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Technical Assistance FAQs

In addition to providing training, resources, and support to State Ombudsmen and program representatives, NORC is responsible for responding to technical assistance requests. NORC staff respond to a variety of requests across the country. Technical assistance requests often involve questions regarding program management, issue advocacy, systems advocacy, and ombudsman skills training. In order to share our technical responses more broadly, this page archives frequently asked TA requests in a concise format. If you have a question or need assistance, please email ombudcenter@theconsumervoice.org.

NOTE: Click on the questions to reveal the response.


Abuse, Neglect, and Exploitation

(1) Based on the duties and requirements for the LTCOP outlined in the Older Americans Act and final LTCOP rule, how should a LTCO proceed if she personally witnesses abuse, gross neglect, or exploitation of a resident?

Based on the duties and requirements for the LTCOP outlined in the Older Americans Act and final LTCOP rule, how should a LTCO proceed if she personally witnesses abuse, gross neglect, or exploitation of a resident?

The Ombudsman program investigates and resolves complaints on behalf of residents, but the LTCO program is unique in that its goal is to resolve the complaint to the “satisfaction of the resident or complainant” as opposed to seeking to “substantiate” a complaint by gathering evidence to prove the allegation occurred (NORS Instructions, ACL). This difference means that the LTCO program does not have the same standard of evidence required for complaint investigation and resolution as other entities, such as Adult Protective Services, state survey agency and law enforcement. The investigation by other entities seeks evidence to demonstrate that laws or regulations were broken. Since the LTCOP’s primary goal is to resolve complaints to the satisfaction of the resident, the LTCO seeks resolution “on behalf of a resident regardless of whether violation of any law or regulation is at issue”. However, according to the Older Americans Act (OAA) LTCO are also supposed to seek remedies to protect the “health, safety, welfare, and rights of all residents [(OAA of 1965. Section 712 (a)(3)(A)].

Based on the duties and requirements for the LTCOP outlined in the Older Americans Act and final LTCOP rule, how should a LTCO proceed if she personally witnesses abuse, gross neglect, or exploitation of a resident? The OAA does not provide direction regarding the disclosure of information and reporting of suspected abuse when a LTCO witnesses abuse or the resident is unable to provide consent. However, the final LTCOP regulations require that state LTCOP procedures for disclosure shall provide that (45 CFR 1324.19):

  • The LTCO shall seek informed consent from the resident, or resident representative, and follow resident direction.

If the resident cannot communicate informed consent and does not have a representative, the LTCO shall:

  • Open a case with Ombudsman/representative as the complainant,
  • Follow complaint resolution procedures, AND
  • Refer and disclose information to facility management and/or appropriate agency if:
    • No evidence that resident would not want referral
    • Reasonable cause to believe that disclosure would be in best interest of resident, AND
    • Representative obtains State Ombudsman approval (or follows program policies).

Ombudsmen must employ advocacy strategies when responding to allegations of abuse, where consent is not given, in order to protect resident confidentiality and do their best to ensure resident safety. For advocacy strategies for this situation and others review the Responding to Allegations of Abuse: The Role and Responsibilities of LTCO technical assistance guide.

For detailed information regarding the LTCOP Final Regulations visit the NORC website for the final rule text, an overview, webinar recordings and additional resources. The Frequently Asked Questions (FAQs) by the Administration for Community Living (ACL) regarding implementation of the LTCOP Rule also provides additional information regarding the role of the Ombudsman program in investigating complaints regarding abuse (see questions 22 and 23).

Some language above adapted from New Long-Term Care Ombudsman Rule, New Opportunities (Becky Kurtz, 2015 SLTCO Conference).

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(2) What advocacy strategies can Ombudsman programs use when investigating complaints regarding abuse in assisted living?

What advocacy strategies can Ombudsman programs use when investigating complaints regarding abuse in assisted living?

As with all LTCO work, advocacy strategies in response to allegations of abuse vary depending on the situation (e.g., type of abuse allegation, type and size of long-term care setting, identity of the perpetrator). For example, a LTCO’s approach in response to an allegation of abuse in a small personal care home may differ from their approach in response to a similar allegation in a large nursing home. Fear of retaliation or the amount of power an individual caregiver has may be greater in a small setting. Refer to the Quick Tips section of the May 2016 issue of the Ombudsman Outlook (archived issues here) for information on key similarities and differences in LTCO advocacy in nursing homes and in assisted living facilities.

