State Long-Term Care Ombudsman Program Revised Primer for State Agencies

State Log-Term Care Ombudsma Program 2019 Revised Primer for State Agecies

The NATIONAL LONG-TERM CARE OMBUDSMAN RESOURCE CENTER (NORC) was established as a result of 1992 amedmets to the Older Americas Act. Its purpose is to ehace the skills, kowledge, ad maagemet capacity of the State Log-Term Care Ombudsma Programs. The Ceter provides atioal techical assistace, traiig ad iformatio dissemiatio, servig as a resource o Ombudsma Programs fuded by State Agecies o Agig. The Ceter is admiistered by The Natioal Cosumer Voice for Quality Log-Term Care, i cooperatio with the Natioal Associatio of States Uited for Agig ad Disabilities. For more iformatio cotact the Ceter at 1001 Coecticut Ave., NW, Suite 632, Washigto, DC 20036, (202) 332-2275, Fax: (202) 332-2949, www.ltcombudsma.org. The NATIONAL ASSOCIATION OF STATES UNITED FOR AGING AND DISABILITIES (NASUAD) was fouded i 1964 uder the ame Natioal Associatio of State Uits o Agig (NASUA). I 2010, the orgaizatio chaged its ame to NASUAD i a effort to formally recogize the work that the state agecies were udertakig i the field of disability policy ad advocacy. Today, NASUAD represets the atio s 56 state ad territorial agecies o agig ad disabilities ad supports visioary state leadership, the advacemet of state systems iovatio ad the articulatio of atioal policies that support home ad commuitybased services for older adults ad idividuals with disabilities, ad their caregivers. The missio of the orgaizatio is to desig, improve, ad sustai state systems deliverig home ad commuity-based services ad supports for people who are older or have a disability, ad their caregivers. For more iformatio, cotact: NASUAD, (202) 898-2578, Fax: (202) 898-2583, www.asuad.org. The NATIONAL CONSUMER VOICE FOR QUALITY LONG-TERM CARE was fouded out of public cocer for the quality of care i ursig homes i 1975, as the Natioal Citizes Coalitio for Nursig Home Reform. This cosumer-based oprofit orgaizatio advocates for public policies that support care ad quality of life i all log-term care settigs. With the expaded focus to advocate for people who eed log-term care i ay settig, the ame was chaged to The Natioal Cosumer Voice for Quality Log-Term Care. The Cosumer Voice empowers ad educates cosumers ad families by providig them with the kowledge ad tools to advocate for themselves ad their loved oes. Its members comprise a diverse, atioal coalitio of cosumers, citize advocacy groups, state ad local log-term care ombudsme, lawyers, professioal groups, frotlie workers ad uios, cocered providers, atioal orgaizatios, ad family ad residet coucils. For more iformatio cotact: The Cosumer Voice at 1001 Coecticut Ave., NW, Suite 632, Washigto, DC 20036, (202) 332-2275, Fax: (202) 332-2949, www.thecosumervoice.org.

State Log-Term Care Ombudsma Program 2019 Revised Primer for State Agecies

Ackowledgmets Thak you to the followig idividuals who cotributed to the developmet of this documet ad cotiuig coversatio. Hilary Dali, Director, Office of Elder Justice ad Adult Protective Services, Admiistratio for Commuity Livig/Admiistratio o Agig, U.S. Departmet of Health ad Huma Services Becky Kurtz, (former Director of the Office of Log-Term Care Ombudsma Programs) for her sigificat cotributio to the fial Log-Term Care Ombudsma program rule Amity Overall-Laib, Director, Natioal Log-Term Care Ombudsma Resource Ceter (NORC) Adam Mosey, (former) Seior Policy Aalyst, Natioal Associatio of States Uited for Agig ad Disabilities (NASUAD) Martha Roherty, Director, Natioal Associatio of States Uited for Agig ad Disabilities (NASUAD) Louise Rya, Ombudsma Program Specialist, Admiistratio for Commuity Livig/Admiistratio o Agig, U.S. Departmet of Health ad Huma Services Lori Smetaka, Executive Director, Natioal Cosumer Voice for Quality Log-Term Care Edwi Walker, Deputy Assistat Secretary for Agig ad Director of the Office of Log-Term Care Ombudsma Programs About this documet This project was supported, i part, by grat umber #90OMRC0001-01-00 from the U.S. Admiistratio for Commuity Livig, Departmet of Health ad Huma Services, Washigto, DC 20201. Gratees udertakig projects uder govermet sposorship are ecouraged to express freely their fidigs ad coclusios. Poits of view or opiios do ot, therefore, ecessarily represet official Admiistratio for Commuity Livig policy. 2 Natioal Associatio of States Uited for Agig ad Disabilities (NASUAD)

Table of Cotets Itroductio...4 Why a Ombudsma Program Primer for State Agecies?...4 Older Americas Act (OAA) Requiremets...6 Older Americas Act...6 Elder Rights...7 Log-Term Care Ombudsma Program...8 Itroductio to the Ombudsma Program Rule...8 The Ombudsma Program Rule: Key Provisios...10 Establishmet of the Office of the State Log-Term Care Ombudsma...10 Fuctios ad Resposibilities of the State Log-Term Care Ombudsma...13 State Agecy Resposibilities Related to the Ombudsma Program...17 Resposibilities of Agecies Hostig Local Ombudsma Etities...19 Duties of the Represetatives of the Office...19 Coflicts of Iterest...20 Uique Role ad Resposibilities of Log-Term Care Ombudsma...23 Role of the Ombudsma Program i a Chagig Log-Term Services ad Supports Ladscape...26 Appedix A: History of the Log-Term Care Ombudsma Program...30 Appedix B: Glossary of Useful Terms...32 Appedix C: Acroyms...33 Appedix D: Resources...34 Appedix E: Fact Sheet: Log-Term Care Ombudsma Program What You Must Kow...35 Appedix F: Ifographic: Log-Term Care Ombudsma Program...36 State Log-Term Care Ombudsma Program: 2019 Revised Primer for State Agecies 3

Itroductio Why a Ombudsma Program Primer for State Agecies? Ombudsma: a Swedish word meaig aget, represetative, or someoe who speaks o behalf of aother. State Log-Term Care Ombudsma programs (Ombudsma programs) serve as advocates for residets of ursig homes, board ad care homes, assisted livig ad similar adult care facilities. They work to resolve problems of idividual residets ad to brig about improvemets to residets care ad quality of life at the local, state, ad atioal levels. Begu i 1972 as a demostratio program, Ombudsma programs today exist i all States, the District of Columbia, Puerto Rico ad Guam, uder the authorizatio of, ad appropriatios to implemet, the Older Americas Act (OAA). These states ad territories have a Office of the State Log-Term Care Ombudsma (the Office), headed by a full-time State Log-Term Care Ombudsma (the Ombudsma) 1. This Primer is iteded to support State Agecy 2 Directors to uderstad the uique role of the State Log-Term Care Ombudsma Program. By Cogressioal itet, the admiistratio ad fuctios of the Ombudsma program are i may ways distict from other programs admiistered by State agecies. For istace, ulike most OAA programs, this is a statewide program, headed by the Ombudsma, who heads the Office of State Log- Term Care Ombudsma ad leads the Ombudsma program uder a established set of policies ad procedures. These federal provisios also mea that the Ombudsma program may ot easily fit withi a typical agecy structure. While the Ombudsma may work as a state employee or uder the directio of the State Agecy director, the Ombudsma does have specific fuctios that require idepedece ad autoomy. The Ombudsma s duties also require a good workig relatioship amog agecies that support the itet of the Older Americas Act as laid out i the statute ad the implemetig regulatio for the Log-Term Care Ombudsma Program. The Ombudsma collaborates with the State Agecy to desig ad implemet a elder rights ageda withi the Agig Network but must represet logterm care residets autoomously. 1 I this documet, Ombudsma refers to the State Log-Term Care Ombudsma who heads the Office of the State Log-Term Care Ombudsma as stipulated i the OAA. 2 The term State Agecy, State Uit o Agig, State uit ad State agecy are sometimes used iterchageably ad have the same meaig. 4 Natioal Associatio of States Uited for Agig ad Disabilities (NASUAD)

