What To Do If You Have Concern About Quality
in a California Nursing Home

Introduction

Nursing homes in California provide continuous skilled nursing and supportive services to residents who need care on an extended basis. California has more than 1,300 licensed facilities, and most provide quality care most of the time. However, there are times when residents or family members have concerns about the quality of care in a nursing home.

• What should a resident or family member do if they have a concern about quality?
• Who should they talk to?

This brief provides answers to these questions and links to resources that can help. It addresses steps you can take within a nursing home or with organizations that regulate or oversee nursing homes. You certainly also have the option to consider legal action, but that’s not the focus of this brief.

For many of us, it's not easy to act on a concern about the quality of care we or a loved one are receiving in a nursing home. The process can be stressful, frustrating and take a long time. And ultimately others may not agree with the way we see the situation.

• Is it worth it to pursue a concern about quality?

Only you or your loved one can decide. However, consider the continued harm that might take place if you don't take action – for your self, your loved one, and/or other residents and their families.

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What is quality of care?

Quality health care is characterized by doing the right thing, at the right time, in the right way, for the right person — and having the best possible results.

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What are some of your quality of care rights in a California nursing home?

Under the law, you have the following rights:

• To be treated with respect and dignity in recognition of your individuality and preferences
• To receive quality care and treatment that is fair and free of discrimination
• To voice and to file complaints or grievances without fear of retaliation
• To have a relative or legal representative act on your behalf when you are not able to do so

For a full list of all of your rights, see the California Department of Health Services brochure: Your Rights as a Resident in a Nursing Home (also available in Chinese, Spanish and Tagalog) http://www.cdph.ca.gov/HealthInfo/Documents/YourRightsAsAResidentInANursingHome-English.pdf

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What types of quality concerns might you see in a nursing home?

There are a variety of quality of care concerns that you might encounter in a nursing home:

• Some might relate to how well the whole staff works together or whether there are enough staff to provide care for residents.
• Other quality concerns might result from a specific action a staff member takes (or doesn't take), such as giving a drug that causes a known allergic reaction or giving too many drugs.

These types of actions may have no effect on health, may cause some inconvenience or pain, or may have serious health consequences. Some actions are always cause for major concern. Staff who physically harm, abuse or neglect patients, leading to bruises, scratches or bedsores, put you, your loved one and other residents in a situation of “immediate jeopardy” that may lead to serious injury or death.

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What steps should you take if you have a concern about quality?

Step 1 – Talk with a nursing home staff member who can fix the problem

For many quality concerns, it’s often best to try to resolve them with staff or others at the nursing home first. You can talk with the social worker, a nurse, the administrator, or another trusted staff member who you think has the ability to address your concern. You could put your concerns in writing and ask for a written response. You might also bring your concerns to the resident or family council, particularly if the concern affects others in the nursing home.

Step 2 – The Nursing Home Ombudsman Program

If your concern is not addressed or resolved within a reasonable time, or if you are uncomfortable talking first with someone in the nursing home, you can call the Nursing Home Ombudsman Program, a program of the California Department of Aging. Ombudsmen are volunteers who are trained to receive and resolve complaints from residents in nursing homes and other long-term care facilities. Their services are free. All nursing homes are required to post the phone number for their local ombudsman program, or you can call the statewide crisis line: 1-800-231-4024. The crisis line is available 24 hours a day, 7 days a week. In addition, information about all of the ombudsman programs in the state can be found at this website: http://www.aging.ca.gov/programs/ombudsman_contacts.asp

The ombudsman will meet with you and/or a family member in a private setting. With your consent, they’ll talk with nursing home staff or review records to see if they can solve the problem. You or your family member will be informed about the outcome of the investigation either verbally or in writing if you request it. If the concern isn’t resolved to your satisfaction, or if you feel the concern is important enough to alert others about it, you can file a complaint with the California Department of Public Health.

Step 3 – Filing a complaint with the Department of Public Health

California nursing homes are licensed by the California Department of Public Health (DPH). In exchange for meeting certain rules and regulations, they are allowed to care for residents. One function of DPH is to receive and investigate complaints about any organization they license. The department receives over 6,500 complaints a year about nursing homes and has taken some type of action against 1,920 homes.

