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PRINTED: 07/13/2023 FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION
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How to fill out an on-site complaint investigation

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Gather all necessary information related to the complaint.
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Conduct interviews with the complainant and any witnesses.
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Document all findings and evidence gathered during the investigation.
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Analyze the information collected to determine the validity of the complaint.
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Develop corrective actions or recommendations based on the investigation findings.
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Who needs an on-site complaint investigation?

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Anyone who has filed a complaint or has witnessed an incident that requires investigation.
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An on-site complaint investigation is a process where a designated individual visits a location to investigate a complaint or concern.
The entity or individual who receives a complaint or concern is usually required to file an on-site complaint investigation.
To fill out an on-site complaint investigation, the designated individual must visit the location, gather information, and document their findings.
The purpose of an on-site complaint investigation is to address and resolve any issues or concerns raised by a complaint.
Information such as the nature of the complaint, observations made during the investigation, and any actions taken or recommended must be reported on an on-site complaint investigation.
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