Nearly all nursing homes accept residents with either Medicare or Medicaid and are projected to receive nearly $39 billion in federal payments from these programs in 1999. The federal government, through HCFA, has responsibility for establishing requirements that nursing homes must meet to participate in the Medicare and Medicaid programs and ensuring that these standards are met. HCFA carries out this responsibility by contracting with states to monitor nursing homes. As part of these contracts, the states agree to comply with regulations and other general instructions that HCFA prescribes. The Omnibus Budget Reconciliation Act of 1987 revised the standards for homes’ participation in these federal programs and defined federal and state roles for ensuring that nursing homes meet these standards. In this regulatory framework, states (1) license nursing homes to do business in the state, (2) certify to the federal government, by conducting reviews of nursing homes, that homes are eligible for Medicare and Medicaid payment, and (3) investigate complaints about care provided in the homes. As part of their oversight, the states are required to conduct annual surveys of homes. While the annual surveys seek to provide a nationally uniform process to evaluate whether nursing homes meet a comprehensive range of federal standards, they are often predictable in their timing. Complaint investigations can be less predictable than annual surveys and generally provide a unique opportunity for more frequent state inspections that assess conditions at the nursing home while focusing on specific concerns raised by residents, their families, or other observers. HCFA oversees states’ performance by monitoring at least 5 percent of states’ surveys and by requiring states to develop a quality improvement program that incorporates performance goals and measures in seven required core performance areas--including complaint investigations--and other optional state-identified areas. In addition to the requirement that states establish a complaint investigation process, HCFA requires that states investigate the most serious complaints that allege situations immediately jeopardizing the health or safety of residents within 2 workdays, but leaves the timing, scope, duration, and conduct of other complaint investigations to the discretion of the state survey agency. Thus, states establish their own priorities and time frames for investigating complaints that they determine do not represent immediate jeopardy to resident health and safety. In addition, states require nursing homes to report and investigate incidents such as injuries that might signal neglect or abuse. The state then determines whether it will further investigate the incident. When states conduct a complaint investigation, they attempt to substantiate whether the allegations are valid. If a complaint is substantiated, the state may cite the nursing home for violating either federal or state standards. In such cases, the state agency will require the home to develop an approved plan of correction. The state may choose to take action under the state’s licensing authority, using applicable state remedies and sanctions. If the deficiency relates to federal standards, information regarding the deficiency is also to be reported to HCFA. Serious deficiencies require that the home attain compliance within a set time frame or face enforcement sanctions, such as civil monetary penalties, by HCFA or the state. Both federal and state funds finance the costs state agencies incur in inspecting nursing homes and investigating complaints. In 1998, the federal government paid states about $210 million for the nursing home survey and certification process, including about $42 million (20 percent) for investigating complaints. States contributed an additional $17 million for complaint investigations. On average, federal funds account for 71 percent of states’ complaint investigation expenditures. Table 1 compares these expenditures for the states visited. Appendix II includes additional expenditure information for all states and further discusses the allocation of federal and state shares. Generally, the federal government finances states’ complaint investigation costs for nursing homes in the same proportion that it finances annual and other surveys. Although investigations of complaints filed against nursing homes can provide a valuable opportunity for determining whether the health and safety of residents are threatened, complaint investigation practices do not consistently achieve this goal. Some states use procedures that may discourage the public from filing complaints. Furthermore, some states fail to recognize and promptly respond to complaints that may pose immediate jeopardy to a resident’s health, safety, or life. Likewise, some states do not require that other serious complaints, including those that allege harm to residents, be investigated for months after the complaint’s receipt. Additionally, many complaints are not investigated within states’ required time frames for conducting an investigation. Consequently, we found several instances in which, after an extended delay, the complaint investigators substantiated that residents had been harmed and other cases in which the state was unable to determine whether the allegations were true partly because so much time had elapsed since the complaint was received. Because nursing home residents and the public need an effective and expedient means to seek correction of problems that they perceive endanger the health and safety of nursing home residents, the process of filing a complaint should not place an unnecessary burden on the complainant. Nevertheless, some states we reviewed have procedures or practices that may limit the number of complaints. For