state-agency-complaint

name

state-agency-complaint

description

Draft a standalone regulatory complaint DOCUMENT addressed to a state or federal health-oversight body — Ohio Department of Health, Ohio Department of Insurance, Ohio Attorney General Health Care Fraud Section, CMS BFCC-QIO oversight, or the Long-Term Care Ombudsman — from an existing SNF findings set. Reuses `*_HotItems.md` / `*_Findings.md` from the `/snf-review` pipeline, preserves verbatim citations, and produces a venue-appropriate `.docx` complaint with a short cover summary and exhibits list. Use when the user says "/state-agency-complaint", "draft ODH complaint", "file ODI complaint", "draft Ohio AG complaint", "report to Ohio AG health care fraud", "CMS BFCC-QIO oversight letter", "ombudsman complaint", "file regulatory complaint against [facility]", or otherwise signals it's time to produce a separately-filed regulatory complaint.

State Agency Complaint

Draft a regulatory complaint to a health-oversight body from the already-aggregated /snf-review findings. The complaint is formal, cited, and deadline-driven, and every sentence has to survive being read by the agency's intake officer, the target's counsel, and eventually opposing counsel in a hearing. No theatrics; the record does the arguing.

The exception is the Long-Term Care Ombudsman venue, which is an informal, cooperative track. See references/ombudsman.md.

Distinct from hipaa-records-request, which only names agencies as an escalation paragraph inside a records-demand letter. This skill produces the actual standalone complaint that gets filed with the agency.

Inputs to collect

1. Venue — one of:

   • ODH — Ohio Department of Health, Bureau of Long-Term Care Quality
   • ODI — Ohio Department of Insurance
   • OH-AG-HCF — Ohio Attorney General, Health Care Fraud Section
   • CMS-BFCC — CMS BFCC-QIO oversight (when the QIO itself is the target)
   • OMBUDSMAN — Long-Term Care Ombudsman (routed via the county's Area Agency on Aging)

   If the user doesn't pick, briefly describe each venue and the kind of misconduct each one is the right match for (a one-line rationale each). Do not pick for the user.

2. Patient identifiers — name, DOB, facility name, facility address. Header only. Do not repeat PHI in the chat or in the summary back to the user.

3. POA / complainant block — use the case profile's canonical authority block when available; otherwise confirm the complainant's role and resident identifiers per-run.

4. Alleged misconduct — a bullet list. Each bullet must have a source-file citation (filename + page, or entry date + log filename). If the user types narrative, translate to the bullet + cite format and show it for confirmation before drafting.

5. Findings directory — path where <prefix>_HotItems.md, <prefix>_Findings.md, <prefix>_Timeline.md, <prefix>_Gaps.md live (the --out-dir from /snf-review). Optional — if absent, work from the user's bullets alone and flag the absence in the cover summary. Fail gracefully; do not fabricate citations.

6. Requested relief — specific asks. Examples: "survey the facility against 42 CFR 483.12 and 483.21 for the cited dates," "open an unfair-claims-practices inquiry under ORC 3901.20," "refer to Medicaid Fraud Control Unit under ORC 2913.40," "remand the QIO's 06/24 determination for Jimmo-compliant review." If the user defaults to "investigate," push gently for one concrete ask per bullet.

Preparation

1. If a findings directory was supplied, read (in order):

   1. <findings-dir>/<prefix>_HotItems.md — pre-formatted value-3 findings, the primary source of cited evidence.
   2. <findings-dir>/<prefix>_Findings.md — master tagged index; use to backfill adjacent findings supporting a hot item.
   3. <findings-dir>/<prefix>_Timeline.md — anchor the narrative to dated events.
   4. <findings-dir>/<prefix>_Gaps.md — reference if a gap is itself part of the alleged misconduct (e.g., facility refused to produce records).

   If any are missing, continue without them and note the absence in the cover summary's "Scope and sourcing" paragraph.

2. Read the venue-specific reference file in this skill's references/ directory to load framing, citations, recipient routing, and tone rules for the selected venue:

   • references/odh.md
   • references/odi.md
   • references/oh-ag-hcf.md
   • references/cms-bfcc-qio.md
   • references/ombudsman.md

3. Also re-read ${CLAUDE_PLUGIN_ROOT}/skills/snf-records-review/RUBRIC.md to preserve tag semantics when mapping findings into complaint arguments.

Complaint structure (all venues except Ombudsman)

Produce a .docx via the docx skill with this exact structure. Deviations must be venue-driven and explainable in the cover summary.

