Pleasebeasthoroughaspossiblewhencompletingthisform.Youmaycompletethisformelectronicallyorby hand. Please print legibly when completing the form by hand. To send this form electronically, typethe informationdirectlyontheform,saveittoyourharddrive,thenemailorfaxthecompletedformtotheOLCComplaint Unit. Completed forms can also be mailed to the ComplaintUnit.

Section 1. Person Filling Out the ComplaintForm
Youarenotrequiredtofilloutthissectiontofileacomplaint.However,theVDHOfficeofLicensureand Certification(OLC)willnotbeabletocontactyoutoobtainadditionalinformationorreachyoutonotifyyou of the results of theinvestigation.
Name (First andlast):
Address:
City: / State: / ZipCode:
Emailaddress:
Work TelephoneNumber: () / Home TelephoneNumber:
() / Cell TelephoneNumber:
()
Best time(s) to contact you (please check all thatapply):
MorningAfternoonEvening
Date you filed the complaint(mm/dd/yyyy)://
Section 2. Nursing HomeInformation
FacilityName:
Address:
City: / State: / ZipCode:
Telephone Number:()
Section 3. ResidentInformation
Resident Name (first andlast): / Date ofBirth://
Your Relationship to theResident:
Resident(self)Family Member(Spouse/Child/Parent)
FriendPresentor former nursinghomeemployee
OmbudsmanQualityImprovementOrganization
LawEnforcementAgencyMediaAnonymousLegal representative/guardian/power ofattorney
Other, pleaseexplain:
Is the Resident still in the nursinghome:NoYesDo notknow
Section 4. ComplaintInformation
Please provide as much information as possible include the date, time, how oftenthe concern has occurred, and the location where the concern occurred. Feel free touseexamples. Please list the people involved or any witnesses at the bottom of thissection. You may attach additional pages and reports to this form asneeded.
Names of any other person(s) or witness(es) involved in thiscomplaint:
Name (first andlast): Contact Information, if known:( )
Name (first andlast): Contact Information, if known:( )
Section 5. Reporting of theComplaint
Did you report this complaint to the nursing homestaff: [ ] No [ ] Yes
If yes, please complete the itemsbelow.
A. Date the complaint was reported to the nursing home staffperson://
B. Name and title of the nursing home staff person to whom the complaint wasreported:
Name (first andlast): Contact Information, if known:( )
C. What action was taken by the nursinghome?
Section 5. Reporting of the Complaint(continued)
D. Did you report this complaint or incident to any otheragency?
Long-Term CareOmbudsmanLaw EnforcementAgency
Adult ProtectiveServicesAttorneyGeneral
Other, pleaselist:
Section 6. ComplaintResolution
What do you think should happen in thissituation?
Please return completed reportto:
ComplaintUnit
Office of Licensure andCertificationVirginia Department ofHealth 9960 Mayland Drive, Ste.401
Henrico, VA23233-1463
Fax Number:1-804-527-4503
Hot Line Number:1-800-955-1819 Metro Richmond: (804)367-2106
/ OLC treats the identity of the complainant and patient as confidentialduringthe course of its investigation pursuant to § 32.1-138.5 of the CodeofVirginia. However, the OLC reserves the right to disclose to thenursingfacility the nature of the complaint or the identity of the patient who isthesubject of the complaint as permitted by § 32.1-138.5 of the Code ofVirginia.Section 32.1-138.5 authorizes the disclosure of "the nature of thecomplaintor the identity of the patient" to the nursing facility. It only permitsthedisclosure of the complainant's identity in advance of anadministrativehearing in which the Department "intends to rely, in whole or in part, onanystatements made by thecomplainant."
I have read and understand theabove.

NameDate

Instructions for Filing a Nursing HomeComplaint

Anyone with knowledge or concerns about the care of a resident in a nursing home may fileacomplaintwiththeOLC.TheVDHOfficeofLicensureandCertification(OLC)istheagencythathas regulatory responsibility for all nursing homes inVirginia.
You may use the attached form to file a complaint if you are concerned about the healthcare,treatment, or services that you or another person received or did not receive in the nursinghome.Somereasonsforfilingacomplaintwouldbeabuse,neglect,poorcare,notenoughstaff,unsafeor unsanitary conditions, dietary problems, or mistreatment. The OLC does not havejurisdictionover provider fees or charges or provider billingpractices.
You do not have to use this form when filing a complaint. You may file a complaint with the OLCbyany means available to you, including mail, telephone, fax, on-line, orin-person.
Step1:
Please include as much information as possible when submitting your complaint. TheresponseandtimingofanyinvestigationbytheOLCwillbebasedupontheinformationprovided,
Report a concern as soon as possible since it will be easier for you to remember the facts andwillassist the OLC in gathering importantinformation.
Step2:
Following receipt of your complaint, a representative from the OLC will contact you aboutyourconcerns and discuss the appropriate course of action and anticipated timeframes.Therepresentative will also provide you with a telephone number of a contact person at the OLCforfurtherfollow-up.
Step3:
If your concern involves a possible violation of a Federal or State nursing home regulation,theOLCwillconductaninvestigation.Theinvestigationmayincludeareviewofrecords,interviewswith staff and residents, and the observation of residentcare.
Step4:
Attheendoftheinvestigation,theOLCwillnotifyyouoftheresultsifyouhaveprovidedyourcontact information in Section 1 of the complaintform.