I 2015, the Admiistratio for Commuity Livig (ACL) promulgated the first federal regulatio specifically focused o the Ombudsma program ad aimed to create greater aligmet ad cosistecy across state Ombudsma programs. The regulatio provides clarificatio ad delieatio aroud the fuctios ad resposibilities of the Ombudsma program ad the State Agecy. The regulatio also articulates specific provisios for State Log Term Care Ombudsma operatios, such as coflict of iterest, exemptio from madatory reportig requiremets, amog other key requiremets. Throughout this Primer, you will fid boxes titled For Cosideratio, Coversatio Starters, I Practice, ad Key Resources to highlight the uique aspects ad resources of the program. The For Cosideratio prompts may assist State Agecy Directors to thik through key poits regardig State Agecy resposibilities to the Ombudsma program ad the Coversatio Starters ivite State Agecy Directors to iitiate coversatios with the Ombudsma. Get to kow the Ombudsma The Ombudsma has uique expertise ad uderstadig of log-term care services ad supports, offers a idepedet perspective, ad has direct, ope lies of commuicatio with residets i log-term care facilities. Developig a uderstadig of the Ombudsma program work ad commuicatig with them regularly gives the State Agecy Director a compellig perspective of the cosumer s experiece with log-term supports ad services. State Log-Term Care Ombudsma Program: 2019 Revised Primer for State Agecies 5

Older Americas Act Requiremets Older Americas Act I 1972 Cogress established a Ombudsma program to help provide a source of idepedet support to ursig home residets. The Ombudsma program provides iformatio to cosumers about their log-term care optios, works to resolve problems o behalf of residets, ad advocates from improvemets i the log-term services ad supports system. The Ombudsma program has several characteristics that are uique to this program ad are ulike other parts of the OAA. The OAA icludes provisios that aim to protect vulerable elders by stregtheig the Log-Term Care Ombudsma Program ad elder abuse screeig ad prevetio efforts. The 2016 OAA clarified two fuctios of the Ombudsma program icludig 3 : Clarificatio that the Log-Term Care (LTC) Ombudsma program has the authority to serve (ad utilize OAA appropriatios to serve) residets of log-term care facilities, regardless of age. Sectio 711(6) reads, The term residet meas a idividual who resides i a log-term care facility. The provisio related to residets trasitioig from a log-term care facility to a home care settig 712(a)(3) FUNCTIONS. The Ombudsma shall, persoally or through represetatives of the Office (I) whe feasible, cotiue to carry out the fuctios described i this sectio o behalf of residets trasitioig from a log-term care facility to a home care settig; ACL iterprets the term whe feasible to mea that Ombudsma programs shall serve this expaded populatio whe adequate resources exist, without dimiishig services to the residet populatio. ACL iterprets this provisio to authorize the use of OAA appropriatios by states for LTC Ombudsma program services to idividuals livig i a home care settig oly durig a trasitio period. 4 3 This excerpt of the ACL frequetly asked questio o the OAA reauthorizatio is ot a comprehesive review of all OAA reauthorizatio provisios; see https://www.acl.gov/about-acl/authorizig-statutes/older-americas-act for a full review of the 2016 OAA reauthorizatio. 4 This excerpt of the ACL frequetly asked questio o the OAA reauthorizatio. 6 Natioal Associatio of States Uited for Agig ad Disabilities (NASUAD)

Elder Rights ad the Log-Term Care Ombudsma Program Title VII of the Older Americas Act icludes the Ombudsma programs (Chapter 2), Programs for Prevetio of Elder Abuse, Neglect, ad Exploitatio (Chapter 3) ad State Legal Assistace Developmet Program (Chapter 4). These sectios are together uder Elder Rights to emphasize multi-discipliary ad collaborative approaches to promotig the health safety, welfare, ad rights of log-term care residets ad supports the State agecy s coordiatio of programs [to address elder abuse, eglect ad exploitatio] with other state ad local program ad services for the protectio of vulerable adults. 5 The goal for the State LTC Ombudsma Program, legal assistace, ad the elder abuse prevetio programs is to develop strog likages, both iside ad outside the traditioal agig etwork, to support older persos advocacy eeds. I developig a elder rights system, each state is required to: Obtai the views of older persos, Area Agecies o Agig, service providers, ad other iterested persos ad etities regardig Title VII programs Idetify ad prioritize statewide elder rights activities; 6 ad Coordiate, to the greatest extet possible, Ombudsma services with legal assistace provided uder sectio 306(a)(2)(C), through adoptio of memorada of uderstadig ad other meas. 7 Throughout their history, Ombudsme have built skillful coalitios ad successfully egotiated agreemets with a variety of agecies ad programs, ad ivolved residets ad families i developig their advocacy ageda. This creates a iterestig dyamic as the Ombudsma parters with the state to desig ad implemet a elder rights ageda ad admiister a program withi the Agig Network but is also resposible for idepedetly represetig log-term care residets. 5 Sectio 721(d) of the Act. 6 Sectio 705 of the Act. 7 Sectio 712 of the Act. State Log-Term Care Ombudsma Program: 2019 Revised Primer for State Agecies 7

Log-Term Care Ombudsma Program The Older Americas Act calls upo the Ombudsma 8 to be resposible for the maagemet, icludig the fiscal maagemet, of the Office of the Ombudsma ad to persoally or through represetatives of the Office: Idetify, ivestigate, ad resolve complaits made by or o behalf of residets. Provide iformatio to residets about Log-Term Services ad Supports (LTSS). Esure that residets have regular ad timely access to Ombudsma program services. Represet the iterests of residets before govermetal agecies ad seek admiistrative, legal, ad other remedies to protect residets. Aalyze, commet o, ad recommed chages i laws ad regulatios pertaiig to the health, safety, welfare, ad rights of residets. Promote the developmet of ad assist citize advocacy groups that wat to protect the well-beig ad rights of residets. Provide techical support for the developmet of residet ad family coucils to protect the wellbeig ad rights of residets. IN PRACTICE May idividuals livig i log-term care facilities, as well as their family members, may ot have regular access to the iteret, so it is likely Ombudsma programs will cotiue to eed to make resources ad iformatio available i prit (e.g., fact sheets regardig residet rights, posters about the Ombudsma program). Itroductio to the Ombudsma Program Rule This sectio reviews sigificat portios of the Ombudsma program federal rule 45 CFR Part 1324 with supportig referece to the Older Americas Act. The fuctios of the Ombudsma program were outlied i the OAA sice the creatio of the program i the 1970s; however, regulatios were ot promulgated specifically focused o States implemetatio of the program. I the absece of regulatio, there has bee sigificat variatio i the iterpretatio ad implemetatio of these provisios amog states. The State Log-Term Care Ombudsma Programs rule, published i February 2015, became effective o July 1, 2016. 8 This is a broad overview of the fuctios ad resposibilities. For specific details see Sectio 712 SEC. 712. State Log-Term Care Ombudsma Program of the Older Americas Act. https://www.acl.gov/ode/650/ 8 Natioal Associatio of States Uited for Agig ad Disabilities (NASUAD)

Purpose of the Rule: Admiistratio for Commuity Livig Perspective AoA believes that cosumers (particularly residets of log-term care facilities) ad log-term care providers will beefit from the implemetatio of this rule. Cosumers ad other complaiats across the coutry will receive services from Ombudsma programs with more cosistet quality ad efficiecy of service delivery. For years, States, Ombudsme, ad represetatives of the Offices of State Log-Term Care Ombudsme have reported to AoA that they have foud some provisios of the Act cofusig to implemet. This rule seeks to provide the clarity that Ombudsma program stakeholders have requested. Admiistratio o Agig/Admiistratio for Commuity Livig, preamble of the Log-Term Care Ombudsma Program Rule, 7704 Federal Register / Vol. 80, No. 28 / Wedesday, February 11, 2015 / Rules ad Regulatios The rule addresses: Resposibilities of key figures i the system, icludig the Ombudsma ad represetatives of the Office of the Ombudsma; State agecy resposibilities related to the Ombudsma program; Resposibilities of the etities i which LTC Ombudsma programs are housed; Criteria for establishig cosistet, perso-cetered approaches to resolvig complaits o behalf of residets, icludig the role of LTC Ombudsma programs i resolvig abuse complaits; ad Processes for idetifyig ad remedyig orgaizatioal ad idividual coflicts of iterest so that residets have access to effective, credible Ombudsma services. KEY RESOURCES This Primer does ot ited to cover all aspects of the Ombudsma program rule or the Older Americas Act. Visit the Natioal Log-Term Care Ombudsma Resource Ceter (NORC) website, Log-Term Care Ombudsma Program Fial Rule page for liks to the Rule ad materials created by the Admiistratio for Commuity Livig ad NORC. This page is your oe-stop for frequetly asked questios, webiars, issue briefs, side-by-side charts, techical assistace resposes, ad state resources regardig the Rule. http://ltcombudsma.org/library/fed_laws/ltcop-fial-rule. State Log-Term Care Ombudsma Program: 2019 Revised Primer for State Agecies 9

