Department of Health & Human Services
Centers
for Medicare & Medicaid Services
Center for Medicaid and State
Operations/Survey and Certification Group
Ref: S&C-04-10
DATE:
TO: State
Survey Agency Directors
FROM: Director
Survey and Certification Group
SUBJECT:
Guidelines to Support Management of Complaints and Incidents and the
National
Implementation of the
Letter Summary
In this
memorandum we provide direction and guidance in the management of complaints
and reported incidents for nursing homes, home health agencies, end-stage renal
disease facilities, hospitals, suppliers of portable X-ray services, providers
of outpatient physical therapy or speech pathology services, rural health
clinics, and comprehensive outpatient rehabilitation facilities.
The management
of complaints and reported incidents is supported by the national
implementation of the ASPEN Complaints/Incidents Tracking System (ACTS),
effective on
Even if a State
chooses not to implement ACTS until January 1, SAs must continue to upload data
to the Online Survey, Certification and Reporting (OSCAR) Complaint System either by using the
Quick Entry 562 feature in ACTS or by entering all intake and investigation
information in ACTS.
We recognize that the national implementation of
ACTS affects the data entry workload or system integration challenges for some
States that have established business processes with supporting legacy systems
for tracking activities. We may
approve a limited extension of the transition period for a very small number of
states that have exceptionally capable and fully implemented legacy systems and
for whom immediate implementation of ACTS will cause both undue hardship and
loss of critical business function. Such
states must agree to provide data equivalent to ACTS data via electronic means
during the extended transition period, produce periodic reports specified by
CMS, and ensure that CMS receives full information on ACTS-covered complaints
for the period beginning
This memorandum
replaces the interim guidance issued
Improving the management and oversight of
complaints and reported incidents is essential to ensuring protection and
quality of service for the citizens we serve.
We believe ACTS will improve our collective capability to track,
investigate, and respond to complaints and incidents. We also believe it will conserve public
dollars by virtue of a single national system rather than the creation of many
state systems. We therefore appreciate
wholeheartedly the diligent work of participating state and regional staff as
together we address policy and procedural challenges related to ACTS and to the
effective management of complaints and incidents. Thank you.
Contacts: Questions about this memorandum may be addressed to Kathy Lochary at Klochary@cms.hhs.gov and Elaine Lew at Elew@cms.hhs.gov.
Effective Date:
Dissemination: This policy should be shared with all
appropriate survey and certification staff, their managers, QIES coordinators,
and the state/regional office training coordinators.
/s/
Thomas E. Hamilton
CC: Survey and
Certification Regional Office Management (G-5)
Attachment 1 – Guidance to Support Management
of Complaints and Incidents
Attachment 2 - Guidance to Distinguish Between the Priorities of Immediate Jeopardy and
Non-Immediate Jeopardy-High in Nursing Home Allegations
Attachment 3 - ACTS Required Fields
Attachment 4 – ACTS RO Contacts