Most states have mandatory reporting laws that require certain individuals (e.g., facility staff, social workers) to report suspected elder abuse. However, as reiterated in the Administration on Aging's Frequently Asked Questions for the LTCOP, "both the Older Americans Act and the Rule prohibit reporting of resident-identifying information without the resident’s consent" and "Ombudsman program policies and procedures must exclude the Ombudsman and representatives of the Office from abuse reporting requirements when such reporting would disclose identifying information of a complainant or resident without appropriate consent or court order (45 CFR 1327.11(e)(3))." 

Whether a referral is made to another agency regarding suspected abuse, there are many appropriate actions that LTCO can take to support residents.  Refer to the “What Can A LTCO Do in This Situation” section of the Responding to Allegations of Abuse: Role and Responsibilities of LTCO brief for ideas and examples. LTCO have the responsibility to support residents even if a referral cannot be made.

Facilities are required to protect residents from all forms of abuse and to investigate reports of abuse. Due to the lack of federal regulations for assisted living (e.g., board and care, personal care homes) LTCO need to be familiar with the applicable requirements in your state and know how the process works.

You can use the state and local LTCO Program Assessment: Current Activities in Assisted Living Facilities tip sheets when assessing program activities to support residents in assisted living facilities (ALFs). Regular program self-evaluation and assessment is critical to ensure that resources are maximized and to identify program strengths and areas for improvement. The lack of federal regulations for ALFs and reliance on often minimal state regulations and enforcement means increasing LTCO presence in these facilities and systems advocacy to strengthen the laws, regulations, and policies responsible for these settings is critical. These tools can be useful in assessing LTCOP services in Assisted Living, including the need for systems advocacy related to abuse. 

Resources

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(3) What do I do if a resident is being pushed to take antipsychotic drugs?

What do I do if a resident is being pushed to take antipsychotic drugs?

Everyone who enters a nursing home has a right to individualized, person-centered care. Some nursing facilities, however, are giving residents antipsychotic drugs, not to treat a medical diagnosis, such as Schizophrenia or Bipolar Disorder, but rather to control the resident’s behavior or for the staff’s convenience. When used this way, as a chemical restraint, these drugs pose special risks for older people and increase the risk of death in persons with dementia.

Consumer Voice developed materials to assist residents and their families in combatting the inappropriate use of antipsychotic drugs. Long-Term Care Ombudsman programs are encouraged to become familiar with these resources and share them with residents and families.

Learn more »

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Conflict of Interest

(1) What does the LTCOP Rule say about individual conflict of interest for a State Ombudsman, representatives of the Office, and members of their immediate family?

What does the LTCOP Rule say about individual conflict of interest for a State Ombudsman, representatives of the Office, and members of their immediate family?

The LTCOP Rule provides more clarity regarding conflict of interest (COI) for the Ombudsman and for representatives of the Office (LTCOP Rule p. 7766, third column). The Rule lists COIs which cannot be remedied and others for which a remedy may be possible. The Ombudsman is to avoid COI in designating individuals as representatives and must de-designate representatives with a COI that cannot be removed or remedied.

Learn more.

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(2) What does the LTCOP Final Rule say about organizational conflict of interest?

What does the LTCOP Final Rule say about organizational conflict of interest?

Since the implementation of the Ombudsman Rule in July 2016, Ombudsman programs have been looking at their policies and procedures (and state laws) to ensure compliance with all aspects of the Rule. This article focuses on resources regarding organizational conflicts of interest (COI).

Organizational conflicts of interest may have a chilling effect on the LTCOP, at either the state or local level. As noted in the IOM report “Real People, Real Problems," 

“The ombudsman program has a mandate to focus on the individual resident. If the ombudsman finds him or herself in a conflict of interest situation (whether it is a conflict of loyalty, commitment, or control), the resident, even more than the program, may suffer. The resident’s problem may not be resolved, certain avenues of resolution may be foreclosed, the resident’s voice may not be heard by policymakers, and the resident’s interests will be inadequately represented or altogether absent from the table at which public policy is made." See here.