The Ombudsma Program Rule: Key Provisios culmiatio of several years of collaborative work with states ad other parters, this A rule guides implemetatio of the portios of the OAA goverig grats to states for operatio of Log-Term Care Ombudsma Programs. 9 KEY RESOURCES Program Structure Visit NORC s Ombudsma Program Structure ad Maagemet page for more iformatio, icludig the State Log-Term Care Ombudsma Programs: Orgaizatioal Structure report http://ltcombudsma.org/omb_support/pm/structure-maagemet Establishmet of the Office of the State Log-Term Care Ombudsma The rule, i accordace with the OAA, requires the State agecy to establish the State Log- Term Care Ombudsma Office as a distict etity that is separately idetifiable i order to provide ease of access for residets ad complaiats ad to effectively meet other statutory requiremets of the Office. The State agecy may establish ad operate the Office, ad carry out the program, directly, or by cotract or other arragemet with ay public agecy or oprofit private orgaizatio. CONVERSATION STARTERS Program Structure What are your state program s stregths ad weakesses regardig: Visibility ad accessibility of the program? Coflicts of iterest with other etities? What efforts has the program made to address idetified weakesses? What structural chages could the program make to address such weakesses? What are the beefits ad challeges regardig program effectiveess ad collaboratio i the curret structure? 9 This overview does ot cover all provisios of the regulatio, to view the full regulatio see 45 CFR 1324. 10 Natioal Associatio of States Uited for Agig ad Disabilities (NASUAD)

Policies ad Procedures Policies ad procedures specify how the Ombudsma program is carried out i accordace with the Act. Some states covey legal authority upo the Ombudsma to establish policies ad procedures, i cosultatio with the State agecy. I states that do ot have a law that provides the Ombudsma with legal authority to establish policies ad procedures, the Ombudsma shall recommed policies ad procedures to the State agecy or other agecy i which the Office is orgaizatioally located, ad such agecy shall establish Ombudsma program policies ad procedures. The developmet of policies ad procedures must iclude cosultatio with the agecies hostig local Ombudsma etities ad with represetatives of the Office. The policies ad procedures must address the followig provisios: Program admiistratio to moitor local Ombudsma etities by the Ombudsma; stadards of promptess for complait resposes; Procedures for access to facilities, residets, ad appropriate records; Procedures for Disclosure Disclosure is prohibited uless there is residet coset. Must address steps required i order to disclose residet idetifyig iformatio for purposes of complait resolutio. Must clarify that the files, records, ad iformatio maitaied by the Ombudsma program may be disclosed oly at the discretio of the Ombudsma. Must exclude the Ombudsma ad represetatives of the Office from abuse reportig requiremets, icludig whe such reportig would disclose idetifyig iformatio of a complaiat or residet without appropriate coset or court order. Coflicts of iterest of both idividual ad orgaizatioal. Systems advocacy require the Office has sufficiet authority to carry out its statutory resposibilities, as the Office determies is appropriate, ad regardless of State lobbyig laws. Desigatio establish the criteria ad process by which the Ombudsma shall desigate ad refuse, susped, or remove desigatio of local Ombudsma etities ad represetatives of the Office. Grievace process describe the receipt ad review of grievaces regardig the determiatios or actios of the Ombudsma ad represetatives of the Office. State Log-Term Care Ombudsma Program: 2019 Revised Primer for State Agecies 11

Determiatios of the Office the Ombudsma, as head of the Office, shall be able to idepedetly make determiatios ad establish positios of the Office, without ecessarily represetig the determiatios or positios of the State agecy or other agecy i which the Office is orgaizatioally located, regardig: Disclosure of iformatio maitaied by the Ombudsma program. Recommedatios to chages i Federal, State ad local laws, regulatios, policies ad actios pertaiig to the health, safety, welfare, ad rights of residets. Provisio of iformatio to public ad private agecies, legislators, the media, ad other persos, regardig the problems ad cocers of residets ad recommedatios to address those problems ad cocers. CONVERSATION STARTERS Policies ad Procedures I your state, does the Ombudsma have the legal authority to establish policies ad procedures? Are there ay remaiig policies ad procedures to complete? Are there ay roadblocks to achievig full implemetatio of the Ombudsma program regulatio? Have represetatives of the Office ad local Ombudsma etities (if applicable) received traiig o the program policies ad procedures? KEY RESOURCES Ombudsma Program Policies ad Procedures Visit NORC s Policies ad Procedures page for state Ombudsma program examples. (http://ltcombudsma.org/omb_support/pm/policies). 12 Natioal Associatio of States Uited for Agig ad Disabilities (NASUAD)

Fuctios ad Resposibilities of the State Log-Term Care Ombudsma The Ombudsma, as head of the Office, has the resposibility for the leadership ad maagemet of the Office i coordiatio with the State agecy, ad, where applicable, ay other agecy carryig out the Ombudsma program. This maagemet icludes programmatic oversight of the local Ombudsma etities ad represetatives of the Office. Fuctios ad Resposibilities I additio to the complait ivestigatio ad systems advocacy previously described, the Ombudsma, as head of a uified statewide program, is resposible for a variety of programmatic fuctios. The Ombudsma must: 1. Require represetatives of the Office to fulfill the duties i accordace with Ombudsma program policies ad procedures. 2. Determie the use of the fiscal resources appropriated or otherwise available for the operatio of the Office. 3. Desigate local Ombudsma etities, staff ad voluteer represetatives of the Office, icludig the followig programmatic requiremets Review ad approval of plas or cotracts goverig local Ombudsma etity operatios, icludig, where applicable, through Area Agecy o Agig plas, i coordiatio with the State agecy. Moitor local Ombudsma etities. Establish certificatio traiig requiremets for purposes of desigatio. Ivestigate allegatios of miscoduct by represetatives of the Office. Implemet procedures for refusal, suspesio, or removal of desigatio of etities ad represetatives. State Log-Term Care Ombudsma Program: 2019 Revised Primer for State Agecies 13

CONVERSATION STARTERS Program Maagemet Do all idividuals who may eed Ombudsma program services have access to the program? Do they receive timely resposes to their complaits? What is your stadard of timeliess? Withi the past year, what has the Ombudsma program doe to try to address cosumer access to the program? How frequetly do represetatives of the Office submit their complait ad activity data? Do you see differeces i complait treds betwee ursig homes ad board ad care facilities? If you do, how do you ad the Ombudsma uderstad the differeces? How does the Ombudsma determie the use of fiscal resources appropriated or otherwise available for the operatio of the Office? What ca the State agecy do to support the program s efforts? IN PRACTICE Reportig to the Assistat Secretary for Agig: Natioal Ombudsma Reportig System (NORS) States fulfill their obligatio to report to the Assistat Secretary by reportig their NORS data i the ACL approved software-reportig system. NORS data icludes umeric data o cases, complaits ad program activities ad arratives o systems issues, complait examples ad orgaizatioal coflicts of iterest idetificatio ad remedies. ACL s Office of Log-Term Care Ombudsma Programs welcomes Ombudsma program reports i other formats i additio to the submissio of the aual NORS report. 14 Natioal Associatio of States Uited for Agig ad Disabilities (NASUAD)

