States Continued To Fall Short in 

Meeting Required Timeframes for 

Investigating Nursing Home Complaints: 

2016-2018

In this data brief, we examine the extent to which State 

survey agencies (hereinafter, States) met required timeframes 

for investigating the most serious nursing home complaints 

from 2016 through 2018 (preceding the COVID-19 public 

health emergency).1

 We highlight trends for this 

3-year period that raise questions about many States’ 

timeliness in responding to such complaints. We also 

determined whether five States—Arizona, Georgia, Maryland, 

New York, and Tennessee—that fell short between 2011 and 

2015 made progress during 2016 through 2018, as 

compared to 2015.

2

 

Introduction

The nursing home complaint process is a critical safeguard to 

protect vulnerable residents of nursing homes. The Centers 

for Medicare & Medicaid Services (CMS) relies on each State 

to serve as the front-line responder to address health and 

safety concerns raised by residents, their families, and 

nursing home staff.3

 Examples of concerns that might result 

in a complaint are delays in residents being fed, inadequate 

staffing that result in insufficient care, and inappropriate 

social media posts by nursing home employees. 

CMS provides States with procedural guidelines for how to 

intake, prioritize, and investigate complaints for 

Medicare/Medicaid-certified nursing homes.4

 CMS requires 

that a qualified professional with knowledge of clinical 

standards and Federal requirements triage each complaint by 

assigning it a priority level. A complaint’s priority level 

determines the State’s required timeframe for investigating. 

The two most serious priority levels are immediate jeopardy 

and non-immediate jeopardy–high. (In this data brief, we 

refer to non-immediate jeopardy–high complaints as 

high priority complaints.) These complaints allege serious 

Key Results

 The rate of nursing home complaints 

per 1,000 nursing home residents 

increased from 45 in 2015 to 

52 in 2018.

 Twenty-one States failed to meet CMS’s 

timeliness threshold for the secondmost serious level of complaints in all 

3 years from 2016 through 2018, and 

10 of these States did not meet the 

threshold for 8 consecutive years, 

from 2011 through 2018. 

 Of the five States that fell short in 

timely investigation of the most serious 

nursing home complaints from 

2011 through 2015, Georgia had 

limited improvement, while Arizona, 

Maryland, New York, and Tennessee 

continued to fall short through 2018.

 Trends in late investigations of 

complaints from 2016 through 2018 

raise concerns in New Jersey, Illinois, 

and Texas. 

 Because States we communicated with

face challenges in triaging complaints,

we recommend that CMS should 

ensure that all States receive training 

on updated triage guidance.

 We also recommend that CMS should 

identify new approaches to address 

States that are consistently failing to 

meet required timeframes for 

investigating the most serious nursing 

home complaints.

 CMS concurred with both 

recommendations.

U.S. Department of Health and Human Services

Office of Inspector General

Data Brief

September 2020, OEI-01-19-00421
injury or harm and require a rapid response to address the complaint and ensure 

residents’ safety. States must investigate immediate jeopardy complaints within 

2 business days of receipt and high priority complaints within 10 business days of 

prioritization.

5

 See Exhibit 1 for complaint priority levels and definitions.

Exhibit 1: Complaints prioritized as immediate jeopardy or high priority require States 

to conduct a prompt onsite investigation.6 

Source: CMS State Operations Manual (SOM), Pub. No. 100-07, ch. 5, “Complaint Procedures” (Revised 155, 06-10-16).

This evaluation focuses on nursing home complaint investigations from 2018 and 

earlier; it does not include complaints or investigations during the COVID-19 public 

health emergency of 2020. We note that in response to the COVID-19 public health 

emergency, CMS modified its priorities for States’ survey activities. On 

March 23, 2020, CMS temporarily suspended State investigations for complaints less 

severe than immediate jeopardy.7

 

Every year, CMS evaluates each State’s performance in carrying out all its survey and 

certification responsibilities, which include conducting surveys that evaluate the safety 

and quality of care that nursing homes provide and complaint investigations. CMS 

uses its State Performance Standards System (SPSS) to ensure that States meet 

Federal requirements and to identify areas for improvement. As part of this yearly 

evaluation, CMS reviews the timeliness of each State’s investigations of complaints 

regarding nursing homes and other facilities.8

Although CMS requires States to investigate all immediate jeopardy and high priority 

nursing home complaints onsite within certain timeframes, the standards by which it 

measures States’ performance is less stringent. For purposes of the SPSS, States must 

conduct onsite investigations within 2 business days for 95 percent, rather than 

100 percent, of all immediate jeopardy complaints that they receive. This 

performance threshold includes all immediate jeopardy complaints, whether for 

nursing homes or for other facilities, such as hospitals and ambulatory surgery 

centers. Similarly, CMS’s performance threshold regarding high priority complaints 

requires States to conduct onsite investigations within 10 business days for 95 percent 
of the high priority nursing home complaints they receive, even though CMS 

requires States to investigate 100 percent within 10 business days of prioritization. 

If a State does not meet one of these performance thresholds, CMS requires the State 

to develop a corrective action plan and follows up on the State’s implementation of 

the plan.

9

 CMS reported that it may also take further action to help States meet 

performance thresholds, such as conducting site visits to evaluate a State’s processes 

for intake and triage of complaints. In addition, CMS may hire a contractor to work 

with a State onsite. Finally, CMS may take enforcement action by withholding funds 

from a State. 

Related Office of Inspector General (OIG) Work

This study is part of a larger body of work from OIG examining nursing home 

oversight. Specifically, this study updates OIG’s 2017 data brief that found a few 

States fell short in timely investigation of the most serious nursing home complaints.10 

In addition, OIG has a forthcoming report examining oversight of nursing homes

during the COVID-19 public health emergency, including the extent to which States 

conducted onsite surveys during that period and challenges they faced in doing so.

11 

Another forthcoming OIG report is examining CMS oversight of State performance 

specific to nursing homes and may identify additional opportunities or 

recommendations for CMS to improve State performance.12 

To complement this data brief, OIG published an updated interactive map illustrating 

State-by-State trends in nursing home complaints for 2016 through 2018. The 

interactive map is available at https://oig.hhs.gov/oei/maps/2019-nursinghome/index.asp. 

