General Intake Process

5010 - General Intake Process (Rev. 243; Issued: 06-12-26; Effective: 06-12-26; Implementation: 06-12-26) A complaint is an allegation of noncompliance with Federal and/or State requirements. If the SA determines that the allegation(s) falls within the authority of the SA, the SA determines the severity and urgency of the allegations, so that appropriate and timely action can be pursued. Each SA is expected to have written policies and procedures to ensure that the appropriate response is taken for all allegations and is consistent with Federal requirements as well as with procedures in the State Operations Manual. This structure needs to include response timelines and a process to document actions taken by the SA in response to allegations. If a State’s time frames for the investigation of a complaint/incident are more stringent than the Federal time frames, the intake is prioritized using the State’s timeframes. The SA is expected to be able to share the logic and rationale that was utilized in prioritizing the complaint/incident for investigation. The SA response must be designed to protect the health and safety of all residents, patients, and clients. Besides the SA, other public entities receive information and/or perform investigations. These entities include the office of the coroner or medical examiner, end-stage renal disease (ESRD) networks, quality improvement networks (QINs), law enforcement, the ombudsman’s office, and protection and advocacy systems. At times, these public entities will forward information to the SA if there are concerns about the health and safety of residents, patients, and clients. The SAs are required to manage and investigate these referrals as complaints. An allegation is an assertion of noncompliance with Federal health and safety regulations. The point of receipt of the allegation is a critical fact-finding and decision- making point. The SA ensures that its complaint telephone number is listed in local directories. Information regarding the care, treatment and services provided to beneficiaries can come from a variety of sources, including beneficiaries themselves, beneficiaries’ family members, health care providers, concerned citizens, public agencies, or media reports. Report sources may be verbal or written. In some instances, the complainant may request anonymity. The SA and CMS location ensure the privacy and anonymity of every complainant. Generally, the SA follows the disclosure procedures under chapter 3, §3308. The SA discloses the complainant’s identity only to those individuals with a need to know who are acting in an official capacity to investigate the complaint. In addition to these Federal requirements, the SA abides by any State procedures not in direct conflict with CMS instructions. The SA notifies the CMS location if State regulations conflict directly with any part of these complaint procedures. See also Section 5310.1 for information related to facility-reported incidents.