Aual Report The Ombudsma is to idepedetly develop ad provide fial approval of a aual report. The report is to be available to the public ad submitted to the Assistat Secretary, the Goveror, the state Legislature, the State Agecy, the State Licesig ad Certificatio Agecy, ad other appropriate etities. The report must: Describe the activities carried out by the Office i the year for which the report is prepared; Cotai aalysis of Ombudsma program data; Describe evaluatio of the issues experieced by, ad the complaits made by or o behalf of residets; Cotai policy, regulatory, ad/or legislative recommedatios for improvig quality of the care ad life of the residets; protectig the health, safety, welfare, ad rights of the residets; ad resolvig residet complaits ad idetified problems or barriers; Cotai aalysis of the success of the Ombudsma program, icludig success i providig services to residets of, assisted livig, board ad care facilities, ad other similar adult care facilities; ad Describe barriers that prevet the optimal operatio of the Ombudsma Program. FOR CONSIDERATION Data Are there opportuities for the State agecy to utilize NORS data i developig state pla goals ad objectives? CONVERSATION STARTERS Data How is NORS data used for advocacy ad program maagemet? What would improve your ability to use NORS data for advocacy ad program maagemet? What types of treds (complaits, visits, voluteer umbers, etc.) have you idetified? State Log-Term Care Ombudsma Program: 2019 Revised Primer for State Agecies 15

Coordiatio with Other Etities KEY RESOURCES Visit NORC s Program Maagemet page for iformatio regardig collaboratig with other etities, icludig two toolkits (Log-Term Care Ombudsma Programs ad Legal Assistace Developers Collaboratio Toolkit ad Log-Term Care Ombudsma Programs ad Protectio & Advocacy Agecies Collaboratio Toolkit), https://ltcombudsma.org/omb_support/pm. These Toolkits iclude sample Memoradum of Uderstadig (MoU) ad a MoU template. The Rule requires Ombudsma program coordiatio with etities, such as Older Americas Act-fuded legal assistace providers, Protectio ad Advocacy Systems, ad the State Licesig ad Certificatio Agecy, but the ature of that coordiatio may vary. While memorada of uderstadig are a commo approach to clarify ad formalize a workig relatioship betwee etities, they may ot be the best mechaism to promote successful coordiatio i every istace. However, the Act specifically requires adoptio of memorada of uderstadig with respect to coordiatio with oe etity: Title IIIB legal assistace providers ad the State s Legal Assistace Developer. CONVERSATION STARTERS Coordiatio with Other Agecies Does the program have Memorada of Uderstadigs (MOUs) with other programs to esure each program uderstads what services each ca provide ad how ad whe they will work together (e.g., OAA-fuded legal assistace providers, Adult Protective Services (APS), State Licesig ad Certificatio Agecy)? How does the Ombudsma program work with other state agecies or programs, such as State, Licesig ad Certificatio Agecy, APS, Protectio ad Advocacy, the Legal Assistace Developer? Ca you share examples of coordiatio with each of these etities? What barriers have bee idetified which prevet the program from workig more closely with regulatory agecies ad other advocacy programs? What ca the State agecy do to facilitate a coordiated advocacy approach? 16 Natioal Associatio of States Uited for Agig ad Disabilities (NASUAD)

State Agecy Resposibilities Related to the Ombudsma Program The State agecy has distict resposibilities to the program icludig assurace of Ombudsma compliace with the OAA ad the rule ad that the Ombudsma program has sufficiet authority ad access to facilities, residets, ad iformatio eeded to perform the fuctios, resposibilities, ad duties of the Office. The State Agecy is to Provide Traiig opportuities a State agecy may utilize Title IIIB ad Title VII fudig for this purpose. Persoel supervisio ad maagemet for the Ombudsma ad represetatives of the Office who are employees of the State agecy, icludig assessmet of Office fulfillmet of fuctios. Cotract moitorig, icludig fiscal moitorig, where applicable; ad may request reports of aggregated program data for this purpose. Additioally, the State agecy is to esure regardless of the orgaizatioal placemet of Office that Reviews of files, records or other iformatio maitaied by the Ombudsma program is cosistet with the rules goverig disclosure limitatios. It has mechaisms to prohibit ad ivestigate allegatios of iterferece, retaliatio, ad reprisals regardig Ombudsma program duties ad provide for sactios. provides for adequate legal cousel for the program that has competecies relevat to the legal eeds of the program ad of residets ad is without coflict of iterest. requires the Office to provide fial approval of a aual report. IN PRACTICE NORC hosts a aual atioal traiig coferece for State Ombudsme ad provides orietatio traiig for ew State Ombudsme. The OAA states that the State Agecy must esure that the Ombudsma or a desigee participates i traiig provided by the Natioal Ombudsma Resource Ceter [OAA Sectio 712 (h)(4)]. Although may of the fuctios of the Ombudsma program by their very ature are to be autoomous from other State agecy operatios, there are importat prescribed fuctios for the State agecy cocerig the program. For example, the Older Americas Act requires the State agecy to esure that the Ombudsma sets expectatios for both staff traiig ad moitorig of local Ombudsma etities. State Log-Term Care Ombudsma Program: 2019 Revised Primer for State Agecies 17

CONVERSATION STARTERS Program Moitorig What is your assessmet of the quality of the Ombudsma program i our state? What efforts has the program made to ivolve cosumers ad other stakeholders i assessig program effectiveess ad quality? How ca the program improve the quality of services? Do you routiely review NORS data to esure data quality? FOR CONSIDERATION As the State agecy Director, how do you assess whether the Ombudsma program is performig all the fuctios, resposibilities, ad duties required of the Ombudsma ad represetatives of the Office? Does your Ombudsma program provide your State agecy with data (for example, mothly or quarterly reports for moitorig purposes)? Legal Cousel Specific State agecy requiremets related to legal cousel iclude: Represetatio of ay represetative of the Office agaist whom suit or other legal actio is brought or threateed to be brought i coectio with the performace of the official duties. (Older Americas Act Sectio 712(g)(1)(B); 45 CFR 1324.15(j)(1)(iii)). Legal cousel for advice ad cosultatio eeded to protect the health, safety, welfare, ad rights of residets. I additio, legal cousel is required to be available to assist the Ombudsma ad represetatives of the Office i the performace of the official duties of the Ombudsma ad represetatives. (OAA Sectio 712(g)(1)(A); 45 CFR 1324.15(j) (1)(i)). Depedig o idetified programmatic eeds, examples could iclude legal advice related to: Developig programmatic policies or legal documets (e.g., program regulatios, cotracts, ad policy ad procedure maual reviews). Systems advocacy o behalf of residet iterests (e.g., review of legislatio, draftig of recommeded legislative or regulatory laguage). Complait resolutio for complex cases, icludig those that ivolve legal issues. Advice, draftig resposes, ad/or represetatio i respose to formal requests for disclosure of program iformatio (e.g., depositios, subpoeas, iterrogatories, public records requests). 18 Natioal Associatio of States Uited for Agig ad Disabilities (NASUAD)

The Ombudsma, i coordiatio with the State agecy, may beeficially assess their programmatic eeds for legal assistace ad determie umet eeds for access to adequate, available, competet, ad coflict-free legal cousel. It is possible that oe law firm or attorey ca best serve the Ombudsma program legal eeds. Alteratively, the Ombudsma program may eed to access legal services from a variety of sources depedig o the legal eeds. Merely havig a Ombudsma or represetative of the Office who is a licesed attorey is ot sufficiet by itself to meet the requiremets of the Rule. 10 Resposibilities of Agecies Hostig Local Ombudsma Etities States with local Ombudsma etities may divide some resposibilities betwee the host agecy ad the Ombudsma. For example, the host agecy may retai the authority over the persoel fuctios of the agecy, such as hirig ad firig. However, the Ombudsma must have resposibility for the programmatic fuctios of the Ombudsma program, icludig desigatio ad de-desigatio of represetatives of the Office. 11 Represetatives of the Office, icludig those hired by (or voluteers maaged by) a local Ombudsma etity, are to be accoutable to the head of the Office (i.e., the Ombudsma) for purposes of Ombudsma program operatios. For example, they must follow the policies, procedures, ad guidace of the Ombudsma regardig complait processig ad other Ombudsma program activities. I additio, the Ombudsma must provide techical assistace to represetatives of the Office. (OAA Sectio 712(a)(3)(F); 45 CFR 1324.13(a)(6)). Duties of the Represetatives of the Office Through desigatio, both paid, ad voluteer represetatives of the Office address complaits ad must follow the programs policies ad procedures about receivig ad resolvig complaits. Represetatives of the Office are typically the eyes ad ears of the Ombudsma program, addressig residet complaits; supportig residet ad family coucils; ad educatig residets, families, facility staff, ad other stakeholders o residet rights, quality care, ad similar matters. This uique role allows the Ombudsma to expad the reach of the program throughout the state. A key duty of represetatives of the Office is to idetify, ivestigate, ad resolve complaits made by or o behalf of residets. The Ombudsma program rule clarifies may aspects of complait hadlig to support the represetatives of the Office i coductig perso-cetered problem solvig ad complait resolutio. The 2015 Ombudsma rule clarifies the Ombudsma program role related to abuse, eglect, or exploitatio complaits where residets are uable to commuicate iformed coset; it also provides guidace o what to do whe the Ombudsma or represetative of the Office persoally witesses abuse. These provisios support the Ombudsma program to assist those residets i eed of itervetio to address suspected abuse, eglect or exploitatio. 10 45 CFR 1324.15(j)(3)). 11 ACL Frequetly Asked Questios (FAQ) https://www.acl.gov/ode/762 State Log-Term Care Ombudsma Program: 2019 Revised Primer for State Agecies 19