Section §1324.21 of the LTCOP Rule says the following about conflicts of interest. 

“The State agency and the Ombudsman shall consider both the organizational and individual conflicts of interest that may impact the effectiveness and credibility of the work of the Office. In so doing, both the State agency and the Ombudsman shall be responsible to identify actual and potential conflicts and, where a conflict has been identified, to remove or remedy such conflict as set forth in paragraphs (b) and (d) of this section. (a) Identification of organizational conflicts. In identifying conflicts of interest pursuant to section 712(f) of the Act, the State agency and the Ombudsman shall consider the organizational conflicts that may impact the effectiveness and credibility of the work of the Office. Organizational conflicts of interest include, but are not limited to, placement of the Office, or requiring that an Ombudsman or representative of the Office perform conflicting activities, in an organization that: 

(1) Is responsible for licensing, surveying, or certifying long-term care facilities; 

(2) Is an association (or an affiliate of such an association) of long-term care facilities, or of any other residential facilities for older individuals or individuals with disabilities; 

(3) Has any ownership or investment interest (represented by equity, debt, or other financial relationship) in, or receives grants or donations from, a long-term care facility; 

(4) Has governing board members with any ownership, investment or employment interest in long-term care facilities; 

(5) Provides long-term care to residents of long-term care facilities, including the provision of personnel for long-term care facilities or the operation of programs which control access to or services for long-term care facilities; 

(6) Provides long-term care coordination or case management for residents of long-term care facilities; 

(7) Sets reimbursement rates for long- term care facilities; 

(8) Provides adult protective services; 

(9) Is responsible for eligibility determinations regarding Medicaid or other public benefits for residents of long-term care facilities; 

(10) Conducts preadmission screening for long-term care facility placements; 

(11) Makes decisions regarding admission or discharge of individuals to or from long-term care facilities; or 

(12) Provides guardianship, conservatorship or other fiduciary or surrogate decision-making services for residents of long-term care facilities. See here (page 7765, column 3). 

The Rule requires three steps regarding organizational COI: 

  • Identify, 
  • Remove or Remedy, and 
  • Report through the National Ombudsman Reporting System (NORS). 

Below are Issue Briefs which walk through the numerous things to consider, as well as, charts listing COI and possible remedies for both State and Local Ombudsman Entities (LOE). 

QUESTION? Can you can find the answer to the following situations. Is this a conflict that can be remedied or not?

  • The host agency is responsible for eligibility determinations regarding Medicaid or other public benefits for residents of long-term care facilities (CFR 1324.21(a)(9)).
  • The Board of Directors of the host agency includes members who operate a long-term care facility.

The resources above and more are available on the NORC website (click on Library, Federal Laws and Regulations, and then click on: Long-Term Care Ombudsman Final Rule).

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(3) How can programs screen individuals for potential or actual conflicts of interest?

How can programs screen individuals for potential or actual conflicts of interest?

According to the LTCOP Final Rule, the State Agency and the Ombudsman are responsible for identifying conflicts that "may impact the effectiveness and credibility of the work of the Office" [§1324.21(c)(1)].

The LTCOP Rule requires four steps regarding individual conflicts of interest (COI):

1. Establish and implement policies and procedures related to conflicts of interest.

2. Identify conflicts of interest.

3. Avoid appointing or designating individuals with conflicts of interest.

4. Remove or remedy the conflict.

The new NORC resource,  Long-Term Care Ombudsman Program Individual Conflict of Interest Screening Template, was designed to help Ombudsman programs identify conflicts of interest (this resource is available as a fillable PDF and in black and white). 

The template is intended for use as a guide when Ombudsman programs develop or revise individual conflict of interest screening tools. States are responsible for adding any state specific requirements, definitions, or processes that may not be included in this document.

Additional information on individual conflicts of interest, the provisions in the Rule, and examples of screening tools used by Ombudsman programs can be accessed here, specifically the LTCOP Rule Issue Brief on individual conflicts of interest, a related webinar, and this article from a 2016 issue of the Ombudsman Outlook.

