Georgia Long-Term Care Ombudsman Program policies and procedures

GEORGIA LONG-TERM CARE OMBUDSMAN
PROGRAM POLICIES AND PROCEDURES
STATE OF GEORGIA DEPARTMENT OF HUMAN RESOURCES
DIVISION OF AGING SERVICES OFFICE OF THE STATE LONG-TERM CARE OMBUDSMAN

GEORGIA LONG-TERM CARE OMBUDSMAN PROGRAM POLICIES AND PROCEDURES

TABI.E OF CONTENTS

PART I

INTRODUCTION TO THE LONG-TERM CARE OMBUDSMAN PROGRAM

CHAPTER 100 , GENERAL

','

, , . , ,,'1-100-1

CHAPTER 200

DEFINITIONS

, .. 1-200-1

PART II

ADMINISTRATION OF THE LONG-TERM CARE OMBUDSMAN PROGRAM

CHAPTER 100

PROGRAM STRUCTURE

II-lOO-l

CHAPTER 200

DESIGNATION AND DE-DESIGNATION OF OMBUDSMAN

PROGRAMS AND OMBUDSMEN

II-200-1

201 DESIGNATION OF OMBUDSMAN PROGRAMS '

, .. II-200-1

201.1 Criteria for designation as a provider agency

,... II-200-1

201.2 Process for designation of a provider agency, generally

II-200-2

201.3 Process for designation of a provider agency, where the area agency on aging

contracts with a provider agency

, .. ,. II-200-2

201.4 Process for designation ofa provider agency, where the area agency on aging

serves as provider agency

II-200-5

201.5 Process for designation of a' provider agency, where the Division of Aging

Services contracts directly with provider agency

II-200-6

202 DE-DESIGNATION OF OMBUDSMAN PROGRAMS
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II-200-8

202.1 Criteria for de-designation 202.2 Process for de-designation of a. provider agency 202.3 Voluntary withdrawal of a provider agency 202.4 Continuation of ombudsman services

II-2OQ-S II-2OQ-9 ll-ZQO-I0 II-200-10

203 DESIGNATION OF LONG-TERM CARE OMBUDSMEN

11-200-12

203.1 Criteria for designation as a long-tenn care ombudsman

II-2QO-I2

203.2 Minimum qualifications for Long-tenn Care Ombudsman

Coordinators

'.'

~

II-200-13

203.3 Minimum qualifications for long-tenn care ombudsman staff .. II-200-13

203.4 Requests for substitutions or variances

II-200-14

203.5 Notification of designation

,

II-200-14

204 REFUSAL TO DESIGNATE AN IN;DIVIDUAL AS A LONG-TERM CARE

OMBUDSMAN AND DE-DESIGNATION OF A LONG-TERM CARE

OMBUDSMAN

;

II-ZOO-I5

204.1 Criteria for refusal to designate an mdividual as a long-tenn care ombudsman

and de-designation ofa long-term care ombudsman

II-200-I5

204.2 .Proc~ss for refusal to designate an individual as a long-tenn care ombudsman

and de-designation ofa long-term care ombudsman

II-ZOO-I6

CHAPTER 300

ROLES AND RESPONSIBILITIES IN ADMINISTERING THE

PROGRAM

II-300-1

301 DIVISION OF AGING SERVICES RESPONSIBILITIES

II-300-1

302 STATE LONG-TERM CARE OMBUDSMAN RESPONSIBILITIES .. II-300-3

302.1 General responsibilities of the State Ombudsman

II-300-3

302.2 State Ombudsman responsibilities to long-tenn care residents II-300-6

302.3' State Ombudsman responsibilities to community ombudsmen II-300-S

302.4 State Ombudsman responsibilities to the area agency on aging .. II-300-9

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302.5 State Ombudsman responsibilities to the provider agency ..... II-300-l0

303 AREA AGENCY ON AGING RESPONSIBILITIES

:

II-300-1I

304 PROVIDER AGENCY RESPONSIBILITIES

II-30Q-14

305 LONG-TERM CARE OMBUDSMAN RESPONSIBILITIES

II-300-17

305.1 Long-term care ombudsman general responsibilities 305.2 Long-term care ombudsman coordinator responsibilities ., 305.3 Responsibilities of staff and volunteers not designated
as long-term care ombudsmen

II-300-l7 II-300-18
II-3OQ-l9

CHAPTER 400

CONFLICTS OF INTEREST

II-40Q-l

401 IDENTIFYING THE CONFLICT

II-400-l

401.1 Definition of conflict of interest

401.2 Organizational conflicts

;

401.3 Individual ombudsman conflicts

II-400-1 II-400-2 II-400-3

402 REMEDYING CONFLICT

:

II-400-4

402.1 General

;

402.2 Remedying organizational conflicts

402.3 Remedying individual ombudsman conflicts

II-400-4 II-400-5 II-400-6

403 PROCEDURES TO AVOID CONFLICTS OF INTEREST

II-400-7

403.1 Persons seeking certification as ombudsmen 403.2 Persons seeking to become Volunteer Visitors 403.3 Ombudsman involvement in activities

:

II-400-7

II-400-8

II-400-8

404 FAILURE TO IDENTIFY OR REMEDY A CONFLICT OF INTEREST II-400-9

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CHAPTER 500

LONG TERM CARE OMBUDSMAN RECORDS II-SQO-l 0 0 0 0 0 0

501 ACCESS TO LONG TERM CARE OMBUDSMAN RECORDS .. 0.0. ll-SOO-l

502 RESPONSE TO REQUESTS FOR LONG TERM CARE OMBUDSMAN

RECORDS

II-SOO-2 0 0 0 0 0 0 0 0 0 0 0" 0 0 0 0 0 0 0

TABLE II-A: "LTCO RECORDS: SOURCE OF REQUEST" 0 0 ~,o .II-Soo-4

TABLE II-B: "LTCO RECORDS: TYPE OF REQUEST' 0.000000 II-S00-6

CHAPTER 600

LEGAL COUNSEL FOR THE LONG-TERM CARE OMBUDSMAN

PROGRAM

II-600-1 0 0 ' 0 ' . 0 0 0 , 0 0 0 0 0 0 0 0 0

601

ADEQUATE LEGAL COUNSEL II-600-1 0 00.00 0 0 0" 0 0 00 000000

602

PROVISION OF LEGAL COUNSEL

II-600-1 0 0 0 0 0 0 0 0 . . 0 0

TABLE II-C: "LEGAL COUNSEL" . II-600-2 0

0

0 0

0

"' 0

0



0

0

'0

~

o



0



603 OBTAINING LEGAL COUNSEL 0

0

00

o' II-600-3 .

CHAPTER 700

LIABILITY

701 IMNIDNITY FROM LIABILITY ..... 0 0 0 0

702 LIABILITY INSURANCE

0 00 o

00000 00.0

II-700-1 o' 0.00. 0 " II-700-1

CHAPTER 800

INTERFERENCE AND RETALIATION ~ ... 0 0 '0" II-SOO-l 0.0.

801 INTERFERENCE AND RETALIATION PROHIBITED ..... 0 0 0 II-SOO-l

802 PROCEDURES FOR REPORTING INTERFERENCE OR

RETALIATION

0

0 ll-SOO-2

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PART III GUIDELINES FOR OMBUDSMAN PRACTICE

III-1OQ-l

CHAPTER 100 , PROGRAM COl\1PONENTS

III-IOO-l

100.1 Community Long-tenn Care Ombudsman Program Annual Plan. III-lGO-Z

100.2 LOJ.1g-te:rm Care Ombudsman Program evaluation

III-I00-4

101 COMPLAINT PROCESSING

III-lOl-l

101.1 General

101.2 Complaint intake and response

TABLE ill-A: "COl\1PLAINT RESPONSE"

TABLE III-B: "RESIDENT REFUSES CONSENT" ..'

101.3 Investigation process

101.4 Plan ofactiori

101.5 Complaint referrals

101.6 Closing a complaint or case

101.7 Abuse and gross neglect complaints

TABLE ill-C: "WHEN TO REPORT ABUSE"

TABLE llI-D: "WHERE TO REPORT ABUSE"

101.8 Documentation

~

101.9 Complaint numbers

,

TABLE III-E: "COl\1PLAINT ACTIVITY"

TABLE III-F: "CLIENT SATISFACTION WITH COMPLAINT

RESOLUTIO}r'

III-101-1 III-101-1 III-101-3 III-101-5 III-IOI-7 III-101-8 III-101-9 III-lOl-ll
III-I01~13
III-lOl-14 III-lOl-I5 III-101-16 III-101-17 III-lOI-I8
III-101-21

102 INFORMATION AND ASSISTANCE TABLE ill-G: ''INFORMATION AND ASSISSTANCE"

III-I02-1 ill-102-2

103 COMMUNITY EDUCATION .. , TABLE ill-H: "COMMUNITY EDUCATIO}r' . ,

,......... III-103-1

;

III-l03-2

104 IN-SERVICE EDUCATION

, . ,' , ......... III-104-1

TABLE ill-I: "IN-SERVICE EDUCATION FOR FACILITY STAFF" .. III-104-Z

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105 ROUTINE VISITS

III-I05-1

106 ISSUES ADVOCACY

_. _

~

III-I06-1

107 INTERAGENCY COORDINATION

,. _

III-107-1

108 RESIDENT AND FAMILY COUNCILS

III-108-1

TABLE III-J: "INVOLVEMENT WITH RESIDENT AND FAMILY

COUNCILS"

III-108-3

109 ADVISORY COUNCIL DEVELOPMENT

III-109-1

110 VOLUNTEER MANAGEMENT

: III-llo-l

APPENDIX A APPENDIXB APPENDIXC APPENDIXD

Ombudsman Code of Ethics Certification Requirements for Community Ombudsmen Acronyms List Hearing Procedures; Office of Aging Procedural Issuance No. 59 (March 28, 1990)

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PART I. INTRODUCTION TO THE LONG-TERM CARE OMBUDSMAN PROGRAM

. 100. General

101. .Authorization

The Georgia Long-Tenn Care Ombudsman Program (LTCOP) is authorized underthe federal Older Americans Act and the Georgia Long-tenn Care Ombudsman Program Act.

102. purpose

The LTCOP protects and improves the quality of care and quality of life for residents of long-tenn care facilities through advocacy for and on behalf of residents and through the promotion of community involvement in long-term care facilities.

103. Philosophy

The LTCOP is a resident-centered advocacy program. The resident of o.r applicant to a long-tenn care facility is the client, regardless ofthe source ofthe complaint or request for service. The long-tenn care ombudsman will make every reasonable effort to assist, represent, and intervene on behalf of the resident.

104. Applicability

These policies and procedures govern the actions of the Office of the State Long-term Care Ombudsman, certified staff and volunteer ombudsmen, provider agencies, area agencies on aging, the Division of Aging Services of the Georgia Department ofHuman Resources, and other parties involved in the operation of the LTCOP.

REFERENCES

Older Americans Act, 42 U.S. 3001 et seq (hereinafter cited as "OAA"); O.e.G.A. 31-8-50 et seq.

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1-100-1

200. Definitions
200.1 Abuse
Willful infliction of injury, unreasonable confinement, intimidation, cni.el punishment with resulting physical harm, pain, or mental anguish; or deprivation by a person, including a caregiver, of goods or services that are necessary to avoid physical harm, mental anguish, or mental illness. (OAA' 102(13.
200.2 Advisory council development .
Activities related to the preparation for or attendance at meetings ofthe community long-term care ombudsman program advisory council. (Georgia Long-term Care Ombudsman Reporting Manual)
200.3 Area agency on aging
An agency designated by the Division ofAging Services to arrange for the provision of aging services in its planning and service area. (OM 305(a)(2)(A
200.4 Area plan
A plan developed by an area agency on aging for its relevant planning and service area as set forth in the Older Americans Act. (OAA 306(b
200.5 Certification
The designation provided by the State Long-term Care Ombudsman to an individual who meets minimum qualifications, is free of conflicts of interest, and has successfully completed training and other criteria stipulated in the Certification Requirements for Community Ombudsmen. Designation authorizes such individual to act as a representative ofthe Long-term Care Ombudsman Program. (OAA 712(a)(5); O.C.G.A. 31-8-52)

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1-200-1

200.6 Community education
Presentations to community groups or to groups of residents or families on longtenn care issues. (Georgia Long-tenn Care Ombudsman Reporting Manual)
200.7 Community Long-tetDJ Care Ombudsman Annual plan
A plan submitted by the Long-tenn Care Ombudsman Coordinator annually for approval by the State Ombudsman which sets forth goals and objectives for the community long-tenn care ombudsman program.
200.8 Complaint
Infonnation regarding action, inaction, or decisions that may adversely affect the health, safety, welfare, or rights ofresidents which is brought to the attention ofa long-tenn care ombudsman and to which the ombudsman responds in order to address the adverse effect on residents.
200.9 Complaint processing
Services to assist consenting residents of long-tenn care facilities to resolve problems or complaints through investigation, verification and notification. (Georgia Long-tenn Care Ombudsman Reporting Manual)
200.10 Exploitation
The illegal or improper act or process of an individual, including a caregiver, using the resources of an older individual for monetary or personal benefit, profit, or gain. (OAA 102(26

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1-200-2

200.11Family council activities
,
Provision of technical assistance, information, training or support to family members of residents and/or facility staffregarding developing, informing, or maintaining a family council. (Georgia Long~term Care Ombudsman Reporting Manual)
200.12 Guardian
Person or entity appointed by a court to exercise the legal rights and powers of
another individual. (See O.C.G.A. 29-2-1.e1 mV
200. 13Immediate family
Those persons related to an individual as a spouse, child, sibling, or parent.
200.14InfQrnJatiQn and assistance
Services which provide information to individuals on long-term care or the needs/rights oflong-term care residents. (Georgia Long-term Care Ombudsman Reporting Manual)
200.15In-service educatiQn
Presentations to long-tenncare f~cilitystaffon long-term care issues. (Georgia Long-term Care Ombudsman Reporting Manual)
200. 16Interagency cQQrdinatiQn
Activities which involve meeting or coordinating with other agencies to learn about and/or improve conditions fQr one or more residents oflong-term care facilities. (Geo.rgia Long-term Care Ombudsman Reporting Manual)

