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Specialized Information for:
Nursing Homes
Assisted Living/Board & Care
Home and Community Based Services
California Policies & Procedures
Introduction to the Long-Term Care Ombudsman Program Manual
Chapter 1 - Selection and Designation
Chapter 2 - Roles and Responsibilities
LTCOP Complaint Response Timeline
Chapter 3 - Investigation and Mandated Reporting
Chapter 4 - Witnessing
Chapter 5 - Confidentiality, Consent & Disclosure
Flowchart for Consent to Investigate
(Word)
Flowchart for Consent to Access Records
(Word)
Flowchart for Consent to Disclose Confidential Information
(Word)
Chapter 6 - LTC Ombudsman Standards of Professional Conduct
Chapter 7 - Training Requirements
Chapter 8 - Long-Term Care Ombudsman Certification
Chapter 9 - Quality Assurance through Monitoring
Exhibit 9-A AAA Model Monitoring Tool for Local Program-S408 (03-05)
(Word)
Exhibit 9-B Monitoring Tool-S405 (4-14)
(Word)
Exhibit 9-C Document Checklist for Direct Service Monitoring Visit-S402 (1-09)
(Word)
Exhibit 9-D Document Checklist for Contracted Service Monitoring Visit-S403 (1-09)
(Word)
Exhibit 9-E Volunteer Assessment of Local Ombudsman Program-S406 (1-09)
(Word)
Chapter 10 - Access to Long-Term Care Ombudsman Program Services
Chapter 11 - Telephone Protocol
Chapter 12 - Data Reporting and NORS
Chapter 13 - Facility Coverage Plan
Exhibit 13-A Facility Coverage Plan Worksheet
Chapter 14 - Facility Closures and Bankruptcies
Exhibit 14-A
Exhibit 14-B
Chapter 15 - Grievance Process
Chapter 16 - Interference
Exhibit 16-A Access Notice-S600 (03-14)
Exhibit 16-B Certification of Access Notice Provided-S603 (03-14)
Chapter 17 - Medical Parole
Chapter 18 - Information Security and Document Retention
Archive
2015
2015
Table of Contents
Introduction
Chapter 1 - Selection and Designation
Chapter 2 - Roles and Responsibilities
Chapter 3 - Investigation and Mandated Reporting
Chapter 4 - Witnessing
Chapter 5 - Confidentiality
Chapter 6 - Standards of Professional Conduct
Chapter 7 - Training Requirements
Chapter 8 - Certification
Chapter 9 - Quality Assurance through Monitoring
Chapter 10 - Access to Ombudsman Program Services
Chapter 11 - Telephone Protocol
Chapter 12 - Information Systems
Chapter 13 - Facility Coverage
Chapter 14 - Facility Closures and Bankruptcies
Chapter 15 - Grievance Process
Chapter 16 - Interference with Ombudsman Activities
Chapter 17 - Medical Parole
Exhbit 1-A - Program Memo
Exhibit 2-A - Long-Term Care Ombudsman Coordinator Agreement
Exhibit 4-A - Long-Term Care Ombudsman Witness Addendum to an Advance Health Care Directive
Exhibit 4-B - Request for Registration of Ombudsman Witness for Advance Health Care Directives and Property
Exhibit 4-C - Instructions and Form for Long-Term Care Ombudsman Witnessing of an Advance Health Care Directive
Exhibit 4-D - Form for Long-Term Care Ombudsman Witnessing of Property Transfer
Exhibit 5-A - Consent to Access and Disclose Confidential Information
Exhibit 5-B - Response Letter for Subpoena of Confidential Records
Exhibit 5-C - Response Letter for Subpoena of Ombudsman to Testify or Appear in Court
Exhibit 5-D - Statement of Obligation
Exhibit 5-E - Authorization to Release Information and Testify
Exhibit 6-A - Long-Term Care Ombudsman Code of Ethics
Exhibit 8-A - Application for Long-Term Care Ombudsman Certification
Exhibit 8-B - Conflict of Interest Statement
Exhibit 8-C - Pledge of Confidentiality for Ombudsman Trainees Representatives
Exhibit 8-D - Statement Acknowledging Requirement to Report Suspected Abuse
Exhibit 8-E - Requirement for Criminal Background Clearance
Exhibit 8-F - Criminal Record Statement
Exhibit 8-G - Request for Live Scan Service
Exhibit 8-H - Long-Term Care Ombudsman Fingreprint Reporting Form
Exhibit 8-I - Request for Certification of Long-Term Care Ombudsman Representatives
Exhibit 8-J - Congratulatory Letter for New Long-Term Care Ombudsman
Exhibit 8-K - Long-Term Care Ombudsman Coordinator Agreement
Exhibit 8-L - Request for Registration of Ombudsman Witness for Advance Health Care Directives and Property
Exhibit 8-M - Decertification of Long-Term Care Ombudsman Representatives
Exhibit 8-N - Decertification Without Cause Letter
Exhibit 8-O - Decertification With Cause Letter
Exhibit 8-P - Decertification Due to Background Clearance Letter
Exhibit 8-Q - Long-Term Care Ombudsman Code of Ethics
Exhibit 9-A - AAA Model Monitoring Tool for Local Program
Exhibit 9-B - Monitoring Tool
Exhibit 9-C - Document Checklist for Direct Service Monitoring Visit
Exhibit 9-D - Document Checklist for Contracted Service Monitoring Visit
Exhibit 9-E - Volunteer Assessment of Local Ombudsman Program
Exhibit 11-A - Pledge of Confidentiality for Non-Certified Staff Volunteers
Exhibit 11-B - Telephone Techniques
Exhibit 11-C - Telephone Message Examples
Exhibit 11-D - After Hours Crisis Line Error Reporting Form
Exhibit 11-E - Telphone Service Checklist
Exhibit 12-A - Quarterly ODIN Reporting Form
Exhibit 12-B - Long-Term Care Ombudsman Complaint Form
Exhibit 12-C - Long-Term Care Ombudsman Activity Log
Exhibit 12-D - Information and Consultation Log
Exhibit 12-E - Information and Tally
Exhibit 13-A - Facility Coverage Plan Worksheet
Exhibit 14-A
Exhibit 14-B
Exhibit 16-A - Access Notice
Exhibit 16-B - Certification of Access Notice Provided
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