 
Mail survey of State agency directors  
We surveyed State agency directors in all 50 States and the District of 
Columbia on intake, triage and prioritization, and followup of nursing 
home complaints; feedback provided by CMS pertaining to management 
of nursing home complaint investigations; and ACTS usage. We 
  OEI-01-04-00340  NURSING HOME COMPLAINT INVESTIGATIONS  6  I N T R O D U C T I O N  
received completed surveys from 50 State agencies, representing a 
response rate of 98 percent.   
Review of policies and procedures for complaint investigations 
We received nursing home complaint investigation policies and 
procedures from 42 of the 51 State agencies.  We reviewed these policies 
to determine whether they followed the SOM guidelines for complaint 
intake, triage and prioritization, and followup.   
Interviews with CMS regional office staff 
We used a structured interview guide to conduct telephone interviews 
with all 10 CMS regional survey and certification branch chiefs. The 
interviews focused on information the regional offices provided to State 
agencies concerning management of complaint investigations, ACTS 
training for State agencies, and the regional offices complaint 
investigation oversight activities.   
We conducted this inspection in accordance with the Quality Standards 
for Inspections issued by the Presidents Council on Integrity and 
Efficiency and the Executive Council on Integrity and Efficiency. 
  OEI-01-04-00340  NURSING HOME COMPLAINT INVESTIGATIONS  7  FF II NN DD II NN GG SS   
  F I N D I N G S

State agencies did not investigate some of the 
most serious nursing home complaints within 
SOM-required timeframes 
In 2004, State agencies did not investigate 7 percent of complaints alleging 
immediate jeopardy in the required 2-day timeframe   
Nationally, State agencies did not investigate 233 of 3,467 complaints 
alleging immediate jeopardy (7 percent) within 2 working days.  (See 
Table 1.) State agencies took more than 10 working days to 
investigate 155 of these complaints (4 percent).  The potential for 
further harm to a nursing homes residents makes it essential that 
State agencies promptly investigate complaints alleging immediate 
jeopardy onsite within the required 2-day timeframe. 
Table 1: Timeliness of Immediate Jeopardy Complaint Investigations 
Number of Immediate Jeopardy  Percentage of Immediate Jeopardy 
Number of Workdays 
Complaints Investigated  Complaints Investigated 
2 days or fewer  3,234  93 
310 days  78  2 
1145 days  49 1 
46365 days  76  2 
No survey  30  1
 Total  3,467  100* 
*Data may not add to 100 because of rounding.

Source: Office of Inspector General Analysis of ACTS and State complaint data, 2005.

State-level analysis of the data showed that 27 State agencies did not 
investigate all of their complaints alleging immediate jeopardy within   
2 working days.23  Eight State agencies did not investigate more than  
20 percent of their complaints alleging immediate jeopardy within the  
2-day timeframe.  Mississippi did not investigate 93 percent of 
complaints alleging immediate jeopardy within 2 working days.  
Mississippi also accounts for 67 of the 76 immediate jeopardy 
complaints nationwide that State agencies investigated more than  
45 days after complaint receipt.  
  OEI-01-04-00340  NURSING HOME COMPLAINT INVESTIGATIONS  8  F I N D I N G S  
In 2004, State agencies did not investigate 27 percent of complaints alleging 
actual harm (high) in the required 10-day timeframe   
In 2004, complaints alleging actual harm (high) accounted for 44 percent 
of complaints in the ACTS database.  Because of their severity, the SOM 
requires State agencies to investigate complaints alleging actual harm 
(high) onsite within 10 working days of complaint receipt.  The  
2004 complaint data show that, nationwide, State agencies did not 
investigate 8,398 of 30,588 complaints (27 percent) alleging actual harm 
(high) within this timeframe. (See Table 2.)  As an example of a complaint 
alleging actual harm (high), one State agency assigned actual harm (high) 
when a complainant alleged that a family members nursing home failed to 
treat her urinary tract infection, locked her in a dark room, and then 
dropped her in the bathroom, fracturing her arm and injuring her knee.  
Even based on the weaker State Performance Standard of investigating all 
complaints within 20 working days, State agencies did not investigate all 
complaints alleging actual harm (high) timely. State agencies took more 
than 20 working days to investigate 5,437 of these complaints (18 percent).  
Table 2: Timeliness of Actual Harm (High) Complaint Investigations 
Number of Actual Harm 
Percentage of Actual Harm (High) 
Number of Workdays  (High) Complaints 
Complaints Investigated* 
Investigated 
10 days or fewer  22,190  73 
1115 days   1,822 6 
1620 days   1,139 4 
2124 days  699 2 
2545 days  1,943 6 
46365 days  2,422 8 
No survey  373 1
   Total  30,588  100 
*Percentages are rounded.

Source: Office of Inspector General Analysis of ACTS and State complaint data, 2005.