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You can file a complaint with DPH by:

• Contacting one of their District offices: http://www.cdph.ca.gov/certlic/facilities/Pages/LCDistrictOffices.aspx
• Completing and submitting their online complaint form: https://hfcis.cdph.ca.gov/LongTermCare/ConsumerComplaint.aspx
• Calling: 800-236-8747

You should be as specific as possible about your concern if you are writing your complaint. Make sure you make a copy of what you send. Once DPH receives your complaint, it should notify you within two days and give you the name of the DPH staff person who will investigate your complaint, a complaint number and information about how DPH intends to follow up.

The investigation:  What happens next depends on how serious your concerns are. If the complaint involves a situation that could cause imminent danger, death or serious harm (“immediate jeopardy”), the investigators should be at the nursing home investigating within 24 hours of receipt of the complaint. Complaints that don't fall into this category should be investigated within 10 days. Complaint investigations are unannounced — the nursing home administration and staff are not told in advance that the DPH investigator is coming.

The DPH investigator will probably interview you, other residents and family members, review your medical records, interview and observe staff members and inspect the facility. You have the right to ask to accompany (or have a family member accompany) the investigator to the facility. Once the investigation is complete, the investigator will write a report of their findings. You must be provided a copy of the report within 10 working days of its completion.

What are the outcomes?  If the investigation finds your concern(s) to be true, or finds something else of concern while on site, they will issue a report outlining the problems and what the nursing home must do to correct them. Depending on the severity of the violation, the DPH might issue a citation. The nursing home may have to pay a monetary penalty of up to $100,000 for the worst violations, those that result in the death of a patient (called an AA violation). Information on complaints and investigation outcomes for nursing homes is available on several websites noted below.

How long will it take?  The DPH policy is to complete the complaint investigation within 30 days. According to a DPH 2009-2010 annual report, almost 70 percent of the most serious complaints were resolved within 10 days and 79 percent of other complaints were processed within 40 days.

Can I appeal the findings?  If you disagree with the findings in the report, you have the right to appeal the process. Within 5 business days after you receive the findings, you can request an informal conference with the DPH district manager. Here is a list of District Offices: http://www.cdph.ca.gov/certlic/facilities/Pages/LCDistrictOffices.aspx

A representative from the nursing home may also attend the meeting. Within 10 days of that meeting, the DPH district officer should notify you and the nursing home of its determination.

You have one final place to appeal if you are still not happy with the results. Within 15 days of receiving the report from the informal conference, you can appeal to the office of the Deputy Director of the California Department of Public Health. A representative from the Complainant Appeals Unit in that office will review all of the information about the complaint. You have the right to meet with that representative. Based on the Complainant Appeals Unit review, the Deputy Director will make a final decision within 30 days and notify both you and the nursing home.

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Can you remain anonymous when you file a complaint?

You have the right to not give your name and remain anonymous when you file a complaint. If you want that option, you should clearly state it when you file your concern. You should know, however, that it may make your case more difficult to investigate and resolve as investigators won't be able to review your records or interview staff about a specific incident or incidents. You can talk with the ombudsman about the pros and cons of remaining anonymous in your specific situation.

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What if the nursing home retaliates against me or a loved one for filing a complaint?

Being concerned about retaliation is understandable given your, or a loved one's, dependence on nursing home staff for care. However, it is absolutely against the law to retaliate against a resident of a nursing home for filing a complaint. If you feel you are being retaliated against, you should contact the ombudsman program or the California Department of Public Health with your concern.

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Where else can you send a complaint?

Medicare: If your care in the nursing home is paid for by Medicare, you might also consider calling the agency that oversees quality of care in facilities caring for Medicare patients. In California, that agency is called the Health Services Advisory Group (HSAG). They are primarily concerned with the quality of care given by the staff and written down in your medical record. You will be notified if the care received met the expected “standard of care” (that is, whether the nursing home provided the expected level and type of care under the circumstance) or not. HSAG's process is generally focussed on improving the performance of the nursing home, not on punishing them.

