CHAPTER Omb 400 OFFICE OF THE LONG-TERM CARE OMBUDSMAN
PART Omb 401 PURPOSE AND SCOPE
Statutory Authority:
RSA 161-F:10-19, 42 USC 3011, as amended, and
45 CFR 1327
Omb 401.01 Purpose. The purpose of the office of the long-term
care ombudsman is to protect the civil and human rights of persons residing in
long-term care facilities, to investigate complaints, to safeguard residents’
health, safety, and welfare, to enhance their quality of life, and to provide
an independent voice for residents in the development and implementation of
public policy, rules, and laws affecting residents of long-term care
facilities.
Source. (See Revision Note at chapter heading for Omb 100) #4767, eff 2-26-90, EXPIRED: 2-26-96
New. #12379, eff 9-13-17
Omb 401.02 Scope.
These rules shall apply to the residents, staff, and
long-term care and assisted living facilities, including, but not limited to,
nursing homes, skilled nursing homes, extended care facilities, convalescent
homes, homes for the aged, veterans’ homes, assisted living facilities, and any
other residential care facility providing care for the elderly licensed or
certified under RSA 151.
Source. (See Revision Note at chapter heading for Omb 100) #4767, eff 2-26-90, EXPIRED: 2-26-96
New. #12379, eff 9-13-17
PART Omb 402 DEFINITIONS
Omb 402.01 Definitions.
(a) “Abuse” means
“abuse” as defined in RSA 161-F: 43.
(b) “Adult
protection” means the program administered by the department of health and
human services that investigates reports of abuse, neglect, and exploitation of
vulnerable adults and carries out the responsibilities set forth in RSA
161-F:42-57.
(c) “Bureau of
Health Facilities Administration (BHFA)” means the bureau within the department
of health and human services responsible for licensing health care facilities
in accordance with RSA 151, and conducting surveys of nursing facilities to
ensure compliance with Medicaid certification requirements.
(d) “Case” means
each inquiry brought to or initiated by the long-term care ombudsman on behalf
of a resident, or group of residents, regarding one or more complaints or
problems, which requires the opening of a case file that summarizes the
investigation activities of the long-term care ombudsman representative.
(e) “Certified
ombudsman volunteer representatives” mean individuals trained and supervised in
accordance with Omb 411.01, Omb
411.02.
(f) “Complainant”
means a resident of a facility who reports a complaint, or a person acting for
or on behalf of a resident, including but not limited to, a family member,
friend, facility, staff member, or representative of a citizen’s organization
or government agency.
(g) “Complaint”
means complaint as defined in RSA 161-F:11, III
namely, “a problem, concern, issue or situation identified or received by the
office that is made by, or on behalf of, residents that may adversely affect
the health, safety, welfare and rights of residents, including the appointment
and activities of legal representatives, providers of long-term care services,
public agencies and health and social services agencies.”
(h) “Elderly,” means
“elderly” as defined in RSA 161-F:11, IV, namely
a person aged 60 or older.
(i) “Informed consent” means permission provided
by the resident or complainant documented in the case file, allowing the OLTCO
to investigate a complaint, make a referral, or to share identifying
information of the resident or the complainant during the investigation, or
referral. Informed consent includes
written, oral, or visually communicated permission, including communication
through the use of auxiliary aids and services which is documented
contemporaneously by the OLTCO in the case file.
(j) “Exploitation” means “exploitation” as
defined in RSA 161-F: 43, IV.
(k) “Facility” means “facility” as defined in RSA
161-F:11, V.
(l) “Incapacitated” means a condition of
well-being defined in RSA 464-A:2, XI
where a resident has been determined to be incapacitated by a court order and a
hearing pursuant to RSA 464-A.
(m) “Investigation” means the process described
in Omb 405 which is followed to obtain and review
thoroughly the facts and circumstances of a complaint.
