As in effect on April 1, 2008
A. The Long-term Care Ombudsman (LTCO) Program is created for the purpose of promoting, advocating, and ensuring the adequacy of care received, and the quality of life experienced by elderly residents of long-term care facilities within the State.
B. Operation of the LTCO Program is a joint responsibility of the Division and local AAAs. Authority to administer the LTCO Program is derived from the Older Americans Act (OAA) Title VII: Allotments for Vulnerable Elder Rights Protection Activities and Section 62a-3-201 et seq.
C. The Division will establish a State Office of LTCO.
D. The State LTCO is responsible for:
(1) oversight of the statewide LTCO program;
(2) providing training to local LTCO staff and volunteers;
(3) provision of public information regarding the LTCO program;
(4) working with federal agencies, the State Legislature, other units of state government and other agencies to obtain funding and other resources;
(5) developing cooperative relationships among agencies involved in long-term care;
(6) resolving conflicts among agencies regarding long-term care;
(7) assuring consistent, statewide reporting of LTCO program activities:
(8) monitoring local LTCO programs;
(9) providing technical assistance to local LTCO programs;
(10) maintaining close communication and cooperation in the LTCO statewide network;
(11) recommending rules governing implementation of the LTCO program; and
(12) providing overall leadership for the Utah LTCO program.
E. The Division may employ Regional Ombudsmen to assist the State LTCO in meeting his or her responsibilities. In addition to assisting the State LTCO, Regional Ombudsmen are responsible to:
(1) Spend a majority of their time providing ombudsman services, including but not limited to, investigating and resolving complaints when local ombudsmen transfer a case, providing services to assist elderly residents of long-term care facilities, informing and educating elderly residents about their rights, providing administrative and technical assistance to local ombudsmen and volunteers, providing systemic advocacy, providing training to long-term care facilities, and assisting in the development of family and resident councils;
(2) Provide monitoring, oversight, assistance and leadership to local ombudsmen and volunteers in their region;
(3) Ensure that all ombudsmen in their region adhere to established policy and procedure; and
(4) Improve consistency and quality of Ombudsmen services in their region.
F. AAAs are responsible for daily operation of the program, either directly or by contract, as defined in these rules.
G. The Division, State LTCO and AAAs must work together to protect elderly residents, promote quality care in long term care facilities, and promote the LTCO program.
A. "AAA" means area agency on aging as designated by the Division of Aging and Adult Services.
B. "APS" means adult protective services.
C. The Division means the Division of Aging and Adult Services within the Utah Department of Human Services.
D. "Elderly resident" means an adult 60 years of age or older who resides in a long-term care facility.
E. Long-term ombudsman is a person, operating within the guidelines of the Older American Act and the policies of the Division, who advocates for elderly residents of long-term care facilities to ensure the quality and adequacy of care received.
F. "Local LTCO" means the local program and personnel designated by the Division, through each AAA, to implement the (LTCO) Program within a defined geographic area.
G. "Responsible Agency" means the agency responsible to investigate or provide services on a particular case.
H. "State LTCO" means long-term care ombudsman personnel within the Division.
I. "Long-Term Care Facility" means any skilled nursing facility, intermediate care facility, nursing home, assisted living facility, adult foster care home, or any living arrangement in the community through which room and personal care services are provided for elderly residents.
A. AAAs shall operate the LTCO Program in accordance with the following standards:
(1) Supervision: All local LTCO shall have an identified supervisor. The person supervising the ombudsman shall meet all requirements for a supervisor as specified by the AAA and shall have at least a general knowledge of long-term care facilities.
B. Staffing: Each AAA shall recommend for certification one or more paid or volunteer staff members to serve as local LTCO.
(a) Persons assigned this responsibility shall have either education or experience in one or more of the following areas: gerontology, long-term care, health care, legal or human service programs, advocacy, complaint and dispute resolution, mediation or investigating.
(b) Assigned individuals shall be certified by the State LTCO within six months after assuming a local LTCO role.
B. The AAA shall have primary responsibility to provide for certified back-up to the local LTCO. AAAs may enter into cooperative agreements with other AAAs to provide for LTCO back-up. In emergency situations, AAAs may request back-up support from the State LTCO.