The 2004 data show that 46 State agencies did not investigate all of 
their complaints alleging actual harm (high) within 10 working days.24 
While 24 of these State agencies investigated more than 90 percent of 
complaints alleging actual harm (high) within 10 working days, some 
State agencies fell considerably short of the 10-day standard. Eleven 
State agencies did not investigate over 50 percent of complaints alleging 
actual harm (high) within 10 working days. For example, Maryland did 
  OEI-01-04-00340  NURSING HOME COMPLAINT INVESTIGATIONS  9  F I N D I N G S  
not investigate 66 percent of complaints alleging actual harm (high) 
within 10 working days. In addition, 24 State agencies took more than 
45 working days to investigate at least 1 complaint alleging actual harm 
(high), and 5 of these State agencies took more than 45 working days to 
investigate at least 200 of their complaints alleging actual harm (high).  
Appendix B presents 2004 data concerning timeliness of complaint 
investigations for every State agency. 
CMS regional offices and State agencies report that staff shortages and 
insufficient training hinder timely nursing home complaint investigations 
Twenty-two State agencies and 9 of the 10 CMS regional offices cited 
insufficient State agency staffing as a major barrier to timely complaint 
investigations. Seven CMS regional offices reported that State agencies 
in their regions have difficulty recruiting and retaining qualified staff.  
Nursing home complaint investigations require both clinical and 
regulatory knowledge. Staff who lack these skills may have difficulty 
completing investigations timely and appropriately.  Officials at State 
agencies and CMS regional offices explained that a rise in complaint 
volume, high staff turnover, and the demands of higher-priority State 
agency tasks (such as nursing home recertification surveys) all 
contribute to insufficient complaint investigation staffing levels at the 
State agencies. 
CMS regional offices and State agencies identified two types of State 
agency training limitations that hinder timely complaint investigations. 
First, 39 State agencies reported a need for additional ACTS training to 
make the system a more useful complaint management tool. CMS 
regional offices and State agencies explained that sufficient ACTS 
training is crucial because small data errors create time-consuming 
data problems.  Second, 12 State agencies reported a need for additional 
staff training on CMS complaint investigation policy, particularly 
regarding complaint prioritization.25 
  OEI-01-04-00340  NURSING HOME COMPLAINT INVESTIGATIONS  10  F I N D I N G S  
While the ACTS shows potential for managing 
In addition to capturing required 
complaints, State agencies have not taken full 
complaint data, the ACTS enables 
advantage of this system  
State agencies to manage complaint 
investigation information, schedule surveys, generate letters to 
complainants and nursing homes, and create reports related to 
complaint investigation performance.  Despite these capabilities, 
21 State agencies reported operating their own complaint system in 
addition to the ACTS.  State agencies that maintain separate systems 
say they do so to fulfill State licensure requirements, State regulations, 
and State reporting needs since, to date, the ACTS is unable to 
accommodate these needs.  As a result, these State agencies enter the 
same complaint data into two systems:  their own and the ACTS. 
Technical problems with the ACTS hinder its use as a complaint 
management tool.  First, State agencies reported that using the ACTS is 
cumbersome during complaint intake.  The ACTS was designed to allow 
State agency staff to enter intake information directly while the 
complainant is on the phone. Notwithstanding this design, 26 State 
agencies cited the ACTS as a barrier to collecting the necessary 
information during complaint intake; 9 of these 26 State agencies 
specifically mentioned that the ACTS is unreliable for real-time entry.  
State agencies stated that intake information must be entered in a 
certain order in the ACTS, which may not reflect the way the 
complainant gives the information. Additionally, State agencies 
mentioned that the ACTS becomes unavailable during upgrades and 
can be too slow to keep up with the complainants comments.  To deal 
with these data entry problems, 11 State agencies reported entering 
intake data somewhere else first and then taking additional time to 
enter the data into the ACTS. 
Most State agencies received ACTS training, but many reported that it 
did not sufficiently prepare them to use the system effectively.  
Forty State agencies reported receiving ACTS training prior to 
implementation.  While 33 of these State agencies rated the trainings 
content as very or somewhat useful, 24 reported that they received too 
little ACTS training.  State agencies explained that the training 
occurred too long before ACTS implementation; thus, many of the 
trainees had forgotten the details of the training by the time CMS 
implemented the ACTS.  The only classroom training CMS offered was 
in April 2002, which was over a year and a half prior to ACTS 
implementation.  In addition, CMS upgraded the ACTS in the period 
between training and implementation, which made some of the training 
  OEI-01-04-00340  NURSING HOME COMPLAINT INVESTIGATIONS  11  FF II NN DD II NN GG SS  
outdated by the time of implementation. Finally, State agencies cited 
limits with the train the trainer approach, whereby each State agency 
sent at least two people to training who then tried to train the rest of 
the State agency staff. State agencies reported problems with this 
training method when trained persons were unable to convey the 
information to the rest of the staff or left the State agency. 
To address the need for more ACTS guidance, CMS convenes a national 
ACTS workgroup. Representatives from State agencies, CMS regional 
offices, and CMS central office participate in a monthly conference call 
to discuss updates to the system or problems they have encountered. 
CMS has also offered Internet-based training for the States and 
regional offices prior to each ACTS update. In addition, CMS contracts 
with a technical support hotline that State agencies can call for 
assistance. Of the 30 State agencies that told us they reported problems 
to the hotline, 25 found the technical support somewhat or very useful 
while 5 found it not useful. State agencies can also electronically post 
suggestions for ACTS improvement and participate in scheduled 
technical conference calls with CMS central office and regional offices. 
