Iowa LLTCOP Standards

Local Program Standards

Office of the Iowa Long-Term Care Ombudsman

1. Local Program
1. Work hours will be 8:00 AM to 4:30 PM unless otherwise approved.  All state and department policies apply to out-stationed positions.   Adjusted hours will be approved by the PC so that quality service to our customers will be provided.
2. LLTCO must have voicemail that is up to date. 
3. When LLTCO is unavailable during business hours, outgoing message must allow callers to leave a message and must also provide the department toll free number if immediate assistance is needed.
4. During non-business hours, callers must be able to leave a message and have the option to call the emergency phone number.
5. Messages shall be checked at the start of the work day, at least every 2 hours and at the end of the work day.
6. Callers must receive a prompt, timely response.  All messages should be returned within 24 hours or 1 business day.
7. Calendars must be updated daily.  The proposed schedule will be entered prior to the start of the day, and the schedule will be updated as needed—at least daily.  All facility visits must be labeled as private appointments.  Work entered on the calendar will be compared with time card information.

2. Program Materials
1. LLTCO shall wear official state name tags while visiting facilities.
2. LLTCO shall provide business cards to staff, residents and families that request them.
3. Program materials will be developed in the Des Moines office for local program use.   LLTCO shall not distribute materials not approved by the PC or SLTCO.  Local program staff will be consulted in the development of materials.

3. Direct Resident Access to the Program
1. 5 facilities in each district will be monitored on a quarterly basis (NOTE: a visit includes contact with the residents, not just with the administrator or facility staff and involves listening to and observing residents).  At least one of the facilities must be an ALP and one must be a RCF or an EGH.  The PC is available to assist in choosing facilities to be monitored.
2. A minimum of 50% of all facilities in assigned area will be visited at least once during the year.  This includes complaint related visits and non-complaint related visits.
3. Visits to facilities  should generally be unannounced and at varied times.
4. Direct resident contact should be made on all visits to facilities.


4. Outreach and Education
1. LLTCO will provide at least 4 Family/Resident-Family Educational Sessions per year.
2. LLTCO will provide at least 4 Staff Training/Inservices per year.
3. LLTCO will initiate at least 1 Community Outreach Educational Session per year (e.g. trainings, presentations, or discussions organized by other organizations/agencies.  These may be formal or informal programs and should be documented as community education).
4. LLTCO will initiate at least 1 display at a senior or health-related fair.
5. LLTCO will provide technical assistance and support to residents and families in developing or strengthening a resident or family council (in addition to the Educational Sessions).
6. LLTCO will provide written information to educate residents, families and staff on the LLTCO Office and resident rights.

5. Volunteer Management
1. LLTCO will plan and schedule the RAC trainings for their district.  This will be arranged through the PC to avoid conflicts with other district training.
2. LLTCO will be responsible for presenting annual RAC trainings in their district.  The SLTCO and PC will determine the topic and develop training materials in consultation with LLTCO.
3. RAC volunteers will receive support, assistance and guidance through each LLTCO via phone calls, assistance with meetings, etc.
4. LLTCO will monitor meeting minutes and contact RAC or PC if needed.
5. LLTCO will contact new volunteers 2-4 months after orientation.   Documentation of these calls will be made within 3 business days following the contact (technical assistance for RAC).  Any concerns will be submitted to the PC electronically within 3 business days following the call.
6. LLTCO will report any RAC concerns or challenges with the Administrator or staff to the PC within 3 business days of the reported problem.  Reports shall be sent electronically.

6. Data Input
1. LLTCO will be responsible for data entry in Ombudsmanager no later 3 days after occurrence (program activities, journal entries or cases).
2. Documentation will be reviewed by the PC for accuracy, completeness and consistency with national NORS standards.
3. Reports generated from data entry will be used to assist LLTCO in scheduling, monitoring and follow up.