C. Local ombudsmen shall have no conflict of interest which would interfere with performing the function of this position, including:
(1) direct involvement in the licensing or certification of a long-term care facility or of a provider of a long-term care service;
(2) ownership or investment interest, represented by equity, debt, or other financial relationship in a long-term care facility or a long-term care service;
(3) employment by, or participation in the management of, a long-term care facility;
(4) receiving, or having the right to receive, directly or indirectly, remuneration in cash or in kind under a compensation arrangement with an owner or operator of a long-term care facility.
D. AAAs shall establish, and specify in writing, mechanisms to identify and remove conflicts of interest and to identify and eliminate relationships described in paragraph 3 including mechanisms such as:
(1) methods by which the AAA will examine individuals and immediate family members to identify conflicts; and
(2) actions the AAA will require individuals and family members to take in order to remove those conflicts.
E. Local LTCO shall have the ability to act in the best interests of residents of long-term care facilities, including taking public positions on policies or actions which affect residents. Local LTCO shall not be constrained by the local AAA or governing body from taking a stand in good-faith performance of their job.
(1) AAAs shall have on file a written description outlining the working relationship between the AAA and the ombudsman which spells out arrangements for assuring this ability.
(2) Grievance Procedure
(a) AAAs shall establish a grievance procedure to accept and hear complaints regarding an ombudsman's actions. The procedure shall allow for a final appeal to the Utah State Department of Human Services Office of Administrative Hearings.
(3) Records System
(a) AAAs shall maintain a records classification and retention program in accordance with Sections 63-2-301 and 63-2-901 and PL 89-73 42 USC 300-1 et seq.
A. Ombudsman
An Ombudsman, who may be either a paid staff member or volunteer, may perform the following duties:
(1) investigate complaints and develop an action plan to resolve the complaint;
(2) provide supervision over the implementation of the action plan and any follow-up determined necessary;
(3) review complaints to set complaint response priorities;
(4) assign complaints to staff and volunteers;
(5) provide case consultation to long-term care facility staff; and
(6) perform duties of an assistant ombudsman.
B. Assistant Ombudsman
(1) An Assistant Ombudsman, who may be either a paid staff member or volunteer, may:
(a) provide outreach to residents, families, facilities, and other entities concerned about long-term care;
(b) observe actions and quality of care in long-term care facilities;
(c) perform complaint intake;
(d) provide residents, families, and the general public with information about the LTCO program and resident rights;
(e) provide public presentations;
(f) assist with resolution and follow-up on complaints while under the supervision of a Certified Ombudsman; and
(g) provide technical assistance to the general public and long-term care facility staff.
C. Ombudsman Program Director
(1) An Ombudsman Program Director, who may be the AAA director or his designee, may perform the duties of an Ombudsman, if certified as such, and shall:
(a) provide overall administration of the local ombudsman program;
(b) provide overall supervision of LTCO paid and volunteer staff;
(c) conduct quality assurance and complaint case record reviews;
(d) oversee the screening, hiring, and dismissal of LTCO staff and volunteers; and
(e) assess the need for regulatory changes to improve the quality of care and life for long-term care facility residents and advocate for the passage of those changes.
D. Non-certified Staff or Volunteers
Non-certified staff or volunteers may perform the following functions:
(a) complaint intake;
(b) provide public information and presentations regarding the LTCO program, long-term care in general, and other topics on which they may have expertise, as determined by the AAA;
(c) provide outreach to residents, families, facilities, and other entities concerned about long-term care;
(d) visit long-term care facilities and residents; and
(e) any other activity which does not expressly require certification and for which the AAA has determined the individual competent to engage in on behalf of the AAA or LTCO program.
A. Assistant Ombudsman: Prior to applying for certification as an Assistant Ombudsman, an individual shall complete a minimum of 18 hours of required initial training and pass the post-test with a minimum score of 70%. This training shall cover the following areas:
(1) An introduction to the LTCO Program, including a discussion of the scope of work of the LTCO.
(2) An overview of the long-term care system, including a discussion of:
(a) the types of long-term care facilities and providers, their organization and operations;
(b) federal and state regulations applicable to long-term care facilities and providers, with an emphasis on resident rights;
(c) long-term care resident profiles and methods of payment for long-term care services;
(d) the aging process and attitudes of aging; and
(e) the Aging Network and the relationship between the AAAs, the State LTCO, and various regulatory agencies.
