Table of Contents Introduction to the Long-Term Care Ombudsman Program (LTCOP) Manual Intro - 1

Transcription

1 Table of Contents Introduction to the Long-Term Care Ombudsman Program (LTCOP) Manual Intro - 1 I. Preface Intro-1 II. Maintaining and Using the LTCOP Manual as a Primary Reference Tool... Intro-1 Chapter 1 Selection, Designation, and Termination of Local Ombudsman Programs I. Introduction II. Legal Authority III. Eligibility Criteria for Designation IV. Selection and Designation Process V. Changes in Designation VI. Termination of Designated Local LTC Ombudsman Program. 1-4 VII. Emergency Designation Process A. Program Memo 08-29(P) The California Long-Term Care Ombudsman Program Designation Standards for Approved Organizations.. 1-A Chapter 2 Roles and Responsibilities 2-1 I. Introduction II. Legal Authority III. Organization and Management of California s Long-Term Care Ombudsman Program. 2-1 IV. Advocacy V. Reporting Requirements A. Long Term Care Ombudsman Program Coordinator Agreement with the Office of the Long-Term Care Ombudsman (OSLTCO S010).. 2-A Chapter 3 Investigation and Mandated Reporting of Elder and Dependent Adult Abuse and Neglect 3-1 I. Introduction II. Legal Authority. 3-2 III. Receipt and Investigation of Elder and Dependent Adult Abuse Report 3-2 IV. LTC Ombudsman Representatives as Mandated Reporters V. Ombudsman Consent and Cross-Reporting of Complaints to Other Agencies 3-4 VI. Reporting of Elder and Dependent Adult Abuse and Neglect in the National Ombudsman Reporting System (NORS). 3-8 A. Report of Suspected Dependent Adult/Elder Abuse (SOC 341)... 3-A B. Report of Suspected Dependent Adult/Elder Financial Abuse (SOC 342).. 3-B C. State of California Complaint from the Long-Term Care Ombudsman (CDA 223)... 3-C D. Long-Term Care (LTC) Ombudsman Jurisdiction and Referrals (OSLTCO S601) D E. Ombudsman Facility Presence... 3-E 1-1 i 3/13

2 Chapter 4 Ombudsman Witnessing of Advance Health Care Directives and Property Transfers 4-1 I. Introduction II. Legal Authority. 4-1 III. Advance Health Care Directive (AHCD) IV. Physician Orders for Life-Sustaining Treatment (POLST) V. Special Considerations: Conservatorships VI. Property Transfers A. Long-Term Care Ombudsman Witness Addendum to an Advance Health Care Directive (OSLTCO S102)... 4-A B. Request for Registration of Ombudsman Witness for Advance Health Care Directives and Property Transfers (OSLTCO S103).. 4-B C. Instructions and Form for Long-Term Care Ombudsman Witnessing of an Advance Health Care Directive (OSLTCO S101)... 4-C D. Form for Long-Term Care Ombudsman Witnessing of a Property Transfer (OSLTCO S104)... 4-D Chapter 5 Confidentiality 5-1 I. Introduction II. Legal Authority III. Assuring Confidentiality IV. Access to Records V. Disclosure VI. Confidentiality and Complaint Resolution VII. Confidentiality and Complaint Referral VIII. Subpoenas IX. Testimony and Depositions X. Declarations XI. Withholding Identification of Complainants, Witnesses, and Residents A. Consent to Access and Disclose Confidential Information (OSLTCO S201).. 5-A B. Response Letter to Anyone Subpoenaing Confidential Records. 5-B C. Response Letter to Anyone Subpoenaing an Ombudsman to Testify/Appear In a Court Hearing or Deposition C D. Statement of Obligation to Protect Confidential Information. 5-D E. Authorization to Release Confidential Information and/or Testify at a Deposition, Court Hearing or Trial (OSLTCO S202) E Chapter 6 Long-Term Care Ombudsman Standards of Professional Conduct 6-1 I. Introduction II. Legal Authority III. Ombudsman Standards of Professional Conduct IV. Additional State Long-Term Care Ombudsman Program Expectations. 6-5 V. Code of Ethics for Ombudsman Staff and Volunteers A. Code of Ethics for Long-Term Care Ombudsmen The National Association Of State Long-Term Care Ombudsman Programs... 6-A ii 3/13

