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PRINTED: 09/10/2019 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 a complaint investigation survey

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Begin by reading the instructions provided with the survey.
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Fill out your personal information accurately in the designated fields.
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Provide detailed information about the complaint you are reporting.
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Answer all the questions truthfully and to the best of your knowledge.
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Who needs a complaint investigation survey?

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Anyone who has experienced a negative incident or situation that they wish to report and have investigated.
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A complaint investigation survey is a tool used to gather feedback and information regarding complaints filed by individuals.
Certain organizations or agencies may be required to file a complaint investigation survey based on regulations or guidelines.
A complaint investigation survey can be filled out by providing accurate and detailed information about the complaint, including date, nature of the complaint, and any relevant documentation.
The purpose of a complaint investigation survey is to ensure that complaints are addressed in a timely and effective manner, and to identify any underlying issues that may need to be resolved.
Information reported on a complaint investigation survey may include the complainant's contact information, details of the complaint, investigation findings, and resolution steps taken.
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