HHS OIG Data Brief • September 2017 • OEI-01-16-00330 A Few States Fell Short in Timely Investigation of the Most Serious Nursing Home Complaints: 2011–2015 Key Takeaways: This Data Brief In this data brief, the Office of Inspector  Overall, States received one-third more General (OIG) highlights the extent to nursing home complaints in 2015 than which State survey agencies (hereinafter, in 2011 States) met onsite investigation timeframes for the most serious nursing home  States prioritized more than half of complaints from 2011 through 2015. It nursing home complaints into the most serious categories—“immediate updates our 2006 report and offers the jeopardy” and “high priority”—which Centers for Medicare & Medicaid Services require onsite investigations within 2 or (CMS) some insights into the States that 10 working days, respectively have room to improve in prioritizing and responding to nursing home complaints.  States conducted nearly all of the required onsite investigations for the Introduction most serious nursing home complaints The nursing home complaint process is a critical safeguard to protect vulnerable  Although almost all States conducted residents of nursing homes. CMS relies on most of their onsite investigations the States’ respective survey agencies to within required timeframes, a few serve as the front-line responders to States fell short address health and safety concerns raised  Two States accounted for most of the by residents, their families, and nursing late investigations of immediate home staff.1 Examples of concerns that jeopardy complaints might result in a complaint are residents being left sitting in their urine and feces for  Four States accounted for almost half hours, residents being admitted to the of the late investigations of high priority hospital because of preventable infections, complaints and inappropriate social media posts by nursing home employees.  Almost one-quarter of States did not meet CMS’s performance threshold for States must conduct onsite investigations timely onsite investigations of high within certain timeframes for the two most priority complaints in all 5 years serious levels of complaints—those that allege serious injury or harm to a nursing  States substantiated almost one-third of the most serious nursing home home resident and require a rapid complaints each year response to address the complaint and ensure residents’ safety. However, previous reports by the OIG and the Government Accountability Office (GAO) found that States did not conduct onsite investigations within the required timeframes for some of these complaints.2,3 CMS provides States with procedural guidelines for investigating complaints for Medicare/Medicaid-certified nursing homes.4 CMS provides a detailed protocol for States on the process that includes complaint intake, prioritization, and investigation. CMS requires that each complaint be prioritized by a qualified professional who has knowledge of current clinical standards and Federal requirements. The priority level that the State assigns to a complaint is critical because it determines the State’s required action and timeframe for investigating. The two highest priority levels are immediate jeopardy and non-immediate jeopardy—high (high priority), which States must investigate onsite within 2 and 10 working days, respectively. See Exhibit 1 for complaint priority levels and definitions. Exhibit 1: Nursing Home Complaint Priority Levels Source: CMS State Operations Manual, ch. 5, “Complaint Procedures,” (Revised 120, 09-19-14). In addition to assigning a priority level to complaints, States categorize each allegation within a complaint by type. (A complaint can consist of more than one allegation.) Some examples of allegation categories are quality of care, resident neglect, and violation of resident rights. DATA BRIEF: Nursing Home Complaints (OEI-01-16-00330) 2 During its investigation, the State determines whether to substantiate the complaint and may cite the nursing home for deficiencies related or unrelated to the complaint. The State cites the nursing home for a deficiency when the facility is not compliant with specific Federal requirements. CMS instructs surveyors to substantiate an allegation when the State verifies it with evidence, even if the noncompliance has been corrected. Every year, CMS evaluates each State’s performance in carrying out all its survey and certification responsibilities including, but not limited to, responding to complaints at nursing homes. CMS uses its State Performance Standards System to ensure that the States meet Federal requirements and to identify areas for improvement. As part of this evaluation, CMS reviews the timeliness of States’ complaint investigations for nursing homes and other facilities. For additional background, see Appendix A. Our primary source of data for this data brief was complaints regarding Medicare/Medicaid-certified nursing homes and associated investigation information entered into CMS’s Automated Survey Processing Environment Complaints/Incidents Tracking System (ACTS) from 2011 through 2015. For a detailed methodology, see Appendix B. 