Most State agencies written policies and  State agencies policies and 
procedures generally incorporate the SOM;  procedures do not incorporate 
however, those policies do not incorporate all of  several SOM guidelines 
pertaining to intake, triage and 
the SOMs guidelines 
prioritization, and followup. 
While all 42 State agencies policies and procedures we received 
specifically listed some of the intake items addressed in the SOM, only 
5 State agencies require the collection of all the suggested intake items. 
The items most frequently absent concern information that the State 
agencies should provide to the complainant. For example, fewer than 
half of the State agencies direct intake staff to determine the 
complainants expectations for the complaint or to provide the 
complainant with State agency complaint policies, including timeframes 
and expected actions, or with specific contact information, all of which 
the SOM addresses. 
Most State agencies policies, triage categories, and timelines 
incorporate the SOM guidelines. Of the 42 State agencies for which we 
reviewed policies, almost all require that complaints alleging immediate 
jeopardy and actual harm (high) be investigated within the 
SOM-required timeframes. However, only 19 State agencies policies 
OEI-01-04-00340  NURSING HOME COMPLAINT INVESTIGATIONS  12  F I N D I N G S  
incorporate the SOM requirement that the agencies prioritize all 
nonimmediate jeopardy complaints within two working days of receipt, 
unless there are extenuating circumstances that impede the collection of 
relevant information.26 
While most of the State agencies policies direct their staff to send 
follow-up letters to complainants, many of the policies provide little or 
no detail about the required content of these letters.  The SOM lists 
several pieces of information that State agencies should convey to 
complainants in follow-up letters.  However, of the 42 policies we 
reviewed, only 9 require that follow-up letters to complainants include 
all of the components cited in the SOM.  Conversely, seven State 
agencies policies did not include any of the letter components cited in 
the SOM. 
Our file review of 498 nursing 
In a five-State file review, State agencies 
home complaints that resulted in 
followed protocols for complaint intake and 
an onsite survey found that State 
triage; however, many follow-up letters to 
agencies generally collected 
complainants lacked meaningful information 
appropriate information during 
intake, employed qualified professionals to assign priorities to the 
complaints, and provided the complainant and the nursing home with a 
written report of the investigation findings. 
Although 86 and 92 percent of complaint files included letters to the 
nursing homes and complainants, respectively, letters sent to 
complainants often lacked comprehensive information about the 
complaints.  The SOM lists several items to guide State agencies in the 
preparation of follow-up letters to complainants.  These elements are 
important because, for most complainants, this is the only official 
feedback they receive from the State agencies.  Letters to complainants 
mostly lacked references to the State agencys decisionmaking process. 
Table 3 shows the percentage of follow-up letters to complainants that 
lack each of the letter items the SOM suggests State agencies include. 
The information contained in the letters was inconsistent both across 
and within some States.  Oklahoma and Massachusetts sent 
complainants standard letters that contained all of the SOM items.  In 
contrast, Floridas follow-up letters varied based on which field office 
sent them. While some letters contained all of the elements suggested 
by the SOM, others contained just the date the State agency conducted 
the survey and whether the State agency cited deficiencies. 
  OEI-01-04-00340  NURSING HOME COMPLAINT INVESTIGATIONS  13  F I N D I N G S  

Table 3:  Percentage of Follow-Up Letters in the Five States That 
Lacked Information Listed in the SOM 
Letters to 
Letter Items Cited by the SOM  Complainant  Missing 
Item 
(n=327*) 
Acknowledge the complainant's concern  47 
Summarize the investigation methods  50 
Provide the date of investigation  28 
Discuss the State agency's decisionmaking process  27 
Provide a summary of the State agency's findings 9 
*Due to nursing home self-reports and anonymous complaints, 171 of the 498 complaints do 
not include a complainant letter. 
Source:  Office of Inspector General analysis of State agency nursing home complaint files, 2005. 
CMS oversight of nursing home complaint 
investigations is limited 
CMSs State Performance Standard emphasis for nursing home complaints 
is not consistent with SOM requirements for complaints alleging actual 
harm (high) 
While the State Performance Standard emphasis for complaints alleging 
immediate jeopardy reflects the SOM requirement, its emphasis for 
complaints alleging actual harm (high) has changed since 2002 and is 
presently inconsistent with and weaker than the SOM requirement. The 
20042005 State Performance Standard emphasis for complaints alleging 
actual harm (high) is more lenient than both the SOMs requirement of 
investigating complaints alleging actual harm (high) within 10 working 
days and prior State Performance Standard emphases for these 
complaints.  The State Performance Standard emphasis for complaints 
alleging actual harm (high) no longer measures whether State agencies 
investigate all complaints alleging actual harm (high) within the SOM 
requirement of 10 working days. In 2002 and 2003, the emphasis for 
complaints alleging actual harm (high) measured whether State agencies 
investigated 100 percent and 95 percent of complaints alleging actual 
harm (high), respectively, within 10 working days.  (See the box below.) In 
fiscal year 2004, the emphasis changed to measure whether State agencies 
  OEI-01-04-00340  NURSING HOME COMPLAINT INVESTIGATIONS  14  F I N D I N G S  
investigated all complaints alleging actual harm (high) within an average 
of 10 working days, with all complaints completed within 20 working 
days.27 
CMSs State Performance Standard Emphases for Complaints Alleging 
Actual Harm (High), 20022005 
2002:  The State agency triages and initiates investigation of 100 percent of the 
complaints it receives alleging or involving actual harm (high) to individuals 
consistent with CMS and State policy. 