3 Chapter 7 Training Requirements 7-1 I. Introduction II. Legal Authority. 7-1 III. Ombudsman Certification IV. Annual Verification of Training Requirement 7-2 V. Witnessing Advance Health Care Directives and Property Transfers. 7-3 VI. New Coordinator Training Chapter 8 Long-Term Care Ombudsman Certification 8-1 I. Introduction II. Legal Authority. 8-1 III. Requirements for Initial Certification IV. Background Clearance Procedures. 8-2 V. Requirements for Program Coordinator Certification 8-4 VI. Liability Insurance 8-4 VII. Advance Health Care Directive Witness Registration VIII. Annual Recertification IX. Leave of Absence 8-5 X. Voluntary Decertification 8-6 XI. Decertification with Cause. 8-6 XII. Confidentiality After Decertification XIII. Destruction of Certification Cards XIV. Exhibits for Chapter A. Application for Long-Term Care Ombudsman Certification (OSLTCO S002). 8-A B. Conflict of Interest Statement (OSLTCO S009). 8-B C. Pledge of Confidentiality for Long-Term Care Ombudsman Trainees/Representatives (OSLTCO S006)... 8-C D. Statement Acknowledging Requirement to Report Suspected Abuse of Dependent Adults and Elders (SOC 341A) 8-D E. Requirement for Criminal Background Clearance (OSLTCO S003).. 8-E F. Criminal Record Statement (LIC 508B).. 8-F G. Request for Live Scan Service Long-Term Care Ombudsman (LIC9163B)... 8-G H. Long-Term Care Ombudsman Fingerprint Reporting Form (OSLTCO S004)... 8-H I. Request for Certification of Long-Term Care Ombudsman Representatives (OSLTCO S001)... 8-I J. Congratulatory Letter... 8-J K. Long-Term Care Ombudsman Program Coordinator Agreement with the Office of the State Long-Term Care Ombudsman (OSLTCO SO10) 8-K L. Request for Registration of Ombudsman Witness for Advance Health Care Directives and Property Transfers (OSLTCO S103). 8-L M. Decertification of Long-term Care Ombudsman Representatives (OSLTCO S005).. 8-M N. Decertification without Cause Letter. 8-N O. Decertification with Cause Letter... 8-O P. Decertification due to Background Investigation Letter. 8-P iii 3/13

4 Chapter 9 Quality Assurance Through Monitoring 9-1 I. Introduction II. Legal Authority. 9-1 III. California Department of Aging. 9-1 IV. Office of the State Long-Term Care Ombudsman. 9-2 V. Area Agencies on Aging VI. Local Long-Term Care Ombudsman Program VII. Monitoring Visits VIII. Ongoing Monitoring A. Monitoring Tool for Title III-B/Title VII-A Ombudsman Program (OSLTCO S408) 9-A B. Monitoring Tool for Ombudsman Program Service Providers (Title III-B/IV-A) and Elder Abuse Prevention Programs (OSLTCO S405). 9-B C. Document Checklist for Direct Service Monitoring Visit (OSLTCO S402). 9-C D. Document Checklist for Contracted Service Monitoring Visit (OSLTCO S403) 9-D E. Volunteer Assessment of Local Ombudsman Program (OSLTCO S406).. 9-E Chapter 10 Access to Ombudsman Program Services 10-1 I. Introduction II. Legal Authority III. Local Program Responsibility 10-1 IV. Literature V. Letterhead VI. Community Education Forums VII. Electronic Media VIII. Service Excellence Chapter 11 Telephone Protocol 11-1 I. Introduction II. Legal Authority III. Advertised Telephone Numbers 11-1 IV. Main Telephone Number 11-1 V. Number of Telephone Lines VI. Ombudsman Designated Telephone Lines VII. Shared Telephone Lines 11-2 VIII. Telephone Techniques IX. Answering Machines X. Interruption in Telephone or Fax Service 11-5 XI. Statewide CRISISline for the Long-Term Care Ombudsman Program XII. Evaluation of Telephone Accessibility A. Pledge of Confidentiality for Non-Certified Staff and/or Volunteers (OSLTCO S007) 11-A B. Telephone Techniques 11-B C. Recorded Telephone Message Examples 11-C D. After-Hours CRISISline Error Reporting Form (OSLTCO S501). 11-D E. Telephone Service Checklist.. 11-E iv 3/13

5 Chapter 12 Information Systems (NORS) 12-1 I. Introduction II. Legal Authority III. Reporting Requirements IV. Complaint Information Systems Policy 12-2 V. Cases and Complaints Collected in NORS VI. Documentation VII. Complaint Categories in NORS VIII. Ombudsman Activities Collected in NORS A. Quarterly OmbudsManager Reporting Form (OSLTCO S301) 12-A B. Long-Term Care Ombudsman Complaint Form (OSLTCO S306).. 12-B C. Long-Term Care Ombudsman Activity Log (OSLTCO S304).. 12-C D. Long-Term Care Ombudsman Information & Consultation Log (OSLTCO S307A). 12-D E. Long-Term Care Ombudsman Information & Consultation Tally by Topic (OSLTCO S307B) 12-E Chapter 13 Facility Coverage 13-1 I. Introduction II. Legal Authority III. Local Ombudsman Program Responsibility 13-1 IV. Levels of Coverage V. Documentation of Facility Visits 13-2 A. Facility Coverage Plan Worksheet. 13-A Chapter 14 Facility Closures and Bankruptcies 14-1 I. Introduction II. Legal Citations III. Types of Closures 14-1 IV. Facilities in Bankruptcy and the Appointment of a Patient Care Ombudsman A. Memorandum of Understanding Between the Department of Health Services, Licensing and Certification Division, and the Department of Aging, Office of the State Long-Term Care Ombudsman A B. Memorandum of Understanding Between the California Department of Social Services, Community Care Licensing Division, and the Department of Aging, Office of the State Long-Term Care Ombudsman 14-B Chapter 15 Grievance Process for Complaints Against the Long-Term Care 15-1 Ombudsman Program I. Introduction II. Legal Authority III. Complaints Against the Ombudsman Program IV. Complaints Made by or on Behalf of Older Individuals V. Complaints Made by Others VI. Confidentiality VII. Maintenance of Records VIII. Conclusion 15-5 v 3/13