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. To complement this data brief, OIG has published an interactive map illustrating State-by-State trends in nursing home complaints. The interactive map is available at https://oig.hhs.gov/oei/maps/nursing-home/. RESULTS Overall, States received one-third more nursing home complaints in 2015 than in 2011 While the number of nursing home residents decreased slightly between 2011 and 2015, the number of nursing home complaints States received increased 33 percent, from 47,279 to 62,790. Over this 5-year period, the number of complaints that States received per 1,000 nursing home residents increased from 32.7 to 44.9 complaints per year (see Exhibit 2). DATA BRIEF: Nursing Home Complaints (OEI-01-16-00330) 3 Exhibit 2: Rate of Complaints per 1,000 Nursing Home Residents, 2011–2015 Source: OIG analysis of ACTS data and CMS Minimum Data Set (MDS) 3.0 Frequency Report, 2017. State trends in nursing home complaints varied between 2011 and 2015. Thirty-five States had increases in the number of complaints during this time, with increases of 50 percent or more in 11 of those States. In contrast, 16 States had decreases in the number of complaints, with decreases of 50 percent or more in 5 of those States. In addition, the number of nursing home complaints received varied from one State to another. For example, in 2015 the number of complaints that States received ranged from 2.1 per 1,000 nursing home residents to 109 per 1,000 residents (see Exhibit 3). Across all 5 years, Hawaii generally had few complaints—an average of 3.3 per 1,000 residents—while Washington consistently had the highest number of complaints, with an average of 108.7 complaints per 1,000 residents. Exhibit C-1 in Appendix C provides details on the number of nursing home complaints that each State received. DATA BRIEF: Nursing Home Complaints (OEI-01-16-00330) 4 Exhibit 3: Rate of Complaints per 1,000 Nursing Home Residents by State in 2015 Source: OIG analysis of ACTS data, 2017. *In this report, we refer to the District of Columbia as a State. Note: See https://oig.hhs.gov/oei/maps/nursing-home/ for rates of complaints for years 2011–2015 by State. Each year, half of all nursing home complaints required prompt onsite investigation The priority level that the State assigns to each nursing home complaint determines the State’s required action and timeframe for addressing the complaint. The two most serious priority levels of complaints—immediate jeopardy and high priority—require the State to conduct an onsite investigation within 2 working days or 10 working days, respectively, to address the complaint and ensure the resident’s safety. DATA BRIEF: Nursing Home Complaints (OEI-01-16-00330) 5 In 2015, States prioritized 59 percent of complaints as either immediate jeopardy or high priority, compared to 55 percent in 2011 Each year, States prioritized about 7 percent of complaints as immediate jeopardy, a level that requires a State to conduct an onsite investigation within 2 working days. Although the proportion of total complaints remained about 7 percent, the number of immediate jeopardy complaints almost doubled during this time, from 2,844 to 5,341. In addition, States prioritized about 50 percent of complaints each year as high priority, a level that requires a State to investigate onsite within 10 working days (see Exhibit 4). Exhibit 4: Percentage of Nursing Home Complaints That States Prioritized for Prompt Onsite Investigation: 2011–2015 Source: OIG analysis of ACTS data, 2017. The percentage of complaints that States prioritized as immediate jeopardy and high priority varied from one State to another. For example, in 2015, eight States did not prioritize any complaints as immediate jeopardy while three States (Georgia, Kentucky, and Tennessee) prioritized over 40 percent of their complaints as immediate jeopardy. Of the eight States that prioritized no complaints as immediate jeopardy in 2015, three States—New Hampshire, Oregon, and Rhode Island—prioritized no complaints as immediate jeopardy during the entire 5-year period we analyzed. We also found variation from one State to another in the percentages of complaints that they prioritized as high priority. For example, in 2015, Hawaii and North Dakota DATA BRIEF: Nursing Home Complaints (OEI-01-16-00330) 6 prioritized no complaints as high priority while 18 States prioritized more than 50 percent of complaints as high priority. Furthermore, North Dakota prioritized no complaints as high priority in 4 of the 5 years we analyzed. Exhibit C-1 