100 Program Components

Each long-term care ombudsman program (LTCOP) shall provide services to protect the health, safety, welfare, and rights of residents. These services, known as Program Components, shall be performed in accordance with the following procedures and standards and as directed by the Office of the State Long-Term Care Ombudsman (SLTCO). The Program Components are:

  1. Complaint processing.

  2. Information and consultation.

  3. Community outreach and education.

  4. In-service education to facility staff.

  5. Routine visits to long-term care facilities.

  6. Issues advocacy.

  7. Interagency coordination.

  8. Resident council and family council activities.

  9. Volunteer management.

  10. Nursing home pre-survey information.

100.1 The local Ombudsman entity (LE) Annual Plan

  1. Ombudsman Representative Coordinator (ORC) responsibilities

    1. The ORC shall prepare a Long-Term Care Ombudsman Program (LTCOP) Annual Plan for submission to the SLTCO and, when applicable, the area agency on aging (AAA), setting goals for the LTCOP for the following fiscal year related to each program component. Where the AAA is the LE for OR services, the LTCOP Annual Plan shall be submitted as part of that AAA’s area plan for the following fiscal year. Whether through the area plan or directly, the LTCOP Annual Plan shall be submitted to the SLTCO by the due date for the area plan as determined by the SLTCO and communicated to the provider agencies.

    2. If an ORC determines the need for an amendment to the Annual Plan during the course of the fiscal year, such amendment shall be submitted to the SLTCO for review and approval, subject to the same review criteria by the SLTCO as for the originally submitted Annual Plan.

  2. Contents of the LTCOP Annual Plan

    The LTCOP Annual Plan shall:

    1. Include goals for each Program Component.

    2. Provide for complaint processing to be the highest priority Program Component.

    3. Meet or exceed the applicable standard(s) for each Program Component or include a request of a modified standard as set forth in c) iii), below.

  3. SLTCO responsibilities

    1. The SLTCO shall inform the applicable ORC, LE director, DAS program coordinator and AAA of whether the LTCOP Annual Plan is acceptable within 30 days after receipt of the plan. If changes must be made to a LTCOP Annual Plan, the SLTCO shall provide assistance to the ORC to develop an acceptable Plan.

    2. The SLTCO shall consider the comments of the AAA in reviewing the relevant LTCOP Annual Plan.

    3. In determining whether a LTCOP Annual Plan is acceptable, the SLTCO shall consider the following:

      1. Whether the Plan meets the standards set forth in these policies and procedures for each Program Component. Where a standard for a particular Program Component is not met in the Plan, the SLTCO may approve a modified standard only where the Plan describes one or more of the following:

        1. Specific efforts to improve performance related to that Program Component over previous years and specific plans to work toward meeting the standard related to the Program Component.

        2. Specific efforts taken to improve performance of another Program Component. A plan to minimize the negative impact on other Program Components is required.

        3. Initiation of a time-limited project which is consistent with the purpose of the LTCOP and which may require significant staff time or other resources. A plan to minimize the negative impact on other Program Components is required.

        4. Limitations in staff or other resources which make compliance with a particular Program Component standard a hardship for the LTCOP.

      2. The Plan’s anticipated benefit to residents.

      3. The Plan’s anticipated impact on the provision of ombudsman services to long-term care residents.

      4. The performance history of the LTCOP as determined by a review of data relating to performance of Program Components.

      5. When the SLTCO receives an amendment of a LTCOP Annual Plan, the SLTCO shall inform the applicable ORC, LE director, DAS program manager, and AAA of whether the amendment is acceptable within 30 days after receipt of the amendment, using the criteria in paragraph A), above.

100.2 LTCOP evaluation

  1. Role of the ORC

    The ORC shall evaluate the performance of the LTCOP at least quarterly. This review shall include a review of activities and complaint data for the LTCOP and a comparison of the LTCOP with activities and complaint data statewide as statewide data are made available by the SLTCOP.

  2. Role of the SLTCO

    1. The SLTCO shall maintain activities and complaint data for the statewide LTCOP.

    2. The SLTCO shall make aggregate complaint and activities numbers available to the public in the Long-Term Care Ombudsman Annual Report and at other times as the SLTCO deems appropriate.

    3. The SLTCO shall provide aggregate complaint and activities data to ORCs, AAAs, provider agencies, and other interested parties at least annually and upon request as available.

    4. The SLTCO shall review the activities and complaint data of the statewide program and each LTCOP, together with the LTCOP Annual Plan, at least annually to evaluate program performance.

    5. The SLTCO shall make periodic site visits to evaluate the performance of LTCOPs as deemed necessary by the SLTCO. The SLTCO shall notify representatives of the AAA and the LE and may invite them to participate at appropriate times during the site visit.

References

OAA § 712(a)(5)