Pennsylvania Nursing Home Resident Complaint — Long-Term Care Ombudsman / DOH

PENNSYLVANIA NURSING HOME RESIDENT COMPLAINT

TABLE OF CONTENTS

1. Receiving Agency Selection
2. Facility Information
3. Resident Information and Consent
4. Complainant Information
5. Categories of Complaint
6. Statement of Facts
7. Resident Rights Implicated
8. Internal Grievance Procedure
9. Requested Relief
10. Supporting Documentation
11. Confidentiality and Anti-Retaliation
12. Verification
13. Distribution
14. Pennsylvania Practice Notes
15. Sources and References

1. RECEIVING AGENCY SELECTION

This complaint is being submitted to the agency or agencies indicated:

• ☐ PA Department of Aging — Office of the State Long-Term Care Ombudsman (resident advocacy; complaint resolution; requires resident consent)
• Local AAA Ombudsman — county: [________________________________]
• State LTC Ombudsman — 1-717-783-8975
• ☐ PA Department of Health — Bureau of Long-Term Care (regulatory survey and enforcement; CMP authority)
• Complaint line: 1-800-254-5164 | Email: [email protected]
• ☐ PA Department of Aging — Statewide Elder Abuse Hotline (OAPSA / APS) — 1-800-490-8505
• ☐ Centers for Medicare & Medicaid Services (CMS) — federal complaint (in addition to state)
• ☐ Local law enforcement (criminal conduct alleged)
• ☐ Office of Attorney General — Medicaid Fraud Control Section (Medicaid fraud / patient abuse) — 1-717-787-3391

2. FACILITY INFORMATION

3. RESIDENT INFORMATION AND CONSENT

Consent of resident or surrogate (required for Ombudsman intervention under 42 U.S.C. § 3058g(d) and 6 Pa. Code § 13.6):

• ☐ Resident has given informed consent to file this complaint and to disclose information necessary to investigate and resolve it.
• ☐ Resident lacks capacity to consent; surrogate (POA / guardian) consents on resident's behalf.
• ☐ Resident is unable to communicate consent and no surrogate is available; Ombudsman is requested to act in the resident's best interest under 6 Pa. Code § 13.6(c).

Resident or surrogate signature: [________________________________] Date: [__/__/____]

4. COMPLAINANT INFORMATION

5. CATEGORIES OF COMPLAINT

Check all that apply:

Care quality and clinical:

• ☐ Falls / failure to prevent falls
• ☐ Pressure injuries / decubitus ulcers
• ☐ Medication errors (wrong drug, wrong dose, missed dose)
• ☐ Inadequate pain management
• ☐ Failure to assess / treat infection
• ☐ Dehydration / malnutrition
• ☐ Improper use of physical restraints (42 C.F.R. § 483.10(e))
• ☐ Improper use of chemical restraints / antipsychotics without diagnosis
• ☐ Failure to follow physician orders
• ☐ Discharge planning failures

Staffing and supervision:

• ☐ Insufficient nurse / aide staffing
• ☐ Untrained staff / certification lapses
• ☐ Failure to supervise (elopement / wandering)
• ☐ Failure to respond to call light

Resident-rights violations (42 C.F.R. § 483.10 / 28 Pa. Code § 201.29):

• ☐ Dignity / respect violation
• ☐ Privacy violation (treatment, communication, mail)
• ☐ Denial of access to records
• ☐ Denial of right to participate in care planning
• ☐ Denial of right to organize or attend resident council
• ☐ Improper transfer or discharge (42 C.F.R. § 483.15)
• ☐ Retaliation for filing a complaint or grievance

Abuse and neglect (also report to OAPSA hotline):

• ☐ Physical abuse — staff
• ☐ Resident-to-resident abuse with inadequate facility response
• ☐ Sexual abuse
• ☐ Verbal / emotional abuse
• ☐ Financial exploitation by staff

Environmental and safety:

• ☐ Unsanitary conditions
• ☐ Pest / vermin
• ☐ Temperature / ventilation
• ☐ Fire / life safety code

Financial and administrative:

• ☐ Improper charges or "private pay" upcharge to Medicaid resident
• ☐ Mishandling of resident trust fund
• ☐ Failure to give 30-day notice of charge changes (28 Pa. Code § 201.29)
• ☐ Improper billing for missed therapy / services not rendered

6. STATEMENT OF FACTS

6.1. Date(s) of incident(s): [________________________________]

6.2. Location within the facility: [________________________________]

6.3. Staff involved (names / shifts / titles if known): [________________________________]

6.4. Detailed factual narrative:

[________________________________]

