ILLINOIS DEPARTMENT ON AGING

 

LONG TERM CARE OMBUDSMAN PROGRAM

STANDARDS MANUAL

 

TABLE OF CONTENTS

 

CHAPTER 100:  INTRODUCTION

 

101:     General Authority and Mission.....................................................................................

 

102:     Structure of the Illinois LTCOP...................................................................................

 

103:     Organization of this Manual.........................................................................................

 

104:     Clarifications, Revisions, Waivers and

   Transitional Provisions to this Manual........................................................................

 

 

CHAPTER 200:  DEFINITIONS

 

201:     Abuse.......................................................................................................................

 

203:     Area Agency on Aging or AAA....................................................................................

 

205:     Area Plan...................................................................................................................

 

207:     Case.........................................................................................................................

 

209:     Community Education.................................................................................................

 

211:     Complaint..................................................................................................................

 

213:     Conflict of Interest.....................................................................................................

 

215:     Date of First Action....................................................................................................

 

217:     Department or IDoA...................................................................................................

 

219:     Designation................................................................................................................

 

221:     Director....................................................................................................................

 

223:     Exploitation................................................................................................................

 

225:     Family Council Activities.............................................................................................

 

227:     Good Faith................................................................................................................

 

229:     Guardian...................................................................................................................

 

231:     Immediate Family.......................................................................................................

 

233:     Intake Date................................................................................................................

 

235:     Interference...............................................................................................................

 

237:     Inquiry......................................................................................................................

 

239:     In-service Education and Training................................................................................

 

241:     Interagency Coordination............................................................................................

 

243:     Issues Advocacy........................................................................................................

 

245:     Legal Representative...................................................................................................

 

247:     Long Term Care Facility or Facility..............................................................................

 

249:     Long Term Care Ombudsman or LTCO........................................................................

 

251:     Long Term Care Ombudsman Program or LTCOP........................................................

 

253:     Long Term Care Community Ombudsman . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

 

255:          255:           Volunteer Ombudsman                              

257:     Long Term Care Ombudsman Visitor...........................................................................

 

259:     Neglect.....................................................................................................................


261:     Office or SLTCOP.....................................................................................................

 

263:     Official Duties............................................................................................................

 

265:     Ombudsman Annual Services Plan...............................................................................

 

267:     Planning and Service Area or PSA................................................................................

 

269:     Provider Agency........................................................................................................

 

271:     Record......................................................................................................................

 

273:     Regional Ombudsman.................................................................................................

 

275:     Regional Long Term Care Ombudsman

   Program or Regional LTCOP....................................................................................

 

279:     Registry or Ombudsman Registry.................................................................................

 

281:     Resident....................................................................................................................

 

283:     Resident Council Activities..........................................................................................

 

285:     Resident's Representative............................................................................................

 

287:     State Long Term Care Ombudsman or SLTCO..............................................................

 

289:     State Long Term Care Ombudsman

   Program or SLTCOP...............................................................................................

 

287:     Unit of Service...........................................................................................................


 

CHAPTER 300:  ORGANIZATION STANDARDS AND RESPONSIBILITIES

 

301:     IDoA Responsibilities..................................................................................................

 

302:     SLTCOP Responsibilities.............................................................................................

 

303:     Office of the Illinois LTCOP Responsibilities.................................................................


304:     AAA Responsibilities...................................................................................................

 

305:     Provider Agency Responsibilities..................................................................................

 

306:     Designation of Regional LTCOPs.................................................................................

 

307:     Refusal to Designate and De-designation

   of Regional LTCOP.................................................................................................

 

308:     Designation of LTCO..................................................................................................

 

309:     Refusal to Designate and De-designation

   of LTCO................................................................................................................

 

 

CHAPTER 400:  LTCOP SERVICE DELIVERY STANDARDS

 

401:     LTCOP Service Components.......................................................................................

 

402:     Investigative Services.................................................................................................

 

403:     Regular Presence in Long Term Care Facilities..............................................................

 

404:     Public Information and Education.................................................................................

 

405:     Issue Advocacy.........................................................................................................

 

406:     Resident and Family Councils Development

   and Support............................................................................................................

 

407:     Regional LTCOP Annual Services Plan.........................................................................

 

408:     Evaluation of the LTCOP............................................................................................

 

 

CHAPTER 500:  PROTOCOLS FOR PROBLEM RESOLUTION AND INVESTIGATIVE SERVICES

 

501:     Receipt of Complaints.................................................................................................

 

502:     Complaint Investigations.............................................................................................

 

503:     Verification of Complaints ..........................................................................................

 

504:     Resolution of Complaints.............................................................................................

 

505:     Notice of Complaint Disposition...................................................................................

 

1:              Documentation of Investigative Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

 

 

CHAPTER 600:  ACCESS TO RESIDENTS AND FACILITIES, RESIDENTS' RECORDS, AND STATE AND FACILITY RECORDS

 

601:     Access to Residents and Facilities................................................................................

 

602:     Access to Residents' Records......................................................................................

 

603:     Access to State and Facility Records............................................................................

 

 

CHAPTER 700:  LEGAL ISSUES

 

701:     Legal Advice and Consultation.....................................................................................

 

702:     Representation for Legal Action...................................................................................

 

703:     Noninterference.........................................................................................................

 

704:     Retaliation and Reprisals..............................................................................................

 

705:     Guardianship..............................................................................................................

 

 

CHAPTER 800:  CONFIDENTIALITY AND DISCLOSURE

 

801:     Confidentiality of LTCOP Records...............................................................................