in Appendix C provides details on the percentages of nursing home complaints that each State prioritized as immediate jeopardy and high priority. Among the most serious complaints, the most common allegations related to quality of care or treatment Between 2011 and 2015, for complaints prioritized as immediate jeopardy or high priority, States categorized an average of 42 percent of the allegations as relating to quality of care or treatment. In 2015, allegations regarding quality of care or treatment were the most common (41 percent), followed by allegations regarding resident neglect (12 percent) and resident rights (8 percent). See Exhibit 5 for examples of allegations in each category and the percentages of total allegations for these categories in 2015. Exhibit 5: Percentages of the Types of Allegations Associated With the Most Serious Nursing Home Complaints in 2015, with Examples Source: OIG analysis of ACTS data and examples provided by CMS, 2017. DATA BRIEF: Nursing Home Complaints (OEI-01-16-00330) 7 States conducted nearly all required onsite investigations for the most serious nursing home complaints each year Over this 5-year period, States did not investigate 9 immediate jeopardy and 166 high priority nursing home complaints onsite, representing less than 1 percent of these complaints collectively. States received about half of these complaints in 2015 (see Exhibit 6). For immediate jeopardy complaints, no State missed more than two required onsite investigations in any year. For high priority complaints, however, 4 States—Arizona, California, Delaware, and New Jersey—missed onsite investigations for more than 10 high priority complaints in at least 1 of the 5 years. Being onsite allows surveyors to directly observe the conditions and care practices at a nursing home. Exhibit 6: Number of Immediate Jeopardy and High Priority Complaints Without Onsite Investigations, 2011–2015 Number of nursing home complaints without onsite investigations Year Immediate Jeopardy Complaints High Priority Complaints 2011 0 of 2,844 total complaints 9 of 23,221 total complaints 2012 0 of 3,329 21 of 25,715 2013 3 of 3,905 16 of 26,681 2014 2 of 5,009 37 of 28,810 2015 4 of 5,341 83 of 31,748 Total 9 of 20,428 166 of 136,175 Source: OIG analysis of ACTS data, 2017. Although almost all States conducted most of their onsite investigations within required timeframes, a few States fell short The potential for further harm to nursing home residents makes it essential that States conduct prompt onsite investigations of immediate jeopardy and high priority complaints. Two States accounted for most of the late investigations of immediate jeopardy complaints Each year, Tennessee and Georgia accounted for over half of the immediate jeopardy complaints that were not investigated within 2 working days. Across the 5-year period, Tennessee accounted for most of the immediate jeopardy complaints that were DATA BRIEF: Nursing Home Complaints (OEI-01-16-00330) 8 investigated within 2 working days, whereas until 2015 Georgia had accounted for only a few of the late investigations. In 2015, Tennessee and Georgia received a total of 912 immediate jeopardy complaints (17 percent of all immediate jeopardy complaints). Of these 912 complaints, they investigated 654 complaints late. These 654 complaints constituted 86 percent of the 764 immediate jeopardy complaints nationwide that were investigated late (see Exhibit 7). Nationwide, the percentage of immediate jeopardy complaints that States did not investigate within 2 working days was 14 percent in 2015, compared to 7 percent in 2011. For the 49 States other than Tennessee and Georgia, the overall percentage of immediate jeopardy complaints not investigated within 2 working days was about 2 percent each year. Exhibit 7: Number of Immediate Jeopardy Complaints Not Investigated Onsite Within 2 Working Days: 2011–2015 Source: OIG analysis of ACTS data, 2017. CMS states that it is working with Tennessee to address a backlog of complaints, which the State attributed to insufficient staff and loss of institutional knowledge as a result of staff turnover. CMS stated that vacancies contributed in a similar fashion to Georgia’s late complaint investigations, and that the State is working to hire additional surveyors. DATA BRIEF: Nursing Home Complaints (OEI-01-16-00330) 9 CMS noted that both States have hired contractors to help conduct surveys. Exhibit C-2 in Appendix C provides details on each State’s number of immediate jeopardy nursing home complaints not investigated within required timeframes. Furthermore, these two States investigated many immediate jeopardy complaints weeks late. For example, in 2015, Tennessee and Georgia accounted for almost all of the immediate jeopardy complaints (467 of 473) that States investigated onsite 15 or more days after complaint receipt (see Exhibit 