For additional background on the complaint investigation process, see Appendix A. 
Data Brief: States Continued To Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016-2018 

OEI-01-19-00421 National Trends | 4

The rate of complaints that States received increased slightly from 2015 to 2018, 

going from 45 complaints per 1,000 nursing home residents to 52 per 1,000. This

included a slight increase in the rate of high priority complaints and a larger increase 

in the rate of less serious complaints. The most serious nursing home complaints (i.e., 

immediate jeopardy and high priority complaints), which require prompt onsite 

investigation, accounted for about half of all nursing home complaints. 

Exhibit 2: In both 2015 and 2018, About half of all nursing home complaints 

require prompt onsite investigation. 

 

Source: OIG analysis of data from the Automated Survey Processing Environment Complaints/Incidents Tracking 

System (ACTS), 2019.

4 4

23

25

18

24

High Priority 

Complaints 

Immediate 

Jeopardy 

Complaints 

All Other 

Complaints 

2015 2018

received 

per 1,000 

nursing

home 

residents

Complaint Types that 

Require Prompt Onsite 

Investigation 

NATIONAL TRENDS
Data Brief: States Continued To Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016-2018 

OEI-01-19-00421 National Trends | 5

The percentage of complaints that States 

investigated late increased slightly for high priority 

complaints but not for immediate jeopardy 

complaints. The percentage of high priority 

complaints that States investigated late increased 

from 15 percent in 2015 to 19 percent in 2018, while 

the percentage of immediate jeopardy complaints 

States investigated late remained about the same 

(14 percent in 2015 and 13 percent in 2018). 

See Appendices B and C for the number of nursing 

home complaints and the number of late investigations for immediate jeopardy and 

high priority complaints by State for 2016 and 2018 (Appendix B) and for 2011 and 

2015 (Appendix C).

States investigated

19% 

of high priority complaints 

late in 2018.
Data Brief: States Continued To Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016-2018

OEI-01-19-00421 Results | 6

RESULTS

Twenty-one States failed to meet CMS’s timeliness threshold for 

high priority complaints in all 3 years from 2016 through 2018

Many States are consistently failing to meet CMS’s performance threshold for

timeliness for high priority complaint investigations. We identified 21 States that did 

not meet this threshold in every year from 2016 through 2018. Our prior data brief

identified 10 of these States as not meeting CMS’s threshold in every year from 

2011 through 2015. This means that these 10 States—Arizona, Delaware, 

Massachusetts, Maryland, Mississippi, Nevada, New York, Oregon, South Carolina, and 

Tennessee—have failed to meet CMS’s performance threshold for timely investigation 

of high priority complaints for 8 consecutive years, from 2011 through 2018 (see 

Exhibit 3).

Exhibit 3: Twenty-one States failed to meet CMS’s performance threshold for 

timeliness in all 3 years from 2016 through 2018, and 10 of these States did 

not meet it for 8 consecutive years, from 2011 through 2018.

Source: OIG analysis of ACTS data, 2019.

D.C.

Did not meet threshold in all 3 years, 2016-2018

Did not meet threshold in all 8 years, 2011-2018 
Data Brief: States Continued To Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016-2018

OEI-01-19-00421 Results | 7

We reviewed a sample of 12 corrective action plans from 2016 through 2018 and 

found that these plans most often cited staff support and data monitoring as ways to 

address States’ failure to meet timeliness requirements. For example, 11 of the 12 

corrective action plans we reviewed said that the States would hire and/or train staff 

to increase timeliness. According to one plan, the State would attempt to fill eight 

vacancies to address staffing shortages that affect timely investigations. Another plan 

said that the State would train all its surveyors to investigate complaints. In addition, 

eight of the corrective action plans said that the States would increase or continue to 

monitor complaint data to ensure timeliness. One plan noted that the State’s survey 

staff would complete biweekly reviews of immediate jeopardy and high priority 

complaints to ensure that the State investigates on time. 

To address States that consistently fail to meet CMS’s performance threshold, CMS 

may take additional actions beyond corrective action plans, but it faces challenges in 

doing so. For example, CMS told us that it may conduct site visits to evaluate a 

State’s processes or have a contractor work with a State onsite, among other actions. 

But according to CMS, it cannot use just one approach to help various States because 

they face different challenges with timeliness, requiring different approaches from 

CMS. Furthermore, CMS told us that the increase in nursing home complaints each 

year has been a challenge for CMS and States because resources to investigate these 

complaints have remained flat. Specifically, complaints have increased by 20 percent 

since 2013, but CMS’s funds for survey and certification have remained the same

since 2015 at about $390 million. Although CMS can work with States to improve 

investigation timeliness, CMS told us that it is limited in the enforcement actions it 

can take against States that consistently perform poorly. CMS told us it is limited to 

only taking punitive actions which could undermine a State’s ability to respond to 

complaints, such as withholding funds. 

Of the five States that fell short in timely investigations from 

2011 through 2015, one had limited improvement, and four 

continued to fall short through 2018

In our previous data brief, we identified five States—Arizona, Georgia, Maryland, New 

York, and Tennessee—that fell short in investigating immediate jeopardy and high 

priority complaints on time from 2011 through 2015. Our prior data brief highlighted 

how these States were working to improve their investigation response times to 

serious nursing home complaints. However, we found that only Georgia improved its 

timeliness for investigations of immediate jeopardy complaints, while the other 

four States continued to fall short through 2018 in investigating complaints on time.
Data Brief: States Continued To Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016-2018

OEI-01-19-00421 Results | 8

Georgia improved in meeting required timeframes for 

investigating immediate jeopardy complaints but not for 

high priority complaints.

From 2015 to 2018, Georgia improved the timeliness of its investigations of 

immediate jeopardy complaints. In 2018, Georgia investigated 7 percent of its 

immediate jeopardy complaints late, a decrease from 54 percent in 2015 (see 

Exhibit 4). During this time period, Georgia investigated complaints during the 

weekends and advocated for additional resources to address its complaint workload.

Exhibit 4: Georgia investigated a much smaller percentage of its immediate 

jeopardy complaints late in 2018 than in 2015.

Source: OIG analysis of ACTS data, 2019.

Notably, Georgia also prioritized fewer complaints as immediate jeopardy in 

2018 than in 2015. The number of complaints Georgia prioritized as immediate 

jeopardy decreased from 478 in 2015 to 133 in 2018. According to Georgia, prior 

to 2018, the State prioritized a disproportionately high percentage of complaints as 

immediate jeopardy that did not warrant an immediate jeopardy prioritization. In 

response, CMS worked with Georgia to improve the State’s triage process for 

complaints.