(n) “Legal representative” means “legal
representative” as defined in RSA 161-F:11, VII,
namely “any individual, duly appointed or designated in the manner required by
law to act on behalf of another individual, including:
(1) An attorney;
(2) A guardian or
conservator; and
(3)
An agent acting pursuant to a power of attorney.”
(o) “Long-term care
ombudsman (LTCO)” means “long-term care ombudsman” as defined in RSA 161-F:11, VIII.
(p) “Long-term care
ombudsman representative (LTCOR)” means “long-term care ombudsman
representative” as defined in RSA 161-F:11, IX.
(q) “Neglect” means
“neglect” as defined in RSA 161-F: 43, III.
(r) “Not verified”
means the status of a complaint following an investigation where the LTCO
determined that there was insufficient information to substantiate or prove the
complaint by a preponderance of the evidence.
(s) “Office of the Long-Term Care Ombudsman
(OLTCO)” means “Office” as defined in RSA 161-F:11, XI. The term includes the term “office.”
(t) “Patient
personal representative” means “patient personal representative” as defined in
RSA 151:19, V namely, “a person, other than the licensee of, an employee of, or
a person having a direct or indirect ownership interest in, a facility, who is
designated in writing by a patient or patient’s legal guardian for a specific,
limited purpose for the general purpose of assisting the patient in the
exercise of any rights. The term
includes personal patient representative.”
(u) “Resident” means
an individual living in a long-term care facility.
(v) “Retaliation”
means an adverse action taken against a person.
(w) “Verified” means
the status of a complaint following an investigation where the LTCO determined
there was sufficient information to substantiate or prove the complaint by a
preponderance of the evidence.
(x) “Vulnerable”
means “vulnerable” as defined in RSA 161-F:43, VII.
(y) “Willful interference” means actions or
inactions taken by an individual, or a facility representative or staff, in an
attempt to intentionally prevent, interfere with, or attempt to impede the
long-term care ombudsman, or long-term care ombudsman representative from
performing any of the duties set forth in RSA 161-F:13-19.
Source. #12379, eff 9-13-17
PART Omb
403 COMPLAINT
PROCESS
Omb 403.01 Complaint Process.
(a) As authorized by
RSA 161-F:10-19 the LTCO and LTCOR shall:
(1) Elicit, receive,
identify, respond to, and resolve complaints;
(2) Investigate the complaints of residents or complainants;
(3) Document
investigations in a case file related to each complaint;
(4) Document and
investigate all complaints regarding facilities;
(5) Include all
complaints in a statewide uniform complaint documentation system, designed,
implemented, and maintained by OLTCO pursuant to RSA 161-F:17.
(b) Any resident, or
complainant making a complaint on behalf of a resident, may report a complaint
to the LTCO.
(c) Complaints may
be anonymous, if requested.
(d) Complaints may be provided to the OTCO by:
Mail or delivery in-person to the following address:
Office of the Long-Term Care Ombudsman,
Brown Building, 129 Pleasant Street,
Concord, NH 03301;
Telephone to: (603) 271-4375 or 1(800) 442-5640; or
Fax: (603) 271-5574; or Email to OLTCO@dhhs.nh.gov.
(e) Identifying
information of the resident or complainant shall not be shared during the
complaint process unless the LTCOR receives:
(1) Oral or written
informed consent from the resident, or the personal patient representative, or
legal representative, if the resident is unable to provide informed consent to
share or refer the resident’s identifying information;
(2) Informed consent
from the resident by means of a visual indication or through the use of
auxiliary aids and services provided that the consent is documented
contemporaneously in writing by the LTCOR;
(3) Oral or written
informed consent from the complainant to share or refer his or her identifying
information;
(4) A court order
requiring disclosure of identifying information; or
(5) The LTCO
determines there is reasonable cause to believe that disclosure of the personal
identifying information of the resident is required due to circumstances set
forth in Omb 404.01(e), Omb
404.02, Omb 405.01(g), or Omb
406.02a.(6).
Source. #12379, eff 9-13-17
Omb 403.02 Complaint Intake Information.