8). Exhibit 8: Number of Immediate Jeopardy Complaints Investigated by Number of Workdays From Complaint Receipt, 2015 Source: OIG analysis of ACTS data, 2017. Note: See Appendix D for national data on the number of immediate jeopardy complaints investigated by the number of workdays from complaint receipt for 2011 through 2015. Four States accounted for almost half of the late investigations of high priority complaints As was the case with immediate jeopardy complaints, some States accounted for a higher number of late onsite investigations of high priority complaints than did others. Across all 5 years, Arizona, Maryland, New York, and Tennessee accounted for almost half of the high priority complaints not investigated onsite within 10 working days. For example, in 2015, these four States did not investigate 2,680 of 4,743 high priority complaints (57 percent) within the required timeframes (see Exhibit 9). In 2015, these four States accounted for 13 percent of all high priority complaints. The national DATA BRIEF: Nursing Home Complaints (OEI-01-16-00330) 10 percentage of high priority complaints not investigated within 10 working days was 15 percent in 2015, compared to 18 percent in 2011. For the 47 States other than these 4, the overall percentage of high priority complaints not investigated within 10 working days was 7 percent in 2015, compared to 11 percent in 2011. Exhibit 9: Number of High Priority Complaints Not Investigated Onsite Within 10 Working Days: 2011–2015 Source: OIG analysis of ACTS data, 2017. Furthermore, these four States investigated many high priority complaints weeks late. For example, in 2015, these States accounted for two-thirds (2,067 of 3,043) of high priority complaints that States investigated onsite 26 days or more after complaint receipt (see Exhibit 10). According to CMS, these States generally faced challenges related to staff shortages and are working to improve response times for complaint investigations. Exhibit C-2 in Appendix C provides details on the each State’s number of high priority nursing home complaints not investigated within required timeframes. DATA BRIEF: Nursing Home Complaints (OEI-01-16-00330) 11 Exhibit 10: Number of High Priority Complaints Investigated by Number of Workdays From Complaint Receipt, 2015 Source: OIG analysis of ACTS data, 2017. Note: See Appendix D for national data on the number of high priority complaints investigated by the number of workdays from complaint receipt for years 2011 through 2015. Almost one-quarter of States did not meet CMS’s performance threshold for timely onsite investigations of high priority complaints in all 5 years Although CMS requires that States investigate all high priority nursing home complaints onsite within 10 working days, it will impose a sanction or remedy when a State does not investigate 95 percent of these complaints within that timeframe.5 Eleven States (22 percent) did not meet CMS’s performance threshold for timely onsite investigations of high priority nursing home complaints every year between 2011 and 2015 (see Exhibit 11). In addition, Colorado, Connecticut, Iowa, and Maine did not meet CMS’s threshold for 4 of these 5 years. Furthermore, Mississippi, and Tennessee did not conduct onsite investigations for 95 percent of the immediate jeopardy nursing home complaints they received each year. We cannot determine whether these States met CMS’s annual performance threshold for timely investigation of immediate jeopardy DATA BRIEF: Nursing Home Complaints (OEI-01-16-00330) 12 complaints because CMS includes other facilities with nursing homes in its calculations for this performance threshold. However, these 2 States are included among the 11 States that did not meet CMS’s performance threshold for timely investigations of high priority complaints each year. Exhibit 11: States That Did Not Meet CMS’s Performance Threshold for Timely Investigations of High Priority Nursing Home Complaints Every Year Between 2011 and 2015 Source: OIG analysis of ACTS data, 2017. *In this report, we refer to the District of Columbia as a State. States substantiated almost one-third of the most serious nursing home complaints Between 2011 and 2015, States substantiated 31 percent, on average, of the immediate jeopardy and high priority nursing home complaints that they investigated (see Exhibit 12).6 When we analyzed the two priority levels of complaints separately, we found little difference between the average percentages substantiated for each priority level—on average, States substantiated 34 percent of immediate jeopardy complaints and 30 percent of high priority complaints. DATA BRIEF: Nursing Home Complaints (OEI-01-16-00330) 13 Exhibit 12: Average Percentage of the Most Serious Nursing Home Complaints That States Substantiated, 2011–2015 Source: OIG analysis of ACTS data, 2017. States varied in the