However, Georgia did not notably improve the timeliness of its investigations of high 

priority complaints. In 2018, Georgia investigated 46 percent of its high priority 

complaints late, about the same percentage as in 2015 (49 percent). 

54%

7%

2015 2018

of Georgia's immediate 

jeopardy complaints 

were investigated late
Data Brief: States Continued To Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016-2018

OEI-01-19-00421 Results | 9

Tennessee continued to investigate many of its most serious 

nursing home complaints late. 

Although Tennessee improved the timeliness of 

its most serious complaint investigations from 

2015 to 2018, it continued to fall short. In 2018, 

Tennessee investigated 61 percent of its 

immediate jeopardy complaints and 40 percent 

of its high priority complaints late. In fact, 

Tennessee accounted for more than half of the 

national total of immediate jeopardy 

investigations that were late in 2018. Tennessee 

conducted over half of its late investigations of 

immediate jeopardy complaints more than 

2 weeks late in each year from 2016 through 

2018. According to Tennessee, changes of ownership, bankruptcies, and nursing 

home terminations increased during this period, which contributed to an increase in 

immediate jeopardy and high priority complaints, while State agency staffing 

remained the same.

From 2016 through 2018, Tennessee attempted to address late complaint 

investigations. For example, it hired contractors to allow its surveyors to address late 

complaints. Tennessee also improved the efficiency of complaint investigations by 

allowing surveyors to send investigation findings electronically, among other efforts. 

During this time, CMS withheld a portion of funds from Tennessee because the State 

failed to meet established performance benchmarks for investigation timeliness.

Arizona, New York, and Maryland continued to fall short in 

meeting required timeframes for investigations of high priority

complaints. 

Both Arizona and New York investigated their high priority complaints late more often 

in 2018 than in 2015. In 2018, Arizona investigated 93 percent of its high priority 

complaints late, an increase from 87 percent in 2015. Similarly, New York increased its 

late investigations of high priority complaints from 53 percent in 2015 to 78 percent

in 2018 (see Exhibit 5). In addition, both States conducted over 80 percent of their 

late investigations more than 2 weeks late in 2018. However, Arizona and New York 

conducted most investigations of their immediate jeopardy complaints on time 

from 2015 through 2018. 

Arizona told us that it is working to investigate its complaints within required 

timeframes. For example, Arizona is currently conducting a comprehensive 

assessment of its intake process for complaints regarding long-term care facilities and 

plans to improve its complaint triage process, among other improvements. Arizona 

has also initiated discussions with lawmakers regarding funding to help the State

Tennessee accounted for 

55% 

of late investigations of 

immediate jeopardy complaints 

nationally in 2018.
Data Brief: States Continued To Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016-2018

OEI-01-19-00421 Results | 10

investigate complaints within required timeframes. New York did not provide us 

information on any efforts to address late complaint investigations.

Despite some progress since 2015, Maryland continued to investigate many of its 

high priority complaints late. In 2018, Maryland investigated 65 percent of its high 

priority complaints late (see Exhibit 5). Furthermore, Maryland conducted 65 percent 

of these late investigations more than 2 weeks late in 2018. However, like Arizona 

and New York, Maryland conducted most investigations of its immediate jeopardy 

complaints on time from 2015 through 2018. 

To improve its investigation timeliness for high priority complaints, Maryland 

developed a 7-year plan to increase its number of surveyors and is working to 

improve staff recruitment and retention through a variety of efforts, including training 

and career development. In addition, Maryland improved the efficiency of its 

complaint investigation process by shifting from paper-based to cloud-based 

systems.

Exhibit 5: Arizona, New York, and Maryland continued to investigate many 

of their high priority complaints late in 2018.

Source: OIG analysis of ACTS data, 2019.

65%

78%

93% of Arizona's high 

priority complaints 

were investigated late

2015 2018

New York

Maryland

87%

74%

53%
Data Brief: States Continued To Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016-2018

OEI-01-19-00421 Results | 11

Trends in late complaint investigations from 2016 through 2018 

in three additional States raise concerns

New Jersey, Illinois, and Texas also fell short in investigating the most serious nursing 

home complaints on time since 2015. The trends in complaint investigations from 

2016 through 2018 in these States raise questions about how the States are 

responding to serious nursing home complaints. These findings emphasize the 

importance of CMS’s continued oversight of States’ timeliness in nursing home 

complaint investigations, as States that meet required timeframes in one year may fall 

short the next year. 

New Jersey investigated over 70 percent of its most serious 

nursing home complaints late from 2016 through 2018. 

New Jersey investigated most of its immediate jeopardy and high priority nursing 

home complaints late. From 2016 through 2018, New Jersey investigated between 

72 and 89 percent of both its immediate jeopardy and high priority complaints late 

each year. In addition, New Jersey accounted for 25 percent of late investigations of 

immediate jeopardy complaints nationally in 2018, an increase from 11 percent 

in 2016 (see Exhibit 6). New Jersey’s proportion of late investigations of immediate 

jeopardy complaints nationally in 2018 was higher than all other States except 

Tennessee.

 

Exhibit 6: New Jersey accounted for a greater percentage of late investigations of 

immediate jeopardy complaints nationally in 2018 than in 2016.

Source: OIG analysis of ACTS data, 2019.

0%

25%

50%

75%

100%

2016 2018

New Jersey

Tennessee

All Other States

Percentage of late 

investigations 

nationally
Data Brief: States Continued To Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016-2018

OEI-01-19-00421 Results | 12

New Jersey pointed to its triage practices and staff shortages as reasons for late 

investigations. According to New Jersey, from 2016 through 2018, its staff not only 

prioritized complaints at a higher severity level than appropriate, but the State also 

lacked the staff resources to investigate complaints within required timeframes. CMS 

trained staff on complaint triage during this same time period, and the State 

implemented supervisory review of complaint triage. The State is also trying to hire 

additional survey staff. 

Illinois and Texas investigated many more of their high priority 

complaints late in 2018 than in 2016. 

From 2016 to 2018, Illinois and Texas had large increases in their late investigations of 

high priority complaints. In 2016, Illinois investigated only 1 percent of its high 

priority complaints late, but in 2018, it investigated 26 percent of these complaints 

late. In Texas, 10 percent of these investigations were late in 2016, which increased to 

43 percent in 2018 (see Exhibit 7). Furthermore, Illinois and Texas accounted for 

38 percent of all late investigations of high priority complaints nationally in 2018, an 

increase from 9 percent in 2016. 