 

802:     Monitoring the Records of the Regional LTCOP............................................................


803:     Disclosure of Information...........................................................................................

 

 

CHAPTER 900:  CONFLICT OF INTEREST

 

901:     Adherence to Procedures............................................................................................

 

902:     Identifying a Conflict of Interest .................................................................................

 

903:     Disclosure of a Conflict of Interest...............................................................................

 

904:     Reviewing and Remedying the Conflict of Interest.........................................................

 

905:     Failure to Identify or Remedy a Conflict of Interest........................................................

 

 

CHAPTER 1000: VOLUNTEER MANAGEMENT

 

The following appendices are not availbable in this document, but can be obtained through the Illinois Department on Aging.

 

APPENDIX A:          OLDER AMERICANS ACT

 

APPENDIX B:           ILLINOIS ACT ON AGING

 

APPENDIX C:          LTCOP RULES

 

APPENDIX D:          DOCUMENTATION FORMS

 

LTCOP Activity Form Instructions (IL-402-0660)

 

County Codes

 

Complaint Taxonomy

 

Case Recording Form Instructions (IL-402-0661 and 0662)

 

LTCOP Release of Information Form Instructions (IL-402-0779)

LTCOP Representative Registry Instructions (IL-402-0690)

 

Regional LTCOP Quarterly Report Instructions (IL-402-0411)

 

LTCOP Policy Clarification Request Instructions (IL-402-0932)

 

LTCOP Complaint Referral to a State Agency Instruction (IL-402-0955)

 

Access to Records of Resident Incapable of Giving Consent (IL-401-0999)

 

Request for Forms

 

APPENDIX E:           REPRESENTATION AND INDEMNIFICATION OF STATE EMPLOYEES’ ACT

 

APPENDIX F:           IDOA APPEAL PROCEDURES

 

APPENDIX G:          DESIGNATION AND TRAINING

 

APPENDIX H:          OMBUDSMAN CODE OF ETHICS

 

APPENDIX I: ILLINOIS ABUSE AND NEGLECT NURSING HOME RESIDENT REPORTING ACT

 

APPENDIX J:           ILLINOIS PROBATE ACT SECTIONS REGARDING POA AND GUARDIANSHIP

 

                                            CHAPTER 100:  INTRODUCTION

 

101:     General Authority and Mission.....................................................................................

 

102:     Structure of the Illinois LTCOP...................................................................................

 

103:     Organization of this Manual.........................................................................................

 

104:     Clarifications, Revisions, Waivers and

   Transitional Provisions to this Manual........................................................................

 

2:        General Authority and Mission

 

A.               The Illinois LTCOP is authorized by and acts in accordance with the federal Older Americans Act, 42 U.S.C. Section 3001 et seq. and the Illinois Act on Aging, 20 ILCS 105/4.04.

 

B.                The LTCOP protects and improves the quality of care and quality of life for residents of long term care facilities in Illinois through individual and systemic advocacy for and on behalf of residents, including the promotion and cultivation of best practices within long term care services, and through the promotion of family and community involvement in long term care facilities.

 

C.               The LTCOP is a resident-centered advocacy program.  The resident of, or applicant to, a long term care facility is the program’s client, regardless of the source of the complaint or request for service.  The LTCO will make every reasonable effort to assist, empower, represent, and intervene on behalf of the resident.

 

D.               These policies and procedures are standards to govern the actions of the SLTCOP, all designated paid and volunteer ombudsmen, provider agencies, AAA, the IDoA, and other parties involved in the operation of the LTCOP.

 

506:          Structure of the Illinois LTCOP

 

A.     The IDoA shall establish and operate an Office of SLTCO and carry out  through the Office a state LTCOP in accordance with the Older Americans Act, the Illinois Act on Aging, and applicable federal and state regulations.

 

B.     The state agency shall oversee the Office in accordance with all applicable federal and state laws and regulations, in consultation with IDoA staff, leadership and counsel, and in conformance with IDoA policies.

 

C.     The Office shall assure that all residents of Illinois long term care facilities have access to the services of the LTCOP and that every area of the State has a designated Regional LTCOP.

 

D.    Regional LTCOP services shall be delivered through provider agencies and individuals designated by the SLTCO and shall be operated through a grant or contract with the IDoA or an AAA.

 

 

103:    Organization of this Manual

 

The general organization of this Manual is as follows:

 

Chapter 100:  Introduction - describes the mission, responsibilities and authority of the Illinois LTCOP, the organization of this Manual, and the procedures to follow to revise any portion of this manual.

 

Chapter 200:  Definitions - lists and defines the terms used throughout this Manual.

 

Chapter 300:  Organizational Standards and Responsibilities - describes the organizational standards and responsibilities of the IDoA, the SLTCOP, the SLTCO, the Area Agency on Aging, provider agencies, and the Regional LTCOP in relation to the SLTCOP and the process for designation and de-designation of provider agencies and LTCOs.

 

Chapter 400:  Long Term Care Ombudsman Program Service Delivery Standards - describes the five service delivery components to be provided by the SLTCOP through Regional LTCOPs.

 

Chapter 500:  Protocols for Problem Resolution and Investigative Services - provides the Regional LTCOPs with the minimum guidelines for investigating, verifying, and resolving complaints received by or on behalf of long term care residents.

 

Chapter 600:  Access to Residents and Facilities, Residents' Records, and State and Facility Records - explains how to gain access to residents and  facilities, to resident, state, and facility records and the process to follow when access is denied.