percentage of complaints they substantiated. CMS instructs According to CMS, how States apply CMS’s definition of surveyors to substantiation may not be consistent from one State to another. For substantiate an example, following an investigation, a State confirmed that a resident fell and dislocated a shoulder as alleged in the resident’s complaint, allegation when the but the State had insufficient evidence to support a Federal deficiency. State verifies it with In this example, some States would consider the complaint evidence, even if the substantiated because the resident did fall and did dislocate a noncompliance has shoulder; however, other States would consider the complaint been corrected. unsubstantiated because the State did not cite a Federal deficiency. For States that in 2015 investigated most than 20 of the most serious complaints (i.e., immediate jeopardy and high priority complaints), the percentages of the complaints that they substantiated ranged from 4 percent to 82 percent. Six States substantiated more than 50 percent of their most serious complaints, whereas only Rhode Island substantiated less than 10 percent of its most serious complaints. Exhibit C-3 in Appendix C provides details on the percentages of immediate jeopardy and high priority nursing home complaints that each State substantiated. DATA BRIEF: Nursing Home Complaints (OEI-01-16-00330) 14 CONCLUSION Overall, nursing home complaints rose by one-third across States from 2011 to 2015, while the number of nursing home residents decreased about 3 percent. However, we do not know whether an increase in complaints represents a decrease in quality of care. Other factors may contribute to an increase in complaints, such as more accessible and user-friendly options to file complaints, better tracking of complaints, or possibly an increased willingness among consumers to report on their nursing home experiences. This data brief raises questions about how some States respond to complaints, as these responses could have serious consequences for nursing home residents in those States. Residents and their families rely on a functioning complaint system to take their complaints seriously and to investigate them appropriately. A functioning complaint system also complements other oversight efforts, such as routine surveys. However, a handful of States accounted for about half of the late investigations of the most serious nursing home complaints, with most such investigations being weeks late. Further, some States never prioritized any complaints as immediate jeopardy. This data brief offers CMS some insights into the States that have room to improve in prioritizing and responding to nursing home complaints. Nursing home residents are a vulnerable population, and States serve as the front-line responders in addressing concerns raised by residents, their families, and nursing home staff. To ensure the health and safety of nursing home residents, CMS must remain vigilant and assist the States that are falling short in meeting timeframes for investigations of complaints. OIG will continue to monitor the oversight of nursing homes and will initiate additional reviews as necessary. DATA BRIEF: Nursing Home Complaints (OEI-01-16-00330) 15 APPENDIX A: DETAILED BACKGROUND Nursing Home Oversight CMS, in conjunction with States, oversees nursing homes to ensure that they meet Federal standards. States conduct certification surveys on behalf of CMS on average every 12 months but no less frequently than every 15 months.7 These surveys evaluate the safety and quality of care that nursing homes provide.8 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 and incidents 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 working 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 working 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. Complaint Investigation and Substantiation The State will determine during its investigation whether to substantiate the complaint and may cite the nursing home for Federal deficiencies related or unrelated to the DATA BRIEF: Nursing Home Complaints (OEI-01-16-00330) 16 complaint. CMS also requires that the State follow up with the nursing home after its investigation and provide information to the complainant. When a State investigation cites a Federal deficiency at the level of immediate jeopardy, CMS requires the State to revisit the facility and confirm removal of the immediate jeopardy. The facility must remove the immediate jeopardy no later than 23 days from the last day of the State’s investigation.9 The State should also impose other remedies such as monetary fines or State monitoring and require a corrective action plan to address any underlying deficiencies. When a State investigation cites a deficiency but immediate jeopardy does not exist, the State may (1) require a corrective action plan