Exhibit 7: Illinois and Texas investigated a greater percentage of their high

priority complaints late in 2018 than in 2016. 

Source: OIG analysis of ACTS data, 2019.

Texas and Illinois pointed to insufficient staffing to explain their increase in late 

investigations. For example, Texas experienced high staff turnover and difficulty filling 

1%

10%

26% of Illinois' high priority 

complaints were investigated late

43% of Texas' high priority 

complaints were investigated late

2016 2018
Data Brief: States Continued To Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016-2018

OEI-01-19-00421 Results | 13

positions. In Illinois, the number of surveyors remained constant while the number of 

complaints increased. Both States are addressing late investigations by reallocating 

surveyors to assist in areas with more complaints. Specifically, Texas divided the 

workload more uniformly among survey staff. In addition, Texas implemented an 

abbreviated template for investigation reports to reduce the time for surveyors to 

complete complaint investigations. 
Data Brief: States Continued To Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016-2018

OEI-01-19-00421 Conclusion and Recommendations | 14

Our analysis raises questions about some States’ ability to address serious nursing 

home complaints and also about the effectiveness of CMS’s oversight of States. Many 

States are consistently failing to meet required timeframes for investigating the most 

serious nursing home complaints. Generally, we found that the States we 

communicated with face challenges with receiving high volume of complaints,

triaging complaints, and having adequate human resources to investigate complaints. 

CMS has worked with States to address these challenges, yet few States have made 

progress. Moreover, CMS’s survey and certification funding has not increased along 

with the volume of complaints. Complaints have increased by 20 percent since 2013, 

while survey and certification funding has remained flat since 2015. Furthermore, 

CMS told us that it is limited in the enforcement actions it can take against States that 

consistently perform poorly (i.e., withholding funds from States) without further 

undermining a State’s ability to respond to complaints. 

It is imperative that CMS ensure that States improve their timeliness, as late responses 

to complaints could have serious consequences for nursing home residents in those 

States. This is especially important for those States that have consistently investigated 

complaints late over several years. According to CMS, the agency is revising guidance 

on complaint triage processes in the State Operations Manual and plans to train 

States on this guidance. 

In light of our findings we recommend that:

CMS should ensure that all States receive training on CMS’s 

updated triage guidance. 

Assigning the appropriate priority level to complaints ensures that States conduct 

prompt onsite investigations for complaints when warranted. CMS already has plans 

to update its triage guidance. Ensuring that all States receive training on that 

updated guidance could improve States’ timeliness of complaint investigations. 

CMS should identify new approaches to address those States 

that are consistently failing to meet the required timeframes for 

investigating the most serious nursing home complaints. 

States face challenges to conducting timely investigations of serious nursing home 

complaints that extend beyond appropriate triage. Despite CMS tailoring its efforts to 

address each State’s unique challenges with investigating complaints on time, we

CONCLUSION AND RECOMMENDATIONS
Data Brief: States Continued To Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016-2018

OEI-01-19-00421 Conclusion and Recommendations | 15

found that few States made progress, and some States worsened over time. CMS 

should identify new approaches to help these States improve. CMS could identify 

new approaches through a review of best practices implemented in corrective action 

plans or used by States that consistently investigate complaints within required 

timeframes. Such practices may include those that increase investigation efficiency, 

improve State intake and triage processes, and increase performance monitoring. 

CMS could also identify additional nonpunitive actions it can take that would support 

States’ ability to respond and may create incentives for States to improve. 
Data Brief: States Continued To Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016-2018

OEI-01-19-00421 Agency Comments and OIG Response | 16

CMS concurred with our recommendation to ensure that all States receive training on 

CMS’s updated triage guidance. CMS stated that it plans to issue guidance on 

prioritizing complaints and will ensure that States receive appropriate training. CMS 

also noted that it already provides a comprehensive national training program. We 

appreciate CMS’s commitment to training and look forward to the updates on the 

status of its guidance and an accounting of States that have received the training in 

its Final Management Decision. 

CMS also concurred with our recommendation to identify new approaches to address 

those States that are consistently failing to meet required timeframes for investigating 

the most serious nursing home complaints. CMS stated that in April 2018, it launched 

an initiative to evaluate and improve how CMS monitors State performance. CMS 

said that it will assess whether new approaches would help States that are consistently 

failing to meet required timeframes for investigating the most serious nursing home 

complaints. We look forward to receiving CMS’s Final Management Decision, 

including any outcomes from its initiative.

For the full text of CMS’s comments, see Appendix D.

AGENCY COMMENTS AND OIG RESPONSE
Data Brief: States Continued To Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016-2018

OEI-01-19-00421 Methodology | 17

METHODOLOGY 

Our primary source of data for this data brief was Medicare/Medicaid-certified 

nursing home complaints and associated investigation information entered into 

CMS’s Automated Survey Processing Environment Complaints/Incidents Tracking 

System (ACTS) from 2015 through 2018. In addition, we corresponded with State 

survey agency and CMS staff. 

ACTS Data

CMS provided us with data on all Medicare/Medicaid-certified nursing home 

complaints and associated investigation information States entered into ACTS from 

2016 through 2018. We removed 32,921 records in which the State entered a start 

date for the onsite investigation that was prior to the complaint receipt date. Our 

final dataset included 652,335 records from all 50 States and the District of Columbia. 

Complaints can include multiple allegations; each record represents one allegation. 

We did not review facility-reported incidents from nursing homes.

We determined the national and State trends for nursing home complaints between 

2016 and 2018. We analyzed these data to determine: (1) the number of 

nursing home complaints that States received; (2) the percentage of complaints that 

States prioritized as immediate jeopardy and high priority; and (3) the percentage of 

immediate jeopardy and high priority complaints that States investigated onsite 

within required timeframes. To compare across States, we obtained the number of 

nursing home residents for each State from the nursing home resident Minimum Data 

Set 3.0 Public Reports on the CMS website. To determine whether States investigated 

complaints within required timeframes, we excluded weekends and Federal holidays 

and calculated the number of days that elapsed between the complaint receipt date 

and onsite investigation date. We did not exclude State-only holidays from our 

analysis.

