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... 1-1 II. Legal Authority..... 1-1 III. Eligibility Criteria for Designation...... 1-1 IV. Selection and Designation Process.. 1-2 V. Changes in Designation.... 1-4 VI. Termination of Designated Local LTC Ombudsman Program. 1-4 VII. Emergency Designation Process.. 1-5 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... 2-1 II. Legal Authority..... 2-1 III. Organization and Management of California s Long-Term Care Ombudsman Program. 2-1 IV. Advocacy.... 2-10 V. Reporting Requirements. 2-12 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.. 3-1 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... 3-3 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).... 3-D E. Ombudsman Facility Presence... 3-E 1-1 i 3/13
Chapter 4 Ombudsman Witnessing of Advance Health Care Directives and Property Transfers 4-1 I. Introduction... 4-1 II. Legal Authority. 4-1 III. Advance Health Care Directive (AHCD).. 4-1 IV. Physician Orders for Life-Sustaining Treatment (POLST)... 4-5 V. Special Considerations: Conservatorships.... 4-6 VI. Property Transfers.. 4-7 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... 5-1 II. Legal Authority.... 5-1 III. Assuring Confidentiality.. 5-2 IV. Access to Records..... 5-2 V. Disclosure.... 5-3 VI. Confidentiality and Complaint Resolution...... 5-5 VII. Confidentiality and Complaint Referral.... 5-5 VIII. Subpoenas... 5-5 IX. Testimony and Depositions...... 5-6 X. Declarations..... 5-7 XI. Withholding Identification of Complainants, Witnesses, and Residents...... 5-7 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.... 5-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)...... 5-E Chapter 6 Long-Term Care Ombudsman Standards of Professional Conduct 6-1 I. Introduction... 6-1 II. Legal Authority..... 6-1 III. Ombudsman Standards of Professional Conduct...... 6-1 IV. Additional State Long-Term Care Ombudsman Program Expectations. 6-5 V. Code of Ethics for Ombudsman Staff and Volunteers.. 6-6 A. Code of Ethics for Long-Term Care Ombudsmen The National Association Of State Long-Term Care Ombudsman Programs... 6-A ii 3/13
Chapter 7 Training Requirements 7-1 I. Introduction.. 7-1 II. Legal Authority. 7-1 III. Ombudsman Certification... 7-1 IV. Annual Verification of Training Requirement 7-2 V. Witnessing Advance Health Care Directives and Property Transfers. 7-3 VI. New Coordinator Training... 7-4 Chapter 8 Long-Term Care Ombudsman Certification 8-1 I. Introduction.. 8-1 II. Legal Authority. 8-1 III. Requirements for Initial Certification... 8-1 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... 8-4 VIII. Annual Recertification... 8-5 IX. Leave of Absence 8-5 X. Voluntary Decertification 8-6 XI. Decertification with Cause. 8-6 XII. Confidentiality After Decertification.. 8-7 XIII. Destruction of Certification Cards... 8-7 XIV. Exhibits for Chapter 8... 8-8 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
Chapter 9 Quality Assurance Through Monitoring 9-1 I. Introduction... 9-1 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... 9-3 VI. Local Long-Term Care Ombudsman Program.. 9-3 VII. Monitoring Visits.. 9-4 VIII. Ongoing Monitoring... 9-6 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... 10-1 II. Legal Authority. 10-1 III. Local Program Responsibility 10-1 IV. Literature... 10-1 V. Letterhead.... 10-2 VI. Community Education Forums.. 10-2 VII. Electronic Media... 10-2 VIII. Service Excellence.. 10-2 Chapter 11 Telephone Protocol 11-1 I. Introduction... 11-1 II. Legal Authority. 11-1 III. Advertised Telephone Numbers 11-1 IV. Main Telephone Number 11-1 V. Number of Telephone Lines.. 11-2 VI. Ombudsman Designated Telephone Lines... 11-2 VII. Shared Telephone Lines 11-2 VIII. Telephone Techniques... 11-3 IX. Answering Machines... 11-4 X. Interruption in Telephone or Fax Service 11-5 XI. Statewide CRISISline for the Long-Term Care Ombudsman Program... 11-5 XII. Evaluation of Telephone Accessibility... 11-10 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
Chapter 12 Information Systems (NORS) 12-1 I. Introduction... 12-1 II. Legal Authority. 12-1 III. Reporting Requirements. 12-1 IV. Complaint Information Systems Policy 12-2 V. Cases and Complaints Collected in NORS... 12-3 VI. Documentation. 12-3 VII. Complaint Categories in NORS... 12-4 VIII. Ombudsman Activities Collected in NORS. 12-5 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... 13-1 II. Legal Authority. 13-1 III. Local Ombudsman Program Responsibility 13-1 IV. Levels of Coverage. 13-2 V. Documentation of Facility Visits 13-2 A. Facility Coverage Plan Worksheet. 13-A Chapter 14 Facility Closures and Bankruptcies 14-1 I. Introduction... 14-1 II. Legal Citations. 14-1 III. Types of Closures 14-1 IV. Facilities in Bankruptcy and the Appointment of a Patient Care Ombudsman.. 14-6 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... 14-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... 15-1 II. Legal Authority..... 15-1 III. Complaints Against the Ombudsman Program... 15-1 IV. Complaints Made by or on Behalf of Older Individuals..... 15-2 V. Complaints Made by Others...... 15-4 VI. Confidentiality... 15-4 VII. Maintenance of Records.... 15-4 VIII. Conclusion 15-5 v 3/13