 

Chapter  700:  Legal Issues - describes the process to follow in seeking legal advice or consultation from the Office by LTCOs and provider agencies, representation and indemnification from the Attorney General or others, and procedures to follow when interference, retaliation, and/or reprisals exists.

 

Chapter 800:  Confidentiality and Disclosure - outlines the requirements to be followed by the LTCOP and LTCOs to assure confidentiality of residents, complainants, witnesses, or others assisting in the report, complaint, or investigation.

 

Chapter 900:  Conflict of Interest - defines conflict of interest for entities and individuals involved in the LTCOP and procedures for the disclosure, review and remedying of a conflict of interest along with the penalties for failure to identify or remedy a conflict of interest.

 

Chapter 1000:  Volunteer Management - defines the qualifications and role of volunteers in the program services of the SLTCOP.

 

Appendix A:  Older Americans Act - a copy of

Sections 102(13),(18),(22-24),(32)

Section 201(d)

Section 202(a)(18)

Section 207(b)(1)

Section 301(c)

Section 304(d)(1)(B)

Section 306(a)(9)

Section 307(a)(9)

Section 321(a)(10)

Section 321(d)

Section 421

Sections 701-705

Sections 711-713

Sections 762-764

 

Appendix B:  Illinois Act on Aging - a copy of the Illinois Revised Statutes. 20 ILCS 105/1 et seq.

 

Appendix C:  Long Term Care Ombudsman Program Rules

 

Appendix D:  Documentation Forms - copies and instructions for the  Regional LTCOP Quarterly Report, LTCOP Activity Form, and the LTCOP Case Recording Form.

 

Appendix E:  Representation and Indemnification of State Employees Act - a copy of the Representation and Indemnification of State Employees Act, 5 ILCS 350/1 et seq.

 

 

Appendix F:  IDoA Appeal Procedures

 

Appendix G:  Designation and Training

 

Appendix H: Ombudsman Code of Ethics

 

Appendix I: Illinois Abuse and Neglect Nursing Home Resident Reporting Act

 

 

Appendix J: Illinois Probate Act Sections Regarding POA and Guardianship

104:    Clarifications, Revisions, or Waivers and Transitional Provisions to this Manual

 

A.        Policy Clarification Requests (PCR)

 

1.        From time to time, users of this manual may find that certain standards require additional clarification by the Office.  In order to systematically respond to these inquiries, the IDoA implements this clarification process.

 

2.        PCRs (see Section 905.11 of the Policies, Procedures, and Standards for the Area Agencies on Aging Manual) are to be submitted to the Office by any AAA, any provider entity, or LTCO.  PCRs received by the Office will be logged in and routed to  appropriate staff for research and response.  A response to a PCR will be made within thirty (30) working days by either responding directly to the clarification request or requesting further information from the requestor.  Depending upon the nature of the request, a PCR may be handled in one of two ways:

 

a.        if the PCR refers to a subject that is unique to a specific AAA, provider entity, or designated representative then an individual response will be forwarded to the AAA, the provider entity or designated representative.  Any AAA, provider entity, or Regional Ombudsman may request or receive a copy of the response to this kind of PCR.

 

b.        if the subject of the PCR suggest a need for statewide clarification or a need to modify the contents of this Manual, sequentially numbered information memoranda will be released to all AAA, provider entities, and Regional Ombudsman.   The informational memoranda will clarify the pertinent issue, and if appropriate, outline the steps to be taken by the IDoA and/or the SLTCOP to initiate the changes to this Manual.

 

3.        The Office shall consult, if needed, with the Department managers in the issuance of Policy Clarifications.  The Office may consult with the PCR workgroup for recommendation, review and clarification

 

3:                 When the PCR contains a technical assistance question concerning this manual and the response does not affect LTCOP policy, the Office shall issue the response and provide a copy to the Director and appropriate managers.

 

4:                 When the PCR contains a question which involves an interpretation of LTCOP policy, the Office shall consult with Department managers prior to the drafting of a response.  When the response has been drafted and approved by the Director, the Office shall issue the PCR response and provide a copy to the Director and appropriate managers.

 

B.        Changes to this Manual

 

1.        Changes to this Manual will be made by the Department, after consultation with the Office, and if appropriate, with the review and input of the AAAs, provider entities, and Regional Ombudsmen.

 

2.        Changes requiring adherence to the state Administrative Procedures Act process will follow normal rule making procedures, with Manual changes provided once such rules become final.

 

C.                          Waivers

 

1.     The Department may award a waiver to a standard of this Manual  when a written request is received from an AAA, provider entity or Regional Ombudsman which contains justification to support the approval.  The AAA, provider agency and Regional Ombudsman will be notified in writing if a waiver has been approved.

 

2.     A request for waiver must be made in writing to the Office and approved by the Department prior to:

 

                                                 a.           hiring or promotion of the employee in question;

 

                                                 b.           implementing the reduced minimum standard; or

 

                                                 c.           implementing the practice.

 

3.     Requests for waivers related to minimum LTCOP service components may be requested through the LTCOP Annual Services Plan according to Section 407(C)(3).

 

D.               Transitional Provisions

 

1.     As of the date of issuance of these standards, any entity providing LTCOP services under a grant or contract with the IDoA or an AAA shall continue to be designated as a provider agency for the duration of the previously established designation period unless the provider agency is de-designated by the SLTCO.

