South Carolina Nursing Home Resident Complaint — LTC Ombudsman / SCDHEC Bureau of Health Facilities Licensing

SOUTH CAROLINA NURSING HOME RESIDENT COMPLAINT — LTC OMBUDSMAN / SCDHEC

TABLE OF CONTENTS

1. Receiving Agency
2. Resident and Complainant Information
3. Facility Information
4. Resident Rights at Issue
5. Statement of Complaint
6. Witnesses, Evidence, and Documentation
7. Internal Grievance Process Pursued
8. Relief Requested
9. Concurrent and Cross-Reports
10. Confidentiality and Anti-Retaliation
11. Resident / Representative Authorization
12. Signature Block
13. South Carolina Practice Notes
14. Sources and References

1. RECEIVING AGENCY

(Check all that apply — concurrent filing is permitted and often appropriate.)

☐ South Carolina Long Term Care Ombudsman Program — South Carolina Department on Aging.

• Hotline: 1-800-868-9095 | Local: (803) 734-9900
• Mail: SCDOA Long Term Care Ombudsman, 1301 Gervais Street, Suite 350, Columbia, SC 29201 (verify)
• Email/web: aging.sc.gov/programs-initiatives/long-term-care-ombudsman-program
• Statutory authority: 42 U.S.C. § 3058g; S.C. Code § 43-38-10 et seq.

☐ SCDHEC Bureau of Health Facilities Licensing (BHFL) — South Carolina Department of Health and Environmental Control.

• Phone: (803) 545-4370 | Toll-free: 1-800-922-6735
• Fax: (803) 545-4212
• Mail: SCDHEC, Bureau of Health Facilities Licensing, 2600 Bull Street, Columbia, SC 29201
• Online: scdhec.gov (Health Facilities Complaints)
• Statutory authority: S.C. Code § 44-7-260; Reg. 61-17

☐ CMS / Medicare-Medicaid Certified Facility Complaint — routed through DHEC as state survey agency. Federal authority: 42 C.F.R. § 488.

☐ Adult Protective Services / SLED — file separate APS report (see APS template) if abuse, neglect, or exploitation suspected. Hotlines: APS 1-888-227-3487 (community); LTC Ombudsman 1-800-868-9095 (facility); SLED Vulnerable Adults Unit (DMH/DDSN facilities).

☐ Local Law Enforcement / 911 — emergency or imminent harm.

2. RESIDENT AND COMPLAINANT INFORMATION

3. FACILITY INFORMATION

4. RESIDENT RIGHTS AT ISSUE

(Check all rights implicated. Federal cites are 42 C.F.R. § 483.10; state cites are S.C. Code § 44-81 and Reg. 61-17.)

☐ Right to be free from abuse, neglect, exploitation, and misappropriation — 42 C.F.R. § 483.12; S.C. Code § 44-81-40

☐ Right to be free from physical, chemical, and inappropriate restraints — 42 C.F.R. § 483.10(e)(1); § 483.12(a)(2)

☐ Right to dignity, respect, and self-determination — 42 C.F.R. § 483.10(a)–(c); S.C. Code § 44-81-30

☐ Right to participate in care planning / informed consent — 42 C.F.R. § 483.10(c)(2)–(3)

☐ Right to refuse treatment / refuse experimental research — 42 C.F.R. § 483.10(c)(6)

☐ Right to privacy in treatment, communication, and personal records — 42 C.F.R. § 483.10(h)

☐ Right to medical care meeting professional standards — 42 C.F.R. § 483.25 (quality of care); 42 C.F.R. § 483.45 (pharmacy services)

☐ Right to adequate staffing — 42 C.F.R. § 483.35; SCDHEC Reg. 61-17

☐ Right to a safe, clean, homelike environment — 42 C.F.R. § 483.90; Reg. 61-17

☐ Right to nutritional adequacy and personal hygiene — 42 C.F.R. § 483.60; § 483.25

☐ Right to visitors of resident's choice — 42 C.F.R. § 483.10(f)(4)

☐ Right to grievance and prompt response — 42 C.F.R. § 483.10(j); S.C. Code § 44-81-30

☐ Right to be free from involuntary transfer or discharge — 42 C.F.R. § 483.15(c) (only for permitted reasons; 30-day notice; right to appeal)

☐ Right to manage personal funds / written quarterly accounting — 42 C.F.R. § 483.10(f)(10)

☐ Right to be informed of services and charges — 42 C.F.R. § 483.10(g)

☐ Right to organize and participate in resident / family councils — 42 C.F.R. § 483.10(f)(5)–(6)

☐ Right to access the State LTC Ombudsman, advocates, and surveyors — 42 C.F.R. § 483.10(f)(4)(i)(D)

☐ Right to be free from retaliation for exercising rights — 42 C.F.R. § 483.10(b)(2); S.C. Code § 44-81-30

☐ Right to receive written/oral notice of rights and grievance procedures at admission — 42 C.F.R. § 483.10(g); S.C. Code § 44-81-20

☐ Right against discrimination by source of payment, sex, race, color, religion, national origin — S.C. Code § 44-81-30; 42 C.F.R. § 483.10(a)(2)

☐ Other: [________________________________]

5. STATEMENT OF COMPLAINT

Provide a chronological, fact-based narrative. Distinguish what was personally observed from what was told to you. Identify staff by name, title, shift, and date where possible.