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COVID-19

Click on the questions below to visit the COVID-19 TA FAQ page.

(1) What does the updated March 2021 guidance from CMS mean for Ombudsman access in long-term care facilities?

(2) What tips for effective communications and strategies do you have when working with families during challenging situations?

(3) Can long-term care facilities accept food delivered by families or restaurants for residents during COVID-19?

(4) What are the updates on resuming nursing home visitation as of September 2020?

 


Consent

(1) What does the LTCOP Final Rule say about consent?

What does the LTCOP Final Rule say about consent?

The final rule for State Long-Term Care Ombudsman Programs reinforces the requirement of LTCO to obtain informed consent from a resident, or the resident representative, prior to investigating a complaint or disclosing information and follow resident direction throughout the complaint investigation and resolution process. 

The rule provides the following requirements for duties of the representatives of the Office (representatives are the employees or volunteers designated by the State LTC Ombudsman to fulfill the duties of the LTCO program) regarding obtaining informed consent and providing advocacy for residents unable to provide informed consent. 

1327.19 Duties of the representatives of the Office 

(b) Complaint Processing

(1) With respect to identifying, investigating and resolving complaints, and regardless of the source of the complaint (i.e. complainant), the Ombudsman and the representatives of the Office serve the resident of a long-term care facility. The Ombudsman or representative of the Office shall investigate a complaint, including but not limited to a complaint related to abuse, neglect, or exploitation, for the purposes of resolving the complaint to the resident’s satisfaction and of protecting the health, welfare, and rights of the resident. The Ombudsman or representative of the Office may identify, investigate and resolve a complaint impacting multiple residents or all residents of a facility.

(2) Regardless of the source of the complaint (i.e. the complainant), including when the source is the Ombudsman or representative of the Office, the Ombudsman or representative of the Office must support and maximize resident participation in the process of resolving the complaint as follows:

(i) The Ombudsman or representative of Office shall offer privacy to the resident for the purpose of confidentially providing information and hearing, investigating and resolving complaints.

(ii) The Ombudsman or representative of the Office shall personally discuss the complaint with the resident (and, if the resident is unable to communicate informed consent, the resident’s representative) in order to:

(A) Determine the perspective of the resident (or resident representative, where applicable) of the complaint;

(B) Request the resident (or resident representative, where applicable) to communicate informed consent in order to investigate the complaint;

(C) Determine the wishes of the resident (or resident representative, where applicable) with respect to resolution of the complaint, including whether the allegations are to be reported and, if so, whether Ombudsman or representative of the Office may disclose resident identifying information or other relevant information to the facility and/or appropriate agencies. Such report and disclosure shall be consistent with paragraph (b)(3) of this section;

(D) Advise the resident (and resident representative, where applicable) of the resident’s rights;

(E) Work with the resident (or resident representative, where applicable) to develop a plan of action for resolution of the complaint;

(F) Investigate the complaint to determine whether the complaint can be verified and

(G) Determine whether the complaint is resolved to the satisfaction of the resident (or resident representative, where applicable).

(iii) Where the resident is unable to communicate informed consent, and has no resident representative, the Ombudsman or representative of the Office shall:

(A) Take appropriate steps to investigate and work to resolve the complaint in order to protect the health, safety, welfare and rights of the resident; and

(B) Determine whether the complaint was resolved to the satisfaction of the complainant.

(iv) In determining whether to rely upon a resident representative to communicate or make determinations on behalf of the resident related to complaint processing, the Ombudsman or representative of the Office shall ascertain the extent of the authority that has been granted to the resident representative under court order (in the case of a guardian or conservator), by power of attorney or other document by which the resident has granted authority to the representative, or under other applicable State or Federal law.

Informed consent is not defined in the final rule and in response to a comment asking for a definition the Administration on Aging provided the following response, “we believe that the term ‘‘unable to communicate informed consent’’ improves the clarity of the term ‘‘unable to consent’’ which is used in the Act, related to Ombudsman program access to resident records. Section 712(b)(1)(B)(i)(II) of the Act. Our expectation is that States will operationalize the use of this term by incorporating it into the Ombudsman program’s procedures for resident records and complaint processing. We are also available to provide States with technical assistance should the need arise for further clarity on how to operationalize this term within Ombudsman program operations.” 