to address deficiencies, (2) impose monetary penalties or other remedies, and/or (3) revisit the nursing home. The facility must resolve any noncompliance no later than 6 months from the last day of the State’s investigation. State Performance Standards System Every year, CMS evaluates each State’s performance in carrying out all its survey and certification responsibilities. The State Performance Standards System consists of 19 measures across 3 categories of performance standards: frequency; quality; and enforcement and remedy. Under the quality standard, CMS reviews the timeliness of States’ investigations of complaints and facility-reported incidents for nursing homes and other facilities.10 Although CMS requires States to investigate all immediate jeopardy and high priority nursing home complaints onsite within certain timeframes, the threshold by which it measures States’ performance is lower. For purposes of the State Performance Standards System, States must conduct onsite investigations within 2 working days for 95 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 is for States to conduct onsite investigations within 10 working days for 95 percent of the high priority complaints they receive. If a State does not meet one of these performance thresholds, CMS provides the State with a corrective action plan and follows up on the State’s implementation of the plan.11 DATA BRIEF: Nursing Home Complaints (OEI-01-16-00330) 17 APPENDIX B: DETAILED METHODOLOGY Our primary data source for this data brief was all nursing home complaints and associated investigation information entered in ACTS from 2011 through 2015. We also interviewed CMS staff. ACTS Data CMS provided us with data on all Medicare/Medicaid-certified nursing home complaints and facility-reported incidents and associated investigation information entered into ACTS from 2011 through 2015. We removed records in which the State entered a start date for the onsite investigation that was prior to the complaint receipt date (42,869 records). Our final dataset included 874,972 records from all 50 States and the District of Columbia. Complaints and incidents can include multiple allegations; each record represents one allegation. We analyzed these data using SAS to determine national and State trends for nursing home complaints between 2011 and 2015. 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; (3) the percentage of immediate jeopardy and high priority complaints that States investigated onsite within required timeframes; and (4) the percentage of immediate jeopardy and high priority complaints that States substantiated. To compare across States, we obtained the number of nursing home residents for each State from the nursing home resident Minimum Data Set 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. CMS Interviews We conducted interviews with CMS staff to learn about ACTS data and how States use ACTS. Nursing Home Incidents In addition to receiving complaints, States also receive reports of and respond to nursing home incidents. Incidents are self-reported by the nursing home, whereas complaints come from all other sources, including residents, family members, and nursing home staff. Nursing homes must self-report incidents that involve any suspected mistreatment, abuse, neglect, or misappropriation of resident property. States triage and prioritize incidents in the same manner as complaints. In addition, CMS holds States to the same timeframe requirements for onsite investigation of incidents prioritized as immediate jeopardy or high priority. We analyzed data on incidents in addition to complaints, but for the purposes of this data brief, we reported DATA BRIEF: Nursing Home Complaints (OEI-01-16-00330) 18 results only on complaints. We did this because CMS told us that complaints and incidents could be redundant—i.e., a State might record a single situation in ACTS as an incident as well as a complaint. In addition, our analysis of incidents revealed similar patterns as our analysis of complaints (See Appendix E). Limitations Our analysis had some limitations. We did not assess the extent to which the data in ACTS are complete or the appropriateness of State responses to complaints or of 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 information collected directly from States. DATA BRIEF: Nursing Home Complaints (OEI-01-16-00330) 19 APPENDIX C: 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 Percentage Percentage of Percentage of Percentage Complaints of Complaints of Total Rate of Prioritized Complaints Total Rate of Prioritized Complaints Number of Complaints as Prioritized Number of Complaints as Prioritized Complaints per 1,000 Immediate as High Complaints per 1,000 Immediate as High Received Residents Jeopardy Priority Received Residents Jeopardy 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% Ohio 