Complaint Investigation Process

Table of Contents

Introduction

The California Department of Public Health (CDPH) Center for Health Care Quality (CHCQ) works to ensure that all Californians receive safe, effective, and quality health care, and it does so through regulatory oversight of licensed health care facilities, providers, and certain types of health care professionals. Our job is to make sure that these facilities, providers, and professionals operate in compliance with state and federal laws.

What sort of action can you take if you have a complaint about your care? What are your rights? What do we do with your complaint once it is in our hands? How long does the investigation process take? And what are the consequences or results for health care facilities and providers? We address these and related questions below. The California Health and Safety Code section 1420 is an additional resource that may be helpful, specifically for long-term care complaints.

Definition of a Complaint

CHCQ defines a complaint as, “a report of a facility’s alleged noncompliance with state and/or federal laws and regulations.”

The facility or provider type in question must be one that we license under state law or certify on behalf of the Centers for Medicare and Medicaid Services (CMS) to receive federal Medicare funds. These facilities include general acute care hospitals, hospices, home health agencies, skilled nursing facilities, primary care clinics, and many other health care facility types. For a complete list of facility types CDPH regulates see: Facility/Provider Types.

(Note that the California Department of Social Services regulates assisted living facilities and other types of non-medical residential facilities.)

Anyone can file a complaint against a healthcare facility or provider – a patient or facility resident, a relative or friend, even a member of the public – either anonymously or by name. Regardless of whether you choose anonymity, CHCQ will keep your identity confidential.

Filing Your Complaint

You can file a complaint against a health care facility or provider in a number of ways. The most direct route is digitally through our online California Health Facility Information Database (Cal Health Find) on the CDPH web site. Once you complete the form, the system will route your complaint to the appropriate district office.

Health care consumers or their advocates can also call in a complaint by phone, or send a written letter by fax or mail. Our district office phone numbers, fax numbers, and mailing addresses are online, along with information about which counties each district office serves.

The process for filing a complaint is the same for all facility types, including long-term care (LTC, such as a skilled nursing facility or intermediate care facility) and for non-long-term care (NLTC, such as general acute care hospitals, home health agencies, hospices and various types of clinics).

Complaints Against Certified Nurse Assistants, Hemodialysis Technicians, Home Health Aides, and Nursing Home Administrators

CHCQ’s Professional Certification Branch (PCB) also investigates complaints against hemodialysis technicians, home health aides, nurse assistants, and nursing home administrators.

You can file a complaint with the Professional Certification Branch by calling the complaint hotline at
916-492-8232 or by calling the main PCB line at 916-445-4423. You can also email, fax, or mail a complaint against an applicant or certified nurse assistant, home health aide, or hemodialysis technician to:

CDPH/PCB/Investigations
PO Box 997416, M3303
Sacramento, CA 95899-7416
Fax: 916-552-8788
Email: cnamisconduct@cdph.ca.gov

Complaints Against Medical Doctors, Registered Nurses, and Licensed Vocational Nurses 

CDPH does not license medical doctors (MDs), registered nurses (RNs) or vocational nurses (LVNs), but does investigate allegations involving these professional types if the facility or provider where they provide services are also potentially accountable. For example, if a skilled nursing facility resident is not receiving physician visits as frequently as spelled out in his or her plan of care, CDPH could cite the facility.

File complaints against these professional classifications with the appropriate regulatory agencies:

Complaints Against Assisted Living Facilities

CDPH does not regulate assisted living facilities or other non-medical residential facilities. Please contact the California Department of Social Services at (844) 538-8766 if your complaint concerns these types of non-medical centers.

Processing Your Complaint

CDPH documents every complaint received in an electronic tracking system and assigns it to a health facilities evaluator supervisor, a registered nurse who classifies the allegation. Complaint categories range from resident/patient abuse and quality of care/treatment to dietary services and resident/patient rights.

The health facilities evaluator supervisor prioritizes the complaint based on content, the immediacy, the risk of the allegation in question, and the state statutes and federal requirements that CDPH enforces. Depending on the allegation, CDPH might also refer the complaint to other governmental agencies, such as the Department of Justice’s Bureau of Medi-Cal Fraud and Elder Abuse. The health facilities evaluator supervisor also assigns the complaint investigation to a CDPH health facilities evaluator nurse (HFEN), commonly referred to as a surveyor.

All complainants should expect to receive acknowledgment of the receipt of their complaints within 10 days by mail from the appropriate district office or sooner if the complaint was filed on-line.

The Complaint Timeline: Long-Term Care  

How quickly an investigation is conducted depends in large part on the severity of the allegation. In cases involving a threat of imminent danger of death or serious bodily harm (called an “immediate jeopardy” situation); CDPH is required by law to go on site within 24 hours for long-term-care facilities and providers and within 48 hours for hospitals and other non-long-term-care providers.

The law also spells out completion timelines for long-term care complaint investigations. Those involving threats of imminent danger, death, or serious bodily harm must be closed within 90 days of receipt, with up to 60 additional days for extenuating circumstances.