Perso-Cetered Complait Processig Approach The Ombudsma or Represetative of the Office shall support ad maximize residet participatio by: Offerig privacy; Discussig the complait with the residet (ad/or residet s represetative) i order to: Determie the perspective of the residet; Request iformed coset i order to ivestigate the complait; Determie the wishes of the residet with respect to the resolutio of the complait; Disclosure of iformatio to the facility ad/or outside agecies; Advise the residet of his/her rights; Work with the residet to develop a pla of actio for resolutio of the complait; Ivestigate to determie whether the complait ca be verified; ad Determiig whether the complait is resolved to the residet s satisfactio. 12 The Ombudsma program ca work with the appropriate residet represetative if a residet is uable to commuicate coset. The Ombudsma program has the authority to work to resolve complait (ad disclose relevat iformatio) whe the residet is uable to commuicate iformed coset, ad has o residet represetative available to do so. If a residet caot coset, the represetative of the Office may refer ad disclose residetidetifyig iformatio to appropriate agecies uder certai criteria ad with the coset of the Ombudsma. Coflicts of Iterest The State Agecy ad the Ombudsma are resposible for idetifyig coflicts that may impact the effectiveess ad credibility of the work of the Office [ 1324.21(c)(1)]. The Ombudsma program Rule requires the establishmet ad implemetatio of policies ad procedures related to coflicts of iterest icludig a process to idetify ad remove or remedy coflicts of iterest. The purpose is described i the Ombudsma program rule preamble which states; We believe that the approach we have take i the fial rule at 1324.21, which provides for aual idetificatio of orgaizatioal coflicts ad descriptio of steps take to remedy or remove coflicts, will provide a orderly process that will implemet the requiremets of the Act, ehace trasparecy, avoid burdesome reportig requiremets o Ombudsma programs, ad emphasize the importace of States providig credible, coflict-free Ombudsma programs for residets. 13 12 45 CFR 1324.19(b) 13 ACL/AoA Log-Term Care Ombudsma Program rule preamble (page 188) 20 Natioal Associatio of States Uited for Agig ad Disabilities (NASUAD)

FOR CONSIDERATION Coflicts of Iterest Does program moitorig iclude a review of coflicts of iterest screeig tools, both idividual ad orgaizatioal? Does the State agecy eed to eact ay orgaizatioal or procedural restructurig to esure proper firewalls exist betwee the Ombudsma program ad other programs? The Rule Requires Five Steps Regardig Orgaizatioal Coflicts of Iterest (COI) 1. Avoid COI prior to desigatig or reewig desigatio. 2. Establish a process for periodic review ad idetificatio of COI. 3. Require disclosure of COI ad steps take to remove or remedy. 4. Establish criteria ad process for review ad approval of steps to remedy or remove the COI. 5. Report idetified coflicts ad remedies through the Natioal Ombudsma Reportig System. Prohibited Coflict of Iterest those that caot be remedied Placemet of the Office i the orgaizatio that: Is resposible for licesig, surveyig or certifyig LTC facilities; Is a associatio (or a affiliate of such a associatio) of LTC facilities; or Has owership, operatioal, or ivestmet iterest i a LTC facility. The Rule Requires Four Steps Regardig Idividual Coflicts of Iterests 1. Establish ad implemet coflict of iterest policies ad procedures. 2. Idetify coflicts of iterests. 3. Avoid appoitig or desigatig idividuals with a coflict of iterests. 4. Remove or remedy the coflict. The State agecy must esure that o idividual, or member of the immediate family of a idividual, ivolved i the desigatig, appoitig, otherwise selectig or termiatig the Ombudsma is subject to a coflict of iterest. State Log-Term Care Ombudsma Program: 2019 Revised Primer for State Agecies 21

Prohibited Idividual Coflict of Iterest For Ombudsma: Has bee employed by or participatig i the maagemet of a LTC facility withi the previous twelve moths. For represetatives of the Office: curret employmet, receipt of, or right to receive remueratio from a facility or its maagemet. Has direct ivolvemet i licesig, surveyig, or certifyig LTC facilities. Has owership, operatioal, or ivestmet iterest i a LTC facility. CONVERSATION STARTERS Coflicts of Iterest Orgaizatioal Coflicts of Iterest How do the State agecy ad the Ombudsma cosider both the orgaizatioal ad idividual coflicts of iterest that may affect the effectiveess ad credibility of the work of the Office? What are the program s stregths ad weakesses regardig ay coflicts of iterest with other state agecies such as state licesig agecies, APS? What efforts has the program made to address ay weakesses? Idividual Coflicts of Iterest Does the program, icludig local Ombudsma etities where applicable, have established coflict of iterest policies ad procedures? Do the policies ad procedures iclude mechaisms, such as screeig questios o applicatios, iterview questios, disclosure of coflicts form to assist with idetificatio of coflicts? Do the policies ad procedures outlie mechaisms to remove or remedy the coflicts? 22 Natioal Associatio of States Uited for Agig ad Disabilities (NASUAD)

Uique role ad resposibilities of Log-Term Care Ombudsma The State agecy will have situatios where a iteral coflict betwee the Ombudma's resposibility to advocate directly for LTC residets might coflict with the views of the State agecy. It is importat to ote that this aspect of Ombudsma work is commo ad occurs i may other kids of Ombudsma programs aroud the world (e.g., busiess Ombudsma, college Ombudsma, govermet Ombudsma, etc. 14 ). Whe ecessary, educatio to other state agecies ad/or the goveror s office ca provide a full uderstadig of the uique role the Ombudsma has i makig recommedatios, which may differ from others i state govermet. This applies equally to Ombudsma programs that are ot part of state govermet. Regardless of the orgaizatioal structure, State agecies must eable the Ombudsma to fulfill all of the fuctios of the State Log- Term Care Ombudsma. Systems Advocacy A Idepedet Voice O-goig ad ope commuicatio betwee the State Ombudsma ad the State Agecy Director is critical. The Ombudsma has a good pulse o emergig issues facig residets i log-term care facilities. The State Ombudsma keeps me well iformed o his advocacy efforts ad positios o key issues. While we have differet roles ad resposibilities, we work together i a very complemetary way to iform policy deliberatio ad mometum i addressig these issues. Lora Coolly, Former Califoria State Agig Director ad NASUAD Past Presidet I additio to idividual problem resolutio, Ombudsma programs advocate for residet iterests i public policy areas. The OAA requires the Ombudsma to aalyze, commet o, ad recommed chages i laws, regulatios, ad govermet policies ad actios to beefit residets. Ombudsme commoly refer to this resposibility as systems advocacy. A state s policies ad procedures must assure that the Office of the State Log-Term Care Ombudsma is required ad has sufficiet authority to carry out its resposibility to, amog other thigs, recommed chages to laws, regulatios, ad policies as the Office determies to be appropriate. 15 Such procedures must exclude the Ombudsma ad represetatives of the Office from ay state lobbyig prohibitios to the extet that such requiremets are icosistet with sectio 712 of the Act. 14 See The America Bar Associatio Ombuds Stadards, which describes various Ombudsma models. http://apps.americabar.org/dch/thedl.cfm?fileame=/al322500/sitesofiterest_files/last_year.doc 15 Older Americas Act Sectio 712(h)(2); 45 CFR 1324.11(e)(5) State Log-Term Care Ombudsma Program: 2019 Revised Primer for State Agecies 23