(3) Ombudsman skills, including:
(a) interpersonal communication, observation, and interviewing;
(b) building working relationships with providers; and
(c) complaint handling, with an emphasis on intake.
(4) An overview of complaint resolution skills, with an emphasis on advocacy, negotiating, empowering residents, and follow-up activities.
(5) LTCO Program policies and procedures, including:
(a) confidentiality;
(b) access to facilities and residents;
(c) complaint investigation and resolution;
(d) reporting; and
(e) ethics.
(6) Case record documentation.
(7) Mediation and negotiation between residents.
(8) Any additional topics deemed appropriate by the State LTCO in consultation with the Division, AAAs, long-term care regulatory agencies and local LTCO Program Directors.
B. Ombudsman: Prior to applying for certification as a local Ombudsman, an individual shall complete a minimum of 30 hours of required initial training and pass the post-test with a minimum score of 70%. This training shall include all training described in Section A plus an additional 12 hours of training covering the following areas:
(1) a more in-depth review of the content areas covered for candidates for certification as ombudsman representatives, including written exercises, case studies, role plays, research exercises, and analysis of systemic issues;
(2) development of a complaint resolution action plan;
(3) legal, administrative, and other remedies;
(4) actions regarding public disclosure of actions or inactions which affect residents of long-term care facilities, including appropriateness, confidentiality of certain information, and how to work with the media;
(5) review of client records;
(6) alternative dispute resolution options for use in complaint handling; and
(7) advocacy skills.
C. Post-tests: The post-tests referred to in Sections A and B shall be developed by the State LTCO and shall be structured in sections to correspond to major training topics. If an applicant does not receive a score of at least 70% on a post-test they shall be eligible to retake the test one time within 30 days. If they do not receive a minimum score of at least 70% on the retake test, they will need to complete the training pertaining to the test sections on which they did not receive a passing score. Upon completion, they will be allowed to take the test one additional time. If a passing score is not obtained, the applicant will be deemed by the State LTCO to not be appropriate for certification as an Assistant Ombudsman or Ombudsman.
D. Ongoing Training: To maintain certification, an assistant ombudsman must complete a minimum of 12 hours of training annually; an ombudsman must complete a minimum of 24 hours of training annually.
(1) The State LTCO will provide for at least 48 hours of LTCO specific training per year. Training shall be scheduled at various times throughout the year and in various locations throughout the State.
(2) During the first year in which a person functions as an assistant ombudsman or ombudsman the required initial training will count toward the annual training requirement;
(3) Relevant training offered in the community can serve to meet annual training requirements in lieu of state-sponsored LTCO training on an hour-for-hour basis. Documentation of attendance at a training, including a copy of the training agenda, shall be submitted to the State LTCO for approval.
A. Central Registry
(1) The State LTCO shall maintain a central registry of all local ombudsmen and assistant ombudsmen. The registry shall retain the following information on each:
(a) the ombudsman's or assistant ombudsman's name, address, and telephone number;
(b) a summary of the ombudsman's or assistant ombudsman's qualifications;
(c) the ombudsman's or assistant ombudsman's classification;
(d) the AAA with which the ombudsman or assistant ombudsman is associated;
(e) the most recent date of certification;
(f) a position description which contains any prohibitions applicable to the ombudsman or assistant ombudsman. Prohibitions may include limitation on the duties that may be performed, limitations on the providers the ombudsman or assistant ombudsman may investigate or attempt complaint resolution with, or any limitations due to a conflict of interest; and
(g) information pertaining to any decertification actions and the results of those actions.
(2) Local ombudsman and assistant ombudsman shall register with the State LTCO through the AAA within 30 days of accepting assignment as a local ombudsman or assistant ombudsman.
Decertification of an ombudsman or assistant ombudsman may occur through voluntary resignation or decertification by the State LTCO or AAA or sponsoring agency which employs him. A person who has been decertified may not be assigned to ombudsman duties.