1. Header block — complainant name and role (POA), recipient and office, date, subject line in the form: Complaint — <Facility Name>, <Resident Identifier>, <Dates of Service> — <one-phrase characterization>
2. Parties — resident (name, DOB, current location), facility and corporate parent (name, address, license numbers if known, Medicare/Medicaid enrollment if applicable), payer (if relevant to venue), complainant (POA with documentation-available-on-request boilerplate).
3. Summary of complaint — 3–6 sentences. Lead with the business outcome requested: survey, investigation, referral, remand. Name the statutes and regulations being invoked by citation only (full text in the Relief Requested section).
4. Factual background — short, dated, neutral. Pull from _Timeline.md where available. No argumentation in this section.
5. Allegations — each alleged violation gets its own numbered subsection:
   • ### Allegation <N>: <one-line characterization>
   • Regulatory basis — CFR / OAC / ORC citation; for any Ohio-specific citation add the user-verification flag (see Guardrails).
   • Evidence — verbatim quotes from findings or hot items. Each citation: Source: <filename> p.<page>, author/role, verbatim quote, strategic relevance. Do not paraphrase quotes.
   • Why it violates the cited authority — one short paragraph. Stay in "the record shows" framing.
6. Relief requested — the concrete asks, one per line.
7. Exhibits list — numbered, with filename and page range. Every exhibit referenced in Allegations must appear here. Every exhibit here must be referenced in Allegations. Reconcile before finalizing.
8. Signature block — POA / representative signature and contact preferences from the case profile, or user-supplied email, phone, and certified-mail address.

Complaint structure (Ombudsman venue)

See references/ombudsman.md — cooperative tone, shorter letter, no "Allegations" heading. Still cited, still dated, but framed as a request for the Ombudsman's assistance in resolving a dispute with the facility, not a regulatory filing.

Cover summary

Always produce a short markdown cover summary alongside the .docx:

• One-paragraph description of what the complaint argues and what it asks for.
• Top 3 citations used (filename + page).
• Any hot items intentionally withheld and why.
• Sourcing gaps (missing findings directory, missing _Gaps.md, etc.).
• [user: verify before submission] checklist for any state-specific or agency-specific citation (see Guardrails). Use that exact bracketed lower-case string so every marker is findable with one search.

The cover summary is for the user, not the agency. Save it as a sibling .md file.

Execution

1. Create the output directory if it doesn't exist. Default: <findings-dir>/complaints/ or the user's workspace root if no findings directory.
2. Output filenames:
   • .docx — Complaint_<Venue>_<FacilityShortName>_<YYYY-MM-DD>.docx
   • Cover summary — same stem, .md extension.
3. Use the docx skill to build the .docx. Preserve verbatim quotes as block quotes where the Word format supports it, otherwise inline with quotation marks.
4. After writing, return to the user: file paths, one-paragraph summary, the verification checklist, and a prompt to append an admin-interaction-log entry recording that a complaint draft was prepared for the specified venue.
5. If case-context/ exists, propose adding the complaint draft to document_index.md and the requested relief / open agency response to issue_log.md.

House-style rules

• State facts, not conclusions. "On 04/14 the record shows X" — not "the facility deliberately concealed X." The regulator draws the conclusion; the record does the arguing.
• No rhetoric, no adjectives of outrage, no sarcasm. Anger in a complaint gives the reader a reason to discount it.
• Enumerate. Numbered allegations and numbered asks — intake officers triage by scanning structure.
• Set a firm response date where a deadline is appropriate.
• First-person from the POA ("I submit this complaint in my capacity as Medical and Financial Power of Attorney …"). Documentation-available-on-request boilerplate on first mention.
• Enumerated items wherever there's a list. Bold dates and citations inline.
• Name the escalation path for unresolved complaints where appropriate — same four-agency ladder the hipaa-records-request skill uses. Don't use it as a threat; use it as a routing note so the current agency knows you know the path.
• Ohio-specific citations are acceptable but must be flagged for user verification before submission (see Guardrails).

Guardrails

• Reuse citations verbatim. Never paraphrase a chart quote when pulling it from _HotItems.md or _Findings.md. If the source quote is illegible or fragmentary, pass that through, don't smooth it.
• Fail gracefully on missing inputs. If the findings directory hasn't been generated, say so in the cover summary and proceed with the user's bullets. Do not invent evidence.
• Ohio-specific citation check. Any Ohio Revised Code, Ohio Administrative Code, or state-agency-specific citation must carry a [user: verify before submission] marker in the draft, same pattern as snf-appeal-supplement. Remove the marker only after the user confirms.
• No medical advice, no legal advice. Frame every factual claim as "the record shows" or "the following evidence supports." Do not characterize a clinician's decision as malpractice or a lawyer's argument as meritorious — name the regulation and cite the evidence, and let the agency draw the conclusion.
• PHI handling. Include name + DOB in the header and body only as needed to identify the resident for the agency. Do not include SSN, Medicaid ID, or Medicare/Member ID unless the venue's reference file says otherwise.
• Venue fit. If the alleged misconduct doesn't match the selected venue (e.g., a Medicare Advantage billing complaint routed to ODH), say so and recommend the right venue. Do not silently reshape the complaint.
• Deduplication. If the user has already filed with this venue for this case, read any prior complaint before drafting. Cross-reference the prior filing's date and reference number in the new complaint's header rather than re-litigating closed allegations.
• Privilege. If any finding was surfaced by the user's attorney (vs. the user's own review), flag before including — privileged material should not land in a regulatory complaint without counsel's sign-off.