(a) During the
complaint intake process the OLTCO shall request the following information:
(1) The
complainant’s identifying information, including:
a.
The name of the complainant or the entity; and
b.
The address and telephone number of the complainant or the entity;
(2) The resident’s
identifying information, including:
a.
The resident’s name;
b.
The resident’s date of birth; and
c.
The resident’s address, including room
number or current location if known;
(3) The name and
contact information for the resident’s legal representative,
or personal patient representative, if applicable; and
(4) Informed consent
if the complainant or resident wishes to provide informed consent.
(5) Information
related to the complaint(s) including but not limited to:
a.
The date and time that the incident or the subject of the complaint
occurred;
b.
A description of what occurred;
c.
If the complaint is being made by a healthcare facility
representative, the name of the person who originally made the report to the
facility;
d.
Contact information for any staff member involved in the incident
or situation described by the complaint; and
e.
Any action the facility has taken or plans to take to respond to the
incident or situation described by the complaint.
(b) When a complaint
is received, the LTCO or LTCOR shall open a case.
Source. #12379, eff 9-13-17
PART Omb 404 DISCLOSURE OF IDENTIFYING INFORMATION
AND REFERRALS TO OTHER AGENCIES
Omb 404.01 Confidentiality and
Disclosure of Complaint and Resident Information.
(a) The OLTCO shall
keep all complainant and resident identifying information confidential, except
as otherwise provided in RSA 161-F and Omb 400.
(b) The OLTCO shall
seek permission to reveal resident or complainant’s identifying information as
necessary to fully investigate the allegations within a complaint.
(c) A complainant
may give the OLTCO permission to reveal his or her identifying information, but
not the resident’s identifying information, by providing written or oral
informed consent.
(d) A resident or
resident’s personal patient representative or legal representative may give the
OLTCO permission to disclose the resident’s identifying information by
providing informed consent in the form of:
(1) Written informed
consent signed by the resident;
(2) Oral or visual
communication, or through the use of auxiliary aids, and the resident’s consent
is documented contemporaneously in writing by an LTCOR; or
(3) If the resident
is unable to provide informed consent pursuant to (d)(1)
or (2) above, written informed consent signed by the resident’s
personal patient representative or legal representative.
(e) The OLTCO shall
disclose identifying information of residents for the purposes of referring
complaints pursuant to Omb 404.04 if:
(1) The OLTCO has
received informed consent pursuant to (d) above; or
(2) The OLTCO
determines that disclosing the resident’s identifying information is necessary
to protect the resident, as determined by:
a.
The resident’s inability to communicate informed consent, if such
consent was not previously given;
b.
The resident’s lack of a personal patient representative or legal
representative;
c.
Reasonable cause to believe that an action, inaction, or decision is
imminent that might adversely affect the health, safety, welfare, or rights of
the resident;
d.
The best interests of the resident; and
e.
A lack of evidence indicating that the resident would not wish to
have his or her identifying information disclosed.
(f) No LTCOR shall
disclose resident identifying information pursuant to (e)(2),
above, without that decision first being discussed with and approved by the
LTCO.
Source. #12379, eff 9-13-17
Omb 404.02 Complaints From Personal
Observation by Ombudsman Staff.
(a) If an LTCOR personally
witnesses suspected abuse, gross neglect, or exploitation of a resident, the
LTCOR shall seek informed consent from the resident to disclose what the LTCOR
witnessed pursuant to Omb 404.01(d) above. If the LTCOR cannot obtain such consent, he
or she shall follow the process described in Omb
404.01(e) to determine if disclosure is nonetheless appropriate. Either with or without the resident’s
consent, if disclosure would be permitted by Omb
404.01(e)(2), Omb 405.01(g)
or 406.02a.(6), the LTCOR shall open a complaint on the resident’s behalf.
(b) When an LTCOR
determines that disclosure is appropriate pursuant to (a), above, the LTCOR
shall:
(1) Document his or
her observations in the case file;
(2) If the
disclosure is permitted, document the factors used by the LTCOR to determine
that reasonable cause existed supporting disclosure in the case file; and
(3) Review his or
her observations with the LCTO to determine that requirements to disclose
without consent pursuant to Omb 404.01(e)(2) have been met.