The Ombudsma must fulfill other fuctios related to systems advocacy, icludig leadership to statewide systems advocacy efforts of the Office icludig coordiatio of systems advocacy efforts carried out by represetatives of the Office. 16 Examples of Ombudsma Systems Advocacy Strategies Iitiatig dialogue with policymakers, agecy heads, legislators, ad their staff regardig idetified problems for residets that require a system level resolutio Respodig ad actively egagig i legislative ad regulatory proposals Submittig writte commets o state/federal regulatios Testifyig at legislative committee meetigs or public hearigs Systems Advocacy i Practice IN PRACTICE Advocacy ad represetig the iterests of residets at the state, local, ad federal level ca iclude may cocers about the actios or iactios of a wide variety of etities that ca positively or egatively affect a residet s health, safety, or welfare. The Ombudsma ot oly egages i systems advocacy at a local ad state level but also must be aware of policies from a atioal perspective, which may impact idividuals receivig log-term care services ad the state. The Natioal Associatio of State Log-Term Care Ombudsma Programs (NASOP) helps iform State Ombudsme of atioal log-term services ad supports issues ad opportuities for advocacy. Ombudsme report their systems advocacy ageda, barriers, ad resolutio strategies i the Natioal Ombudsma Reportig System (NORS) each year. Reported i Federal Fiscal Year 2016 is that iappropriate evictio ad discharge cotiue to be the most commo complait amog residets i ursig homes ad board ad care settigs. Ombudsma programs support idividual residets to oppose the evictio ad work to address the root causes through systems advocacy. 16 45 CFR 1324.13(a)(7)(iv) 24 Natioal Associatio of States Uited for Agig ad Disabilities (NASUAD)

Examples of ways Ombudsme support residets through system advocacy iclude: Developig task forces, proposig legislatio, speakig with the media to educate the public. Traiig both hospital social workers ad log-term care facility staff o relevat requiremets. Traiig residets ad their families o their rights regardig discharge ad trasitioig out of a log-term care facility. CONVERSATION STARTERS Systems Advocacy Withi the past year, what systems advocacy activities have the Ombudsma iitiated or accomplished? What is the Ombudsma program s advocacy ageda for the curret year? How is the advocacy ageda developed? Are there barriers to Ombudsma program (state ad local level) participatio i advocacy (e.g., speakig with legislators, the media, ad the public)? If so, what are they? What would it take to remove the barriers? Describe your leadership strategies to coordiate ad geerate participatio i systems advocacy with Ombudsma program represetatives. What ca the State agecy do to improve the program s ability to egage i systems advocacy? May Ombudsme ad State agecy Directors fid clear commuicatio about public policy ad legislative issues to be cetral to a successful workig relatioship. I may cases, they will work together to strategize about how to support the program s priorities o behalf of idividuals livig i log-term care facilities. I some cases, State agecy Directors work to educate other state agecies ad Goverors offices about the Ombudsma program ad its positios o specific legislative issues. State Log-Term Care Ombudsma Program: 2019 Revised Primer for State Agecies 25

Home ad Commuity-Based Services KEY RESOURCES Systems Advocacy Visit NORC s Systems Advocacy page for additioal iformatio icludig a resource titled, Role ad Resposibilities of Ombudsma Programs Regardig Systems Advocacy. There are separate versios for Ombudsme ad represetatives of the Office (http://ltcombudsma.org/omb_support/advocacy). The Ombudsma program i a chagig Log-Term Services ad Supports Ladscape Role of the Ombudsma Program i a Chagig Log-Term Services ad Supports Ladscape The role of the Ombudsma i the plaig of a moderized system of log-term services ad supports (LTSS) is evolvig. As states trasform their log-term care services with a focus o perso-cetered commuity settigs, the role of the Ombudsma program may expad. Historically, the role of the Ombudsma is to hold systems accoutable to fulfill their resposibilities to residets. The potetial role for the Ombudsma program i this expadig log-term services ad supports system could be the same, esurig that the systems that are i place work toward assurig safety ad quality for cosumers. Ombudsma programs have a kowledge base ad skill set that ca be helpful to cosumers both i resolvig issues for idividuals ad i shapig log-term care policies i a variety of settigs ad services. Home ad Commuity-Based Settigs Rule The Medicaid home ad commuity-based services (HCBS) provided uder sectios 1915(c), 1915(i) ad 1915(k) of the Medicaid statute add aother layer of complexity to Ombudsma programs as states develop their trasitio plas to brig their Medicaid HCBS systems ito compliace with the ew federal regulatios o commuity-based settigs. Ombudsma programs have the opportuity to participate i trasitio plaig ad to represet the residet perspective. 26 Natioal Associatio of States Uited for Agig ad Disabilities (NASUAD)

The fial HCBS rule icludes additioal requiremets for provider-owed or cotrolled home ad commuity-based residetial settigs. These requiremets iclude such protectios as assurig residet privacy i their uit icludig lockable doors, choice of roommates ad freedom to furish or decorate the uit; cotrols over schedules; access to food at ay time; ad access to visitors, to ame a few. These requiremets give Ombudsma programs a framework that may add additioal advocacy ad complait hadlig to esure that residets i these residetial settigs beefit from this regulatio. Note: The Ceters for Medicare & Medicaid Services (CMS) has exteded the trasitio period for states to demostrate compliace with the home ad commuity settigs criteria util March 17, 2022. CONVERSATION STARTERS Role of the Ombudsma Program i HCBS Is the Ombudsma program ivolved i the HCBS settigs trasitio plaig? What ca the Ombudsma program do withi its curret federal resposibilities relevat to HCBS, ursig home diversios, ad ursig home trasitios? Maaged Log-Term Services ad Supports Ombudsma I 2013, Ceters for Medicare ad Medicaid Services (CMS) bega requirig states, as a coditio of approvig ay ew 1915(b) or 1115 waiver implemetig a maaged log-term services ad supports (MLTSS) program, to establish a member Ombudsma program. It is oe part of a comprehesive idepedet cosumer support system that must provide preerollmet assistace as well as post-erollmet assistace. A few states have embedded this fuctio i their LTC Ombudsma program, recogizig the fuctioal similarities betwee the two services. This placemet allows states to utilize existig ifrastructure, such as toll-free phoe lies, websites ad trackig databases while addig additioal staff with expertise i commuity-based services ad maaged care. Geerally, the Ombudsma program coordiates with other advocacy etities to provide this Ombudsma service i accordace with their jurisdictio ad area of expertise. The Ombudsma program addresses cocers of MLTSS erollees who are livig i facility settigs, while other etities provide services to address cocers of MLTSS erollees who are ot livig i log-term care facilities. State Log-Term Care Ombudsma Program: 2019 Revised Primer for State Agecies 27

FOR CONSIDERATION Expadig the Role of the Ombudsma Program Has the state cosidered expadig Ombudsma program services ito o-facility HCBS settigs such as home care ad adult day services? What are some reasos for or agaist expadig? Is your state cosidered or offerig MLTSS? If so, is the Ombudsma program uder cosideratio to provide MLTSS Ombudsma services? What policy ad procedural chages would be ecessary, e.g., statutory authority, staffig, fudig, protectios agaist coflict of iterest, if the Ombudsma Program services were to expad? KEY RESOURCES Visit NORC s HCBS ad Medicare ad Medicaid pages for additioal iformatio o HCBS, LTSS/MLTSS ad the Ombudsma program http://ltcombudsma.org/ home-ad-commuity-based-services ad http://ltcombudsma.org/issues/medicare-admedicaid. This Primer is a startig poit to improve your uderstadig of the distict provisios of the Log-Term Care Ombudsma program ad to provide techical assistace i support of effective ad credible Ombudsma programs. The resources i the appedix provide further details o all aspects of the Ombudsma program allowig for deeper exploratio. The complexities of the Ombudsma program are vast; do ot hesitate to call upo the Natioal Ombudsma Resource Ceter, the Natioal Associatio for States Uited o Agig ad Disabilities (NASUAD,) or the Admiistratio for Commuity Livig whe questios arise. 28 Natioal Associatio of States Uited for Agig ad Disabilities (NASUAD)

