When investigating complaints about nursing homes, state survey agencies follow state policies and procedures based on CMS instructions. To oversee state survey agencies’ complaint investigation processes, CMS uses data from its complaints database and State Performance Standards System. CMS’s State Operations Manual outlines procedures for state survey agencies’ investigation of nursing home complaints. This manual is based on requirements in statutes and regulations and includes a detailed protocol for handling complaints and incidents, such as directions for key parts of the complaints process—intake, prioritization, investigation, and reporting of results. Intake. State survey agencies receive complaints via phone calls, e-mails, or letters. At intake, staff review the information provided by the complainant and, because each complaint can have more than one allegation, determine the type(s) of allegations involved, such as resident abuse or poor quality of care. Prioritization. Based on the nature of the allegations, staff assign a priority level to the complaint, which determines if an onsite investigation is required. Four of the eight priority levels require an onsite investigation. (See table 1.) For example, investigations for complaints that allege “immediate jeopardy” to a resident’s health, safety, or life must be started within 2 working days of receipt, while investigations for complaints that allege a high level of actual harm (“actual harm-high”) to a resident must be started within 10 working days of prioritization. Investigation. During the unannounced investigation, state agency surveyors may conduct a document review and observe nursing home conditions. Additionally, surveyors interview witnesses, including the resident about whose care the complaint was filed and other residents with similar care needs, being careful to protect the anonymity of those involved in the complaint. Surveyors determine whether the allegations are substantiated and whether the nursing home should be cited for any deficiencies (failure to meet federal or state quality standards), which may be related or unrelated to the complaint allegations. Deficiencies are categorized according to scope and severity. Scope refers to the number of residents potentially or actually affected and has three levels—isolated, pattern, or widespread. Severity refers to the degree of relative harm and has four levels—immediate jeopardy (actual or potential for death or serious injury), actual harm, potential for more than minimal harm, or potential for minimal harm. Reporting of Results. After the complaint investigation is completed, the state survey agency notifies the complainant and the nursing home of the outcome of the investigation, following guidelines specified in the State Operations Manual. CMS oversees state survey agencies’ complaint investigation processes using its complaints data and State Performance Standards System. CMS’s Complaints Data. As of January 1, 2004, state survey agencies were required to enter data about all complaints and incidents into the ACTS—Automated Survey Processing Environment (ASPEN) Complaints/Incidents Tracking System—database according to guidance provided by CMS. Officials in CMS’s headquarters and regional offices can access all information in ACTS, though the information is stored on individual state servers. CMS provides guidance to state survey agencies regarding ACTS database procedures, including what complaint information states are required to enter. The information is then uploaded into CMS’s national complaints database, which contains a variety of information about complaints, such as the date of the alleged event, the name of the nursing home involved, and the source of the complaint. (See table 2.) State Performance Standards System. CMS’s 10 regional offices are responsible for annually evaluating state survey agencies’ nursing home complaint investigations using four performance standards. (See table 3.) CMS developed the State Performance Standards System in fiscal year 2001 to assess whether state survey agencies were meeting the requirements for the survey and certification program and to identify areas for improvement. In fiscal year 2006, CMS reorganized the performance standards system, and in the following years made several revisions to the four nursing home complaint performance standards. None of the standards focus exclusively on nursing home complaints. For some standards, the scope of review includes incidents as well as complaints, facilities other than nursing homes, or standard surveys as well as complaint investigations. For all except the timeliness standard, the review is based on samples rather than the universe of complaints and incidents. Upon completion of the performance evaluation, CMS regional offices share the results with each respective state survey agency and CMS headquarters, which in turns shares each state’s scores with all of the other states. State survey agencies that fail performance standards must submit corrective action plans to their CMS regional offices, which the regional offices can accept or reject, depending on whether they believe the state has outlined appropriate steps to address poor performance. The regional offices use these plans to follow up with state survey agencies as part of their monitoring activities. CMS’s national complaints data show that state survey agencies received over 50,000 complaints about nursing homes