Source. #12379, eff 9-13-17
Omb 404.03 Accessing Resident Records.
(a) When access to a
resident’s record is necessary to investigate the allegations in a complaint,
the OLTCO shall seek the resident’s informed consent or determine that such
inspection is necessary pursuant to RSA 161-F:14.
(b) If a personal
patient representative or legal representative is the subject of the complaint,
the OLTCO shall access the records upon determining the following:
(1) The resident is
unable to give informed consent; and
(2) There are no
other methods of communicating with the resident.
(c) The OLTCO shall
document the existence of the conditions in (b), above, and provide a written
determination that they exist to the facility where the resident resides.
(d) When access to a
resident’s record is obtained pursuant to (a) above, the LTCO or LTCOR shall
have access to the following:
(1) All records and
logs held at the facility, and any books, files, medical records, or other
records, including internal reports completed by the facility, that pertain to
the resident;
(2) Licensing and
certification for the facility maintained by the state; and
(3) All records
permitted by the Health Insurance Portability Accountability Act (1996) Privacy
Rule (HIPAA) 45 CFR Part 160 and 164.
(e) If the resident
refuses to give oral or written informed consent or authorization above is not obtained, the LTCO shall not
review the medical record, unless one of the circumstances described in RSA
161-F:14, II exists.
(f) If the
investigation is related to the actions or inactions of the personal patient
representative or legal representative, OLTCO may request an accounting or
other information relating to the fiduciary or financial relationship.
(g) If the
information during the investigation or authorized by RSA 161-F:14 is not forthcoming within 60 days of the date on the
request, the LTCO shall commence all available remedies under the law including
but not limited to those remedies available pursuant to including, but not
limited to, those remedies available pursuant to RSA 161-F:14, III.
Source. #12379, eff 9-13-17
Omb 404.04 Referrals.
(a) Prior to
referring a complaint, the OLTCO shall either obtain informed consent or
determine that disclosure is necessary pursuant to RSA 161-F:14,
Omb 404.01(e), Omb
405.01(g), or Omb 404.02. If the OLTCO cannot obtain informed consent
or disclosure is not necessary, then it shall not refer complaints to other
agencies.
(b) Due to its
obligation to keep resident identifying information confidential under RSA
161-F:13, II, the OLTCO and its employees and
volunteers shall only report abuse pursuant to RSA 161-F:46 by making a
referral for one of the purposes listed in (c), below.
(c) If disclosure is
permitted or necessary, the OLTCO shall refer complaints to any state or
federal entity or agency for the purposes of:
(1) Regulatory
oversight;
(2) Adult protective
services;
(3) Access to
administrative, legal, or other remedies; or
(4) Law enforcement
action.
(d) The OLTCO shall
provide residents, complainants, or residents’ personal patient representatives
or legal representatives with contact information and directions about how to
file a complaint with the agencies or entities listed in (c) above.
Source. #12379, eff 9-13-17
PART Omb 405 INVESTIGATION OF COMPLAINTS
Omb 405.01 Investigations.
(a) Cases and case
files shall only be opened by LTCO for complaints investigated by the OLTCO.