Resident empowerment and supporting resident decision-making ability to the greatest extent possible is a core responsibility of LTCO program advocacy. However, conducting an assessment to determine capacity does not fall under the responsibilities of the LTCO program. LTCO use communication skills such as active listening and observation to ensure a resident understands her rights, choices, potential outcomes, and can express her wishes in order to obtain consent and direction. 

Visit the NORC website for more information regarding ethical considerationscommunication skills and advocacy strategies, and promoting resident-centered care

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(2) A resident gives an Ombudsman program representative permission to review her medical record as part of the complaint investigation, but she does not want the representative to disclose her name in the process, how can the representative proceed?

A resident gives an Ombudsman program representative permission to review her medical record as part of the complaint investigation, but she does not want the representative to disclose her name in the process, how can the representative proceed?

During a nursing home visit a resident you are familiar with tells you her medications have changed and she wants to know what she is being given. She wants you to check her chart in order to get her current list of medications; however, she doesn't give you permission to speak to staff or let anyone know she is questioning her medications. You inform her that you can’t look at her medical chart without her permission and you would have to share her name to access the chart. Needing to review a resident's medical records without disclosing the resident's name is a challenging situation, what are your next steps?

If a resident gives you permission to investigate her concern and review her medical record, but does not want you to disclose her name, talk with the resident:

  • Discuss the reasons the resident does not want her identity revealed. If this will limit your ability to resolve the issue, discuss this with the resident and tell her you will do as much as possible without revealing her identity. 
  • Explain the resident’s right to look at their medical records, to be informed about medications and other medical care being provided, 
  • Explain the situation,
  • Discuss any potential risks involved in the resident being identified.

If you cannot resolve the issue without revealing her identity, tell her what you’ve done and why you cannot take the case further. If appropriate, encourage the resident to discuss her concern with the Resident Council or:

  • Look for supporting evidence during your regular visits.
  • Look for supporting evidence when visiting other residents; perhaps several other residents share the same issue and you can proceed on their behalf.
  • Inform the resident that you will be available to pursue this issue if she changes her mind. Check back with her regarding this.

What you DON’T want to do:

  • Guarantee that retaliation will not occur.
  • Ask to see several charts to hide the one you are really wanting to see as you would need permission from each resident to even request their chart. 

Oftentimes reviewing medical records may not be the best place to start or may not even be necessary as there are usually other ways to get answers to questions besides, such as:

  • Speaking with the charge nurse or DON,
  • Addressing the issue during a care plan meeting, or
  • Meeting with the doctor. 

When possible, participating in conversations with the resident and appropriate staff is often the most effective, resident-centered way to support a resident and ensure their concerns are addressed. 

Resources

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(3) After working with a resident on a complaint, the resident asked me for a copy of my case records stating since the complaint was about his care, they are his records. Do my case records belong to the resident?

After working with a resident on a complaint, the resident asked me for a copy of my case records stating since the complaint was about his care, they are his records. Do my case records belong to the resident?

The records maintained by the Long-Term Care Ombudsman program (LTCOP) are the property of the program. They do not belong to the resident or the complainant. Each state should have policies and procedures outlining their process for providing copies of records to anyone requesting them, including the resident or their representative. The Final LTCOP Rule states:

Policies and procedures regarding disclosure of files, records and other information maintained by the Ombudsman program must include, but not be limited to: (i) Provision that the files, records, and information maintained by the Ombudsman program may be disclosed only at the discretion of the Ombudsman or designee of the Ombudsman for such purpose and in accordance with the criteria developed by the Ombudsman, as required by § 1324.13(e);

For an overview of the issue of disclosure of records, look at this resource: Disclosure of Files, Records, and Other Information Maintained by the LTCOP.

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Guardianship

(1) As some Ombudsmen and program representatives have experienced, occasionally the decisions of a guardian may conflict with those of the resident or a guardian may not be acting in the best interest of the resident. How does a LTCO support residents with guardians in these situations?