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

Time(s) / shift(s): [________________________________]

Specific room / area of facility: [________________________________]

Staff involved (name, title, shift): [________________________________]

Narrative:

[____________________________________________________________]

[____________________________________________________________]

[____________________________________________________________]

[____________________________________________________________]

[____________________________________________________________]

[____________________________________________________________]

[____________________________________________________________]

[____________________________________________________________]

(Attach additional pages as needed; mark each page with complainant name and date.)

6. WITNESSES, EVIDENCE, AND DOCUMENTATION

Witnesses:

Evidence Attached or Available:

☐ Photographs (with dates) of injuries, conditions, environment

☐ Care plan / MDS assessments

☐ Physician orders and medication administration records (MARs)

☐ Nurse notes and progress notes

☐ Incident / accident reports (request under 42 C.F.R. § 483.10(g)(2))

☐ Facility grievance log entries and responses

☐ Discharge / transfer notice and Notice of Appeal Rights (where applicable)

☐ Resident's Trust Fund account statements

☐ Bills, invoices, billing disputes

☐ Surveillance / room camera (where lawful)

☐ Police / EMS run reports

☐ Witness statements (signed, dated)

☐ Hospital records from any related ER / hospital admission

☐ Email / text exchanges with facility staff

☐ Other: [________________________________]

7. INTERNAL GRIEVANCE PROCESS PURSUED

Under 42 C.F.R. § 483.10(j) and S.C. Code § 44-81-30, the facility must maintain a grievance procedure with a designated Grievance Official.

☐ Internal grievance filed — Date: [__/__/____] Recipient: [________]

☐ Facility response received — Date: [__/__/____] Outcome: [________]

☐ No response received within facility's stated timeframe

☐ Internal grievance not pursued because: ☐ Fear of retaliation ☐ Resident lacks capacity ☐ Emergency ☐ Facility refused to accept grievance ☐ Other: [________]

Attach copies of any written grievance and facility response.

8. RELIEF REQUESTED

(Check all that apply.)

☐ Independent investigation by SCDHEC Bureau of Health Facilities Licensing (Reg. 61-17 inspection / complaint survey)

☐ Ombudsman advocacy and mediation with facility administration

☐ Citation / Statement of Deficiency under federal F-tags (42 C.F.R. Part 483)

☐ Civil money penalty against facility (42 C.F.R. § 488.408)

☐ Denial of payment for new admissions

☐ Mandatory directed plan of correction

☐ License revocation, suspension, or non-renewal

☐ Referral to APS / SLED for criminal investigation of abuse, neglect, or exploitation

☐ Referral to SC Medicaid Fraud Control Unit (MFCU) — [________]

☐ Referral to SC Department of Labor, Licensing and Regulation — [________] (for licensed individual professionals — RN/LPN/MD/CNA)

☐ Order of immediate corrective action regarding resident

☐ Restitution of misappropriated funds / personal property

☐ Other: [________________________________]

9. CONCURRENT AND CROSS-REPORTS

Indicate whether the complainant has filed (or intends to file) reports with any other agency:

10. CONFIDENTIALITY AND ANTI-RETALIATION

• Ombudsman confidentiality. Records and identity of complainants and residents are confidential under the Older Americans Act, 42 U.S.C. § 3058g(d), and may not be disclosed without the consent of the complainant or resident, except as required by court order.
• DHEC complaint records. SCDHEC investigative records are protected under S.C. Code § 44-7-315 and Reg. 61-17 to the extent they identify individual residents or reporters.
• Anti-retaliation. Retaliation against a resident who exercises rights, files a grievance, or assists in an investigation is prohibited by 42 C.F.R. § 483.10(b)(2) and S.C. Code § 44-81-30. Forms of prohibited retaliation include: increasing charges, decreasing services, transferring or discharging the resident, abusing or threatening the resident, or restricting visitors.

11. RESIDENT / REPRESENTATIVE AUTHORIZATION

I, [RESIDENT or AUTHORIZED REPRESENTATIVE NAME], authorize the receiving agency or agencies identified in Section 1 to investigate the matters described in this complaint, to access relevant facility, medical, financial, and personal records of the Resident, and to contact the witnesses identified herein.

I request that:

☐ My identity remain confidential to the maximum extent permitted by law.

☐ I be contacted by ☐ phone ☐ email ☐ mail at the address provided in Section 2.

☐ A copy of all written findings and any plan of correction be provided to me.

I understand that no civil or criminal liability shall arise from the good-faith filing of this complaint and that South Carolina law prohibits retaliation against residents and their representatives for filing complaints regarding facility care.