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1-200-3

200 171ssues advocacy
Activities supporting and promoting issues which benefit residents oflong-term care facilities. (Georgia Long-term Care Ombudsman Reporting Manual)
200. 18Legal representative
An agent under a valid power of attorney, provided that the agent is acting within the scope ofms or her agency; an agent under a durable power of attorney for health care; or an executor, executrix, administrator, or administratrix ofthe estate ofa deceased resident. (O.C.G.A. 31-8-55(b
200.19Long-tenn care facility
Any nursing home or personal care home or similar entity providing long-term care services and subject to regulation and facility licensure by the Department of Human Resources. (O.C.G.A. 31-8-51 (2
200.20 Long-tern care services
A set of health, personal care, and social services delivered over a sustained
period of time to persons who have 19st or never acquired some degree of functional mental or physical capacity. (Institute ofMedicine, Real People, Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs ofthe Older Americans Act, 1995 at p. 290)
200.21 Neglect
The failure to provide for oneself the goods or services that are necessary to avoid physical harm, mental anguish, or mental illness or the failure of a caregiver to provide the goods and services. (OAA 102(37

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1-200-4

200.22 Ombudsman Services Plan
A plan developed by any entity in response to a request for proposal to provide ombudsman services. The State Long-term Care Ombudsman and the area agency on aging, if applicable, review such plans to determine the most appropriate entity to designate as the provider agency in a particular area
200.23Program Components
Services of the Long-term Care Ombudsman Program performed with the goal of protecting the.health, safety, welfare and rights of long-term care residents.
200.24Provider agency
The entity designated by the State Ombudsman to provide ombudsman services in a particular service area.
200.25Resident council activities
Provision of technical assistance, information, training or support to residents and/or facility staff regarding developing, informing, or maintaining a resident council. (Georgia Long-term Care Ombudsman Reporting Manual)
200.26Routine visits
Visits to a nursing facility or personal care home for the purpose ofmonitoring and assessing the general condition of residents and/or the physical plant ofthe facility. (Georgia Long-term Care Ombudsman Reporting Manual)
200.27Volunteer management
Recruiting, training, managing and providing technical assistance to volunteers assisting the community long-term care ombudsman program in carrying out its responsibilities. (Georgia Long-term Care Ombudsman Reporting Manual)

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1-200-5

200.28Vo]unteer Visitor
A volunteer who is not certified but who visits residents in coordination with the community long-term care ombudsman program and otherwise provides assistance to the program. A Volunteer Visitor must wode under the direct supervision of a certified staff ombudsman and is not authorized to investigate complaints.

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1-200-6

PART II. ADMINISTRATION OF THE LONG-TERM CARE OMBUDSMAN PROGRAM
100. Program Structure
100.1 Division of Aging Services role
The Division of Aging Services of the Department ofHuman Resources (DAS) shall establish and operate the Office of the State Long-term Care Ombudsman (SLTCO).
100.2 State Ombudsman role
The SLTCO shall assure that all residents of long-term care facilities in the State have access to the services of the Georgia Long-tenn Care Ombudsman Program (LTCOP) and that each service area in the State has a designated LTCOP.
1003 COntracts for ombudsman services
The community LTCOP in each service area shall be operated through a contract with the DAS as follows:
a. contracts shall exist in each service area between the DAS and the area agency on aging (AAA) and/or an entity or entities meeting the criteria for designation (II-201.1, below).
b. an AAA may directly provide long-tenn care ombudsman (LTCO) services, if not otherwise prohibited from directly delivering services, or may subcontract with another entity meeting the criteria for designation (see II-201.1, below). i) where an AAA provides LTCO services directly, it must also fulfill the responsibilities of a provider agency.

REFERENCES OAA 712 (a)(l); O.C.G.A. 31-8-52.
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II-100-1

200. Designation and De-Designation of Ombudsman Programs and Ombudsmen
How to use this Chapter: This Chapter sets forth procedures for designation and de-designation by the Office of the State Long-term Care Ombudsman as follows: I) designation ofombudsman programs (i.e. provider agencies), 2) de-designation of ombudsman programs, 3) designation of ombudsmen (including minimum qualifications), and 4) refusal to designate an individual as an ombudsman and de-designation ofombudsmen. Each Section includes: I) criteria used in designating (or de-designating) and 2) the process used in designation (or designating). For designation (or de-designation) ofombudsman programs, the process is described separately for the possible placements ofthe provider agency: a) area agency on aging contracts with the provider agency~ b) area agency on aging serves as the provider agency; and c) provider agency contracts directly with the Division ofAging Services.

201. DesignatiQn QfOmbudsman Programs
POLICY
The State Ombudsman shall designate provider agencies to provide ombudsman services throughout Georgia.
PROCEDURES
201.1 Criteria fQr designatjQD as a proyjder agency
In order to be eligible for designation by the Office ofthe State Long-term Care Ombudsman (SLTCO) as a provider agency, an entitY must:
a. be a public or nonprofit entity;
b. not be an agency or organizatiQn responsible for licensing Qf certifying long-term care services;
c. nQt be an associatiQn (or an affiliate of an associatiQn) ofproviders of IQng-term care or residential services for older persQns;

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II-200-1

c
d. have no financial interest in a long-term care facility;

e. have demonstrated capabIlity to carry out the responsibilities of the provider agency (see ll-304, below);

f.

have no unremedied conflict of interest (see ll-400, below); and

g. meet all contractual requirements ofthe Department ofHuman Resources.

201.2 Process for designation ofa provider agenQY. generaUy

a. As of the effective date of these procedures, any entityproviding long-term care ombudsman (LTCO) services under contract with the Department ofHuman Resources, Division ofAging Services (DAS) or the relevant area agency on aging (AAA) shall be designated as a provider agency.

201.3 process for designatimi of a provider agency. where the area agency on aging contracts with a provider agency

Where an AAA contracts with a provider agency, the designation ofa new provider agency shall occur as follows:

a. The AAA shall issue a request for proposal (RFP) seeking an entitY to provide LTCO services within its service area. The RFP shall identify the criteria for designation as. a provider agency and shall request submission of documents supporting the entity's claim to meet these criteria.

b. The AAA shall require that all of the responding entities which meet the criteria for designation develqp an Ombudsman Services Plan setting forth:

f:das\Itco\plcsrnan.wpd 7/97

ll-200-2

i)

the goals and objectives ofsuch entity in providing LTCO

services, and

ii) a description ofhow each Program Component shall be met

by such entity (see ill-lOO, below), and including its

staffing plan.for the community long-term care ombudsman

program (LTCOP), and

iii) a description of the resources of the entity which will be

provided to assist in the operation ofthe community

LTCOP.

c. The AAA shall forward copies ofthe Ombudsman Services Plans of all responding entities to the SLTCO.

d. The AAA shall recommend an entity for designation as a provider agency to the SLTCO and shall provide the SLTCO with information supporting its recommendation.

e/.

The SLTCO shall review and consider all the Ombudsman

Services Plans submitted to the AAA and the recommendation of

the AAA, and shall determine the entity most appropriate to

designate as the provider agency.

f.

The SLTCO shall notify the AAA ofthe determination within

thirty (30) days of receiving the AAA's recommendation.

g. The AAA shall notify the responding entities of the SLTCO decision within fifteen (15) days ofreceiving such notification. The AAA notification shall include notice of the right ofevery entity not chosen to request a hearing to appeal the SLTCO'S determination pursuant to the Older Americans Act Hearing Procedures (hereinafter cited as "Hearing Procedures," attached as Appendix D).

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II-200-3

h. Upon designation by the SLTCO, the AAA may enter into a contract with the provider agency for the provision ofLTCO serVices in the relevant service area, Such contract must: i) specify the service area; ii) require the provider agency to adhere to all applicable federal and state laws, regulations, and policies; and iii) provide that designation by the SLTCO continues fur the duration of the contract and subsequently renewed contracts unless the provider agencY,is de-designated by the SLTCO ... (see II-202, below).

1.

The execution date of the provider agency's contract with the AAA

to provide LTCO services shallconstitute the effective date ofthe

designation.

J.

Should the contract between the provider agency and the AAA to

provide LTCO services not be renewed or be terminated for any

reason, the AAA shall:

i) immediately notify the SLTCO;

ii) follow the steps to designate a new provider agency (ll-

201.3, a - i, above) as soon as practicably possible; and

iii) follow the steps to provide continuation of ombudsman

services (II-202.4, below).

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II-2Q0-4

201.4 Process for designation ofa provider agenQY. where the area agency OD aging serves as provider agency
Where the AAA seeks to serve as the provider agency, the designation ofa new provider agency shall occur as follows:
. a. The AAA may be considered as a provider agency where the SLTCO determines that either: i) designation of the AAA as the provider agency is necessary to assure an adequate supply of ombudsnian services; or ii) services of comparable quality can be provided more economically by the AAA.
b. The AAA shall request consideration to be designated as a provider agency and submit an Ombudsman Services Plan to the SLTCO setting forth: i) the goals and objectives of such entity in providing LTCO servIces, ii) a description ofhow each Program Component shall be met by such entity (see ill-IOO, below), and including its staffing plan.for the community LTCOP, and iii) a description ofthe resources of the entity which will be provided to assist in the operation ofthe community LTCOP.
c. The SLTCO may designate the AAA as the provider agency where: i) the AAA meets the criteria for designation; ii) the AAA submits an acceptable Ombudsman Services Plan; and iii) the AAA is not otherwise prohibited from fulfilling the duties of the provider agency.
d. The SLTCO shall notify the AAA within thirty (30) days ofthe

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II-200-5 _

receipt of the Ombudsman Services Plan ofits decision. Ifthe SLTCO refuses to designate the AAA as the provider agency, the notification shall include notice ofthe right of the AAA to request a hearing to appeal the SLTCO's determination pursuant to the Hearing Procedures (Appendix D).

e. The execution date of the AAA's contract with the DAS to provide LTCO services shall be the effective date ofthe designation.

201.4 process for designatioD ofaprovider agency, where the DivisjoD of Aging Services contracts directly with provider agency

Where the contract for LTCO services is not with or through the AAA, the designation of a new provider agency shall occur as follows:

a. The DAS shall issue a RFP seeking an entity to provide LTCO services within a particular service area. The RFP shall identify the criteria for designation as a provider agency and shall request submission of documents supporting the entity's claim to meet these criteria.

b. The DAS shall require that all of the responding entities which

meet the criteria for designation develop an Ombudsman Services

Plan setting forth:

i)

the goals and objectives of such entity in providing LTCO

services, and

ii) a description of how each Program Component shall be met

by such entity (see ill-lOO, below), and including its

staffing plan for the community LTCOP, and
I
iii) a description of the resources of the entity which will be

provided to assist in the operation of the community

LTCOP.

c.

The SLTCO shall review each submitted Ombudsman Services

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II-200-6

Plan and shall choose the entity most appropriate to serve as the provider agency based on the submitted Ombudsman Services Plans and on the criteria for designation. In considering which entity is most appropriate to designate as the provider agency, the SLTCO may consult with the AAA serving the relevant service area.

d. The SLTCO shall notify the responding entities of this determination within forty-five (45) days. The notification shall include notice of the right ofevery entity not chosen to reqneSt a hearing to appeal the SLTCO's determination pursuant to the Hearrn.g Procedures (Appendix D).

. e. The DAS shall contract with the provider agency to provide LTCO services. Such contract must: i) specify the service area; ii) require the provider agency to adhere to all applicable federal and state laws, regulations, and policies; and iii) provide that designation by the SLTCO continues for the duration of the contract and subsequently renewed contracts unless the provider agency is de-designated by the SLTCO (see II-202.2, below).

f.

The execution date of the provider agency's contract with DAS to

provide ombudsman services shall be the effective date ofthe

designation.

REFERENCES

OAA 307(a)(1O), 712(a)(4),(5); proposed rule 45 C.F.R. 1327.21(1);.s.e.e OAA 705(aX5)

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ll-200-7

202. De-Designation of Ombudsman Programs

. POLICY

The State Ombudsman may de-designate an entity as a provider agency for cause.

PROCEDURES

202.1 Criteria for de-designatioD

The SLTCO may refuse to designate or may de-designate an entity as a provider agency for one or more ofthe following reasons:

a.

failure ofthe entity to continue to meet the criteria for designation,

(II-201.1, above);

b. existence in the entity of an unremedied conflict of interest with the LTCOP;

c. deliberate failure of the entity to disclose any conflict of interest;

d. violation ofLTCO confidentiality requirements by any person
employed by, supervised by, or otherwise acting as an agent of the
entity;

e. failure of the entity to provide adequate LTCO services, including but not limited to failure to perform enumerated responsibilities (see II-304, below), failure to fill a vacant ombudsman position within a reasonable time, failure to submit a Community LTCOP Annual Plan (see III-IOO.I, below) for approval by the SLTCO, or failure to use funds designated for the LTCOP for LTCO services;

f.

failure of the entity to adhere to the provisions of the contract for

the provision of ombud~manservices; or

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II-200-8

g. failure of the entity to adhere to applicable federal and state laws, regulations, and policies.

202.2 process for de-designatioD ofa provider agency

a. Where an AAA contracts with a provider agency, the process to

de-designate the provider agency shall be as follows:

i)

The SLTCO shall send notice of the intent to de-designate

at a specified date to the AAA and the provider agency.

The notice shall include the reasons for de-designation and

notice ofthe Hearing Procedures (Appendix D).

ii) De-designation of a provider agency shall not become

effective until all appeals are exhausted.

iii) The provider agency, AAA, and SLTCO shall provide for

the continuation of ombudsman services (11-202.4, below).

iv) The AAA shall terminate its contract for LTCO services

with the provider agency.

b. Where a AAA serves as a provider agency, the process to de": designate the provider agency shall be as follows: i) The SLTCO shall send notice of the intent to de-designate at a specified date to the AAA. The notice shall include the reasons for de-designation and notice ofthe Hearing Procedures (Appendix D).
ii) De-designation of the AAA as a provider agency shall not
become effective until all appeals are exhausted. iii) The AAA and the SLTCO shall provide for the
continuation of ombudsman services (II-202A, below). iv) The DAS shall terminate the portion of the contract
between the AAA and the DAS which provides for ombudsman services.

c. Where a provider agency contracts directly with the DAS, the process to de-designate the provider agency shall be as follows:

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11-200-9

i)

The SLTCO shall send notice ofthe intent to de-designate

at a specified date to the provider agency_ The notice shall

include the reasons for de-designation and notice of~e

Hearing Procedures (Appendix D).

ii) De-designation ofa provider agencyshaII not become

effective until all appeals are exhausted.

iii) The provider agency and the SLTCOshall provide for the

continuation of ombudsman services (II-202.4, below).

iv) The DAS shall terminate its contract with the provider

agency.