(b) During the
course of the investigation, the LTCO or LTCO designee shall:
(1) Personally
discuss the complaint with the resident, or if the resident is unable to
communicate, with the personal patient representative or legal representative;
(2) Determine the
resident’s perspective and wishes relating to the investigation and resolution
of the complaint. If the resident is unable to communicate, determine the
perspective and wishes of the resident after discussion with the resident’s personal patient representative or legal representative;
(3) Obtain informed
consent from the resident or the personal patient representative or legal
representative in order to investigate, seek a resolution, report the complaint
or related information, or share the resident’s
personal identifying information as permitted or authorized during the investigation or referral of the
complaint;
(4) Keep the
resident informed throughout the course of the investigation and obtain the
resident’s perspective and elicit further input and direction;
(5) If the complaint
was generated by a complainant, obtain a detailed statement of the incident or
the facts and circumstances of the complaint from the complainant and determine
the resident’s wishes with respect to resolving the complaint;
(6) Advise the resident,
of his or her rights under RSA 151:21 and work to develop a plan of action in
order to resolve the complaint;
(7) Investigate the
complaint by conducting interviews with the complainant, resident(s), facility
administrator(s), staff and any other person(s) who may have information
relevant to the complaint;
(8) Obtain written
statements if possible, and review information contained in facility records
and other records as authorized by RSA 161-F:14 and
within Omb 405.03;
(9) Determine whether the complaint is verified by a
preponderance of evidence according to Omb 405.03;
(10) Determine if
complaint is resolved to the satisfaction of the resident. If the resident is unable to communicate
satisfaction the LTCOR shall determine satisfaction through communication with
the personal patient representative or legal representative as determined by
law;
(11) Notify the
resident(s), the personal patient representative, or legal representative of
the determination once it is made and further disclose the determination with
the resident’s permission;
(12) Request a
statement from the resident, personal patient representative of legal
representative that describes the incident or situation;
(13) If the
complaint is being made by a healthcare facility representative, obtain a copy
of the report documenting the complaint completed by the facility; and
(14) Obtain
documentation of statements made by any witness or staff involved.
(c) The case file
shall contain the complaint and all information obtained during the
investigation.
(d) During the
course of the investigation, the LTCO or LTCOR shall only reveal personal
identifying information of the resident without informed consent, as authorized
by RSA 161-F: 13, II, or Omb 404.01(f)-(i) above.
(e) Pursuant to RSA 161-F:14, when conducting
investigations, the LTCO and LTCOR shall be authorized to:
(1) Enter any
facility and visit where the alleged incident or situation took place;
(2) Communicate
privately and without restrictions with any resident who consents to the
communication;
(3) Observe all
common areas of the facility, except for the living area of any resident who
objects to the observation; and
(4) Conduct
announced or unannounced visits during the time of day that the alleged
incident or situation was alleged to have taken place.
(f) During the
investigation, the long-term care ombudsman, or long-term care ombudsman
representative shall interview the resident about the complaint.
(g) If the resident
does not wish the OLTCO to act on a complaint, the LTCO or LTCOR shall close
the complaint, unless:
(1) Circumstances
described in Omb 404.02 exist; or
(2) There is a
suspected violation of the standards listed in RSA 151-a, I(a)
presenting an immediate risk to the resident or other residents.
(h) If the LTCO
determines to act on a complaint without resident consent, the LTCOR shall
notify the resident, the personal patient representative, or legal
representative, or the complainant, if the complainant was not the resident, that the investigation shall continue.
Source. #12379, eff 9-13-17
Omb 405.02 Completion of the
Investigation and Determinations.
(a) The LTCO shall
review all information and documentation gathered during the investigation in
order to determine whether a complaint is verified by a preponderance of the
evidence.
(b) The complaint
shall be determined verified if the incident or situation described in the
complaint was:
(1) Observed
directly or occurred in the presence of the LTCO or LTCOR;
(2) Substantiated by
a preponderance of the evidence through interviews, records, inspections or
other observations of the LTCO or LTCOR;
(3) Documented and
verified in the reports of another agency; or
(4) Acknowledged by
the subject of the complaint, facility, or facility staff as being accurate.
(c) The complaint
shall be determined not verified if after investigation there is insufficient
information to substantiate or prove the complaint by a preponderance of the
evidence.
(d) The LTCO or
LTCOR shall record all information regarding the investigation and the basis
for the determination that a complaint was verified or not verified in the case
file.
(e) The LTCO or
LTCOR shall make a determination that a complaint is verified or is not
verified shall be made after review of all information and documentation
obtained during the investigation.
(f) The
determination that a complaint is verified or not verified made by the LTCO
shall be independent of any decision or disciplinary action taken against the
individual by any facility, licensing board or other entity.