2003:  The State agency investigates 95 percent of the complaints about Medicare- 
and Medicaid-certified facilities it receives alleging or involving actual harm (high) to 
residents consistent with CMS and State policy. 
2004:  The State agency investigates all complaints about long term care Medicare- 
and Medicaid-certified facilities it receives alleging or involving actual harm (high) to 
individuals within an average of 10 working days, with all complaints completed 
within 20 working days (long term care only). 
2005:  For Medicare- and Medicaid-certified nursing homes, the State agency 
initiates an investigation for all complaints and those incidents that require a Federal 
onsite survey alleging a higher level of actual harm within an average of 10 working 
days, with all onsite investigations completed by 20 working days.  For fiscal year 
2005, measuring the 20-working-day completion is in a developmental stage (nursing 
homes only). 
Source:  Office of Inspector General analysis of CMS State Agency Performance Review Standards, 2005. 
Changes to the State Performance Standard emphases also limit CMSs 
ability to track State agency performance over time.  In addition, the 
weakening of this standard can mask deteriorating State agency 
performance over time. For example, a State agency that failed to meet 
this emphasis in 2002 could meet the 2004 standards while performing 
worse in 2004 than in 2002. 
CMS regional offices conduct few FOSSs 
The FOSS provides CMS regional offices with a valuable oversight tool 
for nursing home complaint investigations.  However, the SOM states 
that State survey agencies should provide CMS with at least 2 weeks 
notice of all complaint investigations.  Because this 2-week period 
exceeds the investigation timeframes for complaints alleging immediate 
jeopardy and actual harm (high), such advance scheduling hinders 
regional offices from conducting the FOSSs for the most serious nursing 
home complaints.28 
Overall, CMS regional offices conduct few FOSSs of complaint 
investigations. Nine of the ten CMS regional offices conducted FOSSs 
  OEI-01-04-00340  NURSING HOME COMPLAINT INVESTIGATIONS  15  FF II NN DD II NN GG
 SS  
for nursing home complaint investigations in 2004. However, regional 
offices reported conducting the FOSS in only half of the States in their 
region. Five regional offices reported they would like to conduct more of 
these surveys. 
Many CMS regional offices do not follow up formally on State Performance 
Standard Reviews until the subsequent performance review 
All 10 CMS regional offices require State agencies to submit a plan of 
correction when the agency fails to meet a performance standard. 
However, six regional offices do not conduct any additional followup on 
the performance reviews until the subsequent annual performance 
review, a year after the State agency fails to meet a performance 
standard. Two CMS regional offices report that although they do not go 
onsite for formal followup, they do evaluate midyear data samples from 
the State agencies and require State agencies that fail to meet 
performance standards to provide performance updates between 
performance reviews. 
Some CMS regional offices lack sufficient expertise in the ACTS to help 
State agencies or to use it for oversight 
The ACTS equips CMS to examine complaint investigations in detail 
and to assess State agency actions. However, 6 of the 10 CMS regional 
offices reported that they lacked sufficient staff with enough knowledge 
about the ACTS to provide assistance to the State agencies. 
CMS regional offices cite staffing shortages and insufficient training as 
reasons for the lack of ACTS expertise within their offices. Three regional 
offices report that ACTS training did not prepare staff to use the ACTS for 
oversight functions, such as running reports or troubleshooting State 
agencies data entry, because the training primarily covered data entry 
rather than complaint management. Five regional offices cite staff 
turnover and shortage for the lack of ACTS expertise within their offices. 
Four of these regions report that the only person proficient with the ACTS 
in their office is also responsible for using it to oversee other provider 
types and has insufficient time to focus on nursing home complaint 
investigations. 
OEI-01-04-00340  NURSING HOME COMPLAINT INVESTIGATIONS  16    R E C O M M E N D A T I O N S  

The nursing home complaint investigations process continues to have 
problems. Many State agencies did not meet investigation timeframes 
for the most serious complaints, State policies and file reviews indicate 
that State agencies did not incorporate some aspects of the investigation 
process suggested in the SOM, and oversight by CMS regional offices is 
limited. In addition, State agencies are not fully utilizing the ACTS 
despite its potential for complaint management. To address these 
problems, we recommend that CMS take the steps listed below. 
Strengthen the oversight of nursing home complaint investigations by: 
Requiring State agencies to meet the 10-day timeframe for investigating 
complaints alleging actual harm (high) 
CMS uses the State Performance Standard to hold State agencies 
accountable for the timeliness of their complaint investigations, yet 
the performance standard for complaints alleging actual harm (high) 
is more lenient than the 10-day standard required by the SOM.  The 
2004 and 2005 State Performance Standard emphasis for complaints 
of actual harm (high) requires that State agencies initiate 
investigations for complaints alleging a higher level of actual harm 
within an average of 10 working days, with all onsite investigations 
completed by 20 working days.  CMS should make the State 
Performance Standard timeframe consistent with the SOM. This 
would strengthen the State Performance Standard emphasis for 
complaints alleging actual harm (high) in nursing homes by 
measuring whether State agencies investigate 100 percent of these 
complaints within 10 working days.   