Appedices State Log-Term Care Ombudsma Program: 2019 Revised Primer for State Agecies 29

Appedix A: History of the Log-Term Care Ombudsma Program 17 1970s 1980s 1990s 2000s The Nursig Home Ombudsma Program is created as part of Presidet Nixo s iitiative to improve coditios ad respod to widespread reports of residet abuse i the atio s ursig facilities. The iitiative started as a demostratio program to test its effectiveess, ad by the late 1970s, all states were required to have Ombudsma Programs as a requiremet of the Older Americas Act (OAA). The Ombudsma Program expaded i the 1980s to iclude board ad care as well as other similar adult care facilities. Clarifyig laguage was icluded ito the OAA i the late 1980s to esure that the Ombudsma program s access to log-term care facilities, residets ad access to residet ad facility records. The amedmets also provided immuity from liability to the Ombudsma ad represetatives of the Office who were actig i good faith i the performace of their duties. The program was also reamed the Log-Term Care Ombudsma Program to reflect its expaded scope. The 1992 amedmets to the OAA created the Vulerable Elder Rights title, Title VII of the OAA. Title VII ad focused reewed attetio o the idividual ad collective advocacy fuctios of the agig etwork ad recogized the uique role played by each of the four advocacy programs: Ombudsma, elder abuse prevetio, legal assistace, ad beefits couselig. Title VII emphasized the beefit of a coordiated advocacy approach to address older persos uderstadig ad exercise of their rights ad access to assistace with problems they ecouter. The 1992 amedmets icluded the creatio of a Office of the State Log-Term Care Ombudsma (the State Ombudsma Office) ad some clarificatio of coflicts of iterest. The 2000 OAA amedmets icluded specific laguage that prohibited Ombudsme etities ad represetatives of the Office from fiacial gai through a actio or potetial actio brought o behalf of idividuals they served. It also required coordiatio of the program with state ad local law eforcemet agecies. The OAA amedmets retaied ad updated ombudsma provisios i Titles II, III ad VII, icludig specific coflict of iterest provisios; the Ombudsma Title III miimum fudig requiremet was arrowed from the broad requiremet i the 1992 OAA Amedmets. 17 A detailed history of the program is o the NORC website. http://ltcombudsma.org/about/about-ombudsma/program-history 30 Natioal Associatio of States Uited for Agig ad Disabilities (NASUAD)

2006 Reauthorizatio added Assisted Livig Facilities to the defiitio of Log-term Care Facility thereby requirig the Ombudsma program to provide services to residets of Assisted Livig Facilities. 2015 Log-Term Care Ombudsma Programs Fial Rule was published i February with a effective date of July 1, 2016, to allow states appropriate time to make ay chages ecessary i order to comply with the fial rule. The rule adds clarity to may of the program resposibilities ad provisios i the OAA. 2016 The 2016 OAA amedmets added clarity ad additioal authority to the Ombudsma Program i several areas. Pertiet amedmets to the Ombudsma Program iclude: Authorized the program to serve all LTC facility residets regardless of their age; To serve residets trasitioig from a log-term care facility to a home-care settig, whe feasible; Clarifies that the program may work to resolve complaits o behalf of residets uable to commuicate their wishes, icludig those lackig a authorized represetative; Requires programs to actively ecourage ad assist i the developmet of residet ad family coucils; Clarifies that the program is cosidered a health oversight agecy for purposes of the Health Isurace Portability ad Accoutability Act (HIPAA). State Log-Term Care Ombudsma Program: 2019 Revised Primer for State Agecies 31

Appedix B: Glossary of Useful Terms 18 Local Ombudsma Etity A etity desigated by the Ombudsma to carry out the Ombudsma program duties withi a geographic area. Examples of agecies hostig local Ombudsma etities iclude Area Agecies ad other public or oprofit orgaizatios. Natioal Ombudsma Reportig System (NORS) NORS is a set of data collectio requiremets that Ombudsma programs collect. NORS is comprised of data o residet complaits ad outcomes o complaits, Ombudsma program activities ad arratives. I accordace with the OAA, Ombudsme report their NORS data aually i the ACL approved software-reportig tool. NORS data is available at https://agid.acl.gov/. Office of the State Log-Term Care Ombudsma (Office) The orgaizatioal uit i a state or territory which is headed by a State Log-Term Care Ombudsma. Ombudsma A Swedish word meaig aget, represetative, or someoe who speaks o behalf of aother. Represetatives of the Office of the State Log-Term Care Ombudsma Staff or voluteers desigated by the Ombudsma to fulfill the duties of the State s Log-Term Care Ombudsma Program. State Log-Term Care Ombudsma (SLTCO) or Ombudsma The idividual who heads the State LTC Ombudsma Office ad is resposible to persoally, or through represetatives of the Office, fulfill the fuctios, resposibilities ad duties set forth i the OAA ad Ombudsma program rule. State Log-Term Care Ombudsma Program The program through which the fuctios ad duties of the State Ombudsma Office are carried out, cosistig of the Ombudsma, the Office headed by the Ombudsma, ad the represetatives of the Office. State Agecy A desigated state divisio or departmet that holds the primary resposibility for the plaig, policy developmet, admiistratio, coordiatio, priority settig, ad evaluatio of all state activities related to the objectives of the OAA. The specific title ad orgaizatio of the govermetal uit will vary from state to state. Most states admiister the OAA programs through their State Agecy o Agig ad Disabilities, referred to as State Uit o Agig (SUA). The Older Americas Act ad the Ombudsma program rule use the term State agecy. Willful iterferece Is the actios or iactios take by a idividual i a attempt to itetioally prevet, iterfere with, or attempt to impede the Ombudsma program from performig ay of the fuctios or resposibilities or duties. 18 Further clarificatio o the defiitios of the Ombudsma program ca be foud i 45 CFR 1324.1 of the Code of Federal Regulatios. 32 Natioal Associatio of States Uited for Agig ad Disabilities (NASUAD)

Appedix C: Acroyms AAA Area Agecy o Agig AoA Admiistratio o Agig ACL Admiistratio for Commuity Livig APS Adult Protective Services COI Coflict of iterest CMS Ceters for Medicare & Medicaid Services HCBS Home ad Commuity-Based Services HIPAA Health Isurace Portability ad Accoutability Act LOE Local Ombudsma etity LTC Log-Term Care LTCO Log-Term Care Ombudsma LTCOP Log-Term Care Ombudsma Program LTSS Log-Term Services ad Supports MLTSS Maaged Log-Term Services ad Supports NORC Natioal Log-Term Care Ombudsma Resource Ceter NORS Natioal Ombudsma Reportig System OAA Older Americas Act SLTCO State Log-Term Care Ombudsma SUA State Uit o Agig State Log-Term Care Ombudsma Program: 2019 Revised Primer for State Agecies 33

Appedix D: Resources Admiistratio for Commuity Livig Log-Term Care Ombudsma Programs, Frequetly Asked Questios: https://www.acl.gov/ode/762 AGig Itegrated Database (AGID) https://agid.acl.gov/ Code of Federal Regulatios (CFR) Title 45: Public Welfare PART 1324 ALLOTMENTS FOR VULNERABLE ELDER RIGHTS PROTECTION ACTIVITIES Subpart A State Log-Term Care Ombudsma Program: https://www.govifo.gov/cotet/pkg/cfr-2017-title45-vol4/xml/cfr-2017-title45-vol4-part1324.xml Natioal Associatio of Local Log-Term Care Ombudsma: https://alltco.weebly.com/ Natioal Associatio of State Log-Term Care Ombudsma Programs: http://www.asop.org/ Natioal Associatio of States Uited for Agig ad Disabilities: http://asuad.org/ Older Americas Act of 1965 [Public Law 89 73] [As Ameded through P.L. 114 144, Eacted April 19, 2016]: https://legcousel.house.gov/comps/older%20americas%20 Act%20Of%201965.pdf Older Americas Act: ACL Resources: https://www.acl.gov/ode/650/ State Log-Term Care Ombudsma Programs Fial Rule as Published i the Federal Register February 11, 2015: https://www.federalregister.gov/ documets/2015/02/11/2015-01914/state-log-term-care-ombudsma-programs#sectoreferece-1327.11%20. {NOTE: whe published the LTC Ombudsma program rule was 45 CFR 1327; it is ow 45 CFR 1324.} State Log-Term Care Ombudsma Programs: Fial Rule (2015) Overview, 45 CFR 1321 ad 1324; Admiistratio for Commuity Livig; PowerPoit Presetatio: http://ltcombudsma.org/uploads/files/support/ltco-rule-overview-traiig.pdf The Natioal Cosumer Voice for Quality Log-Term Care: http://thecosumervoice.org/ The Natioal Log-Term Care Ombudsma Resource Ceter: http://ltcombudsma.org 34 Natioal Associatio of States Uited for Agig ad Disabilities (NASUAD)