As some LTCO have experienced, occasionally the decisions of a guardian may conflict with those of the resident or a guardian may not be acting in the best interest of the resident. How does a LTCO support residents with guardians in these situations?

Even residents with guardians should be given the opportunity to make decisions and express preferences to the extent possible and LTCO would assist residents with guardians in asserting their rights. According to the Older Americans Act, LTCO are responsible for identifying, investigating, and resolving complaints, including those regarding the "welfare and rights of the residents with respect to the appointment and activities of guardians and representative payees" [Section 712 (a)(3)(A)(ii)]. Additionally, the State shall ensure LTCO access to records related to investigating a complaint in which the guardian refuses access, the LTCO "has reasonable cause" to believe the guardian is not acting in the best interest of the resident, and gains approval from the State LTCO [Section 712 (b)(1)(B)(ii)].

What Can A LTCO Do?

  • After identifying the resident's wishes and/or needs (if possible), check for the legal documentation outlining the guardianship, as some individuals may present themselves as a guardian without actually being appointed.
  • Consult with your LTCO supervisor and State LTCO
  • Emphasize the importance of resident-centered decision making. Becoming familiar with the National Guardianship Association (NGA) Standards of Practice will help during discussions with guardians, residents, facility staff, and others. The standards include guidelines for the guardian to make decisions based on informed consent (when possible) and decisions that are the least restrictive on the person's independence and self-determination, as well as supporting relationships and social connections consistent with the person under guardianship's preferences.
  • Gain an understanding about guardianship in your region and state. For example, is there a state and/or regional guardianship program, is there a multi-disciplinary task force to discuss guardianship issues (e.g. WINGS), are there state long-term care facility regulations regarding guardianship and residents' rights?
  • Develop relationships with and educate the probate court and/or public guardianship program about residents' rights and the role of the LTCO program.
  • Review resources regarding guardianship and the role of LTCO on the NORC website and discuss these issues with your LTCO staff and volunteers (e.g. Making Guardianship Work for Vulnerable Elders, Guardianship: Challenges, Opportunities, and Advocacy, Informational Brief on Unbefriended Elders).

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Residents' Rights

(1) What rights do residents have to receive visitors and what are some tips to make visits from family and friends as meaningful as possible?

What rights do residents have to receive visitors and what are some tips to make visits from family and friends as meaningful as possible?

The resources below address visitation rights, bringing food in, signs of abuse/neglect and financial exploitation, gift ideas, and activity ideas for visitors. LTCOPs may use this information in training and/or educating staff, residents, and family members.

A Closer Look at the Revised Nursing Facility Regulations

Visitation Rights

The revised nursing facility regulations state that the resident “has a right to receive visitors of his or her choosing at the time of his or her choosing, subject to the resident’s right to deny visitation when applicable, and in a manner that does not impose on the rights of another resident.” In effect, nursing facilities are prohibited from imposing “visitation hours” on any residents.

The revised regulations require the facility to have a written visitation policy and inform residents of their visitation rights, the facility policy, any restrictions, the reasons for the restrictions, and to whom the restrictions apply. To ensure residents' rights are honored, LTCOPs are encouraged to be familiar with facility visitation policies and procedures of those they visit. Read more about visitation rights here.

Bringing in Food to a Resident

The CMS State Operations Manual (SOM), Appendix PP, Guidance to Surveyors for Long-Term Care Facilities, provides interpretive guidance regarding the federal requirements for long-term care facilities. The SOM is a useful resource in Ombudsman program advocacy as it provides further information about the requirements for facilities. The SOM says the following about visitors bringing in food for residents:

  • “NOTE: The food procurement requirements for facilities are not intended to restrict resident choice. All residents have the right to accept food brought to them by family or visitor(s).” [F 812, page 591]
  • “The facility must have a policy regarding food brought to residents by family and other visitors. The policy must also include ensuring facility staff assists the resident in accessing and consuming the food, if the resident is not able to do so on his or her own. The facility also is responsible for storing food brought in by family or visitors in a way that is either separate or easily distinguishable from facility food. [F 813, page 606] 

Tips for Family, Friends, and other Visitors

Family members, friends, and other visitors can bring a lot of joy to residents as well as provide an extra set of eyes to observe any signs of poor care or abuse. This tip sheet from Consumer Voice provides ideas for visitors to make visits as meaningful for residents as possible and how to identify signs of potential abuse. 