6.5. Resident's stated experience and wishes:

[________________________________]

6.6. Observable injuries, conditions, or harm:

[________________________________]

6.7. Pattern or repeat conduct (prior incidents):

[________________________________]

7. RESIDENT RIGHTS IMPLICATED

The conduct described implicates the following resident rights under federal and Pennsylvania law (check all that apply):

Federal — 42 C.F.R. § 483.10 (incorporated by 28 Pa. Code § 201.29):

• ☐ § 483.10(a) — exercise rights as a citizen
• ☐ § 483.10(b) — be fully informed of rights and rules
• ☐ § 483.10(c) — participate in care planning and treatment decisions
• ☐ § 483.10(d) — choose attending physician
• ☐ § 483.10(e) — privacy and confidentiality
• ☐ § 483.10(f) — voice grievances without retaliation
• ☐ § 483.10(g) — facility communication / posting requirements
• ☐ § 483.10(h) — examine survey results
• ☐ § 483.10(i) — environment that is homelike
• ☐ § 483.10(j) — refuse transfer to another room
• ☐ § 483.12 — freedom from abuse, neglect, exploitation
• ☐ § 483.15 — admission, transfer, and discharge rights
• ☐ § 483.21 — comprehensive person-centered care plan
• ☐ § 483.24 — quality of life
• ☐ § 483.25 — quality of care
• ☐ § 483.45 — pharmacy services / unnecessary drugs

Pennsylvania — 28 Pa. Code § 201.29:

• ☐ Posted resident rights notice
• ☐ Personal notice of rights at admission and on changes
• ☐ Treatment with consideration, respect, and recognition of dignity and individuality (subsection (j))
• ☐ 30-day advance written notice of charge changes
• ☐ Other Pennsylvania-specific rights at § 201.29(c.3)

Health Care Facilities Act — 35 P.S. § 448.806 and related sections: failure to comply with licensure conditions and resident-rights authority delegated to the Department of Health.

8. INTERNAL GRIEVANCE PROCEDURE

Has the complaint been raised internally with the facility?

• ☐ Yes — describe below
• ☐ No — explain

Date raised internally: [__/__/____]

Person to whom raised (name / title): [________________________________]

Method: ☐ Oral ☐ Written ☐ Resident council ☐ Grievance form

Facility response (verbatim where possible): [________________________________]

Date of facility response: [__/__/____]

Status: ☐ Resolved ☐ Unresolved ☐ Retaliation alleged ☐ No response received

9. REQUESTED RELIEF

The complainant requests that the receiving agency take the following actions (check all that apply):

• ☐ Open an investigation under 42 C.F.R. § 488.332 / 28 Pa. Code Chapter 51
• ☐ Conduct an unannounced on-site survey
• ☐ Issue a Statement of Deficiencies (Form CMS-2567) and require an acceptable Plan of Correction
• ☐ Impose a federal civil money penalty under 42 C.F.R. § 488.408 / § 488.438 (currently up to approximately $25,484 per day for immediate-jeopardy deficiencies, adjusted annually for inflation)
• ☐ Impose state civil money penalty under 28 Pa. Code § 51.3 / 35 P.S. § 448.815
• ☐ Impose a denial of payment for new admissions
• ☐ Recommend appointment of a temporary manager (42 C.F.R. § 488.415)
• ☐ Refer for license revocation or non-renewal
• ☐ Refer to Office of Attorney General, Medicaid Fraud Control Section
• ☐ Coordinate with OAPSA / APS for protective services
• ☐ Require staff retraining and re-credentialing
• ☐ Provide Ombudsman advocacy and complaint resolution under 42 U.S.C. § 3058g
• ☐ Other: [________________________________]

10. SUPPORTING DOCUMENTATION

Attached or available upon request:

• ☐ Medical records (subpoena or HIPAA authorization on file)
• ☐ Medication Administration Record (MAR)
• ☐ Care plan / minimum data set (MDS)
• ☐ Incident reports
• ☐ Photographs (date-stamped) of injuries or conditions
• ☐ Resident or family timeline / journal
• ☐ Correspondence with facility administration
• ☐ Witness statements
• ☐ Bank statements / financial records (exploitation cases)
• ☐ Prior survey results / Form CMS-2567
• ☐ Other: [________________________________]

11. CONFIDENTIALITY AND ANTI-RETALIATION

11.1. Ombudsman confidentiality. The State Long-Term Care Ombudsman and AAA ombudsmen are bound by 42 U.S.C. § 3058g(d) and 6 Pa. Code § 13.4 to maintain the confidentiality of complainant and resident identity except as authorized by the resident or by court order.