202.3 Voluntary withdrawal of a provider agen}'

A provider agency may voluntarily relinquish its designation by providing notice to the SLTCO and to the AAA in the relevant service area. Such notice sba1l be provided sixty (60) days in advance ofthe date of the relinquishment of designation.

202.4 Continuation QfOmbudsman Services

Where a provider agency is in the process of appealing its de-designation or has relinquished designation: .

a. the provider agen9Y, the AAA, if applicable, and the SLTCO shall . arrange for the provision of ombudsman services until a new provider agency is designated;

b. the provider agency shall surrender intact to the SLTCO or the
SLTeO designee all LTCO case records, documentation ofall LTCO activities and complaint processing as required by the ombudsman reporting system, and identification cards ofall community LTCOs associated with the provider agency;

c. the provider agency shall, at the discretion of the DAS, surrender

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II-20D-IO

any equipment purchased with funds designated for LTCO services; and
d. the provider agency shall surrender the balance of any advanced state or federal monies to the ~ or to the DAS where the AAA serves as the provider agency.

REFERENCES

OAA. 307(a)(5); proposed rule 45 C.F.R. 1327.21; Hearing Procedures, Appendix D ...

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II-200-11

203. Designation ofLoDg-Tenn Care Ombudsmen

POLICY

The State Ombudsman designates individuals as ombudsmen to participate in the Longterm Care Ombudsman Program and to represent the Office ofthe State Long-term Care Ombudsman.

PROCEDURES

203.1 Criteria for designation as an ombudsman

To be designated as a LTCO, an individual must:

a. have demonstrated capability to carry out the responsibilities of a LTCO;

b. . be free ofunremedied conflicts ofinterest (see II-400, below);

c. meet the minimum qualifications for the applicable LICO position;

d.

sati~factorily complete the applicable certification training

requirements as specified in the Certification Requjrements For

Community Ombudsmen, (Appendix B). For LTCO Coordinators

and staff, the certification training requirements shall be completed

within six (6) months after attending the classroom training

provided by the SLICO.

e. be awarded his or her certification card, signed by the SLICO;

f.

satisfactorily fulfill LICO responsibilities (see II-305, below); and

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II-200-12

g. receive notice from the SLTCO ofhis or her renewed certification every two (2) years.
203.2 Minimum qualificatiQns fQr LQng-term Care Ombudsman CQordinatQr
a. In Qrder to qualify as a LTCO CQordinator, an individual must have: i) an undergraduate. degree from a four-year college or university; and ii) the equivalent of three (3) years of full-time work experience with at least two years in aging, IQng-term care or related fields. At least one year in a consultative or supervisory capacity is desirable.
b. Comparable experience may be substituted at the discretion oflhe SLTCO. Experience may be substituted for undergraduate education on a Qne-to-one basis; however, the same experience cannQt be used to meet both the education and experience requirements. Graduate education may be substituted for one year .of experience; hQwever, a minimum of two years of experience is required.
203.3 Minimum qualificatiQns fQr staff Qmbudsmen .
a. In order to qualify for a LTCO staff position, an individual must have: i) completed two years of undergraduate education; and ii) two years of professional experience with at least one year in aging, long-term care or related fields.
b. Comparable education and/or experience may be substituted at the discretion of the SLTCO upon recommendation of the LTCO COQrdinator.

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II-2QO-13

203.4 Requests for substitutiQDS Qf variaDces
Requests fQr substitutiQDS Qr variances related tQ minimum requirements must be made in writing and approved priQr tQ the hiring Qf promotion of the emplQyee in questiQn.
203.5 Notifi(jatiQD QfdesignatiQD
The SLTeO shall send written notification of an individual's designation
as a LTCO to the individual being designated. the' AM and the provider
agency in the relevant service area within thirty (30) days of the . determination.

REFERENCES

OAA 712(a)(5); O.C.G.A. 31-8-52; Office ofAging Procedural
Issuance No. 73 (Sept. 13. 1991) (pI No. 73)

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II-200-14

204. Refusal tQ Designate an Individual as a LQng-teon Care Ombudsman and De-DesignatiQn Qf a LQng-teon Care Ombudsman
POLICY
The State Ombudsman may refuse to designate or may de-designate an individual as a ombudsman.
PROCEDURES
204.1 Criteria fQr refusal tQ designate an individual as an ombudsman and dedesignatiQn Qfan Qmbudsman
The SLTCO may refuse to designate an individual as an LTCO or may dedesignate a LTCO for any of the following reasons:
a. failure of the individual to meet and/or maintain the criteria for designation (II-203.I, above);
b. existence of an unremedied conflict of interest;
c. deliberate failure of the individual to disclose any cqnflict of interest;
d. violation of confidentiality requirements;
e. failure to provide adequate and appropriate services to long-term care residents;
f. falsifying records;
g. failure to follow direction of the SLTCO regarding LTCO policies, procedures and practices;

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II-20o-IS

h. a change in employment duties which is incompatible with LTCO duties;

1.

separation from the LTCOP. Examples include: removal from

employment by the provider agency, an extended absence ofthe
rca L preventing fulfillment ofjob responsibilities, provider

agency's contract for the provision ofLTCO services is not

renewed; or

J.

failure to act in accordance with applicable federal and state laws,

regulations, and policies.

204.2 process for refusal to designate an individual as an ombudsman and dedesignation of an ombudsman

a. Prior to refusing to designate or de-designation, the SLTCO shall
consult with the relevant AAA and the provider agency to consider remedial actions which could be taken to avoid the refusal to designate or the de-designation.

b. refusal to designate The SLTCO shall refuse to designate an individual as a LTCO by providing written notice of such refusal to the provider agency, the administrating agency and the Director ofDAS. Such notice shall: i) specify the reasons for the refusal to designate, and ii) set forth the effective date of such refusal.

c. . de-designation. The SLTCO shall provide written notice of the intent to dedesignate an LTCO to the LTCO to be de-designated, the provider agency, the AAA, and the Director of the DAS. Such notice shall: i) specify the reasons for the intended de-designation, and ii) set forth the effective date of the de-designation.

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II-200-16

d. If the refusal to designate an individual as a LTCO or the dedesignation of a LTCO results in the absence of ombudsman services in the relevant service area, the provider agency, the AAA, and the SLTCO shall arrange for the provision of ombudsman services until a LTCO is designated.

REFERENCES

OAA 712(a)(5).

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II-200-17

300. . Roles and Responsibilities in Administering the Program
301. Division of Aging Services Responsibilities
POLICY
The Division of Aging Services shall establish and operate an Office of the State Longterm Care Ombudsman and carry out through that Office the statewide Long-term Care Ombudsman Program.
PROCEDURES
301.1 Division of Aging Services responsibilities
The Department of Human Resources, Division ofAging Services (DAS) sball:
a. provide for a full-time State Long-term Care Ombudsman;
b. provide funding for a statewide Long-term Care Ombudsman
Program (LTCOP) in accordance with allocation formula and maintenance of effort requirements;
c. provide legal representation for the Office of the State Long-term Care Ombudsman (SLTCO) and community long-term care ombudsmen (LTCOs) (see ll-600, below);
d. provide support to the SLTCO to enable it to fulfill its responsibilities consistent with all applicable federal and state laws, regulations, and policies;
e. administer the contracts between the DASand area agencies on aging (AAAs) and/or provider agencies;

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11-300-1

f.

provide technical assistance for and monitor performance of

AAAs; and

g. administer the statewide LTCOP in accordance with all applicable federal and state laws, regulations, and policies.

REFERENCES

OAA 304(d)(1); 307(a)(12); 307(a)(21); 703(a)(2)(C)(i); 705(a)(4); 712(a)(1), (4)

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II-300-2

302. State Long-Term Care Ombudsman Responsibilities
POLICY
The State Long-tenn Care Ombudsman is responsible for providing leadership for the state-wide Long-tenn Care Ombudsman Program.

How to use this Section: This Section addresses the Office ofthe State Long-term Care Ombudsman's responsibilities according to the party which is being served: 1) in general, 2) to long-tenn care residents, 3) to community LTCOs, 4) to AAAs, and 5) to provider agencies.

PROCEDURES

302.1 Genera] respoDsibj]jties of the State Ombudsman

The SLTCO is responsible for:

a. leadership and management of the statewide LTCOP

i)

providing leadership, planning, and direction for the

statewide LTCOP;

ii) providing program management and development;

iii) evaluating statewide LTCOP perfonnance;

iv) setting policies, procedures and standards for

administration ofthe LTCOP and LTCO practice;

v) promoting the development of citizen organizations to

participate in the LTCOP; and

vi) adhering to the Ombudsman Code of Ethics (Appendix A).

b. designation of LTCOs and LTCOPs

i)

prohibiting any representative of the Office from carrying

out any LTCO services unless the representative has

received certification training and has been approved by the

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II-300-3

SLTCO as qualified to cany out the activity on behalfof the Office.
c. long-term careissues advocacy
i) advocating for policy, regulatory and/or legislative changes in long-term care;
ii) coordinating with statewide and national advocacy organizations involved in long-term care issues; and
iii) maintaining awareness ofcurrent issues and trends in longterm care.
d. inter-agency coordination i) coordinating LTCO services with protection and advocacy systems, adult protective services, state agencies licensing and certifying long-term care facilities, legal assistance provided under the Older Americans Act (OAA), and other appropriate agencies.
e. maintaining LTCO records and the LTCO reporting system i) maintaining, through community LTCOPs, case records. Such records are the property of the SLTCO and may not be released, disclosed, duplicated, or removed without the written permission of the SLTCO or designee (see ll-500, below); ii) maintaining, in collaboration with the DAS, a statewide uniform reporting system to collect and analyze data relating to complaints and conditions in long-term care facilities and to residents for the purpose of identifying and resolving significant problems and submitting such data to appropriate entities as required by the OAA; and iii) preparing and distributing the LTCOP annual report as . required by the OAA.

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II-300-4

f. . information and assistance i) providing infonnation and referrals regarding long-tenn care issues and the LTCOP to the general public, residents, community organizations, and other agencies.
g. technical assistance
i) providing specialized technical assistance, consultation, training and resources to community LTCOs, provider agencies, AAAs, and DAS related to the operation ofthe LTCOP..

REFERENCES

OAA 712(a)(2), (3)(H)(iii), (5); 712(c),(d),(h); proposed rule 45 C.F.R 1327.27(b), (c); Office of Aging Procedural Issuance No. 88 (February 1, 1993); Ombudsman Code ofEthics (Appendix A)

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II-300-5

302.2 State Ombudsman respoDsibiljties to long-tenn care residents

The SLTCO shall, personally or through representatives of the Office:

a. identify, investigate, and resolve complaints that are made by o~ on behalf of residents, and relating to action, inaction, or decisions that may adversely affect the health, safety, welfare, or rights of residents (including the welfare and rights of the residents with respect to the appointment and activities ofguardians and representative payees), of: i) providers, or representatives of providers, oflong-term care servIces; ii) public agencies; or iii) health and social service agencies.

b. provide services to assist residents in protecting their health, safety,
welfare, and rights;

c. inform residents about means of obtaining services provided by long-term care service providers, public agencies, or health and social service agencies or other services to assist residents in protecting their health, safety, welfare, and rights;

d. provide regular and timely access to LTCO services for residents and timely responses to complaints;

e. represent the interests of residents before governmental agencies and pursue administrative, legal and other remedies to protect the health, safety, welfare and rights of residents;

f.

analyze, comment on, and monitor the development and

implementation of federal, state, and local laws, regulations, and

other governmental policies and actions pertaining to the health,

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II-300-6

safety, welfare and rights ofresidents, with respect to the adequacy of long-tenn care facilities and services in the state;

g. recommend changes in such laws, regulations, policies, and actions as the Office detennines appropriate;

h. facilitate public comment on laws, regulations, policies, and actions;

1.

provide technical support for the development ofresident and

family councils to protect the well-being and rights of residents;

and

J.

prohibit inappropriate disclosure ofthe identity ofany complainant

or resident with respect to LTCO files or records.

REFERENCES

bAA 712(a)(3),(d); proposed rule 45 C.F.R. 1327.23, .24;
O.c.G.A. 31-8-58

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II-30Q-7

302.3 State Ombudsman responsibilities to community ombudsmen

The SLTCO shall provide to communityLTCOs:

a.

m certification training and ongoing training accordance with the

Certification Requirements fQr Long-term Care Ombudsmen

(Appendix B);

b. program management and develQpment to enable the community LTCOP tQ fulfill the Program CQmponents (TIl-tOO, below)~

c. technical assistance and supervision as needed related to complaint handling and other LTCO services;

d. timely review, comment and approval of the Community LTCOP Annual Plan (III-I00.l,b,i), below); and

e. monitoring and evaluation of the statewide LTCOP.

REFERENCES

OAA 712(a)(3)(F); O.C.G.A. 31-8-52

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ll-300-8

302.4 State Ombudsman responsibjlities to the area agenG}' on aging

The SLTCO shall provide to AAA:

a. administrative and technical assistance to assist in participating in

the LTCOP, including:

i)

information and resources to assisttheAAA in promoting

the LTCOP within its service area~

ii) statewide LTCOP data and data analysis;

iii) assistance with monitoring the community LTCOP; and

iv) review of and comment on relevant sections of area plans;

and

, b.

assistance with arrangements for temporary provision ofLTCO

services during transition to a new provider agency.

c. Where the AAA serves as the provider agency, the SLTCO responsibilities to the provider agency shall also apply to the AAA (see II-302.5, below).

REFERENCES

OAA 712(a)(3)(F)

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II-300-9

302.5 State Ombudsman respoDsibilities to the provider agency
The SLTCO shall provide to the provider agency:
a. administrative and technical assistance to assist provider agencies
in participating in the LTCOP, including: i) information and resources to assist the provider agency in
promoting the LTCOP; ii) statewide LTCOP data and data analysis; and iii) assistance with monitoring the community LTCOP.
b. assistance with screening LTCO applicants for certification requirements, including: i) providing a conflict of interest screening tool; ii) timely response to requests for review of applications and for minimUm qualification substitutions; arid iii) participation in interviews of applicants as members of an interviewing team at the provider agency's request;
c. assistance with job performance review as requested by the provider agency; and
d. assistance with arrangements for temporary provision ofLTCO services when LTCO staff ofthe provider agency are unavailable or the staff position is vacant.