 

2.     Persons hired before October 1, 1989, to serve as a Regional Ombudsman do not have to meet the educational requirement.

 

3.     Persons serving in the capacity of SLTCO, RO, CO or VO and listed on the Registry prior to the date these standards were implemented, are waived from the designation training requirements in Appendix G.

 

 

 

                                                              CHAPTER 200:  DEFINITIONS

 

 

201:     Abuse.......................................................................................................................

 

203:     Area Agency on Aging or AAA....................................................................................

 

205:     Area Plan...................................................................................................................

 

207:     Case.........................................................................................................................

 

209:     Community Education.................................................................................................

 

211:     Complaint..................................................................................................................

 

213:     Conflict of Interest.....................................................................................................

 

215:     Date of First Action....................................................................................................

 

217:     Department or IDoA...................................................................................................

 

219:     Designation................................................................................................................

 

221:     Director....................................................................................................................

 

223:     Exploitation................................................................................................................

 

225:     Family Council Activities.............................................................................................

 

227:     Good Faith................................................................................................................

 

229:     Guardian...................................................................................................................

 

231:     Immediate Family.......................................................................................................

 

233:     Intake Date................................................................................................................

 

235:     Interference...............................................................................................................


237:     Inquiry......................................................................................................................

 

239:     In-service Education and Training................................................................................

 

241:     Interagency Coordination............................................................................................

 

243:     Issues Advocacy........................................................................................................

 

245:     Legal Representative...................................................................................................

 

247:     Long Term Care Facility or Facility..............................................................................

 

249:     Long Term Care Ombudsman or LTCO........................................................................

 

251:     Long Term Care Ombudsman Program or LTCOP........................................................

 

253:     Long Term Care Community Ombudsman     ..............

 

C:               255:.......................................................................................... Volunteer Ombudsman                               

 

257:     Long Term Care Ombudsman Visitor...........................................................................

 

259:     Neglect.....................................................................................................................

 

261:     Office or SLTCOP.....................................................................................................

 

263:     Official Duties............................................................................................................

 

265:     Ombudsman Annual Services Plan...............................................................................

 

267:     Planning and Service Area or PSA................................................................................

 

269:     Provider Agency........................................................................................................

 

271:     Record......................................................................................................................

 

273:     Regional Ombudsman.................................................................................................

 

275:     Regional Long Term Care Ombudsman

   Program or Regional LTCOP....................................................................................

 

279:     Registry or Ombudsman Registry.................................................................................

 

281:     Resident....................................................................................................................

 

283:     Resident Council Activities..........................................................................................

 

285:     Resident's Representative............................................................................................

 

287:     State Long Term Care Ombudsman or SLTCO..............................................................

 

289:     State Long Term Care Ombudsman

   Program or SLTCOP...............................................................................................

 

287:     Unit of Service...........................................................................................................

 

5:                Definitions

 

For the purposes of this Manual, the following definitions will apply:

 

201      Abuse

 

Willful infliction of injury, unreasonable confinement, intimidation, cruel punishment with resulting physical harm, pain, or mental anguish; or willful deprivation by a person, including a caregiver, of goods or services that are necessary to avoid physical harm, mental anguish, or mental illness.

 

203      Area Agency on Aging or AAA

 

A public or private nonprofit agency designated by the IDoA in a planning and service area which is responsible for developing and administering an area plan for a comprehensive and coordinated system of services for caregivers and persons over the age of sixty.

 

205      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.

 

207      Case

 

Each inquiry or allegation brought to, or initiated by, the LTCOP on behalf of a resident or group of residents involving one or more complaints or problems which requires opening a case file and which includes ombudsman investigation, fact gathering, development and implementation of a resolution strategy in keeping with Chapter 500 of this Manual.

 

209      Community Education

 

Presentations to community groups or to groups of residents or families on long term care issues.

 

211      Complaint     

 

A concern or allegation regarding action, inaction, or decisions that may or has adversely affected the health, safety, welfare, or rights of one or more residents that is brought to the attention of, or initiated by, the LTCOP for action.

 

213      Conflict of Interest

 

A competing interest, obligation, or duty which compromises, influences, interferes with (or gives the appearance of compromising, influencing or interfering with) the integrity, activities, or conduct of the LTCO in faithfully and effectively fulfilling his or her official duties as defined in Chapter 900 of this Manual.

 

215      Date of First Action

 

The date indicated by a conversation which results in a preliminary plan for either an investigation or steps to be taken toward resolution.

 

217      Department or IDoA

 

The Illinois Department on Aging (IDoA).

 

219      Designation

 

The certification and classification provided by the Office to:

 

a.      an individual who meets minimum qualifications, is free of conflicts of interest, has successfully completed training and other criteria stipulated in Appendix G and has been registered on the Ombudsman Registry.  Designation authorizes such individual to act as a representative of the Office or in keeping with the standards of this Manual;

 

b.      a provider agency which meets the minimum qualifications stipulated in  Section 305 of this Manual.  Designation authorizes such agency as a local Ombudsman entity to operate a Regional LTCOP in a planning and service area or a specified geographic area thereof.

 

221      Director

 

The Director of the Illinois Department on Aging.

 

223      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.

 

225      Family Council Activities

 

Provision of technical assistance, information, training or support to the family members of residents and/or facility staff about the development, education, work, or maintenance of a family council.