A. Involuntary Decertification With Cause:
(1) No ombudsman or assistant ombudsman shall be recommended for involuntary decertification without cause. Cause may include:
(a) failure to follow policies and procedures that conform to the LTCO statute and rules;
(b) performing a function not recognized or sanctioned by the LTCO Program;
(c) failure to meet the required qualifications for certification;
(d) failure to meet continuing education requirements;
(e) intentional failure to reveal a conflict of interest; or
(f) misrepresentation of the ombudsman's or assistant ombudsman's category of certification or the duties he is certified to perform.
(2) The State LTCO and AAAs shall establish, for their respective programs, policies and procedures for recommending decertification. Those policies and procedures shall require that the State LTCO or AAA attempt to help the LTCO or Assistant LTCO attain satisfactory job performance through professional development, supervision, or other remedial actions prior to recommending decertification.
(3) AAAs recommending decertification shall state their reasons in writing and shall provide any relevant documentation to support the recommendation to the State LTCO. Notice of the recommendation for decertification and the basis for the recommendation shall be provided to the local ombudsman or assistant ombudsman at the same time that information is submitted to the State LTCO.
(4) The State LTCO shall review the recommendation and provide written notification of his decision to the AAA and the local ombudsman or assistant ombudsman within ten working days. The AAA or local ombudsman or assistant ombudsman may appeal the State LTCO's decision in accordance with the Department of Human Services Rule R497-100.
(5) When the State LTCO initiates a decertification action against a local ombudsman or assistant ombudsman, the State LTCO shall provide written notification to the AAA and the local ombudsman or assistant ombudsman. The AAA or the local ombudsman or assistant ombudsman may appeal the decision in accordance with the Department of Human Services Rule R497-100.
(6) Upon completion of the decertification actions, the State LTCO shall record the actions and results in the central registry.
B. Voluntary Decertification Without Cause:
When a local ombudsman or assistant ombudsman voluntarily resigns due to personal reasons which would not otherwise affect certification, they shall surrender their LTCO identification card to the AAA. The AAA shall notify the State LTCO of the voluntary decertification. The State LTCO shall record the date of voluntary decertification in the central registry.
C. Voluntary Decertification With Cause:
When a local ombudsman or assistant ombudsman voluntarily resigns for reasons which would otherwise warrant involuntary decertification, they shall surrender their LTCO identification card to the AAA within seven days. The AAA shall notify the State LTCO of the voluntary decertification with cause and shall notify the local ombudsman or assistant ombudsman of the right to a hearing. The State LTCO shall record the date of voluntary decertification in the central registry.
D. Recertification:
(1) A certified local ombudsman or assistant ombudsman who voluntarily requests decertification may apply to have his certification reinstated when he becomes reemployed or accepted as a LTCO staff or volunteer. Any person seeking recertification shall apply in writing, through the AAA, to the State LTCO. The application shall include the date of the most recent decertification action and a summary of any professional development in or experience with ombudsman skills, long-term care services, problem resolution skills or any related skills the applicant may have received since his decertification.
(2) The State LTCO shall review the application and may require the applicant to receive additional professional development, and take an appropriate examination based upon the length of time since the applicant's most recent certification, and the experience or professional development the applicant has accumulated in the interim. The State LTCO shall make notify both the AAA and the applicant of the decision within ten working days.
A. Intake: The local LTCO Program shall accept and screen referrals from residents, family, facility staff, agency staff and the general community. Ombudsmen and assistant ombudsmen may also serve as the complainant for situations they have personally observed.
(1) If the information indicates that the referral relates to abuse, neglect, or exploitation of a resident, the local LTCO shall refer the complaint to either the local Adult Protective Services (APS) office or local law enforcement. The local LTCO and the APS worker should collaborate on investigating and resolving the complaint whenever possible.
(2) If the information indicates that the referral relates to facilities or operations licensed or certified by the Department of Health Bureau of Medicare/Medicaid Program Certification and Resident Assessment, and the nature of the complaint is other than alleged abuse, neglect or exploitation of a resident, the LTCO shall refer the complaint to the Department of Health. The local LTCO and Department of Health staff should collaborate on investigating and resolving the complaint whenever possible.
(3) Referrals to other agencies shall be made immediately if the situation appears life threatening or, in other situations, within two working days. If a referral is made to another agency, the local LTCO shall complete the intake form, indicating the referral date and entity, and maintain the form as part of the record. The local LTCO shall follow up to see that action was taken by the referral agency.
(4) If the referral involves a resident who is under the age of 60, and the nature of the complaint is limited to impact only on that resident, the local LTCO shall refer the complaint as specified in paragraph (1) or (2) of this section and take no further action. If the referral involves a resident who is under the age of 60 who resides in a facility that has other residents over the age of 60 and the nature of the complaint is such that it impacts those residents, the local LTCO shall refer the complaint as specified in paragraph (1) or (2) of this section as applicable and initiate an investigation.
(5) If the complaint involves residents rights or other issues within the jurisdiction of the LTCO, an investigation shall be initiated to determine if the complaint is valid. Issues within the purview of the LTCO include issues of privacy, confidentiality of information, and other issues relating to the action, inaction, or decisions by providers or representatives of providers of long-term care services, public agencies, or health and human service agencies that may adversely affect the health, safety, welfare, or rights of residents.
B. Investigations:
(1) LTCO investigations shall be initiated within three working days. If the available information indicates serious threat to a resident's life, health or property, the response shall be immediate.
(2) The investigation may involve phone or in-person contacts with the resident and complainant, collateral agency or individual contacts or an on-site investigation. The local LTCO shall:
(a) do a preliminary screening to gather facts and details of the complaint;
(b) categorize the complaint, i.e. resident rights, education, abuse, neglect, technical assistance, etc.;
(c) identify all parties to the complaint;
(d) identify relevant agencies, as required by state and federal statutes;
(e) identify steps already taken by the complainant;
(f) identify information gaps that may require additional research;
(g) determine if an on-site investigation is needed. If it is determined that an on-site investigation is not necessary, the LTCO shall document the reasons in the case file;
(h) determine if the situation is an emergency; and
(i) make verbal or written follow-up with the complainant.
(3) The method and extent of the investigation depends on the circumstances reported. The local LTCO shall complete an intake form on each referral. A complaint consists of the initial referral or any additional contacts regarding the initial referral received during the period that the case is opened. A referral regarding a different matter made during the period the case is opened is considered a new complaint. A referral received after a case is closed is considered a new complaint.
(4) When an on-site investigation is determined to be necessary the local LTCO does not have to give prior notice to the agency or facility in question. The local LTCO may choose to give notice if deemed appropriate. In either case, the ombudsman shall:
(a) upon arrival at the facility or agency, present official identification to the administration or designated person in charge;
(b) identify any factors that may interfere with the investigation;
(c) start the investigatory process to establish as clearly as possible what has happened, why it has happened, who or what is responsible for resolving the complaint, and possible solutions to the problem;
(d) interview the resident, as well as other residents, staff, family, friends and physician as deemed necessary;
(e) make phone calls, on-site observation, review resident records, and make collateral contacts with other agencies and professionals; and
(f) take any other appropriate investigatory actions within the purview of the LTCO Program.
(g) During the course of the investigation, the local LTCO shall look for credible evidence which supports or refutes the complaint. Evidence may be directly observed by the LTCO or indirectly gathered from statements from reliable sources. The State LTCO shall provide consultation and technical assistance regarding the methods used in investigating complaints as requested by the local LTCO.
(h) Ombudsmen shall be provided privacy by the facility or agency during all aspects of the investigative process.
(5) Determining Validity of Complaint
(a) The local LTCO, having gathered evidence regarding the complaint, shall review the evidence to determine whether that evidence supports the allegations made in the complaint. If the local LTCO is uncertain as to whether the complaint is valid, he shall discuss the situation with his supervisor. If further consultation is necessary, contact should be made with the State LTCO, who may suggest additional activities or approaches to the problem. The local LTCO shall gather further evidence from interviews, collateral contacts, and records review, until the body of evidence enables the local LTCO to make a supportable decision regarding validity of the complaint.
(b) Upon determination of the validity of the complaint, the local LTCO shall document the determination and reasons for it in the case file.
(6) Resolution of Complaints
(a) Having determined that the complaint is valid, the local LTCO shall take appropriate steps to resolve the complaint, including:
(i) determining the scope of the problem. Does the problem affect just the residents mentioned in the complaint, or does it affect other residents?
(ii) determining what options exist to resolve the complaint. For example, can the complaint be resolved immediately, will the resolution require negotiation with the facility management, or has the facility already moved to resolve the situation.
(iii) discussing with the resident which of the options are acceptable to resolve the complaint. Determining an acceptable resolution may require negotiation between the parties to achieve an acceptable resolution to the situation.
(iv) developing with the resident and facility a plan to achieve the agreed-upon resolution. The plan may be very simple or may have several steps and involve other agencies. Once the plan is agreed upon, the local LTCO, facility, resident, and other parties shall take action to implement the plan.
(v) making referrals to other agencies if a referrals are required by the plan.
(a) If during the investigation process the local LTCO determines that the incident or activities should be referred to APS, Health Facility Licensure, or Health Facility Review, the LTCO shall immediately make the referral and involve all appropriate agencies.
(b) The local LTCO who has referred the complaint to another agency shall follow up to obtain final results and record the outcome of the other agency's investigation. If the other agency does not respond or if the response is inadequate, the local LTCO may:
(1) contact the agency; or
(2) contact the State LTCO for technical assistance or help in resolving the problem with the other agency; or
(3) collaborate with another advocacy agency, such as the Legal Center for People with Disabilities, the Senior Citizens Law Center, or the local office of Utah Legal Services to resolve the issue and clarify substantive legal rights of elderly residents; or
(4) track on-going problems with an agency or facility to build a body of credible evidence on which to base further action; or
(5) take any other appropriate action within the LTCO scope of authority, including filing legal action against the other agency if the AAA has the legal resources to bring legal action.
(6) compiling documentation of the validity of the complaint, of the agreed-upon outcome, and the steps taken to carry out the plan. The documentation may be summary in nature, but should clearly indicate the situation and its resolution.
(7) determining at what point the case is appropriately closed.
(8) notifying the complainant, verbally or in writing, that the investigation has been completed and the case is closed.
(7) Records
(a) The local LTCO shall maintain a set of records by resident, containing all required forms and relevant documentation, including:
(i) a completed intake form;
(ii) case recording consisting of: the nature of the complaint; validity of complaint and reasons for the determination; plan for resolution; implementation and outcome of plan; and dates and names of any collateral contacts.
(iii) consent forms; and
(iv) copies of any correspondence or written documents pertaining to the complaint, the investigation, the resolution plan, or implementation of the resolution plan.
(b) The local LTCO shall also maintain information by facility relating to all referrals.
(c) All actions, findings, conclusions, recommendations and follow-up shall be documented on the required state forms.
(8) Consent Forms
(a) In order to access resident files maintained in a facility, the local LTCO must attempt to obtain a signed release from the resident or the resident's legal representative. Signed releases shall be maintained in the case file and a copy shall be given to the facility or agency for inclusion in the residents record.
(b) If the local LTCO is unable to obtain written permission, he may get verbal approval from the resident or the resident's legal representative. The date and method of obtaining the verbal approval, e.g. phone contact with guardian, shall be documented in the case file. LTCO shall attempt to have a third-party witness the verbal consent and document it in the record.
(c) If a request for written or verbal consent is denied by the resident or their legal representative, the local LTCO shall not access the records.
(d) If the request for written or verbal consent is unsuccessful for any reason other than specific denial by the resident or legal representative, the local LTCO may proceed to access the records. The reasons for not obtaining consent shall be documented in the case file.
(9) Access to LTCO Records
(a) Records maintained by the local LTCO shall be available to the LTCO, their supervisor, the LTCO Program Director, the State LTCO, and any duly authorized agent of the AAA or the Division with program oversight responsibility. No other staff shall have access to these records.
(b) Residents have the right to read their LTCO records; however, the name of any complainants shall be withheld.
(c) LTCO records shall be released to other persons if the resident provides written consent. The consent form must be filed in the resident's file.
(d) State and federal auditors may have access to LTCO records as required for administration of the program.
(d) Statistical information and other data regarding the LTCO program which does not identify specific residents or complainants is available for public dissemination.
(10) Reporting Requirements to State LTCO
Local LTCO programs shall report to the State LTCO on the operation of the LTCO program. Reports shall include the data required to complete the State's report to the U.S. Department of Health and Human Services, Administration on Aging. Reports shall be submitted within time frames and in a format which shall be mutually agreed upon by the Division and AAAs.
(11) Legal Issues
(a) Legal representation: The Division is responsible for assuring that adequate legal representation is available for local LTCO Programs. AAAs and their governing authorities shall have the option to provide legal representation for their local LTCO Program. If an AAA, through their governing authority, opts not to provide this representation, the Division shall arrange for the representation through the attorney general or through contract. All AAA requests for legal consultation or representation shall be directed to the State LTCO for action. The Division is responsible to assure that no conflict of interest is present in the provision of legal representation to local LTCO Programs.
(b) Liability: The local LTCO must operate within the scope of the ombudsman job description and this policy. Actions such as transporting a client, acting as a guardian or payee, signing consent forms for survey, medication, restraints, etc., signing medical directives, receiving a client power of attorney, and similar actions are outside the scope of the LTCO responsibilities. In doubtful situations the ombudsman should consult with supervisors, legal counsel or the State LTCO.
(c) Guardianship:If a resident has a legal guardian, the local LTCO must work with the guardian. If the local LTCO identifies problems in the guardianship, they will discuss the situation with the local adult protective services staff to determine the advisability of investigating for abuse, neglect, or exploitation. They may also consult legal counsel or present issues to the court which oversees the guardianship.
(12) Volunteers
Local LTCO programs which use volunteers shall follow AAA policy with respect to applications, screening and approval, reference checks, personnel records, reimbursement, supervision, liability and all other relevant aspects of the volunteer program. In addition, volunteers must meet specific training and certification requirements contained in these rules if they are serving in the capacity of local ombudsman or assistant ombudsman.
(13) Public Education
In addition to receiving and investigating complaints, local LTCO Programs are mandated by federal and state statute to provide public education regarding long-term care issues. This may include activities such as frequent presence in facilities, community advocacy, attendance at family or resident councils, technical assistance and in service to long-term care facilities, community organizations, and public information presentations.
A. Pursuant to Utah Code Section 62A-3-106.5, to avoid duplication in responding to a report of alleged abuse, neglect, or financial exploitation in a long-term care facility, the Division hereby establishes procedures to determine whether Adult Protective Services or the Long-Term Care Ombudsman Program will be responsible to investigate or provide services in a particular case and determine whether, and under what circumstances, the agency that is not the responsible agency will provide assistance to the responsible agency in a particular case.
B. The Long-Term Care Ombudsman Program will be the responsible agency in responding to a report of alleged abuse, neglect, or exploitation of an elderly adult who resides in a long-term care facility in the following cases:
(1) When an allegation of abuse, neglect or exploitation occurs, the Long-Term Care Ombudsman will be the responsible agency in cases other than cases that allege sexual abuse or sexual exploitation;
(2) When an elderly resident of a long-term care facility has allegedly abused, neglected, or financially exploited another resident;
(3) When an employee of a long-term care facility has allegedly abused, neglected, or financially exploited an elderly resident and the facility has terminated the employee;
(4) When the police or local law enforcement have initiated an investigation of alleged abuse, neglect, or financial exploitation.
C. Adult Protective Services will be the responsible agency in responding to a report of alleged abuse, neglect, or exploitation of a vulnerable adult who resides in a long-term care facility in the following cases:
(1) When an allegation of sexual abuse or sexual exploitation of a vulnerable adult is received.
D. The agency that is not the responsible agency will provide assistance to the responsible agency in the following circumstances:
(1) When the responsible agency requests the assistance of the non-responsible agency; or
(2) When the responsible agency is the LTCO and there is evidence that the resident's protective need has not been met.
elderly, ombudsman, LTCO
October 23, 2006
August 21, 2007
62A-3-201 to 8; 62A-3-104
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For questions regarding the content or application of rules under Title R510, please contact the promulgating agency (Human Services, Aging and Adult Services). A list of agencies with links to their homepages is available at http://www.utah.gov/government/agencylist.html.
For questions about the rulemaking process, please contact the Division of Administrative (801-538-3764). Please Note: The Division of Administrative Rules is not able to answer questions about the content or application of these rules.
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