Source. #12379, eff 9-13-17
Omb 405.03 Notice of Determination of
Complaint.
(a) When a complaint
has been investigated, and a determination made, the LTCO or LTCOR shall notify
the resident or the resident’s other legal representative. Upon request of any agency and if the
resident gives oral or written consent, the LTCO or LTCOR shall notify the
agency about which the complaint was made.
(b) OLTCO
determinations shall not be subject to Administrative Appeal Hearings (AAU)
pursuant to He-C 200.
Source. #12379, eff 9-13-17
Omb 405.04 Complaint Follow-up Visits. The LTCO or LTCOR shall make follow-up visits
to the facility where the complaint arose as necessary to help ensure that the
complaint remains resolved to the resident’s satisfaction.
Source. #12379, eff 9-13-17
Omb 405.05 Retaliation Prohibited.
(a) Pursuant to RSA
161-F:15, RSA
151:21, VI retaliation, or the threat of retaliation, against any person or
resident who has made a report or complaint with the OLTCO shall be prohibited.
(b) If staff or
certified ombudsman volunteer representative (COVR) of the OLTCO believe they
have been subjected to retaliation or threat of retaliation related to ta
complaint they investigated, they shall immediately inform the LTCO.
(c) Any resident,
legal representative, or member of a resident’s family who has been subjected
to retaliation (e) If the LTCO
determines that there is reason to believe retaliation occurred, the LTCO shall
refer the situation to local law enforcement, the county attorney or the
department of justice for possible action, in accordance with RSA 161-F:15, I.
(f) Pursuant to RSA
151:21, the LTCOR or COVR shall encourage and assist a resident to exercise his
or her rights as a resident and as a citizen.
The resident may voice grievances and recommend changes in policies and
services to facility staff or outside representatives free from restraint,
interferences, coercion, discrimination, or reprisal.
Source. #12379, eff 9-13-17
PART Omb
406 CASE
RECORDS
Omb 406.01 Complaint Case Records.
(a) All case records
shall be held in a secure location and shall be accessible only to the LTCO and
LTCOR pursuant to RSA 161-F:13, II.
(b) All case
information related to complaints that are verified shall be retained for 3
years following completion of the investigation or the date of the notice of
determination.
(c) All case
information related to complaints that are not verified shall be retained for 2
years following the completion of the investigation or the date of the notice
of determination.
(d) If a case
involved multiple complaints, some of which are verified and some of which are
not verified, the case file information shall be retained for 3 years or the
date of the notice of determination.
(e) All records of
the OLTCO relating to an investigation or complaint shall be confidential and
shall not be disclosed except as provided in Omb 406
below.
Source. #12379, eff 9-13-17
Omb 406.02 Disclosure of Information or
Records.
(a) The LTCO shall
disclose case records or information about complaints or cases pursuant to RSA
161-F:13, II, if:
(1) The resident
provides informed consent to disclosing the record;
(2) The resident’s personal patient representative or legal
representative may provide informed consent only when the resident is not able
to provide informed consent;
(3) A court orders
disclosure of written records or notices of the LTCO;
(4) The LTCO or
LTCOR is court ordered to testify about the complaint and the investigation in
court;
(5) The LTCO or
LTCOR is referring a complaint pursuant to Omb 404.01
(d); or
(6) Disclosure
without informed consent falls within one of the circumstances set out in RSA
163-F:13, 14, or these rules.
(b) When disclosing
records or information in (a) above the LTCO or LTCOR shall disclose only that
information necessary to accomplish the purpose of the disclosure.
(c) Personal
identifying information of the complainant or the resident shall not be
disclosed unless:
(1) The resident,
the personal patient representative, or legal representative consents to
disclosure;
(2) The complainant
consents to disclosure;
(3) Disclosure is
court ordered; or
(4) Disclosure of
the personal identifying information of the resident is required under
circumstances set forth in Omb 403.01(e), Omb 404.01, or 404.02.