 

227      Good Faith

 

Evidence of performing duties in “good faith” includes, but is not limited to:

 

1.      Making reasonable efforts to follow procedures set forth in applicable laws and this Manual;

 

2.      Seeking and making reasonable efforts to follow direction from the Office of the State Long Term Care Ombudsman; and,

 

3.      Seeking and making reasonable efforts to follow direction from the relevant Regional Ombudsman.

 

229      Guardian

 

Person or entity appointed by a court to exercise the legal rights and powers of another individual as specified in the court order.

 

231      Immediate family

 

Those persons related to an individual such as a spouse, child, sibling,  parent or domestic partner.

 

233      Intake Date

 

The date of receipt of the information or message received by the LTCOP provider agency.

 

235      Interference

 

Includes, but is not limited to, the following: the infliction of physical harm; threats to inflict physical harm; intimidation; deception; tampering with physical evidence; destroying, hiding, or altering records; making false statements or encouraging others to do so; bribery or attempted bribery; retaliation; and restricting, without legal authority, the personal movements or travel of any individual, when such actions are done for the sole purpose of preventing the ombudsman from discharging his or her official duties. 

 

237      Inquiry

 

The provision of information to individuals on long term care or the needs and rights of long term care facility residents.

 

239      In-service Education and Training

 

A presentation to LTCO or long term care facility staff on long term care issues.

 

241      Interagency coordination

 

Activities that involve meeting or coordinating with other agencies to learn about and to improve conditions for one or more residents of long term care facilities.

 

 

243      Issues Advocacy

 

Activities supporting and promoting issues that benefit or advance the

health, safety, welfare or rights of residents of long term care facilities.

 

245      Legal Representative

 

An agent under a valid power of attorney, provided that the agent or attorney-in-fact is acting within the scope of his or her agency; an agent under a power of attorney for health care; surrogate decision maker; or  an executor, executrix, administrator, or administratrix of the estate of a deceased resident; or guardians of the person and estate.

 

247      Long Term Care Facility or Facility

 

Long Term Care Facility means any facility as defined by Section 1-113 of the Nursing Home Care Act, as amended by Public act 93-0241, of any skilled nursing facility or a nursing facility which meets the requirements of Section 1819 (a), (b), (c), and (d) or Section 1919 (a), (b), (c), and (d) of the Social Security Act, as amended (42 U.S.C. 1395i-3(a), (b), (c), and (d) and 42 U.S.C. 1396r(a), (b), (c), and (d). Facilities or establishments with the following types of licensed beds or certified units are included in the definition:

 

a.                 skilled nursing;

 

b.                skilled nursing unit of a hospital licensed facility;

 

c.                intermediate care;

 

d.                intermediate care for the developmentally disabled (intermediate care for the mentally retarded);

 

e.                 sheltered care;

 

f.                 assisted living;

 

g.                shared housing; and,

 

h.                supportive living - a facility established under Section 5-5.01a of the Illinois Public Aid Code.

 

249      Long Term Care Ombudsman or LTCO

 

Unless otherwise specified, any designated representative of the Office of the State LTCOP.   Specific categories include:

 

a.                 State Long Term Care Ombudsman (SLTCO);

 

b.                Regional Ombudsman (RO);

 

c.                Community Ombudsman (CO) [paid or unpaid];

 

d.                Volunteer Ombudsman (VO); and

 

e.                 Long Term Care Ombudsman Visitor (LTCOV).

 

251      Long Term Care Ombudsman Program or LTCOP

 

Unless otherwise specified, “LTCOP” means the statewide long term care resident advocacy program established and operated by IDoA.

 

253      Long Term Care Community Ombudsman

 

There are two types of community ombudsmen:  paid & unpaid.

 

Community Ombudsman (paid)

A person who has completed the basic and advanced training modules and four (4) hours of probationary supervision as outlined in Appendix G.   This person has full access to resident records and works directly under the supervision of the RO.

 

Community Ombudsman (unpaid)

A person who is a volunteer and has completed the basic and advanced training modules and four (4) hours of probationary supervision as outlined in Appendix G.  This person has full access to resident records and works under the supervision of the Regional Ombudsman or a paid LTCO.

 

255      Volunteer Ombudsman

 

A person who is a volunteer and who has completed the basic  training modules and four (4) hours of probationary supervision as outlined in Appendix G.  Volunteer Ombudsman may also complete the advanced training.  This person provides information about the LTCOP to residents and reports all complaints and issues to the Regional Ombudsman or Community Ombudsman.   She or he works under the supervision of the Regional Ombudsman or Community Ombudsman.

 

257      Long Term Care Ombudsman Visitor

 

A person who is a volunteer and provides information about the LTCOP to residents, reports and refers all complaints and issues to the Regional Ombudsman or Community Ombudsman.

 

259      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.

 

261      Office or SLTCOP

 

The Office of the State Long Term Care Ombudsman Program (SLTCOP) as established and operated by IDoA and headed by the State Long Term Care Ombudsman (SLTCO).

 

263   Official Duties

 

Those duties of a LTCO as set forth in applicable federal and state law and this Manual.

 

265   Ombudsman Annual Services Plan

 

A written plan, prepared by the Regional LTCOP, for submission to the Office and the area agency on aging, setting goals and objectives for the regional LTCOP for the following federal fiscal year.

 

267      Planning and Service Area or PSA

 

A geographic area of the State, as defined in the Illinois Act on Aging, that is designated by the IDoA for the purposes of planning, development, delivery, and overall administration of services under an area plan.

 

269      Provider Agency

 

The entity designated by the Office to operate a Regional LTCOP in a planning and service area or a specified geographic area.