REFERENCES

OAA 712(a)(3)(F)

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II-300-10

303. Area Agency on Aging RespoDsibilities
POLICY
Where the area agency on aging contracts with or serves as the provider agency, it is responsible for assuring the" provision of LTCO services in its service area.
PROCEDURES
303.1 Area agency on aging responsibilities
The AAA shall:
. a. administer the contract for the community LTCOP in its service area, including: i) " contracting with a provider agency which meets the relevant criteria (see II-201.1, above) for the community LTCOP contract; ii) expending an adequate level of funding to support a LTCO Coordinator employed full-time; iii) fiscal and programmatic monitoring of the community LTCOP in order to assess adequate provision ofLTCO services pursuant to the contract; iv) adhering to maintenance of effort requirements for the community LTCOP; and v) monitoring community LTCOP attainment of its goals and objectives as stated in the Community LTCOP Annual Plan (Ill-I00.l,b,i), below).
b. support the community LTCOP by: i) assisting in the development of resources for the operation" ofthe community LTCOP, including financial and human resources; ii) providing opportunitIes for the community LTCOP and

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II-30Q-n

other aging and social services organizations to conaberate to promote the health, safety, welfare and rights of residents; iii) making appropriate referrals to the community LTCOP; iv) promoting awareness ofLTCO services to consumers and the general public within the service area; v) participating in the community LTCOP's advisory council; and vi) supporting the community LTCOP in systems advocacy on behalf of residents.

c. assure that community LTCOP data is provided to the Office of the State Long-term Care Ombudsman in the format required by the DAS and in a timely manner;

d. prohibit inappropriate disclosure ofthe identity of any complainant or resident with respect to LTCO files or records;

e. provide a transition plan to minimize disruption in LTCO services to residents when the contract for the community LTCOP is terminated or not renewed;

f.

request a waiver from DAS if, due to demonstrable and unusual

circumstances, it anticipates it will be unable to comply with any

of these responsibilities; and

g. perform each of Its responsibilities in administering the community LTCOP in accordance with all applicable federal and state law, regulations, and policies.

h. Where an AAA provides LTCO services directly, it must also fulfill the responsibilities of a provider agency (ll-304, below).

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11-300-12

REFERENCES

OAA 306; 712(a)(4); Office ofAging Procedural Issuance No. 39 (February 13, 1987) (PI No. 39)

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11-300-13

304. provider Agency RespoDsibilities
POLICY
The provider agency is designated by the State Ombudsman to house the community long-term care ombudsman program and to assure the provision ofombudsman services in the service area designated by contract with the area agency on aging or the Division of Aging Services.
. PROCEDURES
304.1 Provider agency responsibilities
The provider agency shall:
a. be the sole provider of LTCO services in the service area designated through contract with the AAA or the DAS;
b. operate the community LTCOP in accordance with the provisions dfthe contract for LTCO services with the AAA or the DAS;
c. assure that the community LTCOP performs the Program Components (III-I00, below);
d. require the LTCO Coordinator to submit a Community LTCOP Annual Plan (III-lOO.l,b,i), below) to the AAA, if applicable, and to the SLTCO for approval;
e. provide a full-time LTCO Coordinator, who: i) meets the applicable minimum qualifications (see II-203.2, above); ii) has no duties in the agency outside the scope of the LTCOP; and iii) is employed full-time;

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II-300-14

f.

provide LTCO staff in addition to the LTCO Coordinator if

. necessary in order to:

i) fulfill the Program Components (III-I 00, below);-and

ii) maintain or exceed the level ofservices provided in the

service area during the previous fiscal year;

g. assure that community LTCOP data is provided to the Office of the State Long-term Care Ombudsman in the format required by the DAS and in a timely manner;

h. prohibit inappropriate access to LTCO records located with the provider agency (see IT-500, below);

1.

assure LTCO attendance at certification training and all statewide

LTCO trainings;

J.

provide professional development opportunities for LTCO staff;

k. provide staff support as needed for the operation of the LTCOP such as custodial, fiscal management, clerical, and telephone coverage;

1.

arrange, in consultation with the SLTCO and the APj.A, if

applicable, for temporary provision ofLTCO services in the

serVice area when LTCO staff of the provider agency are

unavailable or the staff position is vacant;

m. request a waiver from DAS if, due to demonstrable and unusual circumstances, it anticipates it will be unable to comply with any of these responsibilities; and

n. perform each of its responsibilities in administering the community LTCOP in accordance with all applicable federal and state law, regulations, and policies.

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IT-300-15

REFERENCES

OAA 306; 712(a)(4), (5)(A); PI No. 39

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II-300-16

305. Long-Term Care Ombudsman Responsibilities
POLICY
An ombudsman is designated by the State Ombudsman to provide ombudsman services in the service area designated in the provider agency contract for ombudsman services. An ombudsman may be employed by the provider agency orserve as a' volunteer.
PROCEDURES
305.1 Ombudsman general responsibilities
LTCOs are responsible for:
a. providing LTCO services to protect the health, safety, welfare and rights of residents in accordance with the provisions of the federal and state laws governing the LTCO and with the provisions ofthe provider agency contract for LTCO services;
b. fulfilling the Program Components (III-I 00, below);
c. documenting LTCO activities and case work as required by the
SLTCO;
d. adhering to the Ombudsman Code of Ethics (Appendix A);
e. prohibiting inappropriate access to LTCO records in the possession of the community LTCOP (see IT-SOO, below);
f. . carrying out other activities that the SLTCO deems appropriate; and
g. performing each responsibility in accordance with all applicable federal and state law, regulations, and policies. I

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IT-300-17

305.2 Long-term Care Ombudsman Coordinator responsibilities

Within'the relevant community LTCOP, the LTCO Coordinator IS responsible
for: .

a.

overall management and development of the communityLTCOP;

b.

supervision of all other LTCO staffand/or volunteers and

Volunteer Visitors;

c. assuring that non-certified staff and volunteers work under the direct supervision of a certified LTeO;

d. submitting to the SLTCO, AAA and provider agency a Community LTCOP Annual Plan (III-I 00. l,b,i), below) for each fiscal year indicating program goals and objectives relating to the Program Components (ill-IOO, below) and other program activities;

e. assuring that the community LTCOP satisfactorily accomplishes
Program Component goals and objectives in the Community LTCOP Annual Plan;

f.

arranging, in consultation with the SLTCO, the provider agency,

and the AAA, if applicable, for provision of LTCO services in the

service area when the community LTCOP is temporarily unable to

provide coverage;

g. regularly reporting on ombudsman activities as required by the

provider agency, AAA, and SLTCO, including:

i)

assuring that accurate d8.ta is provided in a timely manner;

ii) ~egularly reviewing summary reports to check for accuracy

in data entry; and

iii) regularly comparing community LTCOP complaint and

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TI-30Q-18

activity data with statewide statistics and the CommUnity LTCOP Annual Plan for use in program management (see Ill-IOO.I, below); and

h. developing procedures for daily operation ofthe community LTCOP, including procedures for documenting and filing documents related to complaint investigations.

305.3 Responsibilities of staff and volunteers Dot designated as ombudsmen

Persons who are either hired or have volunteered as LTCOs but who have not completed the requirements for designation as an LTCO may provide LTCO services as follows:

a.

Only designated LTCOs may process complaints.

i)

Where the LTCO Coordinator is the only staffperson in the

community LTCOP, he/she shall work towards completion

of certification and, until certified as a LTCO, is

responsible to request SLTCO supervision for the

processing of all complaints.

b. Staff and volunteers not designated as LTCOs may assist in the
provision of LTCO services other than complaint processing under the direct supervision of a designated LTCO. They may not have
m- sole responsibility for the provision of any LTCO service (see
IlO, below).

REFERENCES

OAA 712(a)(5); O.e.G.A. 31-8-50 ets.eq; PI No. 39

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II-300-19

400. CONFLICTS OF INTEREST

POLICY

The organizational placement of the Long-term Care Ombudsman Program and the individuals who carry out the duties of the Program must be free from conflicts of interest.

How to use this Chapter -- This Chapter provides guidance in: 1) identifying and defining actual

and potential conflicts ofinterest, 2) avoiding conflicts ofinterest, 3) remedying conflict where

appropriate, and 4) describing consequences of operating a tong-term Care Ombudsman Program

with an unremedied conflict ofinterest. When a conflict is been identified under ll-401, the reader

should use the procedures set forth in II-402 to determine whether the conflict can be sufficiently

remedied to permit the provision of ombudsman services.

.

PROCEDURES
401. IdentifYing the CQnflict
401.1 DefinitiQn ofcQuflict Qfinterest
a. A conflict of interest exists in the Long-term Care Ombudsman
Program (LTCOP) when other interests intrude upon, interfere with, or threaten to negate the ability ofthe LTCOP to advocate without compromise on behalf of long-tenn care facility residents. Types of conflict of interest include: . i) conflicts of loyalty -- incentives, often related to financial
or emp~oyment considerations, that shape one's judgment Qr behavior in ways that are contrary to the interest of residents; ii) conflicts of commitment -- goals or obligations that direct one's time and/or attention away from the interest of residents; and

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II-400-1

iii) conflicts of control- limitations or restrictions that effectively foreclose one's ability to take actions to
advocate for the interest ofresidents.

401.2 Organizational conflicts

Conflicts arising from organizational location include, but are not limited to, LTCOP placement in an agency which:

a.

has an ownership or investment interest (represented by equity,

debt, or other financial relationship) in a long-term care facility or

a long-term care service;

b. provides long-term care services, including the provision of
personnel for long-term care facilities or the operation ofprograms which control access to or services for long-term care facilities;

c.

operates programs with responsibilities conflicting with LTCOP

responsibilities. Examples of such responsibilities include

developing and carrying out care plans and serving as guardian

over long-term care residents;

d.

has governing board members with ownership, investment or

e1.l1ployment interest in long-term care facilities; and

e.

has direct involvement in the licensing or certification ofa long-

term care facility or long-term care services.

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ll-400-2

401.3 Individual ombudsman conflicts

Conflicts for a long-term care ombudsman (LTCO) include, but are not limitedto7 the following:

a.

employment of an individual or a member ofhis/her immediate

family within the previous year by a long-term care facility in the

service area or by the owner or operator of any long-term care

facility in the service area~

b. participation in the management of a long-tenD. care facility by an individual or a member ofhislher immediate family;

c. ownership or investment interest (represented by equity, debt7 or other financial relationship) in an existing or proposed long-term. care facility or long-term care service by an individual or a member ofhislher immediate family;

d. involvement in the licensing or certification of a long-term care
facility or provision of a long-term care service by an individual or a member ofhislher immediate family;

e. receipt of remuneration (in cash or in kind) under a compensation
arrangement with an owner or operator of a long-term care facility
by an individual or a member ofhislher immediate family;

f.

accepting any gifts or gratuities from a long-term care facility or

resident or resident representative;

NOTE: A LTCO should adequately compensate a facility for food

provided by the facility with the exception of sample portions of

food tested as part of an investigative process.

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ll-40o-3

g. accepting money or any other consideration from anyone other than the provider agency or other entity designated by the Office of the State Long-term Care Ombudsman (SLTCO) for the performance of an act in the regular course ofa LTCO's duties;

h. provision of services with conflicting responsibilities while serving as a LTCO, such as adult protective services; discharge planning; serving as guardian, agent under power ofattorney or o~er surrogate decision-maker for a long-term care resident in the service area; pre-admission screening or case management for . long-term care residents;

1.

serving residents of a facility in which an immediate family

member resides; or

J.

participating in activities which:

i) negatively impact on the ability ofthe LTCO to serve

residents, or

ii) are likely to create a perception that the LTCO's primary

interest is other than as a resident advocate (see IT 403.3,

below).

402. Remedying Conflict

402.1 Genera]

a. notification of the SLTCO Where an actual or potential conflict of interest within the LTCOP has been identified, the SLTCO shall be notified. All agents of the Department of Human Resources, area agencies on aging (AAAs), provider agencies, and LTCOs have a duty to notify the SLTCO of any actual or potential conflict of interest ofwhich they have knowledge.

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IT-400-4

b. The SLTCO shall detennme whether appropriate actions may be taken to sufficiently remedy the conflict. A conflict can be sufficiently remedied only where the existence of the conflict does not interfere with any duties ofthe LTCOP and where the conflict is not likely to alter the perception of the LTCOP as an independent advocate for residents.
402.2 Remedying organizational conflicts
Where organizational conflicts have been identified, the following steps shall be taken where the conflict can be sufficiently remedied:
a. A written remedial plan shall be developed within thirty (30) calendar days of identification ofthe conflict to the SLTCO.
b. The remedial plan must identify the conflict and provide assurances which shallminirnize to the greatest extent possible the negative impact of the conflict on the LTCOP. Examples of such assurances could include: i) The LTCOP will investigate complaints in an unbiased manner and independently detennine actions to be taken in their resolution. ii) No agency employee or governing board member with a conflict of interest will.be involved with or influence any decision to hire or terminate the employment of a LTCO. iii) Governing.board members of the provider agency or AAA who have a conflict of interest: A) must disclose the conflict to the governing board and to the SLTCO; B) may have no involvement with LTCOactivities concerning the entity which is the source of the conflict; and C) must abstain from voting on issues related to the operation of the LTCOP.

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ll-400-5

iv) The agency's policies and procedures adequately set forth procedures to remedy conflicts of interest and ensure that the LTCOs can fulfill their duties without interference.
v) A memorandum of agreement exists between the LTCOP .and another program which provides services with conflicting responsibilities. Such a memorandum must adequately set forth the roles~ responsibilities, and appropriate working relationships ofthe respective programs.

c. The remedial plan must be mutually agreed upon and signed by the agency in which the conflict exists and the SLTCO. Ifeither party cannot agree to the plan, the conflict has not been sufficiently remedied.

402.3 Remedying individual Qmbudsman cQnflicts

Where individual conflicts have been identified, the following steps shall be taken where the conflict can be sufficiently remedied:

a. development of a written remedial plan

i)

Where the individual is an applicant fQr a position as a

LTCO, a plan shall be developed before the individual is

hired for the position.

ii) Where the individual is an applicant for certification as a

LTCO volunteer, a plan shall be developed before the

individual takes any actions on behalf Qfthe LTCOP.

iii) Where the individual is a LTCO staff or volunteer, a plan .

shall be developed within thirty (30) calendar days of

identification ofthe conflict to the SLTCO.