(d) The scope of any
information disclosed pursuant to a court order shall not exceed the stated purpose
of disclosure pursuant to the court order.
Source. #12379, eff 9-13-17
PART Omb 407 DELEGATION OF POWERS AND DUTIES
Omb 407.01 Delegation to Long-term Care
Ombudsman Representatives.
(a) The LTCO shall
delegate the powers and duties described in RSA 161-F:10-19,
to LTCOR, and certified ombudsman volunteer representatives (COVR).
(b) All LTCOR and
COVR shall:
(1) Successfully
complete a training program designed and offered by the LTCO or designee; and
(2) Be supervised
and provided with ongoing training and technical assistance by the LTCO or
designee.
Source. #12379, eff 9-13-17
PART Omb
408 CONFLICT OF INTEREST
Omb 408.01 Conflict of Interest.
(a) The LTCO, LTCOR,
and COVR shall be free from a conflict of interest with a facility or resident
of a facility as defined in RSA 161-F:11, V.
(b) The LTCO shall
implement procedures to prevent a conflict of interest between LTCOR, or COVR
responding to or investigating a complaint and the subject of the complaint.
(c) In order to
avoid a conflict of interest the LTCO, LTCOR, or COVR, or member of his or her
immediate family shall not:
(1) Have a
financial, fiduciary, ownership or investment interest in a facility as defined
in RSA 161-F:11, V;
(2) Be currently
employed at, or participate in, the management of a facility;
(3) Be directly
employed by or participate in the licensing or certification of a facility;
(4) Be assigned a
complaint at a facility in which an immediate family member resides or is
employed;
(5) Be assigned a
complaint at a facility where the LTCOR or COVR is a guardian or legal
representative of a resident at the facility;
(6) Be assigned a
complaint at a facility in which the LTCOR or COVR has been employed within 12
months of the beginning employment, student internship, or volunteer
involvement with the OLTCO;
(7) Receive or have
the right to receive, directly or indirectly, remuneration, either in cash or
in-kind, under a compensation arrangement with an owner or operator of a
facility; or
(8) Accept gifts or
gratuities of significant value from a facility or its management, a resident,
or a resident representative of a facility in which the LTCO or LTCOR provides
services;
(9) Serve as a
resident’s agent, medical decision-maker, or in another capacity, which would
conflict with the role and responsibilities of the OLTCO.
(c) Before an
individual is employed by or otherwise engaged to serve as an LTCOR, or COVR,
LTCO shall review Omb 408.01 (a) and (b) with the
individual. If a potential conflict of interest or conflict of interest exists
LTCO shall require him or her to:
(1) Withdraw from
the situation that is creating the conflict of interest prior to beginning
employment or other involvement with the office;
(2) Sign a statement
“Conflict of Interest” (7/27/17) and indicated that he or she has withdrawn
from the circumstances that created the conflict of interest and shall not
engage in activities which would cause the conflict of interest to return; and
(3) Maintain a copy of the signed statement as long as the LTCOR
is employed or a volunteer with the office.
(d) Each year the
OLTCO shall require all LTCOR and COVR sign, and date a statement “Conflict of
Interest” (7/27/17) indicating that he or she has no conflict of interest that
would arise out of a connection to a long-term care facility or an individual
who is a resident, or employee of a facility in New Hampshire.
(e) If a conflict of
interest arises for a LTCOR or COVR subsequent to employment or volunteer
certification, the individual shall notify the LTCO as soon as possible, and
the LTCO shall:
(1) Determine
whether or not the situation constitutes a conflict of interest described in
(b) above; and
(2) If a conflict of
interest exists, the LTCO shall either:
a.
Reassign the LTCOR to a different area of work that will not
generate a conflict of interest; or
b.
Request that the COVR withdraw from the situation that is creating
the conflict of interest.
Source. #12379, eff 9-13-17
PART Omb 409 REPORTING AND REVIEW
Omb 409.01 Reporting and Review.