11.2. DOH confidentiality. The Department of Health treats the identity of complainants as confidential under 28 Pa. Code Chapter 51 except as required by law.

11.3. Anti-retaliation. Federal law (42 C.F.R. § 483.10(f)(4)) and Pennsylvania law (35 P.S. § 10225.303(d.1) for OAPSA-overlapping conduct; 28 Pa. Code § 201.29) prohibit retaliation against a resident, family member, or staff member for filing a complaint, voicing a grievance, or participating in a survey or investigation. Retaliation should be reported immediately to the receiving agency and to law enforcement where it constitutes intimidation or harassment.

12. VERIFICATION

I, [COMPLAINANT NAME], declare under penalty of perjury under the laws of the Commonwealth of Pennsylvania that the foregoing complaint is true and correct to the best of my knowledge, information, and belief, and that I make this complaint in good faith.

Signature: [________________________________]

Print name: [________________________________]

Date: [__/__/____]

Sworn to and subscribed before me this [____] day of [_______________], 20[____].

Notary Public: [________________________________]

(My Commission Expires: [_______________])

13. DISTRIBUTION

14. PENNSYLVANIA PRACTICE NOTES

• Dual-track regulators. Quality-of-care complaints typically generate the most action when filed simultaneously with the PA Department of Health (regulator with enforcement teeth) and the Long-Term Care Ombudsman (advocate who works the resident's interests in real time). The Ombudsman cannot assess penalties; DOH cannot directly advocate for the resident in care-plan meetings.
• Resident consent is jurisdictional for the Ombudsman. Without resident consent (or a determination of incapacity plus best-interest action), the Ombudsman cannot share information or take action on the resident's behalf. Document consent in Section 3.
• Federal incorporation. 28 Pa. Code § 201.29 expressly incorporates 42 C.F.R. § 483.10. A violation of any federal resident right is automatically a state-law violation.
• Civil money penalties. CMS-imposed CMPs for "immediate jeopardy" deficiencies currently run up to approximately $25,484 per day, adjusted annually for inflation under 45 C.F.R. Part 102; verify the current amount on the CMS Civil Monetary Penalty Inflation Adjustment table before filing. Pennsylvania may also impose state civil penalties under 35 P.S. § 448.815.
• Discharge protections. Improper discharge or "patient dumping" (e.g., refusal to readmit after a hospital stay) is appealable to the Department of Human Services Bureau of Hearings and Appeals under 42 C.F.R. § 483.15(c)(3) and § 431.220. Filing a hearing request stays the discharge.
• Civil litigation overlay. A complaint to DOH or the Ombudsman does not toll the Pennsylvania two-year statute of limitations on negligence (42 Pa.C.S. § 5524) or the survival action / wrongful death statute. If serious injury or death has occurred, retain litigation counsel promptly.
• Mandatory-reporter overlap. Facility employees who witness abuse or neglect have BOTH a complaint pathway (DOH / Ombudsman) and a mandatory-reporter pathway (OAPSA hotline). Both should be used; one does not satisfy the other.

15. SOURCES AND REFERENCES

• 42 U.S.C. § 1395i-3, § 1396r — Nursing Home Reform Act
• 42 C.F.R. Part 483 — Requirements for Long Term Care Facilities — https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483
• 42 C.F.R. § 483.10 — Resident rights
• 42 C.F.R. § 488.408, § 488.438 — Civil money penalties
• 35 P.S. § 448.101 et seq. — Pennsylvania Health Care Facilities Act
• 28 Pa. Code Chapter 201 — https://www.pacodeandbulletin.gov/secure/pacode/data/028/chapter201/chap201toc.html
• 28 Pa. Code § 201.29 — Resident rights
• 6 Pa. Code Chapter 13 — Long-Term Care Ombudsman Program
• Older Americans Act, 42 U.S.C. § 3058g — State LTC Ombudsman
• PA Department of Health — Bureau of Long-Term Care Complaints — 1-800-254-5164 — [email protected]
• PA Department of Aging — Long-Term Care Ombudsman — https://www.aging.pa.gov/aging-services/Pages/Ombudsman.aspx
• PA Department of Aging — Statewide Elder Abuse Hotline: 1-800-490-8505
• CMS Care Compare — https://www.medicare.gov/care-compare/
• PA Office of Attorney General — Medicaid Fraud Control Section: 1-717-787-3391

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. A Pennsylvania-licensed attorney should be consulted in cases involving serious harm, civil claims, or where retaliation is feared. Filing this complaint does not preserve civil-action deadlines.