Conducting meaningful followup to the State Performance Standard 
Reviews 
Many CMS regional offices reported that they generally do not 
follow up with the State Performance Standard failures until the 
next performance review, a year later, despite the fact that the 
annual State Performance Standard is CMSs primary oversight 
mechanism for State agencies nursing home complaint 
investigations. Rather than waiting until the next annual 
performance review, CMS regional offices should increase oversight 
on the State Performance Standard, which includes the timely 
investigation of complaints that allege both immediate jeopardy and 
actual harm (high) and the proper prioritization and investigation of 
complaints.  This could be accomplished by following up throughout 
  OEI-01-04-00340  NURSING HOME COMPLAINT INVESTIGATIONS  17  R E C O M M E N D A T I O N S  
the year, either through onsite visits or regular checks of the State 
agencys ACTS data. 
Eliminating the 2-week advance notice for FOSS contained in the SOM to 
allow regional offices the option of overseeing complaint investigations 
for the most serious nursing home complaints 
The FOSS provides CMS regional offices with a valuable oversight 
tool for nursing home complaint investigations.  The SOM, however, 
states that State survey agencies must provide CMS with at least   
2 weeks notice of all scheduled surveys.  Because of this provision, it 
is unlikely that CMS can conduct the FOSS for complaints alleging 
immediate jeopardy and actual harm (high) because of the 
respective 2- and 10-day investigation timeframes.  CMS should 
eliminate this advance notification to allow its regional offices to 
more fully oversee State agencies investigations of the most severe 
complaints. 
Offer additional ACTS training to its regional offices, as well as to State 
agencies 
The ACTS has the potential to improve complaint management and 
oversight at the State agencies and CMS regional offices.  However, 
both groups reported insufficient ACTS training to fully utilize the 
system. CMS should offer the State agencies further training targeted 
to complaint management.  In addition, CMS should continue to train 
its regional office staff on the ACTS functions specifically related to 
overseeing State agencies. 
To help minimize the time State agencies spend manually entering 
complaint information into both the ACTS and State-specific complaint 
tracking systems, CMS should provide specific training regarding how 
State agencies can use ACTS features designed to download information 
into a State system or capture State-required information. 
AGENCY COMMENTS 
In its comments on the draft report, CMS concurred with three of our 
four recommendations. CMS concurred with our recommendation to 
strengthen the oversight of nursing home complaint investigations by 
requiring State agencies to meet the 10-day timeframe for investigating 
complaints alleging actual harm (high).  While CMS outlined specific 
steps it would take to address this recommendation, such as clarifying 
the language in the State Performance Standard for 2007, it also noted 
  OEI-01-04-00340  NURSING HOME COMPLAINT INVESTIGATIONS  18  that the increase in nursing home complaints as well as resource 
limitations affect its ability to meet these performance expectations.   
CMS concurred with our recommendation to conduct meaningful 
followup to the State Performance Standards and listed steps it is 
implementing to enhance followup.  These steps include strengthening 
regional office followup, particularly in States with significant 
performance failures; holding face-to-face meetings with States at least 
twice per year, with performance as a prominent agenda item; making 
performance standard fulfillment a significant feature of CMSs annual 
National Leadership Summit; and ensuring that ACTS produces reports 
that provide feedback to States on their performance. 
CMS also concurred with our recommendation to offer additional 
training to CMS regional offices as well as State agencies.  The agency 
highlighted a pilot program that would evaluate the extent to which the 
ASPEN information system is integrated with office business practices 
and other State operations.  CMS noted that while it recognizes the 
potential benefits of using ACTS to support States management, ACTS 
is a Federal system and was not intended to support all States possible 
uses. 
CMS did not concur with our recommendation to eliminate the 2-week 
advance notice for the FOSS set forth in the SOM to allow regional 
offices the option of overseeing complaint investigations for the most 
serious nursing home complaints.  CMS does not consider this advance 
notice to be an important barrier to conducting a FOSS survey and 
indicated it could not assume the added administrative costs and 
challenges under the current resource constraints.  CMS also notes that 
regional offices have the authority to conduct onsite visits at nursing 
homes at any time and for any reason.  The full text of CMSs comments 
is in Appendix C. 
OFFICE OF INSPECTOR GENERAL RESPONSE 
With respect to our third recommendation, we remain concerned that 
the 2-week advance notice hinders CMSs ability to conduct FOSS for 
complaints alleging immediate jeopardy or actual harm (high).  The 
2-week advance notice requirement limits the effectiveness of CMS 
oversight of State agencies investigations of nursing homes. We 
encourage CMS to develop a policy that balances the resource 
constraints and the logistical challenge of scheduling surveys in a tight 
  OEI-01-04-00340  NURSING HOME COMPLAINT INVESTIGATIONS  19  timeframe with the need for CMS to monitor State agency 
investigations of the most serious nursing home complaints. 