7.  Cases
1. LLTCO shall initiate a first contact in a case within 3 business days (1^st contact is defined as the date the LLTCO begins investigating the case.  The 1^st contact may be a phone call or visit.)
2. Cases  should be investigated within 10 business days unless  the PC or SLTCO are notified in advance.
3. LLTCO will respond to involuntary discharges by contacting the facility and the resident and/or responsible party within 2 business days.  If an involuntary discharge is appealed by the resident, the SLTCO and PC will be notified within 24 hours of receipt of the Notice of Hearing.  Notification will be made the same day whenever possible.
4. Cases will be prioritized by the LLTCO with assistance of the PC if needed.
5. LLTCO will review all cases at least once per month to evaluate progress, status of resolution and to close completed cases. 
6. Cases will be monitored by the PC for the following items.  Items indicated with a * are required by law:

                                                               i.      *Source and date of the complaint

                                                             ii.      *Method by which the complaint was received

                                                           iii.      *Statement/description of the problem

                                                            iv.      Trigger for the call

                                                              v.      *Payment source/billing status

                                                            vi.      Age

                                                          vii.      List of complaints

                                                        viii.      What the complainant sees as resolution

                                                           ix.      What the ombudsman promises to do (plan of action)

                                                             x.      Permission to proceed with an investigation

                                                           xi.      Investigation notes

                                                         xii.      Complainant kept informed of the progress

                                                       xiii.      Strategy to resolve

                                                        xiv.      *Complaint codes that accurately reflect the complainant’s concerns and any other concerns identified during the investigative process.

                                                          xv.      Resolution, including reasons why the complaints were resolved or why it could not be resolved to the satisfaction of the residents.

                                                        xvi.      *Description of follow up activity--LLTCO shall follow-up or arrange for follow up with the resident/representative regarding his/her satisfaction with the complaint outcome before closing a case.  Follow up may also be appropriate at a later date.

Identified changes in cases and program activities should be made within 15 business days of receipt of changes or discussion with PC or SLTCO.

7.  When appropriate, LLTCO generates complaints based on their own observations and knowledge of situations that affect or that could negatively affect residents.  The PC can assist LLTCO with determining if a situation should be a case or a program activity.

8. Program Activities – Information and Assistance
1. LLTCO will educate and empower consumers to advocate for themselves by providing one-on-one. consultations to individuals
2. LLTCO will respond to all phone calls within 1 business day.  This includes requests from consumers and facility staff.
3. LLTCO will ensure that residents and families are aware of the rights that residents have in a LTC facility.
4. LLTCO will provide prospective residents, their families and the public with guidance and information on selecting a LTC facility.
5. LLTCO will share best practice information with LTC facility providers.

9. Confidentiality
1. LLTCO shall explain the parameters of confidentiality to the resident and/or complainant and maintain those parameters.
2. LLTCO shall assure that meetings with residents and/or complainants are conducted in a private location.
3. All communication relating to a complaint shall remain confidential and shall be shared with others only with the permission of the SLTCO or the PC in the absence of the SLTCO.
4. All data, including those in electronic format, maintained by the LLTCO program, shall remain confidential.  This includes all information received from the Department of Inspections and Appeals.
5. All LLTCO program records, both paper and electronic, shall remain confidential and maintained in secure files.
6. Absolutely no information shall be released without permission from the SLTCO or PC in the absence of the SLTCO.  This does not include information that must be shared with the facility to resolve concerns or information shared with DIA.

10. Relationships with agencies/entities/ individuals/citizens groups, others
1. Each local office will be expected to develop and maintain relationships with a wide range of local agencies, individuals and entities outside of the LLTCO program.  Each LLTCO shall initiate contact with at least 6 of these local agencies, to provide information about the LLTCO office.  Examples include Hospice, AAA, Home Health Agencies, Hospital Discharge Planners, etc. (this will be documented as community education)
2. The local LLTCO and the agencies/organizations with which it interacts should have a clear understanding of each other’s roles, responsibilities, capabilities and limitations.
3. The LLTCO will be expected to make a first contact to referrals and requests for assistance from organizations/agencies within 1 business day.
4. The LLTCO will develop a system for sharing ombudsman information about nursing facilities with DIA surveyors.
5. Each LLTCO will be expected to develop and maintain a professional working relationship with providers, corporations and LTC facility trade associations. 

11. Record Retention
1. All federal, state and department policies regarding record retention must be followed.
2. Official case and program activity records are stored in Ombudsmanager and backed up on a regular basis through the Department and Synergy.
3. All written communications must be kept for at least five years.  If written communications relate to a case or program activity, information should be attached to the back of a printed case or program activity.  This information may be delivered to the Des Moines office for safe keeping.
4. No information may be shredded without consultation from the PC or SLTCO.  This does not include updated case or program activity notes.
5. Closed cases do not need to be printed unless documentation needs to be attached.

 October 18, 2007