Prepare the form in quadruplicate (as well as any attachments), to report complaints
of substandard conditions. The appropriate conditions are prescribed in regulations
dealing with the various types of providers, and are available to the DO. The information
contained in the memorandum must be as specific as possible. This will ensure a more
Complaints concerning the treatment received by an individual patient can best be
resolved if specific information is available, e.g., name, claim number, date of occurrence,
names of those involved, and actions taken by the complainant to resolve the issue.
Indicate if the complaint has brought the situation to the attention of the facility
or any other government agency.
In all instances be sure to attach whatever material is available to document the
complaint. This includes bills, receipts, or notices of any kind (including utilization
review notices). Send three copies of the memorandum (and attachments) to the Health
Standards and Quality Bureau. Send one copy to the AC Field. DO retention of material
will be determined by regional and local guidelines.
Except when regional instructions indicate otherwise, before a complaint is referred
to the HSQ RO, it should be reviewed by someone designated by management to screen
out complaints which do not require a referral for investigation.
Complaints which need not be referred include events which occurred more than one
year ago; complaints from the same person which duplicate previously submitted complaints;
situations involving only an explanation of some routine aspect of the Medicare law;
appeals which should be properly disposed of through the appeals process; and those
situations which generally do not affect either the health or safety of the patient.
If, after considering the above and exercising judgment as to whether the circumstances
represent a bona fide complaint, the DO is undecided, but feels that there may be
reason to doubt the validity of the complaint, forward it to the HSQ RO with an RC
explaining the basis for the DO doubts. The RC will assist the RO in deciding whether
to forward the complaint for investigation. If the complaint is forwarded, the DO
assessment will help decide the timing of the investigation.