example, when a person calls with a complaint, Maryland and Michigan encourage him or her to submit the complaint in writing. Michigan requires that either complainants write a complaint or the state will provide assistance in writing the complaint. About 95 percent of publicly reported complaints were submitted in writing between July 1997 and June 1998. Maryland’s policy is to accept and act on a complaint by phone even though callers are encouraged to submit a written complaint. However, state officials provided us conflicting information as to whether calls would be consistently documented and investigated when callers agreed to submit a written complaint but did not do so. Over 70 percent of Maryland’s publicly reported complaints that the state investigated were identified as written complaints between July 1997 and June 1998. In contrast, Washington readily accepts complaints by phone and nearly all complaints are received by phone. This contributes to Washington receiving a considerably higher number of complaints than Michigan or Maryland. See table 2 for a comparison of the total number of nursing home complaints received in a year by these states. When a complaint is received, the state agency ascertains its potential seriousness. HCFA requires that complaints that may involve immediate jeopardy of a resident’s health, safety, or life be investigated by states within 2 workdays of receipt. For other complaints, states are permitted to establish their own categories and time frames for investigation. States have established varying time requirements for complaint responses and varying criteria for prioritizing these complaints, including criteria for complaints that may involve a significant risk of actual harm to nursing home residents. Some states permit relatively long periods of time to pass between the receipt of all such complaints and their investigation. For example, for complaints that may involve significant risk of actual harm to residents, Michigan’s statute allows 30 days, but in 1998 Michigan’s operating practice was to allow 45 days; Tennessee allows 60 days; and, Kansas allows 180 days. Some states have established other priority categories with similar time frame classifications, but their criteria for determining which complaints to include in these classifications differ substantially. Maryland and Washington both have classification schemes that include categories for complaints to be investigated within 2, 10, or 45 workdays or at the next on- site investigation. Similarly, Pennsylvania classifies complaints to be investigated within 2, 5, 10, or 45 workdays or at the next on-site survey. Criteria for complaints to be included in the 10-day category for Washington and Pennsylvania are similar. Washington’s 10-day category includes complaints alleging significant potential harm to a resident’s physical and/or mental health or safety. Similarly, Pennsylvania characterizes 10-day complaints as those in which residents’ needs, including medical, nursing, and dietary, are not being met. Maryland’s 10- day time frame states that complaints in this category are those that appear to be especially significant, sensitive, or could attract broad public attention; those forwarded from a government or public official; and those where the provider has a history of poor performance relative to the allegations. States sometimes place complaints in an inappropriately low investigation category, thus postponing a prompt review. The infrequent use of high- priority levels in some states raises a question as to whether complaints are being appropriately categorized. Some states have explicit procedures or operating practices that result in the downgrading of a complaint’s severity. We found several instances of complaints that, in our opinion, were inappropriately placed in a low-priority category. As shown in table 3, two of the three states we visited seldom placed complaints in the immediate jeopardy category for the 1-year period we analyzed. Maryland did not identify a single complaint as potentially representing immediate jeopardy. Michigan did prioritize some complaints as immediate jeopardy, but they accounted for only 2 percent of total complaints received. The Pennsylvania state auditor also noted that the number of complaints considered immediate jeopardy in that state had dropped considerably during the first quarter of 1998 in comparison to earlier years, raising the auditor’s skepticism and concern. Some states also categorized relatively few complaints in other high- priority categories, such as those that should be investigated within 10 days. For example, Maryland placed most complaints in its lowest-priority category–to be investigated at the next on-site survey. This contrasts with Washington, which categorized nearly 90 percent of its complaints to be investigated within either 2 or 10 workdays. Table 4 compares the use of similar priority time frames among the states visited. Several states have explicit procedures or operating practices that place serious complaints in lower-priority categories. A Maryland official, for example, acknowledged reducing the priority of some complaints because the state recognized that it could not meet shorter time frames because of insufficient staff. Similarly, a Michigan official also told us that her office gives a complaint low priority if the resident is no longer at the nursing home when the complaint is received--even if the resident died or was transferred to a hospital or another nursing home. The state may investigate these complaints during the home’s next survey or not at all. Failure to investigate such a complaint in a timely manner may compromise the health and safety of other residents who may also be affected by problems cited in the complaint.