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Ombudsman Policies and Procedures Manual ... LONG-TERM CARE OMBUDSMAN POLICIES AND PROCEDURES MANUAL vi 930 Responding to a Communication from the Media or a Public Official

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Text of Ombudsman Policies and Procedures Manual ... LONG-TERM CARE OMBUDSMAN POLICIES AND PROCEDURES MANUAL...

  • State Long-Term Care Ombudsman Program

    Ombudsman Policies and Procedures Manual Revised September 2019

  • LONG-TERM CARE OMBUDSMAN POLICIES AND PROCEDURES MANUAL i

    Contents

    Chapter 100: Introduction ............................................................................... 1

    110 State Long-Term Care Ombudsman Program .................................................................................... 1

    120 Purpose of this Manual ...................................................................................................................... 1

    130 References to the Ombudsman Program in Statutes, Regulations, and Rules .................................. 1

    140 Organization of Manual ..................................................................................................................... 2

    Chapter 200: Definitions ................................................................................. 3

    Chapter 300: Functions of the Office and the State Ombudsman .......................... 9

    310 Responsibility of the State Ombudsman to Provide Programmatic Oversight .................................. 9

    320 Independence of the State Ombudsman and the Office ................................................................... 9

    Chapter 400: General Functions of Certified Ombudsmen .................................. 10

    410 Requirement to Perform the Functions of the Ombudsman Program ............................................ 10

    420 Requirement to Document Performance of the Functions of the Ombudsman Program .............. 10

    Chapter 500: Access to LTC Facilities, Residents, Resident Records, and Other

    Information ................................................................................................. 11

    510 Access to LTC Facilities ..................................................................................................................... 11

    a. Requirement for Visits by a Certified Ombudsman ........................................................................ 11

    b. Authority of a Certified Ombudsman to Access an LTC Facility ...................................................... 11

    c. Requirement for a Volunteer Ombudsman to Obtain Approval to Visit an LTC Facility Other Than

    During Regular Business or Visiting Hours .......................................................................................... 11

    d. LTC Facility’s Visitor Log, Notifying Facility Staff of Visit, and Requesting Resident Information .. 12

    e. Access to Areas in an LTC Facility Not Accessible to the Public ...................................................... 12

    520 Access to Residents .......................................................................................................................... 12

    a. Authority of Certified Ombudsman to Access a Resident .............................................................. 12

    b. Not Interfering with Provision of Care to Resident ........................................................................ 12

    c. Health Precautions when Visiting an LTC Facility ............................................................................ 12

  • LONG-TERM CARE OMBUDSMAN POLICIES AND PROCEDURES MANUAL ii

    530 Access to Resident Representative Information .............................................................................. 13

    a. Authority of Certified Ombudsman to Access Resident Representative Information .................... 13

    b. Obtaining Resident Representative Information ............................................................................ 13

    c. Requirements if LTC Facility Refuses to Provide Resident Representative Information ................ 13

    540 Access to Resident Records ............................................................................................................. 13

    a. Authority of a Certified Ombudsman to Access a Resident Record ............................................... 13

    b. Examples of a Resident Record ....................................................................................................... 14

    c. Process to Access a Resident Record .............................................................................................. 14

    d. Requirements if LTC Facility Refuses to Provide Resident Record or Refuses to Provide Privacy to

    the Certified Ombudsman to Review a Resident Record ................................................................... 15

    e. Process to Review a Resident Record ............................................................................................. 15

    f. Copies of or Notes about a Resident Record ................................................................................... 15

    550 Access to LTC Facility Information ................................................................................................... 15

    a. Authority of Certified Ombudsman to Access LTC Facility Information Accessible to Residents or

    the Public ............................................................................................................................................ 15

    b. Examples of LTC Facility Information Accessible to Residents or the Public .................................. 15

    c. Access to LTC Facility Licensing and Certification Information ....................................................... 16

    560 Affirmation that HIPAA Does Not Prevent Release of Information to a Certified Ombudsman ..... 16

    570 Communicating with a Person Who Speaks a Language Other than a Language the Certified

    Ombudsman Speaks ............................................................................................................................... 16

    Chapter 600: Confidentiality, Consent, and Disclosure Requirements .................. 17

    610 Confidentiality .................................................................................................................................. 17

    a. Confidential Information Regarding a Resident or Complainant .................................................... 17

    b. Maintaining Confidentiality while Visiting an LTC Facility .............................................................. 18

    620 Consent ............................................................................................................................................ 18

    a. Requirement of a Certified Ombudsman to Seek Consent in Order to Access a Resident Record,

    Investigate a Complaint, or Disclose Confidential Information .......................................................... 18

    b. How a Resident or LAR may Communicate Consent ...................................................................... 18

    c. Determining a Resident’s Ability to Communicate Consent ........................................................... 19

    d. Limitation of Consent ...................................................................................................................... 20

  • LONG-TERM CARE OMBUDSMAN POLICIES AND PROCEDURES MANUAL iii

    e. Withdrawal of Consent ................................................................................................................... 21

    f. Requirement to Document Consent ................................................................................................ 21

    630 Oral Disclosure of Confidential Information .................................................................................... 21

    a. Oral Disclosure of Confidential Information Related to a Complaint Investigation ....................... 21

    b. Oral Disclosure of Confidential Information NOT Related to a Complaint Investigation .............. 21

    640 Request for Certified Ombudsman to Disclose Written Confidential Information ......................... 22

    a. Requirement to Notify the State Ombudsman after Receipt of a Request for Written Confidential

    Information ......................................................................................................................................... 22

    b. State Ombudsman Response .......................................................................................................... 22

    c. Examples of a Request for Written Confidential Information ........................................................ 22

    Chapter 700: Complaints .............................................................................. 24

    710 Requirement of a Certified Ombudsman to Identify and Investigate Complaints on Behalf of

    Residents and Requirement to Seek Direction from the MLO or the Office When Needed .................. 24

    a. Requirement to Identify, Investigate, and Resolve Complaints ..................................................... 24

    b. Requirement to Act on Behalf of the Resident ............................................................................... 24

    c. Requirement to Seek Direction from the MLO or the Office when Needed .................................. 24

    720 Definition of a Complaint and Description of Situations that are not Complaints .......................... 24

    a. Definition and Examples of a Complaint ......................................................................................... 24

    b. Communications that Are Not Compla

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