(a) The LTCO shall
file the National Ombudsman Reporting
System (NORS) report, detailing the activities of program during the preceding
federal fiscal year, October 1 – September 30, “Annual Report” as required by
RSA 161-F:17, II and applicable federal law.
(b) After
certification by the Administration for Community Living (ACL), the long-term
care ombudsman’s annual report shall be available to the general public upon
request, and shall be publicized via a press release and published on the OLTCO
website https://www.dhhs.nh.gov/oltco/index.htm.
Source. #12379, eff 9-13-17
PART Omb 410 ADVISORY COMMITTEE
Omb 410.01 Membership.
(a) The LTCO shall
establish an advisory committee pursuant to RSA 161-F:13,
I (c). Members of the advisory committee
shall be appointed by the LTCO.
(b) The LTCO shall determine the duration of appointment
for each member of the advisory committee.
Source. #12379, eff 9-13-17
PART Omb 411 CERTIFIED OMBUDSMAN VOLUNTEER PROGRAM
TRAINING AND SUPERVISION
Omb 411.01 Volunteers.
(a) The LTCO shall
maintain a certified ombudsman volunteer program. Individuals seeking to become a certified
ombudsman volunteer representative (COVR) shall:
(1) Complete and
submit to the OLTCO a signed application form “Long-term Care Ombudsman
Volunteer Application Form” (July 2017);
(2) Serve at the
will of the LTCO and be authorized to represent the OLTCO as delineated in RSA
161-F: 12 and RSA 161-F:14 or as directed by the
long-term care ombudsman;
(3) Be free of any
conflict of interest and review and sign
a statement “Conflict of Interest ” (7/27/17) as required by Omb. 408.01(c);
(4)
Be certified after successfully completing the OLTCO educational and
experiential curriculum;
(b) Authority of the
COVR and LTCOR shall remain in active status by adhering to the following:
(1) Adherence to all
statutes, rules and policies that direct the OTLCO;
(2) Adherence to the
directives of the staff of the OTLCO authorized to direct the COVR; and
(3) Compliance with
COVR program policies and procedures as determined by the LTCO including, but
not limited, regular supervision, continuing education and submission of
required documentation.
Source. #12379, eff 9-13-17
Omb 411.02 Training and Supervision.
(a) COVR shall be
supervised by a staff member who is also a LTCOR.
(b) COVR shall meet
with a supervisor to review assigned complaints and establish an outline for
the investigation.
(c) COVR shall
successfully complete continuing education training as approved by the LTCO.
Source. #12379, eff 9-13-17
APPENDIX
Rule |
Specific State Statute the Rule
Implements |
Omb
401.01 |
RSA
161-F:10, F:11, 42 USC 3058(f)-(g) |
Omb
401.02 |
RSA
161-F:11, F:42-57 |
Omb
402.01 |
RSA 161-F:11,
RSA 151, 45 CFR 1327 |
Omb
403.01 |
RSA
161-F:13-19, 45 CFR 1327 |
Omb
403.02 |
RSA
161-F:13-19 |
Omb
404.01 |
RSA
161-F: 10-19, 45 CFR 1327 |
Omb
405.01 |
RSA
161-F:13, 14, 45 CFR 1327 |
Omb
405.02 |
RSA
161-F:14, 45 CFR 1327 |
Omb
405.03 |
RSA
161-F:13 |
Omb
405.04 |
RSA
161-F:13 |
Omb
405.05 |
RSA
161-F:13 |
Omb
405.06 |
RSA
161-F:15, RSA 151:21, VI |
Omb
406.01 |
RSA
161-F:13, and 14 |
Omb
406.02 |
RSA
161-F:14, 45 CFR 1327 |
Omb
407.01 |
RSA
161-F:13, 14 |
Omb
408.01 |
45
CFR 1327 |
Omb
409.01 |
RSA
161-F:17 |
Omb
410.01 |
RSA
161-F:13 |
Omb
411.01- 411.02 |
RSA
161-F:14, 45 CFR 1327 |