12. SIGNATURE BLOCK

[________________________________]

[COMPLAINANT NAME]

Title / Relationship to Resident: [________________________________]

Date: [__/__/____]

Phone: [________________________________]

Email: [________________________________]

If signed by Authorized Representative, attach: ☐ Durable POA ☐ Health Care POA ☐ Letters of Guardianship/Conservatorship

13. SOUTH CAROLINA PRACTICE NOTES

• Federal floor + state rights. OBRA '87 / NHRA at 42 U.S.C. §§ 1395i-3 and 1396r and 42 C.F.R. Part 483 set the federal floor for resident rights in Medicare/Medicaid-certified facilities. South Carolina's Bill of Rights for Residents of Long-Term Care Facilities, S.C. Code § 44-81-10 et seq., applies to state-licensed facilities (including those not federally certified) and reinforces several federal rights.
• SCDHEC Reg. 61-17. South Carolina Regulation 61-17 ("Standards for Licensing Nursing Homes") establishes physical-plant, staffing, infection-control, medication-administration, and resident-care standards. Violations support deficiency citations and license action.
• Ombudsman vs. licensure agency. The Ombudsman is a confidential, resident-directed advocate without enforcement power; SCDHEC has enforcement and licensure authority. Filing with the Ombudsman does NOT trigger a regulatory survey unless the complainant consents to the disclosure.
• CMS five-star and survey results. Federal survey results for Medicare/Medicaid-certified facilities are published on the CMS Care Compare website. Reference recent 2567 survey forms when complaining of recurring deficiencies.
• Private right of action. S.C. Code § 44-81-40 authorizes a resident, or someone acting on the resident's behalf, to bring a civil action against the facility for violation of resident rights, with available remedies including injunctive relief and recovery of actual damages, costs, and reasonable attorney's fees. The 3-year statute of limitations under S.C. Code § 15-3-530 generally applies to such actions; verify against any contractual arbitration or shorter limitations claimed by the facility.
• Pre-dispute arbitration agreements. Many SC nursing-home admission packets contain arbitration clauses. CMS rules at 42 C.F.R. § 483.70(n) limit but do not prohibit such clauses. Always preserve right-to-rescind language and check whether the resident or only an agent signed.
• APS overlap. Suspected abuse, neglect, exploitation, or misappropriation must be reported under the Omnibus Adult Protection Act in addition to filing this complaint (S.C. Code § 43-35-25). Mandatory reporters have a 24-hour / next-working-day duty.
• Discharge protections. Involuntary transfer or discharge is permitted only for the six reasons in 42 C.F.R. § 483.15(c)(1) (e.g., welfare, health, safety, non-payment, facility closure). Resident is entitled to 30-day written notice and a hearing before SCDHHS / state administrative law judge. Demand the notice in writing.
• Personal-funds accounts. Facilities holding resident funds in trust must provide quarterly accounting and pay interest on accounts > $50 per 42 C.F.R. § 483.10(f)(10). Audit the trust statements when financial concerns arise.
• Care Compare and CMS Region IV. CMS Region IV (Atlanta) supervises SCDHEC's federal survey activities. Where state response is inadequate, escalate to CMS via 1-800-MEDICARE or directly to Region IV.
• Non-Medicaid CRCFs and assisted living. Community Residential Care Facilities are licensed by SCDHEC under Reg. 61-84, not 61-17. Confirm the correct regulation when complaining about an assisted-living-style facility.

14. SOURCES AND REFERENCES

• 42 U.S.C. §§ 1395i-3, 1396r (Nursing Home Reform Act / OBRA '87)
• 42 C.F.R. Part 483 — 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. § 483.12 (Freedom from Abuse, Neglect, and Exploitation)
• 42 C.F.R. § 483.15 (Admission, Transfer, and Discharge)
• 42 C.F.R. § 488.408 (Selection of Remedies / Civil Money Penalties)
• Older Americans Act, 42 U.S.C. § 3058g (State LTC Ombudsman Program)
• S.C. Code Title 44, Chapter 81 (Bill of Rights for Residents of Long-Term Care Facilities) — https://www.scstatehouse.gov/code/t44c081.php
• S.C. Code Title 43, Chapter 35 (Omnibus Adult Protection Act) — https://www.scstatehouse.gov/code/t43c035.php
• S.C. Code Title 43, Chapter 38 (LTC Ombudsman) — https://www.scstatehouse.gov/code/t43c038.php
• S.C. Regulation 61-17 (Standards for Licensing Nursing Homes) — SCDHEC
• South Carolina Department on Aging — https://aging.sc.gov
• SC Long Term Care Ombudsman: 1-800-868-9095
• SCDHEC Bureau of Health Facilities Licensing — https://scdhec.gov | (803) 545-4370 / 1-800-922-6735
• CMS Care Compare — https://www.medicare.gov/care-compare/
• CMS Region IV Atlanta — https://www.cms.gov/About-CMS/Agency-Information/RegionalOffices/RegionalMap

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Facility complaint procedures and citations to South Carolina regulations are subject to amendment. Verify current hotline numbers, mailing addresses, and citation language against the SCDOA, SCDHEC, and SCDHHS websites and the official Code of Laws / Code of Regulations before reliance. Have facility-specific complaints reviewed by a South Carolina-licensed elder law or nursing-home litigation attorney.