We also determined whether States met CMS’s performance threshold for timely 

onsite investigations of high priority nursing home complaints each calendar year. To 

do this, we calculated the percentage of a State’s high priority complaints that it 

investigated within 10 working days each calendar year. We considered the 

performance threshold not met if we calculated the percentage to be under 

95 percent. 

We used data from our previous data brief to determine whether States that 

previously fell short in investigating immediate jeopardy and high priority complaints 

on time have made progress since 2015. For those States, we compared nursing 

home complaint and investigation data from 2015 to nursing home complaint and 

investigation data from 2016 through 2018. Specifically, we compared the number of 
Data Brief: States Continued To Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016-2018

OEI-01-19-00421 Methodology | 18

complaints received, the prioritization of these complaints, and the timeliness of 

complaint investigations. 

Questions to States and CMS Interview 

We sent questions through email to the States identified in this report: Arizona, 

Georgia, Illinois, Maryland, New Jersey, New York, Tennessee, and Texas. We asked 

each of these States about their respective trends in nursing home complaints and 

investigations from 2016 through 2018. In addition, we asked each State about how it 

works with CMS to address late investigations. We also interviewed CMS about CMS’s 

efforts to address late nursing home complaint investigations. 

Review of State Corrective Action Plans

OIG requested States’ corrective action plans for fiscal years 2015 through 2018 from 

each of the 10 CMS Regional Offices. We identified a purposive sample—based on 

CMS Region, State, and year—of 12 corrective action plans from 12 different States

that addressed CMS’s performance measure for timely investigation of high priority 

complaints. We reviewed the sections in these corrective action plans relevant to this 

performance measure and categorized the information based on theme. Finally, we 

used the data from these corrective action plans to provide examples and context but 

did not use them to generalize to all corrective action plans addressing timely 

investigation of high priority complaints. 

Limitations 

We did not assess the extent to which the data in ACTS are complete or the 

appropriateness of State responses to complaints or State investigation results. We 

also did not independently verify the accuracy of the ACTS records. Our analysis is 

based only on ACTS data and not on data collected directly from States or SPSS result 

data from CMS. We acknowledge a discrepancy between the States we identify as 

not meeting CMS’s performance threshold and those that CMS identified. This may 

be because our analysis did not exclude State holidays and was based on the calendar 

year and not the fiscal year. 

Standards

We conducted this study in accordance with the Quality Standards for Inspection and 

Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency.
Data Brief: States Continued To Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016-2018

OEI-01-19-00421 Appendix A | 19

Detailed Background

CMS, in conjunction with States, oversees nursing homes to ensure that they meet 

Federal standards. States conduct certification surveys on behalf of CMS every 

12 months on average, but no less frequently than every 15 months.13 These surveys 

evaluate the safety and quality of care that nursing homes provide.14 In addition, 

States conduct complaint investigations as needed between certification surveys. 

Complaint Investigations

Complaint Intake

CMS instructs States to collect comprehensive information from complainants. 

This information includes, but is not limited to, information about the complainant; 

the nursing home; the individuals involved; a narrative of the allegation; how and why 

the complainant believes the problem leading to the allegation occurred; and the 

complainant’s expectation of the resolution. CMS requires States to enter all data 

regarding complaints into ACTS.

Complaint Priority Levels

Complaints that States prioritize as immediate jeopardy allege a situation in which the 

provider’s noncompliance with Federal requirements has caused, or is likely to cause, 

serious injury, harm, impairment, or death to a resident. States must prioritize and 

investigate these complaints onsite within 2 business days of receiving the complaint. 

To help States identify immediate jeopardy complaints, CMS provides examples of 

circumstances that may indicate immediate jeopardy situations. For example, serious 

injuries such as head trauma or fractures may indicate that the nursing home has 

failed to protect the resident from abuse. 

Complaints that States prioritize as high priority allege a situation in which the 

provider’s noncompliance with Federal requirements may have caused harm that 

negatively affects the resident’s mental, physical, and/or psychosocial status. A high 

priority situation is one that requires a rapid response because of its potential 

consequences to a resident’s well-being. States must investigate high priority

complaints onsite within 10 business days of prioritization. 

For a complaint considered less serious than immediate jeopardy or high priority, 

a State may be required to schedule an onsite survey or to investigate the complaint 

during its next onsite survey at the nursing home. In some cases, a State may perform 

a desk review of the complaint or refer the complaint to a more appropriate agency.

15 

APPENDIX A
Data Brief: States Continued To Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016-2018