  OEI-01-04-00340  NURSING HOME COMPLAINT INVESTIGATIONS  20    E N D N O T E S  

1 See Department of Health and Human Services (HHS), Office of 
Inspector General (OIG), Office of Audit Services, Final Report, Survey 
of Physical and Sexual Abuse in Alabama Nursing Homes,       
A-04-03-07027, June 2004; Government Accountability Office (GAO), 
Nursing Homes:  Prevalence of Serious Quality Problems Remains 
Unacceptably High, Despite Some Decline, GAO/03-1016T, July 2003. 
2 42 CFR  488.308. 
3 Centers for Medicare & Medicaid Services (CMS), State Operations 
Manual, Chapter 5Complaint Procedures. 
4 We refer in this report to provisions of the State Operations Manual 
as requirements even though for two of the States reviewed, 
Pennsylvania and Washington, we were unable to distinguish which 
nursing homes were certified for Medicare and which were certified for 
Medicaid only.    
5 CMS, Guidelines to Support Management of Complaints and 
Incidents and the National Implementation of the ASPEN 
Complaints/Incidents Tracking System, S&C-04-09, November 13, 2003. 
6 In June 2005, CMS released another memorandum to State agency 
directors that offered guidance on complaint allegation intake and triage.  
The memorandum offers specific intake questions for collecting 
comprehensive information as well as criteria for making triage 
assessments.  CMS based the memorandum on complaint management 
practices shared by State agencies.  However, because these are not 
statutory requirements, State agencies are not required to incorporate 
the practices from the memorandum. 
7 CMS, State Operations Manual, Chapter 5Complaint Procedures 
(Section 5010A). 
8 CMS, State Operations Manual, Chapter 5Complaint Procedures 
(Section 5010B). 
9 CMS, State Operations Manual, Chapter 5Complaint Procedures 
(Section 5030A); 42 CFR  489.3. 
  OEI-01-04-00340  NURSING HOME COMPLAINT INVESTIGATIONS  21  10 CMS, State Operations Manual, Chapter 5Complaint Procedures 
(Section 5030B). 
11 CMS, State Operations Manual, Chapter 5Complaint Procedures 
(Section 5040). 
12 GAO, Nursing Homes:  Prevalence of Serious Quality Problems 
Remains Unacceptably High, Despite Some Decline, GAO/03-1016T, 
July 2003. 
13 CMS, FY 2004 State Performance Review Protocol Guidance, 
October 2003. 
14 CMS, FY 2004 State Performance Review Protocol Guidance, 
October 2003, p. 42. 
15 To date, CMS has waived this requirement for two States 
(Pennsylvania and Washington).   
16 CMS, State Operations Manual, Chapter 4Federal Oversight 
Support Survey (FOSS) Expectations and Responsibility (Section 4158). 
17 GAO, Nursing Homes:  Additional Steps Needed to Strengthen 
Enforcement of Federal Quality Standards, HEHS-99-46, March 18, 
1999. 
18 GAO,  Nursing Homes:  Complaint Investigation Processes Often 
Inadequate to Protect Residents, GAO-HEHS-99-80, March 22, 1999. 
19 GAO, Nursing Homes:  Prevalence of Serious Quality Problems 
Remains Unacceptably High, Despite Some Decline, GAO/03-1016T, 
July 2003. 
20 HHS, OIG, Office of Audit Services, Final Report, Survey of Physical 
and Sexual Abuse in Alabama Nursing Homes, A-04-03-07027, 
June 2004. 
  OEI-01-04-00340  NURSING HOME COMPLAINT INVESTIGATIONS  22  21 The Providence Journal, Resident #1, August 22, 2004; Few 
Complaints Lead to Probes of Nursing Homes, August 23, 2004; 
Carcieri Calls for Stricter Nursing Home Supervision, August 25, 2004; 
Nursing Home Death Stirs R.I. Officials to Find Fixes, August 28, 2004.  
22 Rhode Island General Assembly, Press Release:  Long Term Care 
Reform Act of 2005 Signed Into Law, Rhode Island, July 5, 2005. 
23 Five States (Hawaii, North Dakota, South Dakota, Virginia, and 
Washington, D.C.) had no complaints alleging immediate jeopardy in the 
2004 ASPEN Complaints/Incidents Tracking System (ACTS) data.  
Pennsylvania had a waiver and is not included in 2004 ACTS data. 
24 South Dakota had no complaints alleging actual harm in the 
2004 ACTS data.  Pennsylvania had a waiver and is not included in 2004 
ACTS data. 
25 After our survey, CMS offered additional guidance to State agencies 
on complaint prioritization and intake in a memorandum released in 
June 2005.  See CMS, Promising Practices to Support the Intake of 
Nursing Home Complaints, S&C-05-31, June 9, 2005. 
26 CMS, State Operations Manual, Chapter 5Complaint Procedures 
(Section 5020). 
27 Centers for Medicare & Medicaid Services, FY 2004 State 
Performance Review Protocol Guidance, p. 10. 
28 CMS, State Operations Manual, Chapter 4Federal Oversight 
Support Survey (FOSS) Expectations and Responsibility (Section 4158). 