 

271      Record

 

Any medical, social, personal and financial information maintained by any long term care facility, or by any State or local agency, pertaining to a resident of a long term care facility or to the facility.

 

273      Regional Ombudsman

 

A person who works full-time (35-40 hours/week) to perform LTCOP functions exclusively and who shall have no duties in the provider agency outside the scope of the LTCOP as defined in state and federal law and this Manual.  S/he has the overall responsibility for the activities of the Regional LTCOP as defined in this Manual.

 

275      Regional Long Term Care Ombudsman Program or Regional LTCOP

 

An entity designated by the Office as a local Ombudsman entity.

 

277      Registry or Ombudsman Registry

 

The official listing of LTCO, maintained by the Office, who have been designated as representatives of the Office of SLTCO.

279      Resident

 

Any individual age 60 or over who is a current or former resident of any long term care facility, including individuals seeking admission to a long term care facility, if the complaint or request for information involves procedures or practices related to admission, discharge and/or the individual's entitlement to care and services under Federal and State laws and regulations.

 

281      Resident Council Activities

 

Provision of technical assistance, information, training or support to the  residents, family members and/or facility staff about the development, education, work or maintenance of a resident council.

 

283      Resident's Representative

 

Any person who is knowledgeable about a resident's circumstances and has been designated by that resident in writing to represent him or her, including a resident's legal representative as defined in Section 1 123 of the Nursing Home Care Act, or the resident's legal guardian.

 

285      State Long Term Care Ombudsman (SLTCO)

 

A person  authorized to head the SLTCOP, who meets the requirements set forth in this manual.

 

287      State Long Term Care Ombudsman Program (SLTCOP)

 

The Program as established and operated by the IDoA and carried out through the Office of the SLTCOP and headed by the SLTCO.

 

289      Unit of Service

 

One hour of time expended by a LTCO within the LTCOP.

 

                CHAPTER 300:  ORGANIZATION STANDARDS AND RESPONSIBILITIES

 

301:     IDoA Responsibilities..................................................................................................

 

302:     SLTCOP Responsibilities.............................................................................................

 

303:     Office of the Illinois LTCOP Responsibilities.................................................................

 

304:     AAA Responsibilities...................................................................................................

 

305:     Provider Agency Responsibilities..................................................................................

 

306:     Designation of Regional LTCOPs.................................................................................

 

307:     Refusal to Designate and De-designation

   of Regional LTCOP.................................................................................................

 

308:     Designation of LTCO..................................................................................................

 

309:     Refusal to Designate and De-designation

   of LTCO................................................................................................................


301:    IDoA Responsibilities

 

A.        The IDoA shall:

 

1.                submit a State Plan on Aging pursuant to the Older Americans Act in order to receive an allotment under Title III and Title VII;

 

2.                establish and operate an Office of the State Long-Term Care Ombudsman and carry out the LTCOP directly, or by contract or  other arrangement with any public agency or nonprofit private organization in accordance with the Older Americans Act;

 

3.                provide that the Office be headed by a full-time SLTCO meeting the qualifications described in Section 302 of this Manual;

 

4.                determine the allocation levels and allocate and distribute the funding for the LTCOP through the approval of Area Plans on Aging;

 

5.                act as an advocate for long term care residents and will consider the views of area agencies on aging, older individuals, and providers of long-term care in the planning and operation of the program;

 

6.                develop policies and procedures which direct the operation of the LTCOP;

 

7.                ensure the availability of  adequate legal counsel and consultation on matters pertaining to the responsibilities of the Office;

 

8.                publicize the purposes and operation of the LTCOP through public service announcements, posters, and brochures;

 

9.                further interagency coordination through the establishment of working relationships with other state agencies involved in meeting the needs of residents of long term care facilities;

 

10.             monitor and evaluate the compliance of the LTCOP to ensure that the responsibilities of the Department, the SLTCOP, and the SLTCO are being met in accordance with the Older Americans Act;

11.             use funds made available and not supplant any funds that are expended under any federal or state law in existence to carry out the statewide LTCOP in accordance with federal maintenance of effort requirements;

 

12.             establish in accordance with the Office, policies and procedures for monitoring local ombudsman entities; and

 

13.             develop the policies and procedures regarding confidentiality and conflict of interest.

302:    State Long Term Care Ombudsman Responsibilities

 

A.        A full time SLTCO shall have:

 

                                                      1.      the understanding of aging, disability and long term care issues and cultural diversity;

 

                                                      2.      the proven ability to analyze human service data and translate it into lay terms;

 

                                                      3.      the knowledge of advocacy processes and experience in coalition building;

 

                                                      4.      the experience managing staff and volunteers;

 

                                                      5.      basic computer skills;

 

                                                      6.      the ability to work with consultants and accept and act upon constructive criticism;

 

                                                      7.      strong negotiation and written and verbal communication skills;

 

                                                      8.      proven problem-solving abilities;

 

                                                      9.      the familiarity with outcome based evaluation and continuous quality improvement;

 

                                                  10.      an understanding of public relations concepts and the ability to demonstrate strong (non-partisan) political skills;

 

                                                  11.      public speaking experience;

 

                                                  12.      a commitment to consumers of long term care;   

 

                                                  13.      the ability to understand legal concept

 

                                                  14.      three years experience as an ombudsman or in advocacy work is highly desirable; and

 

                                                  15.      a minimum requirement of a Bachelors degree in aging, advocacy, or related fields; graduate work in a related field is preferred but not required.