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(2) What do the Federal Nursing Home Regulations say about resident and family councils?

What do the Federal Nursing Home Regulations say about resident and family councils?

The Federal Nursing Home Regulations give residents the power to determine who can attend resident council meetings. They also give the residents the right to attend family council meetings, while family members (or representatives of the resident) can attend resident council meetings only with the permission of that council.

The regulations also say that facilities must provide private space to meet and assist with publicizing the meetings.

When assisting a current council or starting a new one, making sure residents and families understand their rights is a good place to start. For additional guidance and resources, visit the NORC website.

F565 §483.10(f)(5) The resident has a right to organize and participate in resident groups in the facility.

(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.

(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.

(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.

(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.

(A) The facility must be able to demonstrate their response and rationale for such response.

(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

§483.10(f)(6) The resident has a right to participate in family groups.

§483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.

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(3) What rights do residents have regarding voting and how can the Ombudsman program support their right to vote?

What Rights Do Residents Have Regarding Voting and How Can the Ombudsman Program Support Their Right to Vote?

It is important for Ombudsman programs to promote residents’ right to participate in the election process as residents often experience barriers in voting. Below are resources to help raise awareness about residents’ right to vote, information about facility requirements to support residents’ right to vote, and tips for ensuring voting access.

Know the Laws in Your State

Share Your State Information

  • Discuss residents’ rights, including the right to vote, with residents, facility staff, and family members. 
  • Provide information about the voting process such as when to register, how to register, how to request an absentee ballot, how to locate accessible polling places, how to find transportation to polling sites, and how to connect with outside organizations that could assist residents directly. 
  • Remind facility staff about their responsibility to assist residents in exercising their right to vote including finding transportation to polling sites or identifying other ways residents can cast their ballot (e.g., mobile polling, becoming a polling site). 
  • Create and distribute educational materials about voting rights. View examples of educational materials and activities on the NORC Voting issue page.
  • Encourage resident councils to invite candidates to their meetings to speak and visit with residents. 
  • Investigate complaints regarding residents’ rights and access to information, including the right to vote. Residents’ Right to Vote and Ombudsman Program Advocacy.
  • Don’t Forget Your Role
  • Ombudsman program representatives should not directly assist in requesting absentee ballots, completing ballots, or mailing ballots in.

Resources: NORC Website and Consumer Voice Website

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Older Americans Act

(1) What is included in the 2020 Reauthorization of the Older Americans Act?

What is included in the 2020 Reauthorization of the Older Americans Act?

The Support Older Americans Act (OAA) of 2020 (HR4334) reauthorizes programs for FY 2020 through FY2024. The bill text is available here and the compilation of the OAA of 1965, as amended through P.L. 116-131, enacted March 25, 2020, is available here

Amendments specific to the Long-Term Care Ombudsman program include: 

  • Section 306(a)(9) and 307(a)(9) - Minimum funding and maintenance of effort language was updated to reflect that FY2019 data is to be used rather than FY2000 in both State and Area Agency on Aging (AAA) budgeting. 
  • At both the State and AAA level, the Long-Term Care Ombudsman program will expend not less than the total amount of funds appropriated under this Act and expended by the agency in fiscal year 2019 in carrying out such a program under this title.
  • Section 702(a) OMBUDSMAN PROGRAM.—There are authorized to be appropriated to carry out chapter 2, $18,066,950 for fiscal year 2020, $19,150,967 for fiscal year 2021, $20,300,025 for fiscal year 2022, $21,518,027 for fiscal year 2023, and $22,809,108 for fiscal year 2024.
  • Section 712(a)(5)(E) clarifies that the LTCOP is allowed to provide and financially support recognition for an individual designated as a volunteer to represent the Ombudsman program, and may reimburse or otherwise provide financial support for any costs, such as transportation costs, incurred by representatives of the program.