OEI-01-19-00421 Appendix B | 20

Trends in Nursing Home Complaints by State, 2016 and 2018

Exhibit B-1: Number and Prioritization of Nursing Home Complaints by 

State, 2016 and 2018

2016 2018

Total 

Number of 

Complaints 

Received

Rate of 

Complaints 

per 1,000 

Residents

Percentage

Immediate 

Jeopardy 

Percentage

High 

Priority 

Total 

Number of 

Complaints 

Received

Rate of 

Complaints 

per 1,000 

Residents

Percentage

Immediate 

Jeopardy

Percentage

High 

Priority

Alabama 199 8.6 31% 26% 127 5.4 14% 31%

Alaska 8 12.9 0% 13% 13 20.5 0% 15%

Arizona 760 61.0 1% 68% 280 22.3 <1% 72%

Arkansas 457 25.2 6% 74% 1,034 58.7 9% 74%

California 7,283 67.3 9% 76% 8,656 80.9 14% 79%

Colorado 419 24.4 6% 64% 533 31.2 8% 56%

Connecticut 441 18.5 <1% 3% 533 23.1 1% 7%

Delaware 72 16.4 3% 81% 188 44.4 2% 90%

District of 

Columbia 50 20.0 2% 26% 41 17.1 0% 0%

Florida 2,539 33.0 1% 13% 2,607 33.8 2% 6%

Georgia 1,155 33.6 72% 24% 1,239 36.1 11% 80%

Hawaii 21 5.5 5% 10% 33 8.7 24% 12%

Idaho 103 25.3 3% 16% 127 30.7 2% 69%

Illinois 4,985 70.7 5% 72% 5,749 84.8 2% 79%

Indiana 2,139 53.2 1% 34% 2,393 59.8 3% 41%

Iowa 856 35.2 5% 65% 916 39.1 3% 65%

Kansas 1,167 64.8 14% 18% 1,325 76.9 12% 33%

Kentucky 666 28.2 44% 55% 746 32.1 32% 67%

Louisiana 537 20.2 13% 50% 583 22.0 14% 45%

Maine 400 64.8 1% 11% 316 53.1 2% 9%

Maryland 1,432 55.8 <1% 78% 1,196 47.8 1% 35%

Massachusetts 358 8.7 <1% 89% 494 12.5 0% 82%

Michigan 3,002 73.4 3% 48% 3,243 80.7 2% 23%

Minnesota 444 17.4 13% 34% 1,224 49.3 5% 16%

Mississippi 240 15.0 15% 76% 223 13.8 24% 75%

Missouri 4,191 108.0 6% 53% 4,284 111.9 9% 67%

Montana 99 22.4 1% 11% 113 26.9 1% 10%

Nebraska 688 58.8 9% 22% 653 57.3 6% 18%

Nevada 202 36.7 1% 9% 309 51.6 1% 45%

New Hampshire 139 20.7 1% 1% 92 14.1 0% 2%

New Jersey 829 18.0 26% 18% 709 15.6 29% 14%

New Mexico 106 17.7 2% 36% 85 14.6 8% 34%

New York 4,333 39.6 2% 35% 2,971 27.6 3% 35%

North Carolina 2,612 68.9 8% 35% 2,883 77.1 7% 27%

North Dakota 32 5.7 0% 3% 31 5.7 3% 3%

Ohio 4,202 54.7 18% 72% 4,465 59.8 8% 83%

APPENDIX B
Data Brief: States Continued To Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016-2018

OEI-01-19-00421 Appendix B | 21

2016 2018

Total 

Number of 

Complaints 

Received

Rate of 

Complaints 

per 1,000 

Residents

Percentage

Immediate 

Jeopardy 

Percentage

High 

Priority 

Total 

Number of 

Complaints 

Received

Rate of 

Complaints 

per 1,000 

Residents

Percentage

Immediate 

Jeopardy

Percentage

High 

Priority

Oklahoma 854 45.3 5% 22% 930 50.1 2% 17%

Oregon 326 39.8 <1% 97% 571 72.6 2% 60%

Pennsylvania 3,143 39.6 2% 58% 3,619 46.4 4% 23%

Rhode Island 354 43.5 0% 1% 327 40.8 1% 5%

South Carolina 164 9.4 4% 92% 148 8.5 5% 89%

South Dakota 89 14.4 8% 33% 27 4.6 15% 59%

Tennessee 917 32.3 56% 43% 1,017 36.1 60% 38%

Texas 9,042 91.9 12% 47% 9,817 102.3 7% 31%

Utah 135 22.9 5% 25% 154 26.6 3% 24%

Vermont 126 47.4 5% 25% 144 58.3 3% 24%

Virginia 484 16.6 1% 10% 512 17.8 1% 11%

Washington 1,920 111.6 2% 45% 2,350 141.4 3% 42%

West Virginia 127 13.2 2% 16% 130 13.6 0% 9%

Wisconsin 1,108 43.1 3% 22% 1,323 56.3 2% 25%

Wyoming 122 49.9 6% 20% 119 50.8 13% 32%

National Total 66,077 47.3 9% 50% 71,602 52.3 7% 47%

Source: OIG analysis of ACTS data, 2019. 
Data Brief: States Continued To Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016-2018

OEI-01-19-00421 Appendix B | 22

Exhibit B-2: Number of Immediate Jeopardy and High Priority Complaints 

Not Investigated Onsite Within Required Timeframes by State, 2016 and 

2018

2016 2018

Number of 

Immediate Jeopardy 

Complaints Not 

Investigated Within 

2 Business Days

Number of High 

Priority Complaints 

Not Investigated 

Within 

10 Business Days

Number of 

Immediate Jeopardy 

Complaints Not 

Investigated Within 

2 Business Days

Number of High 

Priority 

Complaints Not 

Investigated 

Within 

10 Business Days

Alabama 3 1 3 0

Alaska N/A 0 N/A 0

Arizona 1 413 0 179

Arkansas 0 10 2 11

California 4 148 16 131

Colorado 3 52 3 55

Connecticut 0 2 0 4

Delaware 0 50 1 135

District of 

Columbia 0 0 N/A N/A

Florida 3 4 2 10

Georgia 783 246 9 453

Hawaii 0 1 3 1

Idaho 1 13 1 71

Illinois 3 36 2 1,189

Indiana 0 13 0 8

Iowa 0 115 2 372

Kansas 2 10 6 75

Kentucky 11 18 6 68

Louisiana 1 5 1 7

Maine 0 0 0 0

Maryland 1 915 0 269

Massachusetts 1 248 N/A 298

Michigan 3 50 6 91

Minnesota 20 96 37 117

Mississippi 5 13 12 14

Missouri 1 123 0 120

Montana 0 2 1 6

Nebraska 2 3 1 0

Nevada 0 9 0 78

New Hampshire 0 0 N/A 0

New Jersey 156 119 164 77

New Mexico 1 1 0 0

New York 0 1150 0 773

North Carolina 6 19 9 25

North Dakota N/A 0 0 0
Data Brief: States Continued To Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016-2018

OEI-01-19-00421 Appendix B | 23

2016 2018

Number of 

Immediate Jeopardy 

Complaints Not 

Investigated Within 

2 Business Days

Number of High 

Priority Complaints 

Not Investigated 

Within 

10 Business Days

Number of 

Immediate Jeopardy 

Complaints Not 

Investigated Within 

2 Business Days

Number of High 

Priority 

Complaints Not 

Investigated 

Within 

10 Business Days

Ohio 0 6 1 0

Oklahoma 1 3 0 1

Oregon 0 259 0 230

Pennsylvania 1 4 1 115

Rhode Island N/A 2 0 2

South Carolina 1 122 1 50

South Dakota 0 0 0 0

Tennessee 426 290 367 152

Texas 11 420 10 1,304

Utah 0 0 1 4

Vermont 0 0 0 1

Virginia 0 2 0 7

Washington 1 57 0 10

West Virginia 0 2 N/A 3

Wisconsin 0 9 2 24

Wyoming 0 0 0 0

National Total 1,452 5,061 670 6,540

Source: OIG analysis of ACTS data, 2019.