For all other long-term care complaints received between July 1, 2017, and July 1, 2018, CHCQ must complete the investigation within 90 days of receipt (with an extension of up to 90 more days). For long-term care complaints received on or after July 1, 2018, the department must complete the investigation within 60 days of receipt with a possible 60-day extension.

The Complaint Timeline: Non-Long-Term-Care

Complaint investigations involving hospitals call for different timeframes. If the allegation indicates an ongoing threat of imminent danger of death or serious bodily harm (called an immediate jeopardy situation), CDPH must complete the investigation within 45 days. If CDPH is unable to meet this deadline, state law requires that we notify the complainant as well as the facility.

Investigating Your Complaint

CDPH investigates most but not all complaints we receive. Those we would not investigate include issues that do not constitute a violation of the regulations or statutes we enforce, complaints intended to willfully harass the facility or provider, and complaints we have already investigated.
 
When we investigate a complaint, a health facilities evaluator nurse primarily investigates in person. If the situation warrants, other CDPH staff members may join the survey team. These can include doctors, pharmacists, dieticians, occupational therapists, and medical records experts, as well as members of our Life Safety Code section trained in fire safety and other non-medical concerns.

Before entering the facility, our surveyors have done their homework. This includes a review of CDPH files, particularly of related issues at the facility and its past compliance history. If the case involves a skilled nursing facility or other long-term care provider, the surveyor may contact the local ombudsman to discuss the allegation and any related complaints the ombudsman’s office has received or substantiated.

Surveyors contact the complainant to get any additional information that may be helpful in the investigation. The complainant is also notified that he or she (or a representative) has the right to accompany the surveyor to the facility but is prohibited from the following: using cameras, video cameras or tape recorders; participating in interviews or review of health records or other confidential materials; and attending the exit conference. 

Finally, the surveyor develops a detailed plan for the visit and reviews the regulatory requirements that pertain to each allegation. Keep in mind that our surveyors enforce both state and federal laws since CDPH functions as the survey agency for the federal Centers for Medicare and Medicaid Services.

On-site, the surveyor conducts observations, interviews with the patient or resident and facility personnel, and reviews medical records. The surveyor may also expand the investigation to review similar conditions or situations at the facility and include other patients or residents. This allows us to determine whether the allegations are more widespread or more serious than the initial complaint.

Investigation Findings

Once the surveyor has gathered all supporting documentation and has finished the on-site investigation, he or she (in consultation with a supervisor) must make the following determinations:

• Whether the complaint is substantiated or unsubstantiated. In other words, can CDPH verify by evidence that the alleged action(s) in the complaint did occur? Or is there no supporting evidence?
• Whether the complaint is substantiated but no regulations were violated;
• Whether the complaint is substantiated and the facility violated one or more regulatory requirements (these violations are also called deficiencies);
• Whether the surveyor has identified additional deficiencies unrelated to the original complaint.

Surveyors use several sources to determine regulatory compliance, including Title 42 of the Code of Federal Regulations, Title 22 of the California Code of Regulations, the California Health and Safety Code, CMS' State Operations Manual, and CDPH's own policies and procedures.

The surveyor shares any deficiencies or violations identified during the investigation with facility administrators at an exit conference, which can take place either in person or by phone. If the complaint involves a skilled nursing facility, CDPH has 90 days to complete the paperwork (60 days as of July 1, 2018) and close out the complaint from the date of this exit conference for a case involving immediate jeopardy and 90 days for all other categories of complaints. (See "The Complaint Timeline.") The results of the investigation are mailed to the facility or provider and to the complainant within 10 business days from exiting the facility.

Severity and Scope

The severity and scope of a problem in a skilled nursing facility helps determine whether any sort of state or federal enforcement action or administrative penalty is appropriate.

Severity reflects the impact of the deficiency and is categorized by four levels of harm:

1. No actual harm with potential for minimal harm;
2. No actual harm with potential for more than minimal harm that is not immediate jeopardy;
3. Actual harm that is not immediate jeopardy and;
4. Immediate jeopardy to resident health or safety.

Scope reflects how many residents were affected by a deficiency. There are three levels: isolated, pattern, or widespread. CHCQ determines the severity and scope levels for each deficiency cited during a survey. Viewed together, severity and scope determine a level of deficiency from A (isolated pattern with minimal harm) to L (widespread pattern with immediate jeopardy), as shown in the chart below.

The Statement of Deficiencies (Form 2567) and Plan of Correction (POC)

Once the surveyor or survey team completes the investigation, the CHCQ district office determines the facility or provider’s compliance with state and federal regulations, and may consult CHCQ management, the CDPH Office of Legal Services, or CMS. Then the surveyor prepares a statement of deficiencies, which details the survey findings.

