Some States Fell Short in Timely Investigation of the Most Serious Nursing Home Complaints between 2011-2015


On September 29, 2017, the Office of Inspector General (OIG) released a report finding that some states fell short in timely investigation of the most serious nursing home complaints between 2011-2015. Under federal and state regulations, CMS relies on individual states’ respective state survey agencies to address various types of concerns raised by residents, family members, and nursing home staff. Such concerns include residents admitted to the hospital because of preventable infections, residents left sitting in their urine and feces for hours, and inappropriate social media posts by employees.

State agencies must conduct onsite investigations within a certain period of time for the most serious level of complaints. Previous reports by the OIG found that state agencies often did not conduct onsite investigations within the required time frame, which requires that immediate jeopardy cases be investigated within two working days and that non-immediate jeopardy-high priority cases be investigated within 10 working days.

OIG Results

The OIG found that during 2011-2015, while the number of nursing home residents decreased overall, the number of nursing home complaints state agencies received increased 33 percent (47,279 to 62,790). The report also found that, in 2015, both Tennessee and Georgia received a total of 912 immediate jeopardy complaints, which accounts for 17% of all immediate jeopardy complaints. Out of 912 complaints, 654 (71%) were investigated late. Additionally, across all five years, Arizona, Maryland, New York, and Tennessee accounted for almost half of the high priority complaints not investigated onsite within 10 workings days. Furthermore, almost one-quarter of states did not meet CMS’s annual performance threshold for timely investigations of high priority complaints in all four years and all states substantiated almost on third of the most serious nursing home complaints.

Overall, the OIG data report offers Centers for Medicare and Medicaid Services some insights into the states that have room for improvement in prioritizing and responding within the required time frame to nursing home complaints. The OIG will continue to monitor the oversight of nursing homes and will initiate additional reviews as necessary.