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II-400-6

b. The remedial plan must identify the conflict and provide

assurances which shall minimize to the greatest extent possible the

negative impact of the conflict on the LTCOP. An example of

such an assurance could include:

i)

prohibiting the LTCO with a conflict ofinterest from

serving the residents ofthe facility with which he/she has a

conflict and arranging for another staffLTCO to serve

those residents. Where appropriate~this arrmigement could

be time-limited.

c. The remedial plan must be mutualIyagreed upon and signed by the provider agency, the LTCO or applicant with the conflict of interest, the LTCO Coordinator, ifapplicable~and the SLTCO.

d.' Volunteer Visitors are not permitted to serve residents in facilities with which they have a conflict ofinterest. The SLTCO may
an delegate to LTCO Coordinator the authority to:
i) consider the conflicts of interest of an individual who wishes to serve as a Volunteer Visitor; and
ii) determine whether conflicts exist which may impede the ability ofthe Voluni~erVisitor to fulfill the duties of that position or may alter the perception ofthe LTCOP as an independent advocate for residents. Ifsuch a conflict exists, the individual cannot serve as a Volunteer Visitor.

403. Procedures to Ayoid Conflicts ofJnterest

403.1 persons seeking certification as ombudsmen

a. identification of the conflict The provider agency shall screen all persons seeking certification as LTCO staff or volunteers to identify any actual or potential individual conflicts of interest. Upon request by the SLTCO, the provider agency shall submit evidence of such screen to the

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II-400-7

SLTCO. The SLTCO may periodically request the provider agency to perform a conflict of interest screen of currently certified LTCO staff or volunteers.
b. disclosure of the conflict All persons seeking employment or certification as LTCO staffor volunteers shall disclose to the provider agency all information relevant to past employment, membership, or interests that may affect, or could reasonably be expected to affect, that individual's ability to carry out duties ofa LTCO without conflicting interest,
403.2 persons seeking to become Volunteer Visitors
a. identification of the conflict The LTCO Coordinator shall screen all persons applyingto become Volunteer Visitors to identify any actual or potential individual conflicts of interest.
b. disclosure of the conflict All persons applying to become Volunteer Visitors shall disclose to the Ombudsman Coordinator all information relevant to past employment, membership, or interests that may affect, or could reasonably be expected to affect, that individual's ability to carry out duties of a Volunteer Visitor without conflicting interest.
403.3 Ombudsman involvement in activities
In detenninirig whether LTCO participation in community groups, professional associations, or other activities constitutes a conflict ofinterest, the following questions shall be considered:
a. Will the LTCOP benefit from LTCO involvement in this activity?

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II-400-S'

b. Will the LTCO be able to represent and assert the views of Iongtenn care residents in this activity?
c. Will the role of the LTCO in the activity benefit residents?
d. How will participating in the activity affect the public perception and the residents' perspective ofthe LTCOP?
e. Will the LTCO be put in a position ofparticipating in a decision about a resident without theresidenCs involvement or permission?
404. Failure to Identify OT Remedy a Confljct ofInterest
a. Failure on the part of a LTC6, provider agency, or administrative agency to identify and report to the SLTCO a known conflict of interest shall be sufficient grounds for refusal to designate or dedesignation of the LTCOP or the LTCO (II-200, above).
b. Existence of an unremedied conflict ofinterest shall be sufficient
grounds for the de-designation of the LTCOP (II-202, above).
c. Failure on the part of a LTCO to identify and report to the SLTCO a known conflict of interest shall be sufficient grounds for the withdrawal of the designation of the LTCO (II-204, above).

REFERENCES

OAA 712(a)(5)(C)(ii), (f); proposed rule 45 CPR 1327.27; 10M Report, pp. 101-127.

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II-400-9

500. LONG TERM CARE OMBUDSMAN RECORDS

POLICY

Records of the Long-tenn Care Ombudsman Program shall be confidential and shall be disclosed only in limited circumstances specifically provided by applicable law and these procedures.

PROCEDURES

501. Access to Long Ierm Care Ombudsman Records

501.1 State Ombudsman access

All Long-tenn Care Ombudsman Program (LICOP) client records are the property of the Office of the StateLong-term Care Ombudsman (SLICO). The SLTCO or designee has access to all LTCOP records at all times for any purpose.

501.2 Ombudsman access

a.

Each LICO has access to records ofthe community LTCOP for

which he or she serves.

b; For the purpose of providing temporary coverage for another corrimunity LTCOP, a LTCO may have access to the LTCO records ofthe other community LTCOP to the extent necessary to provide such coverage.

501.3 Diyjsjon of Aging Services, area agencies on aging, and provider agencies

a. For purposes of monitoring and supervising the LTCOP, the Department of Human Resources, Division of Aging Services (DAS) and the relevant AAA and provider agency may review records which reflect the activities of the LTCOP, including

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II-50Q-l

activity reports and complaint summary reports. The DAS, AAA, or provider agency may not review records which disclose or imply the identity of any resident or complainant.
b. No state agency, AAA or provider agency may require a LTCO to . disclose the identity of a complainant or resident except as specifically provided by these procedures.
502. RespQnse tQ Requests fQr LQng Tenn Care Ombudsman Records
a. Where a request is made to any party for LTCO records, the SLTCO or designee shall be contacted. Records maintained by the LTCOP may not be released., disclosed, duplicated, or removed to anyone who is not a LTCO staffor volunteer without the written pennission of the SLTCO.
b. The SLTCO or designee shall determine whether to disclose all or part of the records as follows: i) written The SLTCO shall require that the request be made in writing and may require a copy ofthe request before determining the appropriate response. Where the request is made orally by a resident, complainant, or legal representative ofthe resident or complainant, the request must be documented immediately and filed as an LTCO record by the LTCO to whom consent was communicated in order to meet this requirement. ii) resident wishes/interest The SLTCO shall review the request with the relevant community LTCOP to determine whether the release of all or part of the records would be consistent with the wishes or interest of the relevant resident(s).

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II-500-2

iii) removal of identity of residents or complainants The SLTCO shall determine whether any part ofthe records should be redacted (i.e. all identifying information removed). The identities of residents or complainants who have not provided express consent for the release oftheir names shall not be revealed. Such consent must be in writing or made orally and documented immediately and filed as an LTCO record by the LTCO to whom consent was communicated.

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II-50Q-3

iv) source of request. The SLTCO or designee shall consider the source ofthe request as follows:

TABLE II-A LTCO RECORDS: SOURCE OF REQUEST

IF the request for LTCO records is made by ...

THEN the SLTCO or designee shall
...

a resident,

release any records generated by the LTCO which are direCtly relevant to that resident provided that the iden.tity of other residents or complainants is redacted

a complainant or by the legal representative of a complainant or resident

release any records generated by the LTCO which are directly relevant to that resident or complainant provided that: the SLTCO has no reason to believe that the release shall be in: conflict with the wishes or interest of the relevant resident, and the identity of other residents or complainants is redacted.

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11-500-4

another agency or program a judge any other party
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release the records only if: the resident has provided consent (If the resident is unable to provide consent, the resident's legal. representative may provide consent.) and the identities ofresidents or complainants who have not provided cOnsent for the release oftheir names are not revealed. NOTE: where federal requirements conflict with Georgia law, the federal requirements take precedence.
release any records directly responsive to a court order, and provide an explanation to the court regarding the,importance ofnot revealing the identity ofresidents and complainants and/or requesting the court to seal the LTCO records where the SLTCO determines that the release ofrecords would be inconsistent with the wishes or interest of the resident.
release the records only if: the resident has provided consent (If the resident is unable to provide consent, the resident's legal representative may provide consent.) and the identities ofresidents or complainants who havenot provided consent for the release of their names are not revealed.
II-500-5

v) type of request The SLTCO or designee shall consider the type of request as follows:

TABLEll-B LTCO RECORDS: TYPE OF REQUEST

IF the request was made as ...

THEN the SLTCO shall .

a general written request (e.g., a letter)

follow the steps II-502, b; i)-iv), above.

a fonnal discovery request

follow the steps II-502, b, i)-iv), above; obtain appropriate legal counsel; and provide legal counsel with infonnation sufficient to object to requests which would require revealing the identities of residents or complainants.

an open records act request

follow.the steps II-502, b, i)-iv), above; and respond according to the procedures set forth in the Georgia open records act. O.C.G.A. 50-18-70 etseq.. NOTE: where federal requirements conflict with Georgia law, the federal requirements take precedence.

a subpoena

follow the steps II-502, b, i)-iv), above; and make a cOurt motion to quash the subpoena where the SLTCO detennines that the release of records would be inconsistent with the wishes or interest of the resident

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II-500-6

IF the request was made as .. a court order

THEN the SLTCO shall ..
release any records directly responsive to the order, and provide an explanation to the court regarding the importance of not revealing the identity ofresidents and complainants and/or requesting the court to seal the LTCO recon:ls where the SLTCO determines that the release ofrecords would be inconsistent with the wishes or interest of the resident.

REFERENCES

OAA 712 (d); O.C.G.A. 31-8-58; proposed rule 42 C.F.R.. 1327.24; PI No. 88.

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ll-500-7

600. Legal Counsel for the Long-term Care Ombudsman Program
POLICY
Ombudsmen shall have access to adequate legal counsel.
PROCEDURES
601. Adequate Legal Counsel
The Department ofHuman Resources, Division.ofAging Services (DAS) shall assure the provision of adequate legal counsel, without conflict o~interest, including:
a. advice and consultation services needed to protect the health,
safety, welfare, and rights ofresidents and assistance t6 the Office of the State Long-tenn Care Ombudsman (SLTCO) and community long-tenn care ombudsmen (LTCOs) in the perfonnance oftheir official duties; and
b. representation in an actual or threatened legal action against any LTCO brought in connection with the performance of their official duties.

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II-600-1

602. provision orLega] Counsel

Legal counsel is available as follows:

Party SLTCO

TABLE II-C LEGAL COUNSEL
Advice/Consultation
Resident issues: ELAP Program operation: ELAP. DHR Legal Services, Law Department

Representation
Ifno conflict of interest: Law Department If conflict ofinterest: independent attorney

Community LTCO

SLTCO,ELAP

Independent attorney

Residents

ELAP

ELAP

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II-600-2

603. Obtaining Legal Counsel
603.1 Office of the State Long":term Care Ombudsman
a; 'For the SLTCO to obtain advice and consultation, the SLTCO or designee may: i) confer with the Legal Service Developer; ii) contact the Department of Human Resources (OHR.) Legal Services Office for guidance on DHR policy or proCedure or other matters for which that office has primary responsibility; or iii) request assistance ofthe State ofGeorgia Law Departinent (Law Department) by following DHR procedures for such
I
requests.
b. For the SLTCO to obtain representation: i) the SLTCO or designee shall advise the DAS Director of the legal action or threatened legal action; and ii) the DAS Director shall follow the procedures of the DHR to obtain representation from the Law Department for representation for the SLTCO. iii) Where a conflict of interest exists, the SLTCO or designee shall arrange for the provision of legal representation of the SLTCO by an independent attorney. A conflict ofinterest may be identified by either the Law Department, the DAS , Director, or the SLTCO. iv) 'The SLTCO or designee shall obtain prior approval from the DAS director for DAS expenditures for legal representation.

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ll-600:"3

603.2 Community ombudsmen
a. For legal advice and consultation, a LTCO shall request assistance from: i) . the SLTCO, which shall assure the provision of adviCe and consultation for the community LTCO; or ii) the ELAP in the relevant service area.
b. For a community LTCOto obtain legal representation: i) the LTCO shall advise the SLTCO of the legal actiOn or threatened legal action; ii) the LTCO shall identify independent legal counsel In doing so, the LTCO may request the assistance ofthe SLTCO and/or ELAP in selecting appropriate legal counsel; and iii) the SLTCO shall obtain prior approval from the DAS director for DAS expenditures for legal representation.
603.3 Area agencies Qn aging and provider agencies
The area agency on aging and provider agency are expected to retain their own legal counsel.

REFERENCES

OAA 712(g); proposed rule 45 C.F.R 1327.26

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II-600-4

700. Liability
POLICY
An ombudsman is immune from liability for the good faith perfonnance ofbis or her official duties.
PROCEDURES
701. Immunity from Liability
A long-term care ombudsman (LTCO) shall not incur any civil or criminal liability for performing his or her official duties in good faith.
a. "Official duties" are those duties of a LTCO set forth in applicable federal and state law and these policies and procedures. They shall include, but not be limited to, making a statement or communication relevant to receivIng a complaint or conducting investigative activity.
b. Evidence of performing duties in "good faith" includes, but is not limited to: i) making every reasonable effort to follow procedures set forth in applicable laws and these policies and procedures; ii) seeking, and making reasonable efforts to follow, direction from the Office ofthe State Long-term Care Ombudsman (SLTCO); and iii) seeking, and making reasonable efforts to follow, direction from the relevant LTCO Coordinator.
702. Liability Insurance
a. The Department of Human Resources, Division of Aging Services does not provide liability insurance or indemnification for area

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II-700-1

agencies on aging (AAAs) or provider agencies. AAAs and provider agencies are expected to retain their own liability policies.

b. L TeO volunteers may apply to receive liability coverage through the State of Georgia. The SLTCO shall provide applications for such coverage upon request.

REFERENCES

OAA 712(i); proposed rule 45 C.F.R 1327.28; O.C.G.A. 31-
8-62

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II-700-2

800. Interference and Retaliation
801. Interference and RetaliatiQn Prohibited
a. No person shall willfully interfere with a long-term care ombudsman (LTCO) in the performance of official duties. "Interference" includes any inappropriate or improper influence frQm any individual or entity, regardless of the source, which will
many way compromise, decrease or negatively impact on:
i) the objectivity of the investigation or outcome of complaints;
ii) the LTCO's role as advocate for the rights and interests of the resident;
iii) the LTCO's work tQ resolve issues related tQ the rights, quality of care and quality of life ofresidents of long-term care facilities; or
iv) the LTCO's statutory responsibility to provide such information as the Office of the State Long-term Care Ombudsman (SLTCO) determines necessary to public and private agencies, legislators and other persons regarding the problems and concerns ofresidents and recommendations related to residents' problems and concerns.
b. No person shall discriminate or retaliate in any manner against any . resident, or relative or guardian of a resident, any employee ofa IQng-term care facility, Qr any Qther person due to filing a .complaint with, providing information to, or otherwise cooperating in good faith with a LTCO.