The Statement of Deficiencies, commonly called “the 2567” (its form number) is the public document of record in a complaint investigation. If the survey does not result in deficiencies or violations, the narrative is brief. Otherwise, the surveyor has up to 10 working days after exiting the facility to complete the write-up, which includes a summary of the observations, interviews, and record reviews as well as the specific regulations the facility has violated. The narratives do not identify patients or facility staff by name.

The CDPH findings go in the left column of the form under the “Summary Statement of Deficiencies.” The right-hand column, or attached documentation, is reserved for the plan of correction, which is written by the facility and details how it will correct the identified problems and in what time frame. Facilities and providers have 10 calendar days after receipt of the 2567 to submit their plan of correction to CDPH. CDPH may accept the plan of correction or send it back for revisions. The complainant receives a letter with the results of the investigation within the 10-day time frame after regardless of whether the facility or provider has submitted an acceptable plan of correction.

If CDPH has found no deficiencies or violations, a plan of correction is not required. Within 10 working days of the formal exit with the facility, the district office sends a letter to the facility or provider and to the complainant, effectively closing the investigation.

Complainant Appeals: Long-Term Care

If a complainant is unhappy with the outcome of the complaint investigation, the complainant can request an informal conference with the district office that conducted the investigation. The facility may also take part in the conference. The district manager should notify the complainant within 10 working days after the informal conference whether the investigation findings stand.

If a complainant is still dissatisfied with the results of the informal conference, within 15 days after receiving the results of the informal conference, the complainant may notify the deputy director of the Center for Health Care Quality (CHCQ) in writing to request an appeal review.

During the appeal review, the complainant may submit information about disputed issues in writing or verbally. The headquarters Appeals Unit staff will conduct the appeal and contact the complainant for an interview, if requested. Any new allegations not previously investigated will be referred to the district office for investigation.

If the complainant is not the resident of the licensed nursing facility or their legal representative established through a corresponding Power of Attorney ("POA") document, a Will (naming the individual as the Executor of their estate) allowing them to provide legal authorization as the Personal Representative of the individual as designated by a Court, or in the event that the resident  wishes to have another party present during these informal conferences, the resident or his/her legal representatives may submit an Authorization for Use and Disclosure of Personal Information, CDPH form 6247 (03/18), which authorizes the use or disclosure of individually identifiable personal information. In the alternative, if form 6247 is not provided, the request for information must still comply with the Information Practice Act. Verification of the identity of the requester and their authority to receive the information will be evaluated on a case-by-case basis by CDPH Office of Legal Services ("OLS"). The form must either be accompanied with documentation of identification of the person signing the form or be notarized by a notary public. Without a duly authorized form 6247, or its equivalent, the amount and type of information CDPH can share may be limited by state and federal laws and regulations that are intended to protect the personal privacy rights of the resident whose care is the subject of the complaint.

Based on the Appeals Unit review, the deputy director will determine whether there are any additional state violations. The district office will issue any deficiencies and resulting state citations to the facility. The findings of the Appeal Unit, reviewed and approved by the CHCQ deputy director, are the final decision. There is no further appeal.

Enforcement Actions

Depending on our investigative findings, CDPH may take state enforcement action beyond citing a deficiency for more serious violations. The following measures vary by facility type and carry monetary consequences.

• Immediate Jeopardy Administrative Penalties – CDPH assesses administrative penalties to hospitals under HSC section 1280.3 for situations of immediate jeopardy (those cases involving a threat of imminent danger of death or serious bodily harm). Penalty amounts range from $25,000 for incidents occurring prior to 2009 to $125,000.
• Non-Immediate Jeopardy Administrative Penalties – CDPH also assesses administrative penalties of up to $25,000 to general acute care hospitals under HSC section 1280.3 for non-immediate jeopardy situations (those that violate state law relating to the operation or maintenance of a hospital that affect the health or safety of hospital patients at a higher level than a minor violation but that do not rise to the level of an immediate jeopardy).
• Failure to Report Adverse Events – Hospitals are required to notify CDPH of adverse events, as defined by HSC section 1279.1 within five days, or risk civil penalties (see HSC section 1280.4) of up to $100 a day for each day the adverse event is unreported.
• State Citations for Long-Term Care – HSC section 1417.1 allows for “prompt and effective civil sanctions” against skilled nursing facilities and other types of long-term care. CDPH issues “AA” level citations, which carry a penalty of $35,000 to $120,000, when it determines that a facility’s violation was a substantial factor in death of a patient or resident. The state may issue “A” or “B” level citations to long-term care facilities or providers for lesser violations. Class "A" citations carry fines of $3,500 to $25,000, and Class "B" citations carry fines of $150 to $3,000. 
• Medical Breach Administrative Penalties – CDPH assesses administrative penalties to facilities that breach patients’ confidential medical information under HSC section 1280.15. The maximum penalty is $250,000.
• Failure to Report – Medical Breaches – Facilities are required to notify CDPH of medical breaches within 15 days, or risk civil penalties  of up to $100 a day for each day the adverse event is unreported.