3,111 38.7 7% 52% 2,817 36.5 16% 73% DATA BRIEF: Nursing Home Complaints (OEI-01-16-00330) 20 2011 2015 Percentage Percentage of Percentage of Percentage Complaints of Complaints of Total Rate of Prioritized Complaints Total Rate of Prioritized Complaints Number of Complaints as Prioritized Number of Complaints as Prioritized Complaints per 1,000 Immediate as High Complaints per 1,000 Immediate as High Received Residents Jeopardy Priority Received Residents Jeopardy Priority 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: Nursing Home Complaints (OEI-01-16-00330) 21 Exhibit C-2: Number of Immediate Jeopardy and High Prority Complaints Not Investigated Onsite Within Required Timeframes By State, 2011 and 2015 2011 2015 Number of Number of Immediate Number of Immediate Number of Jeopardy High Priority Jeopardy High Priority Complaints Complaints Complaints Complaints Not Not Not Not Investigated Investigated Investigated Investigated Within Within Within Within 2 Working 10 Working 2 Working 10 Working Days Days Days 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 North Carolina 7 17 6 108 North Dakota N/A 0 0 N/A Ohio 1 16 1 2 DATA BRIEF: Nursing Home Complaints (OEI-01-16-00330) 22 2011 2015 Number of Number of Immediate Number of Immediate Number of Jeopardy High Priority Jeopardy High Priority Complaints Complaints Complaints Complaints Not Not Not Not Investigated Investigated Investigated Investigated Within Within Within Within 2 Working 10 Working 2 Working 10 Working Days Days Days Days 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: Nursing Home Complaints (OEI-01-16-00330) 23 Exhibit C-3: Number of Immediate Jeopardy and High Priority Complaints Investigated Onsite and Substantiatated by State, 2011 and 2015 2011 2015 Number of Number of Immediate Number (and Immediate Number (and Jeopardy Percentage) of Jeopardy Percentage) of and High Immediate and High Immediate Priority Jeopardy and Priority Jeopardy and Complaints High Priority Complaints High Priority Investigated Complaints Investigated Complaints Onsite Substantiated Onsite Substantiated Alabama 148 59 (40%) 72 21 (29%) Alaska 3 1 (33%) 3 1 (33%) Arizona 395 136 (34%) 786 132 (17%) Arkansas 525 230 (44%) 497 205 (41%) California 147 103 (70%) 5,148 1,900 (37%) Colorado 186 135 (73%) 217 116 (53%) Connecticut 20 13 (65%) 31 22 (71%) Delaware 44 28 (64%) 54 16 (30%) District of Columbia 4 1 (25%) 2 1 (50%) Florida 1,026 350 (34%) 694 241 (35%) Georgia 779 207 (27%) 853 140 (16%) Hawaii 2 1 (50%) N/A N/A N/A Idaho 29 16 (55%) 21 15 (71%) Illinois 1,146 587 (51%) 3,370 1,532 (45%) Indiana 672 468 (70%) 671 552 (82%) Iowa 446 192 (43%) 451 188 (42%) Kansas 110 53 (48%) 211 87 (41%) Kentucky 601 254 (42%) 665 158 (24%) Louisiana 393 211 (54%) 356 119 (33%) Maine 224 34 (15%) 72 15 (21%) Maryland 951 354 (37%) 881 327 (37%) Massachusetts 478 117 (24%) 288 69 (24%) Michigan 1,271 646 (51%) 2,351 1,009 (43%) Minnesota 277 33 (12%) 273 49 (18%) Mississippi 198 89 (45%) 204 53 (26%) Missouri 1,565 273 (17%) 2,458 342 (14%) Montana 11 6 (55%) 9 5 (56%) Nebraska 67 33 (49%) 117 44 (38%) Nevada 45 21 (47%) 25 7 (28%) New Hampshire 4 1 (25%) 1 0 N/A DATA BRIEF: Nursing Home Complaints (OEI-01-16-00330) 24 2011 2015 Number of Number of Immediate Number (and Immediate Number (and Jeopardy Percentage) of Jeopardy Percentage) of and High Immediate and High Immediate Priority Jeopardy and Priority Jeopardy and Complaints High Priority Complaints High Priority Investigated Complaints Investigated Complaints Onsite Substantiated Onsite Substantiated New Jersey 54 11 (20%) 354 109 (31%) New Mexico 29 11 (38%) 21 8 (38%) New York 1,608 172 (11%) 1,961 218 (11%) North Carolina 764 146 (19%) 981 207 (21%) North Dakota 1 1 (100%) 1 1 (100%) Ohio 1,844 667 (36%) 2,486 626 (25%) Oklahoma 515 194 (38%) 372 130 (35%) Oregon 232 80 (34%) 276 112 (41%) Pennsylvania 1,858 454 (24%) 1,417 506 (36%) Rhode Island 11 3 (27%) 47 2 (4%) South Carolina 108 38 (35%) 201 54 (27%) South Dakota 3 3 (100%) 14 10 (71%) Tennessee 616 174 (28%) 873 217 (25%) Texas 4,601 965 (21%) 5,609 947 (17%) Utah 25 10 (40%) 34 14 (41%) Vermont 37 13 (35%) 38 10 (26%) Virginia 81 52 (64%) 87 59 (68%) Washington 1,538 294 (19%) 1,089 224 (21%) West Virginia 136 61 (45%) 35 16 (46%) Wisconsin 214 119 (56%) 294 130 (44%) Wyoming 14 11 (79%) 31 20 (65%) National Total 26,056 8,131 (31%) 37,002 10,986 (30%) Source: OIG analysis of ACTS data, 2017. Not Applicable (N/A) - States had none of these complaints to investigate. DATA BRIEF: Nursing Home Complaints (OEI-01-16-00330) 25 APPENDIX D: Number of Immediate Jeopardy and High Priority Complaints Investigated by Number of Workdays From Complaint Receipt, 2011–2015 Exhibit D-1: Number of Immediate Jeopardy Complaints Investigated by Number of Workdays From Complaint Receipt, 2011–2015 Number of Days from Receipt of Complaint