in calendar year 2009. The number and types of complaints varied among states. State survey agencies investigated all but 102 of the complaints that required an investigation. Among complaints that were investigated and uploaded to CMS’s national database for 2009, 19 percent were substantiated with at least one federal deficiency cited. State survey agencies reported receiving 53,313 complaints about nursing homes in 2009. In 2009, 9 states received fewer than 100 complaints while 17 states received more than 1,000. Six states—Illinois, Missouri, New York, Ohio, Texas, and Washington—accounted for roughly half of all 2009 complaints in CMS’s database. Although the number of nursing home residents has remained relatively stable, the number of complaints received generally increased by about 1,000 complaints a year from 2004 to 2008. In 2009, the number of complaints dropped by about 5,000. Complaint Rate. Nationally, in 2009, CMS’s database showed a complaint rate of roughly 38 complaints per 1,000 nursing home residents. The complaint rate ranged from less than 1 (0.77) in South Dakota to about 137 in Washington. Additionally, 11 states received 15 or fewer complaints per 1,000 nursing home residents, while 14 states received more than 45. (See fig. 1.) Submission of Complaints and Sources. CMS data show that state survey agencies received three-quarters of complaints in 2009 by phone. Complaints also were submitted through other means, such as in writing, through e-mail, or in person. In 2009, complaints were typically submitted by family members (47 percent), anonymously (19 percent), or by residents (10 percent). Complaints were also submitted by current nursing home staff or other sources. Prioritization of Complaints. In 2009, among the complaints in CMS’s national data, state survey agencies prioritized most as either actual harm- high (45 percent) or actual harm-medium (33 percent). Roughly 10 percent of complaints were prioritized as immediate jeopardy and about 4 percent were prioritized as actual harm-low. Approximately 8 percent of complaints were prioritized at the four lowest levels and did not require an onsite investigation. State survey agencies varied in the percentage of complaints they prioritized at different levels. For example, 23 state survey agencies prioritized more than 50 percent of complaints as immediate jeopardy or actual harm-high, while 7 state survey agencies prioritized fewer than 10 percent of complaints they received at these two levels. Allegations. Allegations are specific charges within complaints; each complaint can have multiple allegations. In 2009, according to CMS’s national data, the average number of allegations per complaint was 2.3. Allegations that focused on quality of care or treatment accounted for about 40 percent of all allegations in 2009. (See table 4.) CMS data show that in 2009 about 48,900 of the approximately 53,300 complaints received required an investigation and that state survey agencies investigated all but 102 of those complaints. Among those 102 complaints, 25 percent were prioritized as either immediate jeopardy or actual harm-high (6 and 19 percent respectively). The remaining 75 percent were complaints prioritized as actual harm-medium or actual harm-low. The percentage of complaints investigated from 2004 through 2009 remained relatively stable even as the number of complaints increased in all years except 2009. In 2009, an investigation was initiated within CMS’s required time frames for most complaints prioritized as either immediate jeopardy or actual harm-high. Among immediate jeopardy complaints, an investigation was initiated within 2 working days of receiving the complaint for 88 percent of complaints. Among complaints prioritized as actual harm-high, an investigation was initiated within 10 working days of prioritization for 72 percent of complaints. Roughly 19 percent of the complaints that were investigated and uploaded into CMS’s complaints database for 2009 were substantiated with at least one deficiency cited. However, there was considerable variation across states. In 19 states, more than 30 percent of the complaints investigated were substantiated with at least one deficiency cited, while in 5 states, the proportion was less than 10 percent. Of the approximately 16,000 nursing homes nationwide, about 2,800 had one substantiated complaint where at least one deficiency was cited. In addition, about 1,100 nursing homes had two such complaints. The percentage of immediate jeopardy complaints that were substantiated with at least one deficiency cited was higher than for complaints prioritized at lower levels in 2009. According to CMS’s complaints database, roughly 26 percent of the immediate jeopardy complaints that were investigated were substantiated with at least one deficiency cited. Among complaints prioritized at lower levels, the percentage was around 21 percent for actual harm-high complaints, 17 percent for actual harm- medium complaints, and 12 percent for actual harm-low complaints. In 2009, among the complaints prioritized as immediate jeopardy or actual harm-high, the percentage substantiated with at least one deficiency was higher if the investigation was initiated within required time frames than if it was not. For example, among actual harm-high complaints that were investigated within 10 working days of prioritization, 22 percent were substantiated with at least one federal deficiency cited. (See table 5.)