 

B.                           The SLTCO shall designate entities as Regional Long Term Care Ombudsman Programs pursuant to Section 304 of this Manual,

 

C.                          The SLTCO shall designate individuals who represent the Regional LTCOP pursuant to Section 306 of this Manual.

 

D.                          Operate the Office of the LTCO as delineated in Section 303 of this Manual and in accordance with Department on Aging guidelines.

 

E.                           The SLTCO has the following specific responsibilities to long term care residents, pursuant to the Older American Act:

 

 

1.     identify, investigate, and resolve complaints that are made by, or on behalf of, residents; and relate to action, inaction, or decisions that may adversely affect the health, safety, welfare, or rights of the residents (including the welfare and rights of the residents with respect to the appointment and activities of guardians and representative payees), of:

 

a.                providers, or representatives of providers, of long term care services;

 

b.                public agencies; or

 

c.                 health and social service agencies;

 

2.     provide services to assist the residents in protecting the health, safety, welfare, and rights of the residents;

 

3.     inform the residents about means of obtaining services provided by providers or agencies;

4.     ensure that the residents have regular and timely access to the services provided through the Office and that the residents and complainants receive timely responses from representatives of the Office to complaints;

 

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

 

6.     provide administrative and technical assistance to entities designated under paragraph (5) to assist the entities in participating in the program;

 

7.     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 the adequacy of long term care facilities and services in the State such as but not limited to:

 

a.      recommending any changes in such laws, regulations, policies, and actions as the Office determines to be appropriate; and

 

b.      facilitating public comment on the laws, regulations, policies, and actions.

 

8.     provide for training representatives of the Office;

 

a.      promote the development of citizen organizations to participate in the program; and

 

b.      provide technical support for the development of resident and family councils to protect the well-being and rights of residents.

303:    Responsibilities of the Office

 

A.        The SLTCO is responsible for the leadership and management of the statewide LTCOP in order to:

 

1.        help resolve problems faced by those who reside in long term care facilities;

 

2.        advocate for broad policy, regulatory and/or legislative changes to improve the care of long term care facility residents;

 

3.        plan, develop, and implement training of the LTCOs and the LTCOPs;

 

4.        maintain a registry of all entities and individual representatives of the Office and the geographic areas for which each has been assigned;

 

5.        coordinate the activities of the LTCOP with other Department on Aging programs and other state and federal agencies involved in the care of long term care facility residents;

 

6.        maintain LTCOP records and the LTCOP reporting system;

 

7.        provide Information and Assistance to the general public, residents, legislators, community organizations and other agencies regarding long term care issues and state and federal licensing, certification and regulation;

 

8.        provide technical assistance to AAAs, Provider Agencies, and ROs;

 

9.        provide LTCOP data and analysis;

 

10.      monitor and evaluate the statewide and Regional LTCOPs;

 

11.      appoint and co-lead an advisory work group with term limits for the LTCOP that represents the AAAs, provider agencies, and ROs for each planning and service area; and,

 

12.      prepare and distribute an annual report as described in the Older Americans Act.

304:  AAA Responsibilities

 

A.       AAAs shall administer, either directly or through contract or grant,  Regional LTCOPs that meet and follow federal and state laws, administrative rules, this Manual and the requirements of the Elder Rights Section of the Department on Aging Area Plan. Where the AAA operated the Regional LTCOP through a grant with IDOA, they shall comply with Section 306 D of this Manual.

 

B.        Any AAA contract or grant provision that requires Regional LTCOP service delivery components or data collection standards, practices or protocols different from those presented in this Manual must be approved in writing by the Office and when necessary, submitting a waiver request.  

 

C.       In administering Regional LTCOP services, the AAA shall:

 

1.           support a full-time Regional Ombudsman for each Regional LTCOP;

 

2.           monitor the fiscal and Ombudsman Annual Service Plan activities of its Regional LTCOPs at least once every three (3) years in order to assess the adequacy of LTCOP services and the internal quality assurance procedures pursuant to the contract or grant with the SLTCO being notified of the monitoring visit.  AAAs need to have an active role in monitoring, however duplication and lack of coordination between AAAs and SLTCO must be avoided;

 

3.           adhere to the maintenance of effort requirements for each Regional LTCOP as required by the Older Americans Act;

 

4.           assure that OAA Title VII LTCOP funds are used exclusively for LTCOP services and direct advocacy program activities;

 

5.           make no requirement for matching funds for OAA Title VII funds received by the AAA for Regional LTCOP services;

 

6.           when appropriate, include the Regional LTCOP in discussions, meetings, conferences, reports and other AAA functions and operations such as boards and advisory councils related to long term care, and to serve as the voice for the long term care facility residents; 

 

7.           have no unremedied conflict of interest; and,

 

8.           provide technical assistance and oversight.

 

D.       AAAs shall support the Regional LTCOP, to the extent possible, by:

 

1.     designating AAA staff to attend SLTCOP sponsored trainings and meetings pertaining to the LTCOP;

 

2.     assisting in the development of resources for the operation of the Regional LTCOP, including financial and human resources;

 

3.     providing opportunities for the Regional LTCOP and other aging and social services organizations to collaborate to promote the health, safety, welfare, and rights of residents;

 

4.     making appropriate referrals to the Regional LTCOP;

 

5.     promoting awareness of LTCOP services to consumers and the general public within the service area; and,

 

6.     recognizing the responsibilities of the RLTCOP to promote systems and issues advocacy on behalf of residents.

