Informal Dispute Resolution Procedures

The purpose of Informal Dispute Resolution (IDR) is to offer adult care licensees the opportunity to dispute deficiencies cited with the entity responsible for regulating and licensing the facility.

Availability of IDR
If the licensee believes that a specific deficiency or any finding within a deficiency cited during an inspection is factually inaccurate and would like the opportunity to dispute the specific deficiency and/or finding(s), the licensee will be given one opportunity to do so. IDR requests, and an explanation of why a deficiency is being disputed must be submitted in writing within the 15 working days afforded the facility to submit a plan of correction. If the licensee exceeds this time frame, the IDR coordinator will deny the request for IDR. If the licensee desires further discussion, the IDR coordinator will refer the licensee to section management.

The request must be submitted in writing to the Division of Health Service Regulation office that conducted the survey, as follows:

  1. Adult Care Licensure Section:
    Beth Bowman, Trainer, Raleigh and Clinton Regions
    2708 Mail Service Center, Raleigh, NC 27699-2708

  2. Construction Section:
    Steven Lewis, Section Chief
    2705 Mail Service Center, Raleigh, NC 27699-2705

The licensee may request informal dispute resolution for all deficiencies. In addition, the licensee may dispute the severity level for a violation.

IDR Format
The IDR may be conducted as a face-to-face meeting, telephone conference call or an office review of deficiencies and material. When there are no violations contested and if there is no enforcement action, the IDR shall be conducted as an office review of the cited deficiencies and the written information submitted by the facility. No oral presentations are permitted when the IDR format is an office review.

IDR panel members may consist of two surveyors and a member of either the North Carolina Assisted Living Association, the N.C. Association of Long Term Care Facilities, or an adult care home representative agreed upon by both associations.

Submission of Additional Written Material
The facility may submit additional written information for review to the IDR coordinator but must include or submit the material within the same time frame for submitting the written IDR request as specified in the letter notifying the facility of deficiencies cited. This ensures that the survey team and IDR panel can review the information prior to the IDR. The facility must submit five copies of material and highlight or use some other means to identify written information pertinent to the disputed deficiency(ies) or findings. The panel will not review additional written material that does not meet these requirements. The IDR may be held without submission of additional written material. The submission of additional written information at the IDR meeting is not allowed. Any written material pertaining to conduct or attitude of a surveyor(s) should be brought to the attention of Adult Care Licensure Section management and shall not be submitted with the IDR information.

Scheduling IDRs
Upon receipt of a written request for IDR, the IDR coordinator will verify that the IDR has been requested in accordance with the provisions of IDR procedures. When the facility has submitted additional written material as required, the material will first be shared only with the survey team to determine what effect there may be on a deficiency(ies) or findings. The facility will be notified of any changes and asked to confirm that informal dispute resolution is still desired. If the facility still requests to contest a deficiency(ies) or findings, the IDR format (meeting, office review, conference call) will be confirmed. Office reviews will be scheduled at the convenience of the panel and do not include oral presentations. If the IDR request addresses a violation, the date and time when the IDR will be held will be identified. IDR meetings are normally scheduled monthly. The IDR may be rescheduled one time only.

Notification of and Attendance at IDR
The IDR coordinator ensures that the IDR panel, surveyors, branch and section management and State Long-Term Care Ombudsman are notified of the facilities requesting IDR, IDR format, and if the request addresses a violation, the date, time, and location of the IDR meetings. Attorneys and their employees may not attend the IDR meeting; however, the following individuals may attend the IDR meeting under the conditions stated, and are responsible to protect the confidentiality of resident information:

  1. Facility representatives and staff;
  2. Survey team members and observers from the Adult Care Home Licensure Section;
  3. State Long-Term Care (LTC) and Regional Ombudsman; and
  4. Resident, individual or agency who is a legal guardian or has a medical power of attorney. These individuals can stay only during discussion of information pertinent to the specific resident. The resident, legal guardian, individual or agency having medical power of attorney will be identified and signed authorization forms will be verified prior to the start of the meeting.

IDR Panel Activity
The IDR coordinator will ensure that inspection results and materials submitted by the facility to dispute deficiencies and/or findings are provided to the IDR panel for review. Only those deficiencies identified in the facility's request will be reviewed in informal dispute resolution. IDR meetings are scheduled for a one-hour time frame with an exception in the case when the number of deficiencies/findings disputed cannot reasonably be reviewed and discussed within one hour. Facility staff, survey team members, ombudsman, the resident, legal guardian, or medical power of attorney, may provide verbal information pertinent to the violation and other deficiencies and findings being disputed and respond to questions from panel members. All participants in the IDR process are expected to keep their demeanors professional, respectful and non-confrontational when offering information which may be contradictory to information provided by other participants. The resident, legal guardian, or medical power of attorney may be present and participate only for deficiencies and findings involving the specific resident. With the exception of facility staff, oral statements will be limited to five minutes.

The IDR panel may decide that a deficiency or finding is to be upheld or deleted, that a deficiency is to be upheld with deletion of a finding(s), or that the severity of the violation should be changed to a lower severity. However, at his or her discretion, the section chief may override the decision of the IDR panel. The IDR panel shall not decide to move a deficiency or decide that a deficiency or finding is to be rewritten. The panel will provide its decision in writing to the IDR coordinator. The IDR coordinator will communicate it to the licensee within 10 working days by letter. A copy of the letter will be sent to the State LTC Ombudsman.

Actions Generated by IDR
When the IDR panel decides that a deficiency or finding should not have been cited, the following actions shall occur as applicable:

  1. When the facility requests a marked statement of deficiency form (CMS-2567), the relevant deficiency or finding will be marked "deleted", signed and dated by a supervisor of the surveying entity.
  2. When the facility requests issuance of a new CMS-2567 with the relevant deficiency or finding deleted, the plan of correction for the new report must be completed and documented on the new CMS-2567 and returned by the facility within 10 working days of receipt of the CMS-2567. A marked copy of CMS-2567 will be entered into the facility file as the document of record if a plan of correction is not returned within the 10-day period.
  3. Any enforcement action imposed solely because of a deficiency or finding that has been deleted by IDR will be rescinded.

Additional Opportunity for Informal Dispute Resolution
An IDR may be requested by a facility based on the results of a revisit when there is a continuation of the same deficiency, a new deficiency or a new example of a deficiency. Following a revisit, a deficiency cited at different rule with the same facts previously upheld by the IDR panel but noted at the wrong rule, is not eligible for IDR unless the new tag constitutes a violation.

Invalid Use of IDR
The facility cannot use the IDR process to delay the formal imposition of remedies or to challenge any other aspect of the inspection process, including the:

  1. Remedy imposed by the enforcing agency;
  2. Failure of the survey team to comply with a requirement of the survey process;
  3. Inconsistency of the survey team in citing deficiencies among facilities;
  4. Inadequacy or inaccuracy of the IDR process; or
  5. Surveyor behavior.