HR4334 also requires a report to update best practices for home and community-based ombudsmen, stating that “not later than 3 years after the date of enactment of this Act, the Assistant Secretary shall issue a report updating the best practices for home and community-based ombudsmen that were included in the report entitled “Best Practices for Home and Community-Based Ombudsmen,” issued by the National Direct Service Workforce Resource Center of the Centers for Medicare & Medicaid Services and prepared by the Research and Training Center at the University of Minnesota and The Lewin Group (January 2013).”

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(2) What does the Older Americans Act say about sharing resident information?

What does the Older Americans Act say about sharing resident information?

The Older Americans Act (OAA) imposes strict requirements for protecting the confidentiality of Long-Term Care Ombudsman program (LTCOP) information including the identity of residents, complainants, and investigation information. Human services agencies have confidentiality provisions; however, the LTCOP is distinct because of the narrow limits the OAA puts on the sharing of resident specific information even with other government agencies or departments. All records and information obtained by the LTCOP during conversations with residents and complainants must be held in confidence. It is important to explain to residents and complainants that the information they share with the program is confidential, meaning the information will not be shared (disclosed) with anyone outside of the Ombudsman program without their permission.

Adhering to these confidentiality provisions may be challenging at times. However, the credibility of the LTCOP relies on residents and families trusting the LTCOP to keep their information confidential unless they give permission.

Learn more »

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Survey and Enforcement

(1) Do surveyors have to witness a violation themselves to issue a citation for non-compliance?

Do surveyors have to witness a violation themselves to issue a citation for non-compliance?

View answer as a PDF.

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Systems Advocacy

(1) Is the Ombudsman program required to conduct systems advocacy, such as commenting on or recommending changes to laws, regulations, and policies?

Is the Ombudsman program required to conduct systems advocacy, such as commenting on or recommending changes to laws, regulations, and policies?

Yes. Systems advocacy is a core responsibility of the Office of the State Long-Term Care Ombudsman (OSLTCO) as the Older Americans Act [Section 712 (a)(3)(A)] requires States to establish and operate its OSLTCO to: 

  • Represent the interests of residents before governmental agencies and seek administrative, legal, and other remedies to protect the health, safety, welfare, and rights of residents; 
  • Analyze, comment on, and monitor the development and implementation of federal, state, and local laws, regulations, and other governmental policies and actions, that pertain to the health, safety, welfare, and rights of the residents, with respect to long-term care facilities and services in the state;
  • Facilitate public comment on laws, regulations, policies, and actions related to residents of long-term care facilities and the ombudsman program; 
  • Recommend any changes in laws, regulations, policies, and actions that will further promote the interests, well-being and rights of residents.

The State Long-Term Care Ombudsman Program Final Rule (published in February 2015 and effective July 2016) expands upon the intent of the Older Americans Act and gives more detail regarding the role and responsibilities of the LTCOP, including systems advocacy. In response to comments on the proposed Rule, ACL states, “the Act creates the Ombudsman program to resolve problems for residents of long-term care facilities on individual as well as systemic levels. Therefore, the ability to take positions and make recommendations that reflect the interests of residents is critical to the effectiveness of the Ombudsman program.” The Administration for Community Living (ACL) addressed the importance of coordination and the role of the Ombudsman and program representatives in systems advocacy in question 11 of their Frequently Asked Questions (FAQs) about the LTCOP Rule.

Also, during a NORC webinar regarding systems advocacy, both Melanie McNeil, Georgia State Ombudsman, and Elaine Wilson, local Ombudsman program representative, explained how they work together on statewide and regional advocacy efforts. They emphasized the importance of a joint effort with frequent and ongoing communication before, during, and after a project. For additional information about the LTCOP role and responsibilities regarding systems advocacy visit this page

Feel free to contact NORC if you have questions or comments.

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(2) How does a Long-Term Care Ombudsman advocate for a resident who is on hospice?

How does a Long-Term Care Ombudsman advocate for a resident who is on hospice?

Occasionally there will be a miscommunication or misunderstanding between nursing home staff and a hospice provider that negatively impacts a resident’s care. Understanding the federal requirements nursing homes and hospice providers must follow is vital in successfully advocating for residents. Questions to consider asking when investigating a case involving a hospice providing services to a resident in a facility, applicable federal regulations and surveyor guidance, and successful practices are below. 

Learn more.

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