Appedix E: Fact Sheet: Log-Term Care Ombudsma Program What You Must Kow LONG-TERM CARE OMBUDSMAN PROGRAM What You Must Kow FACT SHEET WHAT IS THE LONG-TERM CARE OMBUDSMAN PROGRAM (LTCOP)? Uder the federal Older Americas Act (OAA) every state is required to have a Ombudsma Program that addresses complaits ad advocates for improvemets i the log-term care system. Each state has a Office of the State Log-Term Care Ombudsma (Office), headed by a full-time State Log-Term Care Ombudsma (Ombudsma) who directs the program statewide. Across the atio, staff ad thousads of voluteers are desigated by State Ombudsme as represetatives to directly serve residets. WHAT DOES THE OMBUDSMAN PROGRAM DO? The Ombudsma program advocates for residets of ursig homes, board ad care homes, assisted livig facilities, ad other similar adult care facilities. State Ombudsme ad their desigated represetatives work to resolve problems idividual residets face ad effect chage at the local, state, ad atioal levels to improve quality of care. I additio to idetifyig, ivestigatig, ad resolvig complaits, Ombudsma program FREQUENTLY resposibilities ASKED iclude: QUESTIONS (FAQ) Educatig residets, their family ad facility staff about Who residets does the rights, Ombudsma good care practices, program ad similar log-term services ad supports resources; represet? Esurig residets have regular ad timely access to ombudsma services; The Ombudsma program s madate is to Providig techical support for the developmet of residet represet ad the family residet coucils; ad assist at his or her Advocatig for chages to improve residets quality of directio. life ad The care; Older Americas Act (OAA) requires Providig iformatio to the public regardig log-term the care Ombudsma facilities ad program services, to have residets residet rights, ad legislative ad policy issues; coset prior to ivestigatig a complait Represetig residet iterests before govermetal or agecies; referrig ad a complait to aother agecy. Seekig legal, admiistrative ad other remedies to protect Whe someoe residets. other tha the residet files a Ombudsma programs do ot: complait, the ombudsma must determie, to the extet possible, what the residet wats. Coduct licesig ad regulatory ispectios or ivestigatios; Perform Adult Protective Services (APS) ivestigatios; What or happes after I brig a cocer to Provide direct care for residets. the Ombudsma program? If someoe other tha a residet cotacts the RESIDENTS RIGHTS Ombudsma program with a complait the ombudsma will visit the residet to see if Ombudsma programs help residets, family members, ad others uderstad residets the residet has similar cocers ad wats rights ad support residets i exercisig their rights guarateed by law. Most ursig homes to pursue the complait. The ombudsma will participate i Medicare ad Medicaid, ad therefore must meet federal requiremets, icludig explai the role of the program, the complait facility resposibilities ad residets rights. For more iformatio ivestigatio about process, residets share rights iformatio about visit http://ltcombudsma.org/issues/residets-rights residets ad http://thecosumervoice.org/ rights, ask about the residet s quality issues/recipiets/ursig-home-residets/residets-rights. of life ad Rights care, ad ad care seek stadards to uderstad for the assisted livig/board ad care facilities are regulated, licesed residet s or certified capacity at to the make state decisios. level. 1 May For more iformatio o assisted livig visit http://ltcombudsma.org/assisted-livig residets, eve residets with demetia, ad are http://thecosumervoice.org/issues/recipiets/assisted-livig. able to express Regardless their wishes. of the type If the of residet facility all residets have the right to be protected from abuse ad wats mistreatmet the ombudsma ad facilities to act o are the required problem, to esure the safety of all residets ad ivestigate reports the of ombudsma mistreatmet. will ivestigate the complait ad cotiue to commuicate with the residet 1 Some assisted livig facilities provide services for residets receivig Medicaid beefits throughout ad must the meet ivestigatio federal stadards process. for that program. If the residet caot provide coset the ombudsma will work with the residet represetative or follow program policies ad procedures if the residet does ot have a represetative. 2 What types of complaits does the Ombudsma program ivestigate? Ombudsme hadle a variety of complaits about quality of life ad care. Not all complaits are about the care provided by a facility, some complaits are about outside agecies, services or idividuals (e.g., Medicaid or Medicare beefits). They ca also receive ad respod to complaits from idividuals other tha the residet (e.g. family member), but still eed residet permissio to ivestigate or share iformatio. 3 Older Americas Act of 1965. Sectio 712 (a)(3)(a) Do ombudsme ivestigate complaits ivolvig allegatios of abuse, eglect, ad exploitatio? Yes. The Ombudsma program ivestigates ad resolves complaits that relate to actio, iactio or decisios that may adversely affect the health, safety, welfare, or rights of the residets ad that icludes complaits about abuse, eglect, ad exploitatio. 3 Ombudsme are directed by residet goals for complait resolutio ad limited by federal disclosure requiremets. Therefore, the Ombudsma program s role i ivestigatig allegatios of abuse is uique ad differs from other etities such as, adult protective services ad state licesig ad certificatio agecies. Ombudsma programs attempt to resolve complaits to the residets satisfactio (icludig those regardig abuse) ad do ot gather evidece to substatiate that abuse occurred or to determie if a law or regulatio was violated i order to eforce a pealty. If ecessary, with residet coset or permissio of the State Ombudsma if the residet ca t coset ad does ot have a legal represetative, the ombudsma will disclose residet-idetifyig iformatio to the appropriate agecy or agecies for regulatory oversight; protective services; access to admiistrative, legal, or other remedies; ad/or law eforcemet actio about the alleged abuse, eglect or exploitatio. 4 Is the Ombudsma program required to report allegatios of abuse? There are strict federal requiremets regardig disclosure of Ombudsma program iformatio. Residet-idetifyig iformatio caot be disclosed without residet coset, the coset of the residet represetative, or a court order. Therefore, these disclosure requiremets prohibit Ombudsma programs from beig madatory reporters of suspected abuse. 5 How do I fid more iformatio about the Ombudsma program ad cotact a ombudsma? Visit the Natioal Log-Term Care Ombudsma Resource Ceter (NORC) website (www.ltcombudsma.org) to lear more about the program. Locate a Ombudsma program by clickig Visit Our Map. 2,4,5 For more iformatio about the program s role i respodig to complaits, icludig allegatios about abuse, see the Admiistratio for Commuity Livig s Frequetly Asked Questios about the LTCO program http://www.aoa.acl.gov/aoa_programs/oaa/resources/ Faqs.aspx#Ombudsma ad the Natioal Ombudsma Resource Ceter (NORC) website http://ltcombudsma.org/issues/abuse-eglectad-exploitatio-i-log-term-care-facilities. This fact sheet was completed i associatio with the Natioal Cosumer Voice for Quality Log-Term Care for the Natioal Ceter o Elder Abuse situated at Keck School of Medicie of USC ad is supported i part by a grat (No. 90AB0003-01-01) from the Admiistratio o Agig (AOA), U.S. Departmet of Health ad Huma Services (DHHS). Gratees carryig out projects uder govermet sposorship are ecouraged to express freely their fidigs ad coclusios. Therefore, poits of view or opiios do ot ecessarily represet official Admiistratio o Agig or DHHS policy. State Log-Term Care Ombudsma Program: 2019 Revised Primer for State Agecies 35

Appedix F: Ifographic: Log-Term Care Ombudsma Program 36 Natioal Associatio of States Uited for Agig ad Disabilities (NASUAD)