to Onsite Investigation 2011 2012 2013 2014 2015 2 days or less 2,654 3,178 3,612 4,620 4,573 3-4 days 47 53 46 81 118 5-9 days 28 15 36 35 111 10-14 days 13 12 19 25 62 15+ days 102 71 189 246 473 Not Investigated 0 0 3 2 4 Total Investigated 2,844 3,329 3,902 5,007 5,337 Source: OIG analysis of ACTS data, 2017. Exhibit D-2: Number of High Priority Complaints Investigated by Number of Workdays From Complaint Receipt, 2011–2015 Number of Days from Receipt of Complaint to Onsite Investigation 2011 2012 2013 2014 2015 10 days or less 19,137 21,348 22,343 24,327 26,922 11-15 days 918 872 933 887 868 16-20 days 497 458 523 428 459 21-25 days 335 394 379 361 373 26+ days 2,325 2,622 2,487 2,770 3,043 Not Investigated 9 21 16 37 83 Total Investigated 23,212 25,694 26,665 28,773 31,665 Source: OIG analysis of ACTS data, 2017. DATA BRIEF: Nursing Home Complaints (OEI-01-16-00330) 26 APPENDIX E: Trends in Nursing Home Incidents, 2011–2015 Exhibit E-1: Rate of Incidents per 1,000 Nursing Home Residents, 2011–2015 Source: OIG analysis of ACTS data, 2017. Exhibit E-2: Percentage of Nursing Home Incidents That States Prioritized for Prompt Onsite Investigations, 2011–2015 Source: OIG analysis of ACTS data, 2017. DATA BRIEF: Nursing Home Complaints (OEI-01-16-00330) 27 Exhibit E-3: Number of Immediate Jeopardy and High Priority Incidents Without Onsite Investigations, 2011–2015 Number of nursing home incidents without onsite investigations Year Immediate Jeopardy Incidents High Priority Incidents 2011 2 of 678 total incidents 17 of 10,328 total incidents 2012 1 of 827 1 of 12,296 2013 0 of 1,032 1 of 12,423 2014 0 of 1,178 4 of 12,330 2015 1 of 1,507 19 of 14,323 Total 4 of 5,222 42 of 61,700 Source: OIG analysis of ACTS data, 2017. Exhibit E-4: Number of Immediate Jeopardy Incidents Investigated by Number of Workdays From Incident Receipt, 2011–2015 Number of Days from Receipt of Incident to Onsite Investigation 2011 2012 2013 2014 2015 2 days or less 641 792 863 1,023 1,187 3-4 days 13 14 23 14 24 5-9 days 9 4 16 15 35 10-14 days 2 3 17 11 26 15+ days 11 13 113 115 234 Not Investigated 2 1 0 0 1 Total Investigated 676 826 1,032 1,178 1,506 Source: OIG analysis of ACTS data, 2017. Exhibit E-5: Number of High Priority Incidents Investigated by Number of Workdays From Incident Receipt, 2011–2015 Number of Days from Receipt of Incident to Onsite Investigation 2011 2012 2013 2014 2015 10 days or less 8,163 9,732 10,281 10,732 12,337 11-15 days 538 663 537 433 522 16-20 days 284 375 306 190 233 21-25 days 205 265 181 137 184 26+ days 1,121 1,260 1,117 834 1,028 Not Investigated 17 1 1 4 19 Total Investigated 10,311 12,295 12,422 12,326 14,304 Source: OIG analysis of ACTS data, 2017. DATA BRIEF: Nursing Home Complaints (OEI-01-16-00330) 28 Exhibit E-6: Average Percentage of the Most Serious Nursing Home Incidents That States Substantiated, 2011–2015 Source: OIG analysis of ACTS data, 2017. DATA BRIEF: Nursing Home Complaints (OEI-01-16-00330) 29 ACKNOWLEDGMENTS Kimberly Ruppert served as the team leader for this study. Other Office of Evaluation and Inspections staff from the Boston regional office who conducted the study include Jeremy Tourish. Office of Evaluation and Inspections central office staff who provided support include Berivan Demir Neubert and Christine Moritz. We would also like to acknowledge the contributions of other Office of Inspector General staff, including Jane Cys and Jessica Swanstrom. 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 Kenneth Price, Deputy Regional Inspectors General. To obtain additional information concerning this report or to obtain copies, contact the Office of Public Affairs at Public.Affairs@oig.hhs.gov. DATA BRIEF: Nursing Home Complaints (OEI-01-16-00330) 30 ENDNOTES 1 Section 1819(g)(4)(A) of the Social Security Act 2 OIG, Nursing Home Complaint Investigations, OEI-01-04-00340, July 2006. 3 GAO, Nursing Homes: More Reliable Data and Consistent Guidance Would Improve CMS Oversight of State Complaint Investigations, GAO-11-280, April 2011. 4 State Operations Manual, Pub. No. 100-07, ch. 5, “Complaint Procedures.” 5 State Operations Manual, Pub. No. 100-07, ch. 8, “Standards and Certification.” 6 States did not investigate some of the most serious nursing home complaints and therefore did not make a determination regarding substantiation in those complaints. 7 Sections 1819(g)(1)(A) and 1819(g)(2)(A)(iii) of the Social Security Act. 8 Sections 1819(g)(1)-(2) of the Social Security Act. 9 State Operations Manual, Pub. No. 100-07, ch. 7, “Survey and Enforcement Process for Skilled Nursing Facilities and Nursing Facilities.” 10 CMS’s Fiscal Year 2016 State Performance Standards System Guidance (CMS internal guidance sent to State survey agencies each year and provided to OIG for the purposes of this report). 11 Ibid. DATA BRIEF: Nursing Home Complaints (OEI-01-16-00330) 31