Section 144-112-4 - COMPLAINT INVESTIGATION AND INCIDENT REPORTS4.1 Complainant resolution. Complainants shall be encouraged to resolve complaints directly with the hospital before initiating a department complaint investigation.4.1.1 Consumer education. Each hospital must publish a toll-free telephone number for complainants to contact the hospital. Each hospital must educate the public about hospital complaint resolution procedures. At a minimum, each hospital must post information in a public part of the hospital explaining the complaint resolution procedures and listing the toll-free complaint telephone number.4.2 Department complaint investigation. The department may investigate complaints, incidents, and suspected non-compliance in order to protect patients from abuse, neglect, exploitation, and inadequate care or supervision, and to determine compliance with these rules. Department investigations may also involve suspected violation of state and/or federal law and/or rules. On-site investigations may be either announced or unannounced. 4.3 First Priority (Immediate Jeopardy). First priority will be given to suspectednoncompliance that may pose the greatest potential for harm to patients. Immediate jeopardy means a situation that may have caused or is likely to cause, serious injury, physical or psychological harm, impairment or death to a patient.4.4 Second priority (High Priority). Second priority will be given to suspected non-compliance that does not allege a threat of serious harm, but could have a negative impact on the health care services provided. These investigations are designed to identify and correct less serious situations that have potential to escalate into threats to the health, safety and welfare of patients.4.5 Medium, low or administrative complaint investigations.4.5.1 By Department. The department may investigate medium, low or administrative complaints.4.5.2 By Hospital. The department may authorize the hospital to investigate the medium, low or administrative complaint, if the complainant gives written or verbal permission.4.6 Criteria for investigation by hospital. The department may authorize a hospital to investigate a complaint when the hospital complies with the following requirements: 4.6.1 The hospital agrees to investigate the complaint. When the hospital agrees to investigate the complaint, the hospital may not withdraw its agreement before the investigation is completed. The hospital investigation of the complaint is complete when the department accepts the hospital's report. See Section 4.7. 4.6.2 The hospital provides the department with the name of a specific staff person, and an alternate, who will coordinate and conduct the investigation and communicate with the complainant and the department.4.6.3 The hospital agrees to complete the investigation and submit its report to the department within forty-five (45) days. The department will then determine whether the report meets the criteria contained in Section 4.7. 4.6.4 The hospital agrees to submit a report that meets the requirements of Section 4.7. 4.7 Hospital report of investigation. The written report to the department must be made on forms approved by the department and must include the following: 4.7.1 A summary of the hospital's investigation;4.7.2 A summary of the hospital's investigation methods;4.7.3 A list of the dates the investigation was conducted;4.7.4 A statement indicating whether the hospital found the allegation to be substantiated (supported by the evidence) or unsubstantiated (not supported by the evidence);4.7.5 Identification of the hospital's areas for improvement, if applicable;4.7.6 Identification of the hospital's plan for improvement, if applicable; and4.7.7 A copy of the hospital's response to the complainant.10-144 C.M.R. ch. 112, § 4