 

E.        AAAs shall submit the required financial and program reports to the IDoA and to the Office in accordance with the established departmental instructions.

 

F.        In the selection of a Title III legal assistance provider, the AAA shall award funds to the applicant(s) that most fully meets the standards set forth in 45 CFR 1321.71 (c), to include the capacity to provide support to the Regional LTCOP and the capacity to provide legal services to institutionalized older persons.

 

A.               The AAA shall cooperate with the Office to implement a transition plan to minimize disruption in LTCOP services to residents when the contract or grant for the Regional LTCOP services is terminated or not renewed.

 

H.        The AAA shall perform each of its responsibilities in administering the Regional LTCOP in accordance with all applicable federal and state laws, regulations, policies, and this Manual.

 

I.         Where an AAA provides LTCOP services directly, it must also fulfill the responsibilities of a provider agency as outlined in Section 305 of this Manual.

 

J.        The AAA shall have the lead responsibility to request a waiver pursuant to Chapter 1, Section 104 of this Manual if, due to demonstrable and unusual circumstances, the AAA anticipates it or its provider agency will be unable to comply with responsibilities in this Manual.

305: Provider Agency Responsibilities

 

A.        The provider agency is designated by the SLTCO to house the Regional LTCOP and to assure the provision of ombudsman services in the service area designated by a contract with, or grant from, the AAA or the IDoA.

 

B.        The provider agency shall be the sole provider of LTCOP services in the service area designated through contract with, or grant from, the AAA or the IDoA.

 

C.        The provider agency shall operate the Regional LTCOP in accordance with the provisions of this Manual and the contract or grant for LTCOP services with the AAA or the IDoA.  Any agency provisions that require LTCOP service delivery components or data collection standards, practices or protocols different from those presented in this Manual must be approved in writing pursuant to Chapter 1, Section 104, C of this Manual.

 

D.       The provider agency shall assure that the Regional LTCOP performs the LTCOP Services Components outlined in Chapter 400.

 

E.        The provider agency shall require the Regional Ombudsman to submit the Regional  LTCOP Annual Services Plan described in Section 407 of this Manual to the AAA for review and comment and to the Office for approval.

 

F.        The provider agency shall provide a full-time Regional Ombudsman, who:

 

6:           meets the applicable minimum qualifications (see Section 308-D of this Manual);

 

7:           has no duties in the agency outside the scope of the LTCOP as defined in state and federal law;

 

8:           consults and participates in the development of an annual Regional LTCOP budget and annual services plan;

 

9:           works full-time to perform LTCOP functions exclusively; and

10:        oversees the activities and functions of developing a regional level advisory group which meets at least three times/ year.

 

G.       Subject to stable local, state and federal funding, adjusted for cost of living increases, and the provisions of an approved Annual Services Plan, the provider agency shall provide sufficient Paid LTCO, in addition to the Regional Ombudsman, if necessary, in order to:

 

4:                 fulfill the LTCOP Services Components described in Chapter 400 of this Manual;

 

5:                 maintain or exceed the level of services provided in the service area during the previous fiscal year in conjunction with the  activities in the Annual Service Plan for the coming year; and

 

6:                 maintain or exceed the level of paid LTCO professional and support staff funded in the service area during the previous fiscal year.

 

G:               The provider agency shall support the Regional LTCOP by:

 

1.                assisting in the development of resources for the operation of the Regional LTCOP, including financial and human resources;

 

2.                providing opportunities for the Regional LTCOP and other aging and social services organizations to collaborate to promote the health, safety, welfare, and rights of residents;

 

3.                promoting awareness of LTCOP services to consumers and the general public within the service area;

 

4.                recognizing the responsibility of  the RLTCOP to promote systems and issues advocacy on behalf of residents; and,

 

5.                providing each regional program with a computer with access to the World Wide Web and internet e-mail capability, a dedicated telephone line if the agency does not have sufficient lines to accommodate callers and usage of a cellular phone for the Regional Ombudsman which enables them to be reached when needed.

 

I.         The provider agency shall assure that Regional LTCOP data, activity reports, and quarterly reports are provided to the AAA in the format and according to the time lines required by the Office.  Financial reports shall be provided to the AAA in the format required by the AAA.

 

J.        The provider agency shall prohibit inappropriate access to LTCOP records located in the custody of the provider agency or unauthorized disclosure of the identity of any resident, complainant or witness with respect to LTCOP files or records.

 

K.        The provider agency shall assure the attendance of all LTCOs at   training for designation.

 

B.                The provider agency shall assure the attendance of the Regional Ombudsman at mandatory statewide LTCOP trainings and meetings.  The Office may approve an exception.

 

C.               The provider agency shall provide professional development opportunities for all LTCOP staff.

 

D.               The provider agency shall provide staff support, case consultation and certified back-up support  as needed for the operation of the LTCOP, such as custodial, fiscal management, clerical, and telephone coverage and supervisory support for program operations.

 

E.                The provider agency shall arrange, in consultation with the Office and the AAA, if applicable, for temporary provision of LTCOP services in the service area when LTCO staff of the provider agency are unavailable or the staff position is vacant.

 

F.                The provider agency shall perform each of its responsibilities in administering the Regional LTCOP in accordance with all applicable federal and state laws, regulations, and this Manual.

306:    Designation of Regional LTCOPs

 

A.        The SLTCO shall designate provider agencies to provide ombudsman services throughout Illinois.

 

B.        In order to be eligible for designation by the SLTCO as a provider agency, an entity must: