Overview: This lesson explores the work of an ombudsman in long-term care facilities. It also is a brief overview of items that will be taught in classroom training.
Learning Objectives: At the conclusion of this lesson, participants will be able to:
- Explain the resident visitation process;
- Identify the ombudsman's role when conducting a visit;
- Explain the work of an ombudsman in long-term care facilities;
- Explain resident and family councils and,
- Identify the "need for consent."
Duration: 30 minutes (approximate)
Preparing for a Facility Visit
Spending at least 10 hours in the field, which may include structured tours and shadowing with an experienced ombudsman; meeting with resident councils; etc., is a minimum requirement of the certification process. Once designated/certified, you will be able to independently visit long-term care facilities. Now that you understand the role of the Ombudsman program and residents’ rights, you can prepare for your first visit to a facility with an experienced representative.
Routine Access Visit (Routine Visit)
Ombudsman are required to conduct routine visits that promote regular and timely access. The National Ombudsman Reporting System (NORS) defines routine access as a facility visited, not only in response to a complaint, in all four quarters of the reporting period (federal fiscal year). However, the frequency of visits is determined by your state’s policies and procedures. When you conduct activities in a facility, such as visit with multiple residents, share information about the Ombudsman program, and/or observe activities in the facility all may be considered part of a routine access visit. Complaints may also be addressed during routine access visits if other program required activities are conducted as well. In fact, you will often hear and follow up on complaints during routine access visits. Complaint Visit - When you visit the facility in response to a complaint and only conduct complaint-related activities, it is a complaint visit.
Before Your Visit
Many residents have weak immune systems so common illnesses may be a serious concern. Residents live in close quarters, and it is not uncommon for infections to travel from one resident to another. In addition to information discussed in this module, make sure to follow the program’s policies and procedures regarding conducting visits safely, especially during potential exposure to communicable diseases such as COVID-19, influenza (flu), or gastroenteritis (stomach flu).
Learn more about Coronavirus Prevention in LTC Facilities; Information for Long-Term Care Ombudsman Programs
Familiarize yourself with the facility by reviewing:
- Previous LTCOP activities
- Notes from the last visit
- Current and/or recent LTCOP cases
- The Ombudsman program’s experience with the facility during conversations with your supervisor
- The most recent annual survey/licensing or certification inspections and any regulatory agency complaint reports
Supervisors may be able to provide insight into facility staff and indicate their willingness to work with the LTCOP, as well as identify residents who are willing to share current information about their experiences.
Gather Ombudsman program brochures, business cards, posters, and consumer education information to hand out during your visits. Don’t forget to include materials you need for taking notes during or after the visit.
As an Ombudsman, you will be required to do monthly visits at Nursing Homes and quarterly visits at Assisted living and adult family care homes. The importance of confidentiality and obtaining consent to advocate for residents successfully' is a requirement. This module will introduce you to routine access visits, and complaint investigations. It will address the National Ombudsman Reporting System and how each State is required by the Older Americans Act to report this data to the United States Administration on Aging (AoA).
Resident Visitations
Routine visits are defined as an ombudsman’s visit to a facility to conduct activities that promote regular and timely access to the Long-Term Care Ombudsman Program.
- Florida has a visitation program that strives to visit every nursing home once per month.
- Assisted Living and Adult family care homes should have a MINIMUM of 4 visits per year (10/1 to 9/30)
For quarterly visits to count, they have to be at the same facility, with one visit in each quarter.
- 1st Quarter: Oct.- Dec.
- 2nd Quarter: Jan. - Mar.
- 3rd Quarter: Apr. - June
- 4th Quarter: July - Sept.
Guidelines for Resident Visitations include the following:
- The ombudsman shall monitor the condition of residents;
- The ombudsman shall provide information regarding the Ombudsman Program; and,
- The Ombudsman shall ensure resident access to an Ombudsman.
FL Statutory Requirements:
- “Resident-Centered Visits” Focus on the rights, health, safety, and welfare of residents.
- The Do’s and Don'ts of Advocacy
- To the extent possible and reasonable, not duplicative of agency surveys.
- Does not unreasonably interfere with the programs and activities of residents.
- Long-term care facilities are required to provide representatives of the LTCOP access to facilities, residents, and residents’ records.
Access Stipulations
- Ombudsmen may enter LTC facilities at any time for any reason. Upon entering, notify management of your presence, sign-in (required), and state whether you’re there to assess the facility, visit residents or both.
Entering the Facility
- Notify the administrator or designee that, as an ombudsman, you are there to visit all residents pursuant to s.400.0074, Florida Statutes.
- Sign in as an ombudsman visiting “all residents” in the facility’s log book.
You may request:
- The facility’s census.
- Resident council meeting minutes.
- A copy of the admission package.
Observations Upon Entry
- Look to see if required postings are visible, accurate, and easy to access and read for all residents, family members and consumers.
- Required postings:
- Facility license (issued by AHCA)
- Advocacy poster
- Resident Bill of Rights
- Ombudsman poster is encouraged, not required.
Approach and Introductions
During visits you will talk with residents with whom you have an established relationship and residents you do not know. You may meet residents in common areas or in their rooms. Before going into any resident’s room, you must knock and receive their permission to enter. Always remember the resident’s room is their home and should be respected as such.
You knock on a resident’s door; how do you ask for permission to enter?
Once you’ve approached a resident, or entered their room with permission, begin with an introduction that includes a clear explanation of who you are and why you are visiting.
How you approach a resident you have never met before and introduce yourself and the Ombudsman program is the first impression the resident will have of you and the LTCOP.
When approaching a resident:
- Assume they can understand
- Approach from the front
- Have the person’s attention
- Smile and use a friendly voice
- Respect their personal space
- Be eye level when possible
Interview Basics
- Resident interviews should make up the majority of your assessment.
- Interviewing residents is simply having a conversation.
- Ombudsmen should view residents as extended family.
- Take time to educate residents, family, and staff about resident rights, culture change, and best practices.
- Encourage residents to advocate for themselves. Encourage staff to create such an environment.
- Ask questions of residents regarding the categories on the assessment form.
Interview Basics - How Should I Start Asking Questions?
- Introduce yourself, and explain the ombudsman program.
- Ask questions about residents’ lives and interests: What do you like doing? Where are you from? What did you use to do?
- Be relaxed, warm, friendly, and compassionate.
- Communicate at eye level.
- After visiting a facility, more frequently residents and staff will begin to recognize you making the interview process much easier and more informative.
Observation
Observation is an important tool used when investigating complaints. Observation involves using all senses to understand, evaluate, and remember your surroundings and to obtain information during facility visits, intake, and investigation. Observation begins as you enter the facility. Pause a moment and take in the environment by using your senses to identify resident experiences and treatment. As you make observations during facility visits consider:
- Approaching with an open mind
- Being impartial and dismissing preconceived notions to avoid misinterpretations
- Using federal and/or state regulations to help you understand the responsibilities of the facility and residents’ rights
- Documenting your observations as soon as possible for an accurate description of
- the facility visit
Ending Your Visit
How you end the visit will depend upon what information you have permission to share, what actions the resident wants you to take, what steps you accomplished during the visit, and what your observations are. If you have observed any concerns that are not resident-specific, you may want to share them at this time. If you have resident-initiated complaints and have permission from the resident to discuss their concerns with staff, make all attempts to do so before leaving the facility.
Things To Discuss
- Discuss: Problems perceived by the residents. Problems observed by the ombudsman that were/were not corrected by staff. Recommendations for improvement.
- Remember: Consent to identify a resident to staff is required when discussing a specific resident issue.
- Contact the district office to open any complaints, including resident concerns or ombudsman-identified complaints, or if there are any issues that need to be referred to another agency.
- Submit the visitation form to the district manager for review.
- Notify the district office that the visit has been completed.
Privacy Standards
- As required by the OAA, Florida has ensured ombudsman access to residents’ clinical records and other information through state law, binding on long-term care facilities. The facility must permit ombudsman access to residents’ records and other information, in accordance with the state requirements. The Privacy Rule does not affect that requirement.
Confidentiality and Disclosure of Ombudsman Program Information
Access allows you to gather information through observations, interviews, and record reviews. It is important to have a system to document your initial findings. Most representatives take notes during their visit or phone calls via pen and paper or an electronic device. Others take notes immediately after. The notes taken will be entered electronic device. Others take notes immediately after. The notes taken will be entered into an electronic-based system managed by the Office.
Confidentiality
It is essential to recognize what information gathered is confidential. All records and information obtained by the LTCOP during conversations with residents and complainants must be held in confidence. It is important to explain to residents and complainants that the information they share with the program is confidential, meaning the information will not be shared (disclosed) with anyone outside of the Ombudsman program without their permission. In addition to federal guidance, always follow the program policies and procedures for confidentiality and disclosure of program information. As a ombudsmen, you must maintain confidentiality by:
- Not identifying residents or complainants without their consent
- Not disclosing any information about a resident or complainant
- Explaining your program’s confidentiality and disclosure requirements to facility staff and others who may expect or request confidential program information
Why is confidentiality Important? Confidential conversations with the LTCOP allow residents and complainants a level of comfort when discussing concerns. When the resident and complainant understand that the information cannot be shared with anyone without their approval, it encourages them to be open about details of their complaints. Maintaining confidentiality is the best way for the Ombudsman program to earn and keep the trust of residents and ensure that actions are resident-directed. When a complainant is not the resident, the Ombudsman program:
- Cannot disclose the identity without their permission
- Must have the resident’s permission to report back to the complainant
- Is required to honor both the resident’s and the complainant’s rights to confidentiality
What information is not confidential? General observations identified about the facility that do not identify any resident or complainant in any way can be shared with facility staff. Such observations include but are not limited to:
- Call lights not being answered
- Cleanliness of the facility
- Cluttered hallways that restrict residents and/or staff
- Odors
- Visible safety hazards
Disclosure of Resident and Complainant Information
Regardless of where the Ombudsman program is located, all files, records, and information maintained by ombudsmen of the Office pertaining to program activities and complaints are the property of the Office of the State Long-Term Care Ombudsman. Disclosure of such information, including identifying information about a resident or a complainant may only occur under the following circumstances and as determined by the State Ombudsman.
- Permission from the resident (or a resident’s representative when applicable)
- Permission from the complainant
- An order from the court
Otherwise, disclosure of files, records, and information maintained by the LTCOP pertaining to program activities and complaints is prohibited. When might the Ombudsman program disclose resident or complainant identifying information, and for what purpose? Some common reasons for disclosure include:
- To resolve a complaint with facility staff
- To refer a complaint to an outside agency
- To discuss resident concerns with their representative or other family or friends
Learn more about the disclosure provisions in the OAA and the LTCOP Rule
Confidentiality & Consent
- Confidentiality - Non-disclosure of confidential information concerning a long-term care resident or other person.
- Consent - Prior verbal or written permission to disclose confidential information given by the resident, resident’s legal representative, or the State Ombudsman – in this order of priority.
Confidential Information
- Residents’ and Complainants’ Names.
- Residents’ Records (medical, social, financial).
- Some files used or held by the Ombudsman Program, such as complaint cases, DCF/APS reports, NH discharge forms, and resident visitation forms when they include resident names/identifiers.
- Any other forms that include resident or complainant information.
Resident Records
- Ombudsmen may access resident records (medical, social, financial) but must have prior consent first.
Three Consent Options
- Option 1 – Visit the resident and obtain consent.
- Option 2 – Contact the legal representative when the resident cannot grant consent.
- Option 3 – Request State Ombudsman consent through the District Ombudsman Manager.
Consent to Release Information
- Consent can be granted to the ombudsman in writing or verbally using the consent form. This allows the ombudsmen to:
- Identify the complainant to the resident, facility staff, other agencies, or all;
- Investigate a complaint case;
- Identify the resident to facility staff or other agencies or both; and,
- Access certain resident’s records; medical, social, financial, or all.
Consent
- Further, we have clarified that the Ombudsman has the authority to determine when resident-identifying information maintained by the Ombudsman program may be disclosed to appropriate agencies for, among other things, “access to administrative, legal, or other remedies” in specified circumstances in which the resident is unable to communicate informed consent.
- Residents with varying abilities may communicate consent in a number of ways. This is why we did not limit communications to verbal communication and have added the use of auxiliary aids and services as an appropriate aid to communication.
Complaint Investigations & Resolution
- There are several aspects of a case that are important for ombudsmen to know:
- Consent, Consent, Consent!
- Visit Skills
- Documentation
- If it’s not written down, it didn’t happen!
- Tell the story so that others may understand.
- Be thorough yet succinct.
- Be knowledgeable of laws & regulations.
Legal Requirements
What is an administrative assessment visit? The ombudsman statute defines an administrative assessment as follows:
§ 400.0060(1) “Administrative assessment visit” means a review of conditions in a long-term care facility that impact residents' rights, health, safety, and welfareto note needed improvement and making recommendations to enhance the quality of life for residents.
- A warrant or advance notice is not required to enter the facility.
- An ombudsman must identify himself or herself to the administrator or designee.
- Do not duplicate agency surveys and inspections.
- An ombudsman conducting an should not reasonably interfere with facility activities.
- An ombudsman should not enter independent living units unless permission is received from the resident.
- Notice to the facility that an ombudsman may return to assess items identified for follow-up may be provided.
The Florida Administrative Code also contains directions on conducting an administrative assessment. Rule 58L-1.008, Florida Administrative Code, requires the following:
- Focus on factors affecting the residents’ health, safety, welfare, and rights as seen from their perspective.
- Identify concerns perceived by the residents or noted by the ombudsman.
- Identify concerns impacting on resident quality of life.
- Identify areas where improvements may be suggested.
Assessment Form - Review
Write in any information that is not pre-populated, which may include:
- Date
- Your name
- Name of any additional ombudsmen
- District & council name
- Time in a
- Total Activity Time this includes drive time, report write-up, exit interview but does not include follow-up
Purpose: A Routine Visit is a general review of conditions in a long-term care community impacting a resident's health, safety, welfare, or rights as viewed from the resident's perspective. Federal law mandates that residents have regular and timely access to ombudsmen and ombudsman program services. Through frequent visits to long-term care facilities, ombudsmen can develop relationships, explain the Ombudsman Program services to residents and family members, and proactively address resident issues to prevent their escalation, thereby safeguarding the quality of life.
How you end the visit will depend upon what information you have permission to share, what actions the resident wants you to take, what steps you accomplished during the visit, and what your observations are. You may need to conduct an exit interview with the Administrator or designee. Discuss:
- Problems perceived by the residents;
- Problems observed by the ombudsman that were/were not corrected by staff; and,
- Recommendations for improvement.
- Remember: consent to identify a resident to staff is required when discussing a specific resident issue.
- Contact the district office to open any complaints, including resident concerns or ombudsman-identified complaints, or if there are any issues that need to be referred to another agency.
- Notify the district office that the visit has been completed.
- Submit the visit form to the district manager for review.
The Three C's: Case, Complaint, Consultation
- A case is each inquiry brought to, or initiated by, the ombudsman on behalf of a resident or group of residents involving one or more complaints which requires opening a case and includes ombudsman investigation, strategy to resolve, and follow-up.
- If the ombudsman and another agency are both actively involved in the complaint investigation and resolution, it is also an ombudsman case.
- The number of cases is equivalent to the number of complainants. One or more people jointly filing a complaint counts as one complainant.
- A complaint is a concern brought to, or initiated by, the ombudsman for investigation and action a) on behalf of one or more residents and b) relating to the health, safety, welfare or rights of a resident.
- One or more complaints constitutes a case.
- You cannot have a case without a complaint.
A consultation is providing information and assistance to an individual or a facility if:
- It does not involve investigating and working to resolve complaints (i.e., a consultation is not a case); or,
- If the ombudsman refers someone with a concern to another agency and is not actively involved in investigating and working to resolve the problem then it is not an ombudsman case or complaint. However, it can be counted as a consultation.
Resident Council
A Resident Council is an independent group of residents that meets regularly to discuss and seek resolution to concerns; offer suggestions about facility policies and procedures affecting residents’ care, treatment, and quality of life; support each other; plan resident and family activities; participate in educational activities; or for any other purpose.
Allows residents to show self-determination, have input into issues such as menu planning, discuss the rights of smokers vs. non-smokers, address the importance of staff attitudes, exercise their rights concerning medications and increases their participation and motivation.
Nursing facility regulations include the following requirements for Resident Councils:
- The facility must provide a Resident Council, if one exists, with a private space for meetings.
- The facility must take reasonable steps, with the approval of the Resident Council, to make residents aware of upcoming meetings in a timely manner.
- The facility must provide a designated staff person who is approved by the Resident Council and the facility to provide assistance and respond to written requests from the Resident Council.
- The facility must consider the views of a Resident Council and act promptly upon grievances and recommendations of the Resident Council concerning issues of resident care and life in the facility.
- The facility must be able to demonstrate their response and rationale for their response.
- The right to a response does not mean facilities are required to implement every request of the Resident Council.
- The Resident Council meetings are closed to staff, visitors, and other guests. For staff, visitors, or other guests to attend, the Resident Council must invite them.
The meeting promotes:
- the role of residents as leaders;
- the recording of minutes and the follow-up;
- the role of staff advisors (social worker, recreational worker);
- how to maintain an agenda; and,
- the function of resident council committees (dietary, welcoming).
Since it is a resident council, the residents need to be as much in control of the planning and running of the meetings as possible. A staff person or volunteer would give only as much assistance as the residents need or request.
The Ombudsman Program and the Resident Council
The Ombudsman program is required to assist with the development of Resident Councils when asked. Ombudsmen often encourage residents to share their concerns during the Resident Council meeting to address concerns that may affect all or some residents, such as call lights not being answered in a timely manner or cold food.
Ombudsmen must have the approval of the Council Members to attend the meetings. Often, representatives are welcome to attend and do so on a regular basis. There are great benefits in attending the Resident Council meetings, such as getting to know residents, being a familiar support to residents, and getting a sense of how the residents are treated and how the facility is managed.
Family Councils
A Family Council is a group of residents’ family members that meets regularly to discuss and offer suggestions about facility policies and procedures affecting residents’ care, treatment, and quality of life; support each other; plan resident and family activities; participate in educational activities; or, for any other purpose.
Members form a united consumer voice which can play a crucial role in voicing concerns, requesting improvements, supporting new family members and residents, and supporting facility efforts to make care and life in the facility the best it can be.
Similar to how parents’ associations work with schools, Family Councils provide a way for concerned persons to actively participate in helping the facility to be the best it can be, through combining and prioritizing shared concerns and then communicating them to facility administrators, making recommendations, and suggesting solutions, sharing answers and information when replies are received, and supplementing staff services via additional actions which enhance residential life.
A Family Council meets regularly and promotes communication, action, support, and education. The specific activities of the Council depend upon the needs of the residents and the choices made by Council members. Family Councils operate on the premises that:
- There is strength in numbers and that combined voices garner more attention than just one
- Increased family involvement fosters greater staff accountability, which in turn decreases possible neglect and abuse
- Streamlining concerns is more efficient and reduces the time staff ultimately spends addressing repeat issues
The Ombudsman Program and the Family Council
In addition to acting as an advocate for residents, the Ombudsman program can educate residents, families, and friends about residents’ rights, state surveys, and federal and state laws that are applicable to nursing facilities and other long-term care facilities. The LTCOP also provides support and advocacy to Family Councils when asked by the Council.
Successful Family Councils maintain open communications with the LTCOP which is mutually beneficial: the program is kept informed of concerns which reflect multiple residents’ experiences (which often reflect the facility culture) and the Council has a human resource which can help to differentiate fact from fiction when members seek to clarify and correct problematic situations.
Learning Summary
This module explored the work of an ombudsman in long-term care facilities. Now you should know how to:
- Explain the resident-centered visitation process;
- Identify the ombudsman's role when conducting a visit;
- Explain the work of an ombudsman in long-term care facilities; and,
- Identify the "need for consent."
Credits:
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