  OEI-01-04-00340  NURSING HOME COMPLAINT INVESTIGATIONS  23    A P P E N D I X   A  

METHODOLOGY 
We based this review on 5 data sources: (1) ASPEN 
Complaints/Incidents Tracking System (ACTS) data, (2) a file review of 
498 complaint records from 5 States, (3) a mail survey of the State 
agencies directors, (4) a review of 42 State agencies policies and 
procedures, and (5) interviews with the Centers for Medicare & 
Medicaid Services (CMS) regional office survey and certification staff. 
ACTS 
We analyzed ACTS data for calendar year 2004 to determine the 
percentage of complaints alleging immediate jeopardy and actual harm 
(high) in Medicare-certified nursing homes that State agencies 
investigated within the respective 2- and 10-working day timeframes. 
We also analyzed ACTS data to determine whether State agencies were 
using ACTS for required complaint data entry.  We received ACTS data 
for all State agencies from CMS on June 16, 2005.  These data included 
208,690 records.  We removed duplicate records and records in which 
the State agency entered a complaint receipt date after December 31, 
2004. We then collapsed records that had the same complaint intake 
identification number but multiple allegation categories down to one 
record.  We also excluded 1,406 complaints because the date 
investigated was prior to the date received.  The final ACTS database 
included 68,826 complaint records. These data included a total of 
35,800 immediate jeopardy and actual harm (high) complaints. 
Pennsylvania and Washington had waivers exempting them from using 
the ACTS, so we collected and analyzed their complaint data separately 
from ACTS data.  Like our ACTS analysis, we included both complaints 
and incidents for calendar year 2004 for all types of nursing homes. 
Though the State Operations Manual (SOM) requirements are binding 
on Medicare-certified and Medicare-Medicaid dually certified nursing 
homes, we were unable to distinguish which nursing homes in these two 
States were certified only for Medicaid.  However, only 17 complaints 
for Pennsylvania and Washington combined (out of a total of 3,197 
immediate jeopardy and actual harm (high) complaints in these States) 
were not investigated within the 2- and 10-day timeframes for 
immediate jeopardy and actual harm (high). 
We analyzed the fields in the ACTS that the SOM requires State 
agencies to enter for every complaint.  We did not verify the accuracy of 
the information in the fields, but rather whether the State agency 
  OEI-01-04-00340  NURSING HOME COMPLAINT INVESTIGATIONS  24  A P P E N D I X   ~   A  
populated them.  We also used SAS to calculate whether State agencies 
met the required timeframes for complaints prioritized as immediate 
jeopardy and actual harm (high).  Excluding weekend days and Federal 
holidays, we calculated the number of days from the date the State 
agency received the complaint to the date the complaint survey started. 
(We did not exclude State holidays from our analysis.)  This allowed us 
to determine whether State agencies met the Federal requirements that 
all complaints alleging immediate jeopardy be investigated within    
2 working days and all complaints alleging actual harm (high) within    
10 working days.   
File review 
For our file review, we drew a sample of 500 nursing home complaints 
from a purposive sample of 5 States:  Florida, Illinois, Louisiana, 
Massachusetts, and Oklahoma.  From the Online Survey Certification 
and Reporting (OSCAR) system, we randomly selected 100 complaints 
from each State that were reported in calendar year 2004.  We used the 
OSCAR system to select the complaints because ACTS data were not 
available to us until June 2005.  We selected our sample in February 
2005 and conducted the file reviews at the State agencies in March, 
April, and May 2005. We excluded 2 complaint files that did not pertain 
to Federal requirements, resulting in a review of 498 complaint files.  
We used several criteria to select the five States.  We selected States 
that had a medium or high volume of complaints in 2002 and 2003.  Due 
to travel constraints, we limited the file review to States with centrally 
maintained complaint files.  Additionally, we selected States with 
different levels of performance on the three State Performance 
Standards emphases pertaining to nursing home complaint 
investigations. Two States we chose met all three emphases in   
2002 and 2003, one did not meet any, and the other two States met only 
one emphasis in 2002 or 2003.   
We reviewed the files using a protocol we developed and entered the 
data into a Microsoft Access database.  Our protocol followed CMSs 
SOM guidelines for complaint intake, triage and prioritization, and 
complainant and nursing home followup.  We evaluated complaint files 
for completeness and conformity with SOM procedural guidelines. 
However, we did not assess whether State agency staff made 
appropriate triage assignments. While onsite at the State agencies, we 
interviewed managers, surveyors, and other relevant personnel to learn 
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more about complaint management in each State.  We analyzed data 
from the file reviews using SAS.  
Mail survey of State agency directors  
We surveyed State agency directors in the 50 States and the District of 
Columbia on nursing home complaint investigations. Our survey 
solicited information in the following areas:  complaint management, 
feedback provided by CMS pertaining to management of nursing home 
complaint investigations, and ACTS use. We also included open-ended 
sections for additional comments and to solicit further explanations for 
some closed-ended answers.  Before sending the survey, we solicited 
comments from CMS central office officials and a State survey director 
about the surveys content and clarity.  We incorporated their feedback 
into the final survey. 
To ensure a high response rate, in March 2005 we sent each State 
agency director in all 50 States and the District of Columbia an 
introductory letter explaining the survey and the review.  Later in the 
month, we mailed the survey.  In April 2005, we sent a follow-up 
mailing to those who had not responded.  In May 2005, we called the 
State agencies that had not yet replied.  We received completed surveys 
from 49 State agencies and the District of Columbia for a response rate 
of 98 percent.  Tennessee did not respond to the survey. 