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ll-SQO-I

802. Procedures for Reporting Interference or Retaliation
a. Any person who has knowledge ofsuch interference or retaliation may report such information to the SLTCO.
b. The SLTCO shall review the information provided, and conduct further investigation if necessary to confirm the occurrence ofthe interference or retaliation.
c. IftheSLTCO, based on such review, determines that enforcement action is warranted, the SLTCO shall pursue the following course of action: i) Where the entity which has interfered or retaliated is a long-term care facility or its staffor agents: A) the SLTCO shall submit a written report ofsuch interference or retaliation to the Office of . Regulatory Services (ORS); B) the ORS shall investigate the report ofthe SLTCO in accordance with its procedures for complaint investigation; and C) if the ORS complaint investigation confirms the occurrence of such interference or retaliation, the ORS has the authority to impose penalties in accordance with its procedures for the imposition of penalties. . ii) Where the entity which has interfered or retaliated is an entity other than a long-:-term care facility or its staffor agents: A) the SLTCO shall report such interference or retaliation to the Department of Human Resources, Division of Aging Services (DAS) Director; B) such interference by an individual who is an official or employee of the Dep~ent of Human Resources, an area agency on aging, or a provider

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n-800-2

REFERENCES

agency shall be deemed to be a violation of OAA 705(a); and C) the DAS Director shall assist the SLTCO in detennining appropriate sanctions and assuring that appropriate sanctions are implemented.
OAA 712(j); proposed rule 45 C.F.R. 1327.29; O.C.G.A. 318-60

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II-800-3

PART III. GUIDELINES FOR OMBUDSMAN PRACTICE

POLICIES



An ombudsman advocates on behalfofresidents to resolve problems to their

satisfaction and improve their overall quality of life and quality of care.



An ombudsman encourages, and provides infonnation and assistance to enable,

residents and complainants to personally work to address their own concerns.

PROCEDURES

100. Program Components

Each community long-tenn care ombudsman prOgram (LTCOP) shall provide services to protect the health, safety, welfare and rights ofresidents. 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-tenn Care Ombudsman (SLTCO). The Program Components are:

1. . complaint processing, 2. infonnation and assistance, 3. comrilunity education, 4. in-service education, 5. routine visits, 6. issues advocacy, 7. interagency coordination, 8. resident co~cil and family council activities, 9. advisory council development, and 10. volunteer management.

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111-100-1

100.1 The Community LTCOP Annual Plan

.a. LTCO Coordinator responsibilities The Long-term Care Ombudsman (LTCO) Coordinator shall prepare a Community LTCOP Annual Plan for submission to the SLTCOand the area agency on aging (AM), setting goals and objectives for the community LTCOP for the following fiscal year. Such Plan shall be submitted to the SLTCO and the AM by April 1 for the following fiscal year unless the AM requests the LTCO Coordinator to submit the Plan at an earlier date (for example, the Fiscal Year 1999 Plail is due by April 1, 1998).

b. Contents of the Community LTCOP Annual Plan

.The Community L'rCOP Annual Plan shall:

i)

include objectives for each Program Component. Eachobjective

.shall be measurable and specify the time frame in which it shall be

accomplished;

ii) provide for complaint processing to be the highest priority Program

Component;

iv) include a plan for staff and telephone coverage for the community

LTCOP in order to assure prompt responses to complaints and

other requests for assistance; and

v) include plans for improved performance ofthe Community

LTCOP over previous years. Objectives for improved

performance may relate to one or more Program Components

and/or the"development of special initiatives.

. b. SLTCO responsibilities

i)

The SLTCO shall inform each LTCO Coordinator and the AM of

whether the Community LTCOP Annual Plan is acceptable within

30 days after receipt of the plan. If changes must be made to a

Community LTCOP Annual Plan, the SLTCO shall provide

assistance to the LTCO Coordinator to develop an acceptable Plan.

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i l l-100-2

ii) Each AAA is encouraged to provide comment to the SLTCO regarding the Community LTCOP Annual Plan submitted by the community LTCOP in its service area within 30 days after receipt of the Plan by the AAA. The SLTCO shall consider the comments of the AAA in reviewing the-relevant Community LTCOP Annual Plan.
iii) In determining whether a Community LTCOP Annual Plan is
acceptable, the SLTCO shall consider the folloWing: A) 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 in a Community LTCOP Annual Plan for a particular community LTCOP only where the Plan describes one or more of the following: I) 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 ofthe LTCOP and which may require significant stafftime 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 community LTCOP. B) the Plan's anticipated benefit to residents; C) the Plan's anticipated impact on the provision of ombudsman services to long-term care residents; and

f:das\ltco\plcsrnan.wpd 7/97

ID-IOO-3

D) the performance history ofthe community LTCOP as detennined by a review ofdata relating to performance of Program Components.
iv) The SLTCO shall notify the relevant community LTCOP and AAA of the SLTCO approval of the Community LTCOP Annual Plan.

100.2 LTCOP evaluation

a. The LTCO Coordinator shall evaluate the performance ofthe community LTCOP at least annually. This review shall include a review of activities and complaint data for the community LTCOP and a comparison of the community LTCOP with activities and complaint data statewide.

b. The SLTCO shall maintain activities and complaint data for the statewide LTCOP regarding Program Components.

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

d. The SLTCO shall provide information regarding these numbers to LTCO Coordinators, AAAs, provider agencies, and other interested parties upon request.

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

f.

The SLTCO shall make periodic site visits to evaluate community

LTCOPs as deemed necessary by the SLTCO.

REFERENCES
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OAA 712(a)(5)

ill-I 00-4

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III-100-5

101. Complaint Processing
POLICY
Processing complaints made on or behalf of residents oflong-term. care facilities: is the long-term care ombudsman program's highest priority service.
PROCEDURES
101.1 General
The community LTCOP shall identify, investigate and resolve complaints made by or on behalf ofresidents. Although the issues and circumstances ofthe complaints will vary, the following are general guidelines which should apply to all complaint handling. Whenever questions arise regarding appropriate LTCO practice in handling complaints, the SLTCO should be contacted for guidance.
101.2 . Complaint intake and response
a. . complaint intake When a LTCO receives information regarding a complaint:, the LTCO shall: i) determine: A) the type of complaint (using the uniform complaint categories provided by the SLTCO); B) what outcome the complainant is seeking; C) what attempts have already been made to resolve the complaint; and D) whether the complaint is appropriate for LTCO activity. Examples of complaints which are not appropriate for LTCO activity include those which: 1) do not directly impact a resident or former resident of a long-term care facility; 2) are outside the scope of the mission or

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ill-101-1

authority of the LTCOP; or 3) would place the LTCOP in the position of
having an actual or perceived conflict of interest with the interest of a resident or residents. NOTE: The LTCO may seek resolution of complaints in which the rights ofone resident and the rights of another resident or residents appear to be in conflict. ii) discuss the following with the complainant: A) alternatives for lian4ling the complaint; B) encouragement for the complainant to personally take appropriate action, with LTCO assistance if needed; C) explanation that the LTCO role is to act in accordance with resident wishes; and D) the LTCO policy of confidentiality.

b. source of complaint

i)

Complaints may be filed with the LTCOP by residents,

families and friends ofresidents, long-tenn care facility

staff, and any other person.

ii) Complaints may be made anonymously to the LTCOP.

Anonymous complaints must remain anonymous.. Ifthe

LTCO receiving the complaint is able to commtmicate

directly with the anonymous complainant, the LTCO may

explain to the complainant that, in some circum~

anonymity could limit the ability of the LTCO to

investigate and resolve the complaint.

iii) ombudsman-generated complaints -- A LTCO shall file a .

complaint when the LTCO has personallmowledge ofan

action, inaction, or decision that. may adversely affect the

health, safety, welfare, or rights of residents and no other

person has made a complaint on such action, inaction, or

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ill-101-2

decision. NOTE: Such actions, inactions, or decisions include facility responses to natural disasters, evacuations, relocations, involuntary change ofmanagement, or other unusual events.

c. timeliness of responses to complaints i) a LTCO shall use his or her best efforts to initiate investigations ofcomplaints in a timely manner in order to resolve the complaint to the satisfaction ofthe resident. A response is considered timely as follows:

TABLEID-A COMPLAINT RESPONSE

IF a complaint involves ...

THEN the standard of promptness for LTeO response is

abuse or gross neglect, and the LTCO has reason to believe that a resident may be at risk

within the next working day

abuse or gross neglect, and the LTCO has no reason to believe that a resident is at risk

within 72 hours

actual or threatened transfer or discharge from a facility

whichever occurs first:

5 working days,

last day ofbedhold period (if resident is

hospitalized), or

,

last day for filing an appeal for an

administrative hearing

other types of complaints

within 7 working days

f:das\ltco\plcsrnan.wpd 7/97

ii) Where the LTCOP will be unable to initiate investigations in a timely manner (e.g., due to a planned vacation or
III-I 01-3

extended illness), the LTCO Coordinator shall develop a plan for temporary coverage in order to meet the standard of promptness. iii) The LTCO may indicate to the complainant when the complainant may expect investigative efforts to begin. iv) . The LTCOP is not designed to serve as an emergency response system; emergency situations should be referred to "911" for immediate response.
d. resident focus i) Regardless of the source of the complaint, the resident"ofor applicant to a long-term care facility is the LTCO's client. ii) Regardless of the source of a complaint, a LTCO shall personally discuss the complaint with the resident inoIder to: A) determine the resident's perception ofthe complaint; B) determine the resident's wishes with respect to resolution ofthe complaint; C) advise the resident of his or her rights; and. D) work with resident in developing a plan of action. NOTE: Where immediate action must be taken in order to protect resident rights, the LTCO may take necessary immediate action if it is not possible to first consult with the resident. The LTCO shall inform the resident ofthe action taken by the LTCO as soon as practicably possible and seek to follow resident wishes d~g the remainder of the complaint process. iii) Where the complaint relates to a nursing facility regulatory violation, the LTCO shall inform the resident and/or complainant that the LTCOP has opportunity to provide information to surveyors and seek resident and/or complainant permission to share the complaint information with surveyors. The LTCO shall provide. the name of the

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ITI-101-4

complainant and/or resident to surveyors with complainant and/or resident consent. iv) resident consent refused or withdrawn A) If, at any point during the complaint process, the
resident expresses that he or she does not want the LTCO to take further action on a complaint involving the resident, the LTCO shall determine whether further efforts should be made on the complaint. In making this determination, the LTCO shall consider the following:

TABLEill-B RESIDENT REFUSES CONSENT

IF the resident ...

THEN the LTCO shall

refuses to consent to LTCO work on the complaint, or withdraws consent before the LTCO has verified the complaint

discontinue work on the complaint; and follow steps ofIII-I01.2,d,iv),B),below

withdraws consent after the LTCO has . verified or partially verified the complaint

discontinue investigation and resolution activities on the complaint; detennine, during subsequent visits to the facility, whether the type of complaint is recuning. If it is recurring, the LTC6 shall determine whether the circumstances merit other strategies towards resolution which would not involve or disclose the identity of the resident who has withdrawn consent (e.g.,
filing an ombudsman-generated complaint,
presentIDg the issue to the residentor family council); and follow steps ofIII-lOl.2,d,iv),B), below

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B) For all complaints in which the resident refuses or withdraws consent, the LTCO shall:
III-101-5

I) attempt to detennine why the resident refused or withdrew consent, considering factors 'such as: past response of facility to complaints; the resident's relationship with the staff, the experience ofthis resident or other residents in the facility related to this type of complaint;
2) infonn the resident that he or she may contact the LTCO regarding the withdrawn complaint or other complaints in the futme; and
3) provide a business card or brochure infonning the resident how to contact the LTCOP.
v) resident unable to provide consent A) The LTCO shall advocate for a resident's wishes to the extent that the resident can express them, even. if the resident has limited decision-making capacity. B) Where a resident is unable to provide or refuse consent to a LTCO to work on a complaint directly involving the resident, the LTCO shall: I) seek evidence to indicate what the resident woUld have desired and, where such 'evidence is available, work to effectuate that desire; and 2) assume that the resident wishes to have his or her health, safety, welfare and rights protected.

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ill-101-6

101.3 Inyestigation process
a. The LTCO investigates a complaint in order to verify ~e troth of the complaint. i) A complaint is "verified" when the LTCO detennines, after completing an investigation, that the circumstances described in the complaint are substantiated or generally accurate. ii) Because a LTCO works on behalfof residents, the LTCO gives the benefit ofany doubt to the resident's perspective.
b. The LTCO shall seek the following information during the investigation of the complaint: i) what has occurred oris occurring; ii) when it occurred and whether the occurrence is on-going; iii) where it occurred; iv) who was involved; v) effect of the occurrence on resident(s); vi) reason for occurrence; and vii) what, if anything, the facility or other interested parties have been done in response to the occurrence.
c. In order to verify a complaint, the LTCO shall take one or more of the following steps, as appropriate to the nature of the complaint: i) research relevant laws, rules, regulations, and policies; ii) personally observe the evidence; NOTE: a LTCO shall not search a resident's body for evidence. iii) interview the resident and/or complainant; iv) interview staff, administration, other residents and families; v) identify relevarit agencies and interview and/or obtain information from their staff; and vi) examine relevant records.

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ill-101-7

d. The LTCO is not required to independently verify a complaint in order to seek resolution on behalfofa resident. Resident perception is a sufficient basis upon which an LTCO can seek resolution.

e. Facility visits for purposes of complaint investigation shall be unannounced.

101.4 plan OfactjOD

a.

Upon verifying or partially verifying a complain4 the LTCO shall

detennine a plan of action to resolve the complaint.

b. The plan of action shall be mutually agreed upon bythe resident and the LTCO.

c. The LTCO shall consider the following factors in developing the plan of action, as appropriate to the nature of the complaint: i) the scope of the complaint; ii) the history of the facility with respect to resolution ofother complaints; iii) available remedies and resources for referral; iv) who would be best able to resolve the complaint; and v) the likelihood ofretaliation against the resident or complainant.

d. One or more of the following may be appropriate plan ofaction in

resolving complaints:

. i)

explanation -- i.e. The findings of the investigation do not

indicate a need for a change or require LTCO intervention.