Not Applicable (N/A) - States had none of these complaints to investigate.
Data Brief: States Continued To Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016-2018

OEI-01-19-00421 Appendix C | 24

Trends in Nursing Home Complaints by State, 2011 and 2015

Exhibit C-1: Number and Prioritization of Nursing Home Complaints By 

State, 2011 and 2015

2011 2015

Total 

Number of 

Complaints 

Received

Rate of 

Complaints 

per 1,000 

Residents

Percentage 

of 

Complaints 

Prioritized as 

Immediate 

Jeopardy 

Percentage 

of 

Complaints 

Prioritized 

as High 

Priority 

Total 

Number of 

Complaints 

Received

Rate of 

Complaints 

per 1,000 

Residents

Percentage 

of 

Complaints 

Prioritized as 

Immediate 

Jeopardy 

Percentage 

of 

Complaints 

Prioritized 

as High 

Priority

Alabama 218 9.3 39% 29% 143 6.2 22% 29%

Alaska 19 31.3 0% 16% 9 14.6 0% 33%

Arizona 612 47.5 1% 64% 1,108 89.5 0% 73%

Arkansas 736 39.7 7% 64% 653 36.5 12% 65%

California 227 2.1 3% 62% 6,521 60.5 6% 73%

Colorado 282 17.0 5% 61% 356 21.1 3% 58%

Connecticut 336 12.9 1% 5% 457 18.9 1% 6%

Delaware 238 55.8 0% 19% 79 18.2 0% 87%

District of 

Columbia 26 9.9 4% 12% 63 24.1 0% 3%

Florida 2,135 27.6 4% 44% 2,433 32.0 2% 26%

Georgia 908 26.0 6% 80% 1,081 31.8 44% 35%

Hawaii 16 4.1 6% 13% 8 2.1 0% 0%

Idaho 106 24.8 4% 24% 144 35.4 3% 11%

Illinois 2,687 35.1 1% 41% 4,792 65.6 6% 64%

Indiana 1,442 36.1 4% 42% 1,851 46.2 1% 35%

Iowa 652 25.7 3% 65% 765 31.3 3% 56%

Kansas 797 42.0 3% 11% 972 53.3 8% 14%

Kentucky 667 28.5 24% 66% 685 28.7 46% 51%

Louisiana 447 17.3 24% 64% 553 21.1 27% 37%

Maine 316 49.2 2% 69% 318 51.0 1% 22%

Maryland 1,083 41.8 1% 87% 1,164 45.5 <1% 75%

Massachusetts 525 11.9 0% 91% 442 10.6 1% 65%

Michigan 1,331 31.5 7% 89% 2,977 73.7 4% 75%

Minnesota 362 12.7 19% 58% 877 33.9 7% 24%

Mississippi 269 16.6 6% 68% 213 13.2 22% 74%

Missouri 2,733 69.9 8% 49% 4,070 105.0 9% 52%

Montana 69 14.3 3% 13% 83 18.8 1% 10%

Nebraska 392 30.9 2% 16% 658 54.9 3% 15%

Nevada 221 38.2 1% 19% 211 40.2 <1% 11%

New Hampshire 45 6.3 0% 9% 209 30.7 0% <1%

New Jersey 1,971 41.1 1% 2% 975 21.3 19% 19%

New Mexico 146 23.0 2% 18% 77 12.9 8% 20%

New York 4,569 40.0 2% 33% 4,338 40.0 2% 43%

North Carolina 1,986 51.5 9% 29% 2,391 63.1 8% 34%

North Dakota 29 5.1 0% 3% 37 6.6 3% 0%

APPENDIX C
Data Brief: States Continued To Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016-2018

OEI-01-19-00421 Appendix C | 25

2011 2015

Total 

Number of 

Complaints 

Received

Rate of 

Complaints 

per 1,000 

Residents

Percentage 

of 

Complaints 

Prioritized as 

Immediate 

Jeopardy 

Percentage 

of 

Complaints 

Prioritized 

as High 

Priority 

Total 

Number of 

Complaints 

Received

Rate of 

Complaints 

per 1,000 

Residents

Percentage 

of 

Complaints 

Prioritized as 

Immediate 

Jeopardy 

Percentage 

of 

Complaints 

Prioritized 

as High 

Priority

Ohio 3,111 38.7 7% 52% 2,817 36.5 16% 73%

Oklahoma 1,050 53.3 13% 37% 1,036 54.4 7% 29%

Oregon 262 32.2 0% 89% 310 38.7 0% 89%

Pennsylvania 1,955 24.0 <1% 95% 2,287 28.7 <1% 62%

Rhode Island 324 38.4 0% 3% 436 54.1 0% 11%

South Carolina 114 6.5 8% 87% 207 12.2 4% 93%

South Dakota 10 1.6 0% 30% 101 16.0 1% 13%

Tennessee 698 21.8 25% 64% 892 31.1 49% 49%

Texas 6,975 67.9 10% 56% 8,939 90.0 14% 49%

Utah 128 21.1 5% 15% 152 25.9 5% 18%

Vermont 139 48.5 6% 21% 170 63.9 3% 19%

Virginia 544 18.3 <1% 15% 530 18.4 <1% 16%

Washington 2,127 118.5 4% 69% 1,915 109.0 2% 55%

West Virginia 294 30.2 1% 45% 113 11.7 2% 29%

Wisconsin 874 28.9 5% 19% 1,052 39.8 3% 25%

Wyoming 76 30.9 5% 13% 120 50.3 7% 19%

National Total 47,279 32.7 6% 49.1% 62,790 44.9 8.5% 50.6%

Source: OIG analysis of ACTS data, 2017.
Data Brief: States Continued To Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016-2018

OEI-01-19-00421 Appendix C | 26

Exhibit C-2: Number of Immediate Jeopardy and High Priority Complaints 

Not Investigated Onsite Within Required Timeframes By State, 2011 and 2015

2011 2015

Number of 

Immediate 

Jeopardy 

Complaints Not 

Investigated 

Within 

2 Working Days

Number of High 

Priority 

Complaints Not 

Investigated 

Within 

10 Working Days

Number of 

Immediate 

Jeopardy 

Complaints Not 

Investigated 

Within 

2 Working Days

Number of High 

Priority 

Complaints Not 

Investigated 

Within 

10 Working Days

Alabama 2 1 0 2

Alaska N/A 0 N/A 0

Arizona 0 344 N/A 682

Arkansas 0 7 1 3

California 0 5 6 104

Colorado 3 27 1 25

Connecticut 0 3 1 4

Delaware N/A 34 N/A 44

District of Columbia 0 0 N/A 0

Florida 0 12 0 10

Georgia 6 31 258 185

Hawaii 0 1 N/A N/A

Idaho 0 0 0 9

Illinois 3 390 1 33

Indiana 0 14 0 6

Iowa 0 13 0 49

Kansas 1 5 1 5

Kentucky 4 296 5 10

Louisiana 6 11 4 6

Maine 0 102 0 0

Maryland 0 742 0 648

Massachusetts N/A 183 0 232

Michigan 3 320 2 70

Minnesota 6 18 4 10

Mississippi 2 62 5 22

Missouri 0 64 0 76

Montana 0 1 0 1

Nebraska 0 2 0 3

Nevada 0 13 0 5

New Hampshire N/A 0 N/A 0

New Jersey 0 0 50 138

New Mexico 0 1 0 0

New York 0 448 2 976
Data Brief: States Continued To Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016-2018