Review of policies and procedures for complaint investigations 
In conjunction with the survey of State agency directors, we requested 
State nursing home complaint investigation policies and procedures.  
We received documents from 46 State agencies. Of these, two State 
agencies responded that they rely on the SOM for nursing home 
complaint investigations and do not maintain separate policies and 
procedures.  Two additional State agencies sent only CMS documents 
and did not offer additional State-specific policies and procedures.  We 
excluded these States and based our analysis on 42 State agencies 
documents. 
We reviewed the policies and procedures using a protocol based on 
CMSs SOM guidelines for complaint intake, triage and prioritization, 
and followup.  The review protocol includes 58 SOM guidelines 
regarding the information to be collected during intake, the 
establishment of triage categories and response timelines, and the 
information included in follow-up letters to complainants.  We reviewed 
each State agencys documents and noted whether written State agency 
policies addressed and incorporated these CMS guidelines.   
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Interviews with CMS regional office staff 
We used a structured interview guide to conduct telephone interviews 
with the 10 CMS regional survey and certification branch chiefs.  The 
interviews focused on information the regional offices provided to State 
agencies concerning management of complaint investigations, ACTS 
training for State agencies, and the regional offices complaint 
investigation oversight activities.  Before the interviews, we solicited 
comments from the CMS central office and a CMS regional office branch 
chief about the interview guides content and clarity.  We incorporated 
their feedback into the final interview guide. 
We conducted the interviews in June 2005.  We asked the CMS regional 
offices to provide us with any documentation they had from State 
agency training activities; oversight actions; and any formal 
communications the regional office had with the State agencies, 
including feedback on State agency performance.  Prior to each 
interview, we sent the interview guide to the CMS regional survey and 
certification branch chiefs and invited them to ask any regional staff 
members with expertise in the covered areas to participate in the 
interviews. At least two OIG staff participated in each interview. 
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Table 4:  2004 State Agency Complaint Investigation Timeliness for Complaints Alleging 
Immediate Jeopardy and Actual Harm (High) 
State  Immediate Jeopardy Complaints  Actual Harm (High) Complaints 
Percentage Not  Total Immediate  Percentage Not 
Total Actual Harm (High) 
Investigated Within  Jeopardy Complaints  Investigated Within 
Complaints in 2004 
2 Working Days  in 2004  10 Working Days 
Alabama  0%  16  10%  289 
Alaska  0  2  17  6 
Arizona  7  29  83  587 
Arkansas  0  53  76  569 
California  5  173  27  903 
Colorado  16  37  20  224 
Connecticut  33  9  26  78 
Delaware  25  4  39  28 
Florida  7  153  3  896 
Georgia  0  30  3  933 
Hawaii  N/A*  0  32  19 
Idaho  0  16  0  55 
Illinois  2  62  1  1,285 
Indiana  1  89  3  604 
Iowa  3  66  4  701 
Kansas  2  101  8  143 
Kentucky  0  41  5  463 
Louisiana  15  53  16  339 
Maine  21  14  4  196 
Maryland  33  6  66  804 
Massachusetts  25  4  1  643 
Michigan  0  98  71  965 
Minnesota  11  19  2  260 
Mississippi  93  131  98  461 
Missouri  0  168  12  2,167 
Montana  0  7  56  9 
Nebraska  0  25  3  129 
Nevada  0  10  17  547 
New Hampshire  0  5  0  14 
New Jersey  8  76  1  145 
New Mexico  33  6  81  156 
New York  4  255  24  2,725 
North Carolina  2  200  7  849 
North Dakota  N/A*  0  100  1 
Ohio  1  100  6  973 
Oklahoma  2  258  56  552 
Oregon  0  14  12  217 
Pennsylvania  0**  40  0  2,095 
Rhode Island  0  1  43  7 
South Carolina  17  46  90  653 
South Dakota  N/A*  0  N/A*  0 
Tennessee  6  205  4  636 
Texas  2  497  50  5,731 
Utah  0  56  0  68 
Vermont  25  8  39  75 
Virginia  N/A*  0  19  138 
Washington   0**  213  1  849 
Washington D.C.  N/A*  0  0  3 
West Virginia  0  6  7  134 
Wisconsin  2  62  8  224 
Wyoming  0  3  25  40 
*The State agency entered no complaints for this category into ACTS for calendar year 2004. 
**Pennsylvania and Washington had waivers from ACTS in 2004. Data for these States come from the State 
agencies' complaint systems. 
Source: Office of Inspector General analysis of 2004 ACTS data, 2005. 
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Agency Comments 
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This report was prepared under the direction of Joyce M. Greenleaf, 
Regional Inspector General for Evaluation and Inspections in the 
Boston regional office, and Russell W. Hereford, Deputy Regional 
Inspector General.  Other principal Office of Evaluation and Inspections 
staff who contributed include: 
Danielle Fletcher, Team Leader 
Maria Maddaloni, Project Leader 
Rosemary Borck, Program Analyst 
Norman Han, Program Analyst 
Sandy Khoury, Program Specialist 
Barbara Tedesco, Mathematical Statistician 
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