The resident or complainant received an explanation which

satisfied the initial problem;

ii) negotiation _.:. i.e. the LTCO advocates on behalf of or with

the resident or complainant in discussing the complaint

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ill-lOl-8

with the appropriate &cility staffor other relevant party to develop an agreement that resolves the complaint; iii) mediation -- i.e., the LTCO acts as an impartial referee between parties ofequal status (e~g.,between residents or between family members) to assist the parties in developing an agreement that resolves the complaint; iv) administrative hearings; v) coordination with and/or referrals to appropriate agencies (see ID-I01.5, 101.6, below); or vi) issues advocacy (See ID-I06, below)
e. The LTCO shall attempt to resolve the dispute directly with the appropriate staff of the facility unless the LTCO and the resident determine that another strategy would be more advantageous to the resident.
101.5 Complaint referrals
a. when a complaint shall be referred i) A LTCO shall make a referral to another agency where: A) the resident gives permission; and B) one or more of the following applies: .1) another agency has resources that may benefit the resident (e.g., Adult Protective Services can physically relocate the resident to another placement); 2) the action to be taken in the complaint is outside ofthe LTCOP's authority and/or expertise (e.g., Office ofRegulatory Services (ORS) takes enforcement actions); 3) the LTCO needs additional assistance in . order to achieve resolution of the complaint; or 4) the resident requests the referral be made.

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ID-101-9

b. referrals to regulatory agencies

i) An LTCO may encourage residents or complainants to

directly contact the appropriate regulatory agency to file a

complaint and offer infonnation and assistance to residents

or complainants in making such contact.

ji) Where ~ LTCO refers a complaint to the ORS, the LTCO

shall:

A) submit the complaint in writing; or

B) contact complaint intake by telephone and

subsequently document the referral by:

1) submitting a confinning letter to the agency;

and/or

-; ,

2) recording in LTCO records.

iii) joint investigatory activities

Where the LTCO is invited by a regulatory agency to assist

in or provide infonnation regarding an investigation of a

facility, LTCOparticipation is appropriate only under the

following circumstances:

A) the LTCO is able to fulfill his or her role as a

resident advocate;

B) the LTCO does not attempt to regulate a facility or

take actions which would lead one to assume that

the LTCO is a regulator; and

C) the LTCO explains to facility administration and

residents that his or her role is to advocate for the

health, safety, welfare and rights ofresidents, not to

enforce regulations.

c. referrals to legal services i) For a resident who is age 60 or older and who is requesting or in need of legal advice and representation, the LTCO shall refer the resident to the Elderly Legal Assistance

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ID-101-10

Program (ELAP) in the service area where the resident resides. ii) For a resident who is under age 60 or older and who is requesting or in need of legal advice and representation, the LTCO shall assist the resident in finding appropriate legal services. LTCOs may contact the ELAP, the SLTCO, the Legal Services Developer, the Georgia Legal Services Program, Of the Atlanta Legal Aid Society for information regarding such services. iii) Where the ELAP is unable to provide the requested legal
service, the LTCO may provide the resident with a list of
private attorneys who may provide the service. The LTCO shall not make referrals to or recommend ofan individual private attorney.

d. follow-up

After a complaint has been referred, the LTCO shall determine:

i)

resident satisfaction with the outcome of actions taken by

the referral agency, and

ii) that appropriate action has been taken by the referral

agency.

101.6 Closing a complaint Of case

a. LTCO activity on a complaint or case is complete, and, therefore, the complaint or case may be closed, when any of the following occurs: i) the complaint has been resolved to the resident's satisfaction; ii) the LTCOP has detennined, after investigation, that the complaint: A) cannot be verified; or B) was not made in good faith;

f:das\ltco\plcsman.wpd 7/97

ill-WI-II

iii) further activity by the LTCO is unlikely to produce satisfaction for the resident;
iv) . the complaint is not appropriate for LT~O activity (see ill101.2, above);
v) the LTCO anticipates no further response regarding the complaint from the agency to which the referral was made; or
vi) the resident requests that LTCO activity end on the complaint.
b. follow-up After a complaint has been closed., the LTCOshall continue to monitor the circumstances ofthe complaint to: . i) assure that the resident is satisfied with the outcome, and ii) determine whether further actions on behalfof the resident should be taken by the LTCOP.

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ID-IOl-12

101.7 Abuse and gross' neglect complaints

NOTE: Specific guidelines are provided with respect to handling and reporting suspected abuse" . neglect and exploitation due to the serious nature of these complaints and in order to comply with. laws which govern the Long-tenn Care Ombudsman Program, including confidentiality requirements and mandatory reporting requirements.

a.

an Upon receiving abuse or gross neglect complaint, a LTCO shall

use his'or her best efforts to ensure protection ofthe resident from

further abuse or neglect.

b. The LTCO shall follow complaint investigation steps (ill-10l2101.6) as in other types of complaints. NOTE: The primary role ofthe LTCO is!o seek resolution to the resident's satisfaction, not to verify the suspected abuse or neglect.

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IIT-101-13

c. The LTCO shall report suspected abuse or neglect as follows:

TABLEm-e WHEN TO REPORT ABUSE

IF the resident ...

THEN the LTCO shall...

gives pennission to a LTCO to make the report

report the suspected abuse or neglect

does not give pennission to a LTCO to make the report; and the complainant is a long-term care service provider, facility staffperson, or other mandatory reporter

inform the complainant of his or her duty to report to the appropriate agency

does not give pennission to a LTCO to .make the report; and the resident acknowledges having been abused

determine: 1) whether other residents have experienced similar circumstances, and 2) whether any other such resident wishes the LTCO to take any action on his or her behalf; and make repeated visits to the resident who alleged abuse in order to encourage the resident to permit the LTCO to report the suspected abuse

is unable to communicate his or her wishes

encourage and provide assistance to any other person who is aware of the suspected abuse to make the report

does not make .the complaint (i.e. the LTCO receives a complaint of suspected abuse or neglect from a complainant other than the resident)
:

advise the complainant to report the suspected abuse or neglect to the appropriate . agency and provide information to assist the complainant in making the report; and visit the resident and follow complaint investigation steps (llI-101:2 - 101.6, above)

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III-IOl-14

IF the resident ...

THEN the LTCO shall

does not make the complaint, and the LTCO personally witnesses abuse of a resident

report the suspected abuse; file an ombudsman-generated complaint; and follow complaint inveStigation steps (III101.2 - 101.6, above)

requests LTCO assistance in moving from the facility
.. -

take steps to facilitate moving the resident to another facility such as assisting with contact of family members or appropriate agencies NOTE: The LTCO shall not physically transport the resident.

TABLEID-D WHERE TO REPORT ABUSE

IF suspectedabuse occurs in ...

THEN a report is be made to .

a nursing facility

Department ofHuman Resources, Office ofRegulatory Services Complaint Intake 404/657-5287

a personal care home

Department ofHuman Resources, Office ofRegulatory Services Personal Care Home Program 404/657-4076

all other settings

Department ofFamily and Children Services Adult Protective Services in the county where the suspected abuse occurred

d.
f:das\ltco\plcsrnan.wpd 7/97

follow-up

ill-WI-IS

The LTCO shall continue to monitor: i) the safety ofthe resident at issue; ii) the involvement and/or investigation ofother agencies; and iii) resident satisfaction with the outcome of actions taken in
response to the suspected abuse or neglect
101.8 DocumentatjoD
a. Regarding each complaint, the LTCO shall document as follows: i) LTCO activity as required in the LTCOP Reporting Manual for purposes ofpreparing NORS reports; ii) complaint intake information, including: A) complainant name, B) telephone number and/or address ofcomplainant, C) complaint category, D) affected resident(s) name(s), E) facility name, and F) name of LTCO taking complaint; iii) a plan of action for resolution of the complaint; iv) description of and dates ofsteps taken to investigate, verify, and resolve the complaint; and v) explanation of the resolution or other reason for closing the complaint.
b. The community LTCOP shall maintain complaint documentation . in an organized manner which: i) can be readily understood by another LTCO or the SLTCO; ii) clearly describes all LTCO activity on the complaint; and iii) permits a ready complaint history of each facility in the service area.

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ill-IOI-16

101.9 Complajnt numbers
a. The LTCO Coordinator shall periodically review the number of complaints brought to the community LTCOP to determine whether: i) the number of complaints is so high as to impact the ability of community LTCOP to adequately fulfill the other program components; ii) the number of complaints is below the average number of complaints per program statewide; and iii) the number of complaints is approximately the same as the projection in the Community LTCOP Annual Plan.

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III-IOI-I?

TABLE III-E COMPLAINT ACTIVITY
How to use this table: This table'is designed to assist LTCO Coordinators, the SLTCO, area agencies on aging, and provider agencies in community LTCOP evaluation and planning. It suggests strategies to use in impacting complaint numbers which appear unusually high or unusually low. It also provides guidailce in evaluating program performance related to complaint processing. The community LTCOP is not required to process a particular number of complaints.

IF complaint numbers are .. low from a particular facility

THEN the LTCO Coordinator shall take the following steps .
determine whether residents, families, or staff feel free to make complaints to LTCOP determine whether residents, families and staff are familiar with the existence of and purpose ofthe LTCOP review whether ombudsman-generated complaints are being accurately recorded by all staff

f:das\ltco\plcsman,wpd 7/97

III-IOI-iS

IF complaint numbers are ....

THEN the LTCO Coordinator shall take the followin; steps .

low for the community LTCOP, indicated by any of the following: more than 10% below the statewide average, or more than 10% below the projected number ofcomplaints in the Community LTCOP Annual Plan

review whether residents, families and staff are familiar with the existence ofand purpose oftheLTCOP increase frequency ofroutine visits increase involvement with resident and family councils increase community education and public information regar4ing the purpose ofthe LTCOP increase the nmnbers ofin-service trainings for facility staff review whether complaints, including ombudsman-generated complaints, are being accurately recorded by all LTCOs

high for a particular facility or company owning/managing facilities

look to systemic approaches to resolve common complaints

high for the community LTCOP, indicated

review whether serious complaints are being

by:

given highest priority for resolution

more than 10% above the statewide average,. reView whether LTCOs are providing

or

sufficient resources and information to enable

more than 10% above the projected number families and residents to personally resolve

ofcomplaints in the Community LTCOP

complaints where appropriate

Annual Plan

b.

The LTCO Coordinator shall periodically review the resolution

status of complaints to monitor resident satisfaction ~ith complaint

activity. In developing the Community LTCOP Annual Plan (Ill-

.lOO.I,b,i), above) and in otherwise setting goals and objectives, the

LTCO Coordinator shall seek to:

i)

improve r~sident satisfaction with co~plaint resolution

Improved resident satisfaction is indicated by an increase in

f:das\1tco\plcsrnan.wpd 7/97

ill-l01-19

I
the total percentage ofthe sum. ofthe following resolution
categories: A) "resolved" (defined as "addressed to the Satisfaction
of the resident," Georgia LTCO Reporting .Manual); B) "partially resolved;" and C) "explained;" NOTE: Some complaints will not be resolved to the resident's satisfaction regardless of LTCO action. Categories which reflect this circumstance are not considered. in determining whether resident satisfaction is increased. These categories are: A) "legislative or regulatory action required.," B) ''withdrawn,'' C) "final disposition not obtained," D) "other agency failed to act on complaint," and E) "no action needed or appropriate."

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ill-I 01-20

TABLE llI-F
RESIDENT SATISFACTION WITH COMPLAINT RESOLUTION

IF the percentage of complaints ...

THEN die LTCO Coordinator shall take the following steps

There is no increase from the previous year in the total percentage of complaints which are: "resolved," "partially resolved," and "explained."

review whether a high percentage of residents have withdrawn their cases. If so, identify possible causes for resident withdrawal ofcomplaints (e.g., is the rate higher for a particular staffperson or volunteer? is the rate higher in a particular facility?) and seek to rectify any identified problems; review whether a high percentage of complaints are ''not resolved." If so, identifY possible causes and seek to rectify; review whether the percentage of complaints are being referred to other agencies have an impact on resolution; and review whether a large number of complaints are related to issues that must be resolved through legislative or regulatory action.

The percentage of complaints which are "not resolved" is increased from the previous year.

review adequacy ofcomplaint investigation techniques, including: responsetimes, thoroughness ofinvestigations, proper identification ofcomplaints, and adequate focus on the resident's wishes

REFERENCES
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aAA 712(a)(5)(B)(ii), (iii), (iv), (v); (g)(I)(A); 731; a.C.G.A. 31-8-80 etseq..; a.c.G.A. 30-5-1 et.seq.; Georgia LTCa Reporting Manual
III-101-21

102. InfOJJD ation and Assistance
POLICY
The Long-tenn Care Ombudsman Program shall provide information and assistance regarding long-tenn care and related issues as requested.
PROCEDURES
a. timely responses i) The community LTCOP shall respond to a request for information and assistance (I&A) during the same day the request was made whenever possible and, in all cases, within two (2) working days. ii) The community LTCOP shall provide for telephone coverage to accept I&A requests when LTCO staffare not immediately available.
b. number of requests for information and assistance i) The LTCO Coordinator shall periodically review the number ofI&A requests brought to the community LTCOP to determine whether: A) the number of I&A requests is so high as to impact the ability of community LTCOP to adequately fulfill the other program components, particularly complaint processing; B) the number ofI&A requests is below the average number of I&A requests per program statewide; or C) the number of I&A requests is approximately the same as the projection in the Community LTCOP Annual Plan (III-IOO.l,b,i), above).

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ill-102-1

TABLEill-G INFORMATION AND ASSISTANCE
How to use this table: This table is designed to assist LTCO Coordinators, the SLTCO, area agencies on aging, and provider agencies in community LTCOP evaluation and planning. It suggests strategies to use in impacting I&A numbers which appear lIDusually high or unusually low. It also provides guidance in evaluating program performance related' to I&A. The community LTCOP is not required to provide a particular number ofI&A activities. '

IF the number of I&A activities is ...