OEI-01-19-00421 Appendix C | 27

2011 2015

Number of 

Immediate 

Jeopardy 

Complaints Not 

Investigated 

Within 

2 Working Days

Number of High 

Priority 

Complaints Not 

Investigated 

Within 

10 Working Days

Number of 

Immediate 

Jeopardy 

Complaints Not 

Investigated 

Within 

2 Working Days

Number of High 

Priority 

Complaints Not 

Investigated 

Within 

10 Working Days

North Carolina 7 17 6 108

North Dakota N/A 0 0 N/A

Ohio 1 16 1 2

Oklahoma 1 274 1 2

Oregon N/A 105 N/A 233

Pennsylvania 0 2 0 2

Rhode Island N/A 0 N/A 27

South Carolina 0 59 0 147

South Dakota N/A 0 1 0

Tennessee 136 362 396 374

Texas 6 25 18 400

Utah 0 3 0 1

Vermont 0 6 0 0

Virginia 1 16 0 19

Washington 0 3 0 62

West Virginia 1 30 0 1

Wisconsin 1 7 0 7

Wyoming 0 0 0 0

National Total 190 4,075 764 4,743

Source: OIG analysis of ACTS data, 2017.

Not Applicable (N/A) - States had none of these complaints to investigate.
Data Brief: States Continued To Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016-2018

OEI-01-19-00421 Appendix D | 28

APPENDIX D

Agency Comments
Data Brief: States Continued To Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016-2018

OEI-01-19-00421 Appendix D | 29
Data Brief: States Continued To Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016-2018

OEI-01-19-00421 Appendix D | 30
Data Brief: States Continued To Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016-2018

OEI-01-19-00421 Acknowledgments and Contact | 31

Acknowledgments

Kimberly Ruppert served as the team leader for this study, and Shanna Weitz served 

as the lead analyst. Others in the Office of Evaluation and Inspections who conducted 

the study include Shweta Palakkode. Office of Evaluation and Inspections staff who 

provided support include Joseph Chiarenzelli, Althea Hosein, and Christine Moritz. 

This report was prepared under the direction of Joyce Greenleaf, Regional Inspector 

General for Evaluation and Inspections in the Boston regional office, and Danielle 

Fletcher and Ken Price, Deputy Regional Inspectors General.

Contact

To obtain additional information concerning this report, contact the Office of Public 

Affairs at Public.Affairs@oig.hhs.gov. OIG reports and other information can be found 

on the OIG website at oig.hhs.gov. 

Office of Inspector General

U.S. Department of Health and Human Services

330 Independence Avenue, SW

Washington, DC 20201

ACKNOWLEDGMENTS AND CONTACT
Data Brief: States Continued To Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016-2018

OEI-01-19-00421 Endnotes | 32

1 For this report, we examined only nursing home complaints and not facility-reported incidents. Facility-reported 

incidents are reports made by the nursing home itself in accordance with reporting requirements in 42 CFR 

§ 483.12(c). Complaints are reports alleging noncompliance with Federal and/or State requirements made by 

anyone other than the nursing home (see CMS State Operations Manual, Chapter 5, Section 5010). 

2 OIG, “A Few States Fell Short in Timely Investigation of the Most Serious Nursing Home Complaints: 2011-2015,” 

OEI-01-16-00330, September 2017.

3 Sections 1819(g)(4)(A) and 1919(g)(4)(A) of the Social Security Act

4 CMS State Operations Manual (SOM), Pub. No. 100-07, Ch. 5 – Complaint Procedures (Revised 155, 06-10-16).

5 During the period of our review (2016 – 2018), this provision of the State Operations Manual used 

“working days” in place of “business days.” Effective July 19, 2019, CMS revised Chapter 5 under Rev. 191 and 

replaced “working days” with “business days.”

6 For complaints prioritized as non-immediate jeopardy medium, States must schedule an onsite survey but do 

not need to conduct the survey within a required timeframe. For complaints prioritized as non-immediate 

jeopardy low, States must investigate the complaint during the next onsite survey (see CMS State Operations 

Manual Chapter 5, 5075.9). States may also assign complaints the priority of “administrative review/offsite 

investigation” if an onsite investigation is not necessary. In this case, the State may confirm the findings of the 

administrative review/offsite investigation at the next onsite survey (see CMS State Operations Manual 

Chapter 5, 5075.5). 

7 CMS, “Prioritization of Survey Activities,” Admin Info: QSO-20-20-All, March 23, 2020.

8 CMS, “FY 2020 State Performance Standards System Guidance,” Admin Info: 20-02-ALL, October 17, 2019; 

“FY 2018 State Performance Standards System Guidance,” Admin Info: 18-02-ALL, October 17, 2017. 

9 Ibid.

10 OIG, “A Few States Fell Short in Timely Investigation of the Most Serious Nursing Home Complaints: 2011-2015,” 

OEI-01-16-00330, September 2017.

11 OIG Work Plan, “Nursing Home Oversight During the COVID-19 Public Health Emergency,” OEI-01-20-00430.

12 OIG Work Plan, “Nursing Homes: CMS Oversight of State Survey Agencies,” OEI-06-19-00460.

13 Sections 1819(g)(1)(A) and(g)(2)(A)(iii) and 1919(g)(1)(A) and (g)(2)(A)(iii) of the Social Security Act. 

14 Sections 1819(g)(1)-(2) and 1919(g)(1)-(2) of the Social Security Act.

15 CMS State Operations Manual (SOM), Pub. No. 100-07, Ch. 5 – Complaint Procedures (Revised 155, 06-10-16).

ENDNOTES