There are timetables that affect the handling of each step of the HSAG review. If you are no longer receiving the services in question, the review can take anywhere from 85 to 165 days to complete depending on whether a quality problem is found. If you are still receiving the services in question, the review should take 38 to 83 days.

HSAG Medicare Beneficiary Complaint Hotline: 1-866-800-8749 Information about complaints and link to complaint form: http://www.hsag.com/camedicare/complaints.aspx

Medi-Cal: You can also call the Medi-Cal Fraud and Abuse Hotline if you have a concern about the quality of care in a nursing home. Examples of abuse in a nursing home include failure to assist in hygiene, failure to provide medical care or protect a resident from heath hazards, or malnutrition or dehydration.

Attorney General's Bureau of Medic-Cal Fruand & Elder Abuse: 800-722-0432
Website: http://ag.ca.gov/bmfea/index.php

Joint Commission: The Joint Commission is a non-profit organization that evaluates and accredits (judges the quality of organizations against a set of standards) health care organizations across the country. Not all nursing homes are accredited by the Joint Commission, but those that are must comply with their complaint process. To find out if the Joint Commission has accredited your nursing home, search for it in the Quality Check database: http://www.qualitycheck.org/consumer/searchQCR.aspx

Information about the complaint process at the Joint Commission: http://www.jointcommission.org/GeneralPublic/Complaint/

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What should you do if you're not getting any response?

California Legislators: If you are not getting a timely response or have other concerns about the way you’re being treated, consider alerting your California Assembly member and senator. They have staff who can help people living in their districts who aren't getting the help they need.

List of California Legislators: http://www.legislature.ca.gov/

California Advocates for Nursing Home Reform (CANHR): CANHR is a statewide non-profit advocacy organization dedicated to improving the choices, care and quality of life for California's long-term care consumers. It provides a wealth of information about nursing homes and has staff that can help with the complaint process.

CANHR Consumer Information Hotline: 800-474-1116
http://www.canhr.org/

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Where can you find information about complaints against a California nursing home?

There are several online resources you can check for complaints against nursing homes, as well as other information about the quality of care they provide:

CalQualityCare.org – Your Guide to Long Term Care in California:

Includes the number and type of nursing home complaints filed against California nursing homes, as well as information on quality of care, and staffing.

http://www.calqualitycare.org/

Nursing Home Guide, California Advocates for Nursing Home Reform:

Includes a summary of complaints, deficiencies and citations by nursing home by year.

http://www.nursinghomeguide.org

California Department of Public Health Nursing Home AA Citations by County:

Provides information on the nursing homes that have received AA citations—a violation that caused the death of a patient.

http://www.cdph.ca.gov/certlic/facilities/Pages/AACounties.aspx

Nursing Home Compare:

A federal website that includes information on deficiencies found during regular surveys and complaint investigations.

http://www.medicare.gov/NHCompare/Include/DataSection/Questions/SearchCriteriaNEW.asp
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Other useful information:

If you are concerned about the quality of care in a California hospital, managed care plan or HMO or physician office or with the care provided by various types of nurses, here is information about what to do:

What To Do If You Have Concern About Quality of Care from a California Hospital:
http://www.informedpatientinstitute.org/HOSQuality-CA.php

What To Do If You Have Concern About Quality of Care from a California Physician:
http://www.informedpatientinstitute.org/PHYQuality-CA.php

Managed Care: California Department of Managed Health Care – Problems and Complaints: http://www.dmhc.ca.gov/dmhc_consumer/pc/pc_default.aspx

Nurses: California Department of Consumer Affairs

Registered Nurses:http://www.dca.ca.gov/online_services/complaints/complain_rn.shtml

Vocational Nurses:http://www.dca.ca.gov/online_services/complaints/complain_vocnurse.shtml

If you want to learn more about Malpractice – the National Health Law Program sponsors a consumer website called HealthCareCoach that includes information on malpractice and how to find an attorney: http://www.healthcarecoach.com/resources/index.php?view=detail&id=102&node=4