THEN the LTCO Coordinator shall take the following steps

low for the community LTCOP, indicated by: more than 10% below the statewide average, or more than 10% below the projected number ofI&A requests in the Community LTCOP Annual Plan

review whether residents, families and staff are familiar with the existence of and pUlpose oftheLTCOP increase commlIDity education and public inforrilation regarding the purpose of the LTCOP review whether I&A activities are being accurately recorded by all LTCOs

high for the community LTCOP, indicated reviewability of community LTCOP to

by:

respond to requests in timely manner

1) more than 10% above the statewide

determine what infonnationis most

average,

commonly requested and provide written

2) the projected number ofI&A requests in materials to reduce time spent on I&A

the Community LTCOP Annual Plan; and

responses

,

impacting the ability of the community

LTCOP to adequately fulfill the other

Program Components

REFERENCES

OAA 712(a)(5)(B)(ii)

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ill-102-2

103. Community Educatjon
POLICY
The Long-tenn Care Ombudsman Program shall educate the community about long-term care, the Ombudsman Program and related issues.
PROCEDURES
a. number of community education sessions i) Each community LTCOP is expected to provide, at a minimum, five (5) community education sessions annually per full-time equivalent LTCO staff ii) The LTCO Coordinator shall periodically review the number of community education sessions provided by the communityLTCOP to determii:le whether: A) the number of community education sessions is so high as to impact the ability ofcommunity LTCOP to adequately fulfill the other program components, particularly complaint processing; B) the number ofcommunity education sessions is below the average number ofcommunity education sessions per program statewide; or C) the number ofcommunity education sessions is approximately the same as the projection in the Community LTCOP Annual Plan (ill-l00.l,bJ), above).

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ill-I 03-1

TABLEIII-H COMMUNITY EDUCATION

IF number of community education sessions is ...

THEN the LTCO Coordinator shall take the following steps

low for the community LTCOP, indicated by: fewer than five (5) sessions annually per full-time equivalent LTCO staff; or more than 10% below the projected number of community education sessions in the Community LTCOP Annual Plan

seek ways to increase the numbers of community education sessions request suggestions and/or opportunities for community education sessions from the AAA, provider agency, SLTCO and/or other community LTCOPs increase provision ofpublic information regarding the purpose and services ofthe LTCOP

high for the community LTCOP, indicated by: 1) more than 10<>/0 above the statewide average, or 2) more than 10% above the projected number of community education sessions in the'Community LTCOP Annual Plan; and impacting the ability of the community LTCOP to adequately fulfill the other Program Components

limit the number of community education sessions provided NOTE: if this number is less than the projected number of community education sessions indicated in the Community LTCOP Annual'Plan or less than 5 per full-time equivalent, the community LTCOP must request approval ofthe SLTCO.

REFERENCES

OAA 712(h)(3)

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ill-I 03-2

104. In-Servic'e Educatjon
POLICY
The Long-term Care Ombudsman Program shall provide in-service education to longterm care facility staff regarding resident rights, abuse reporting, and related issues.
PROCEDURES
a. number of in-service education sessions i) Each community LTCOP is expected to provide annually, at a minimum, in-service education sessions: A) for nursing home staff -- sessions equal to SOO.lo of the number ofnursing facilities in the service area, and B) for personal care home staff-one (1) session, preferably a session made available to a large number ofproviders. ii) The LTCO Coordinator shall periodically review the number of in-service education sessions provided by the community LTCOP to determine whether: A) the number of in-service education sessions is so high as to impact the ability ofcommunity LTCOP to adequately fulfill the other prograIIi components, particularly complaint processing; B) the number of in-service education sessions is below the average number ofin-service education sessions per program statewide; or C) the number of in-service education sessions is approximately the same as the projection in the Community LTCOP Annual Plan (Ill-I 00. I,b,i), above).

f:das\ltco\plcsrnan.wpd 7/97

ill-I 04-1

TABLEm-I IN-SERVICE EDUCATION FOR FACILITY STAFF

IF the number of in-service education sessions is ...

THEN the LTCO Coordinator shall take the following steps ..

low for the community LTCOP, indicated by: less than 50% of the number of nursing facilities in the service area, ~o personal care home staff education seSSIOns, or more than 10% below the projected number of in-service education sessions in the Community LTCOP Annual Plan

review whether facility administration and staff are aware that the LTCOP provides this service evaluate content and presentation methods ofprevious in-service education sessions considerdeveloping new topics or newpresentation methods for in-service education develop a training for personal care home providers within a particular geographic area

high for the community LTCOP, indicated by: 1) more than 10% below the statewide average, or 2) more than 10% below the projected number of in-service education sessions in the Community LTCOP Annual Plan; and impacting the ability of the community LTCOP to adequately fulfill the other Program Components

reviewability of community LTCOP to respond to all requests for in-service . education limit the number of sessions available per nursing facility (e.g., one (1) per year per facility) provide sessions to groups ofpersonal care . home providers and staff, rather than to staff of individual facilities

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ill-104-2

105. Routine Visits
POLICY
The Long-term Care Ombudsman Program shall have a regular presence in all long-term care facilities in order to monitor the condition of residents, provide information regarding the Ombudsman Program, and ensure resident access to an ombudsman.
PROCEDURES
a. The LTCOP shall monitor the condition ofresidents during routine visits. i) Routine visits to facilities shall be unannounced. ii) Timing of routine visits shall be staggered so that facilities have no basis to predict the timing of the visit. iii) The LTCO shall document observations during or immediately subsequent to the routine visit and maintain such documentation with LTCO records. iv) LTCO observations of conditions in the facility which adversely affect the health, safety, welfare or rights of residents shall be docUmented as ombudsman-generated complaints if no other person has lodged the complaint.
b. The LTCOP shall'provide information regarding the LTCOP during routine visits. i) The LTCO shall assure that the facility posts the LTCOP poster in the facility so that it is readily visible to residents, families, and staff. Depending on the facility floor plan, several posters may need to be posted to meet this requirement. ii) The LTCO shall assure that the facility has an adequate supply of LTCO brochures to provide to all residents and their representatives.

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III-105-1

iii) The LTCO shall explain the purpose of the LTCOP and introduce himself or herselfto residents in the facility, particularly to any residents who have been admitted since the LTCO's last routine visit.
c. The LTCOP shall ensure resident access to an ombudsman. i) . LTCO presence in facilities should be as frequent as possible in order to assure residents access to an ombu4sman. ii) .. LTCO presence should be increased in facilities in which there is a history of serious or frequent complaints. iii) The community LTCOP shall visit every nursing home in the service area at least one time per month. iv) The community LTCOP s~ visit every personal care home in the service area at least one time per three-month period and should make every effort to make monthly visits. v) A visit for the purpose of investigating a complaint may be made simultaneously with a routine visit to maximize efficient use of time and resources.

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ffi-105-2

106. Issues Adyocacy

POLICY

The Long-term Care Ombudsman Program shall assure that the interests of residents are represented to governmental agencies and policy-makers.

PROCEDURES

a. examples of issues advocacy

, Issues advocacy activities include~ b~ are not limited to:

i)

educating advocacy groups~ governmental agencies, and

policy-makers regarding the impact'oflaws, policies, or

practices on long-term care residents;

ii) seeking modifications oflaws~ regulations, and other

government policies and actions~ pertaining to the rights

and well-being ofresidents;

iii) . facilitating the ability ofthe public to comment on such

laws, regulations, policies and actions;

iv) developing a task force to study a long-term. care issue;

v) participating in a public hearing relating to a long-term care

Issue;

vi) providing community education or information on a long-

term care issue; and

vii) educating other aging services providers on a long-term

care issue.

b. The community LTCOP may seek to resolve resident complaints through issue advocacy where: i) a complaint cannot be resolved due to a current law, policy, or practice; ii) many residents share a similar complaint or are affected by a policy or practice; or

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iii) other strategies to reach resolution with particular &ciliti.es or agency staffhave been unsuccessful.
c. guidelines for issues advocacy The community LTCOP shall: i) determine which issue advocacy activity to use by considering: A) the p'otential impact of the activity on residents; B) the most appropriate and effective method of addressing the issue; C) the potential impact of the activity on the LTCOP; and D) the possibility ofjoint efforts by the AAA, the provider agency, the LTCOP's advisory council, and/or residents in the activity. ii) inform the AAA, provider agency, and the SLTCO ofplans to engage in the issues advocacy activity; and iii) attempt to involve residents and families in the activity whenever possible.
d. The SLTCO shall: i) link areas or advocacy groups with mutual concerns; ii) coordinate issues advocacy activities within the LTCOP; iii) develop advocacy strategies; iv) provide a clearinghouse on state and national issues; v) identify and meet resources and training needs related to issues advocacy; and vi) provide training and technical assistance to MAs, provider agencies and others in the aging network regarding the LTCOP role in issues advocacy.

REFERENCES

OAA 712(a)(5)(B)(iv),(v), 712(h)(2), (3)

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107. Interagency Coordination
POLICY
The Long-tenn Care Ombudsman Program coordinates with other agencies to improve conditions for residents oflong-tenn care facilities and to make appropriate referrals.
PROCEDURES
a. The community LTCOP shall develop relatioDships with other
programs and agencies with resources, services, and/or interests which could benefit residents, including, but not limited to: i) the Office of Regulatory Services; ii) adult protective services; iii) the Elderly Legal Assistance Program; iv) community serVice boards ofthe Division of Mental
Health! Mental Retardation/Substance Abuse; v) county environmentalists; vi) the Community Care Services Program; vii) the Social Security Administration; viii) Medicaid eligibility units of the Department ofFamily and
Children Services; and ix) protection and advocacy programs (i.e. the Georgia
Advocacy Office)

REFERENCES

OAA 712(a)(5)(B)(iv),(v), 712(h)(6), (7)

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108. Resjdent and Family Councils

POLICY
The ~ong-tenn Care Ombudsman Program shall support the development ofresident and family councils in long-tenn care facilities.

PROCEDURES

a. developing active resident and CamBy councils

i)

The community LTCOP shall promote resident councils in

each nursing facility in the service area.

ii) Where a nursing facility or personal care home does not

have an active resident coun~il, the community LTCOP

shall offer assistance to the residents and the facility in

developing an active resident council.

iii) Where a nursing facility orpersonal care home does not

have an active family council, the community LTCOP shaIl

offer assistance and encouragement to family members in

developing an active family council.

b. LTCO involvement in council activities i) The community LTCOP shall inform the presidents ofeach resident and family council in the service area of: A) the purpose ofthe LTCOP; B) its availability to assist resident and family coun~ including offering appropriate resources; and C) the topics it is prepared to present if requested. ii) A LTCO shall make his or her best efforts to be present at resident and family council meetings to which the LTCO has been invited.

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ill-I 08-1

iii) The SLTCO shall provide resources and technical assistance to community LTCOPs in their efforts to develop resident and family councils.
c.number of resident and family conDeD activities i) Each community LTCOP is expected to provide annually, at a minimum, involvement with: A) resident councils in 1000,10 ofthe nursing facilities in the service area, and B) family councils in 30% ofthe active family councils. ii) The LTCO Coordinator shalI periodically review the number ofresident and family council activities provided by the community LTCOP to determine whether: A) the number ofresident and family council activities is so high as to impact the ability of community LTCOP to adequately fulfill the other program components, particUlarly complaint processing; B) the number ofresident and family council activities is below the minimum standard; or . C) . the number ofresident and family council activities is approximately the same as the projection in the Coinmunity LTCOP Annual Plan (Ill-IOO.l,b,i), above).

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ill-108-2

TABLEID-J INVOLVEMENT WITH RESIDENT AND FAMILY COUNCILS

IF the number of resident or family council THEN the LTCO Coordinator shall take

activities is ...

the following steps .

low for the community LTCOP, indicated by: less than 100% of the resident councils, or . less than 30% of active family councils,

review whether residents, family members~ and facility administration are aware that the LTCOP provides this service initiate regular contacts with resident and family council presidents evaluate previous methods ofdeveloping resident and family councils develop and inform resident and family councils of options for presentation topics explain to the SLTCO why a particular resident council was not receptive to LTCO involvement

high for the community LTCOP, indicated by: I) more than 100% of the resident councils; 2) more than 30% of the active family councils; or 2) more than 10% above the number of resident or family council activities projected in the Community LTCOP Annual Plan; and impacting the ability ofthe community LTCOP to adequately fulfill the other Program Components

limit the number ofmeetings that a LTCO will attend of a single resident or family council (e.g., one meeting per quarter per council)

REFERENCES

OAA 712(a)(5)(B)(vi)

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1

109. Advisory Council Development

c.

compositi( 'ftbf

i) The

POLICY

con ii) The
rep:

The Long-term Care Ombudsma operation from the community.

but

A)

PROCEDURES

B)

C)

a. EachcomJ

Dr

advisoryc

E)

F)

b. TheLTCC

more ofth

G)

i) pre

COl
NC

H)

ill,"_

I) edl'

for cor ii) enl

REFERENCES

OAA 7L

ser iii) act
LT

ten iv) de,

ass:

v) ass:

pr~

f:

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f:das\ltco\plcsman.wpd 7/97

ii) be qualified to perfonn the smp.e responsibilities, including . provision of Program Components, as LTCO staff;
iii) provide appropriate documentation to the commmrity LTCOP of all activities done on behalf of the LTCOP; and
iv) perfonn his or her responsibilities in accordance with all applicable federal and state laws, rules and regulationsand these Policies and Procedures.
d. Volunteer Visitor role
A volunteer who is not certified but who visits residents in coordination with the community LTCOP is a "Volunteer: Visitor." A Volunteer Visitor: i) shall work with direct supervision of a LTCO staffperson
as designated by the LTCO Coordinator. Failure to follow the direction of the LTCO staffperson shall be grounds for the LTCO Coordinator or the SLTCO to prohibit the . individual to serve as a Volunteer Visitor; ii) shall visit residents in long-term care facilities in order to: A) build relationships with residents; and B) provide an independent presence in the facility; iiI) to the extent determined appropriate by the LTCO Coordinator, may assist the community LTCOP in: A) providing infonnation and assistance; B) making routine visits; C) issues advocacy activities; D)" resident and family council activities; and E) advisory council activities; iv) shall not process complaints, but may: A) refer a complaint to a certified LTCO for
investigation, and B) under direct LTCO staffsup~rvision,perform
specific, limited functions to assist the LTCO staff process a complaint.

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ID-IlO-2

e. reporting volunteer activities Activities by LTCO volunteers or Volunteer Visitors may be reported as community LTCOP activities only if: i) all of the requirements of that Program Component are met;
and
ii) the LTCO volunteer or Volunteer Visitor provides infonnation to the LTCO Coordinator or designated LTCO staff after each activity, indicating that all the requirements have been met. Every Volunteer Visitor shall refer to the LTCO Coordinator or designated LTCO staff any complaints received or observed by the volunteer for LTCO investigation.

REFERENCES

OAA 712(h)(4)

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III-ll0-3