New state ombudsman orientation

1. New state ombudsman orientation May 21, 2019

2. Welcome! • Name • State • Length of time as State Ombudsman

3. How NORC Supports You • Technical Assistance • Website, including the PRIVATE side • Training in person or by webinar • Summary Sheets on various subject matters • Orientation and webinars for New/Nearly New State Ombudsman • Topical webinars (including Volunteer Management)

4. Nuggets of Information from ACL • Collaboration with Other Entities, including development of Memorandums of Understanding • NORS Data – Uses for program management and systems advocacy • Ombudsman program rule – Q & A Louise Ryan, Ombudsman Program Specialist, Administration on Aging, Administration for Community Living (AoA/ACL)

6. Self-Study Guide Review - Residents’ Rights

7. Residents’ Rights • Know, Understand, and Share • Nursing Home Reform Act of 1987 (OBRA ‘87) • Code of Federal Regulations (42 C.F.R. Part 483) • State Operations Manual (SOM) Guidance to Surveyors • State law/regulations • Core Components • Quality of Care • Quality of Life

8. As an ombudsman, empowerment needs to be your primary way of relating to individuals • As an ombudsman, you not only have an obligation to provide information about residents’ rights, but also a further obligation to assist residents in exercising those rights. The goal is to foster an environment in which residents, families and staff can talk with each other and make life work well for those living and working in the facility. Remember that you can go no faster in facilitating change than the comfort level of the resident or residents.

9. Why Does Empowerment Matter?

10. From The Rule “…Ombudsman and the representatives of the Office serve the resident of a long-term care facility…” §1324.19(b) “Regardless of the source of the complaint (i.e. the complainant), including when the source is the Ombudsman or representative of the Office, the Ombudsman or representative of the Office must support and maximize resident participation in the process of resolving the complaint…” §1324.19(b)(2)

11. How Can LTCO Empower Residents? • Establish Meaningful Relationships • Individualized care • Information and consultation • Consumer fact sheets • Individual and group settings • ALL Activity is Resident-Directed • Encourage participation • Bring the staff to them • Support them during meetings (e.g. follow their lead, sit next to the resident)

12. Foundation of NH Reform Law Quality of Care Quality of Life A facility must care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident’s quality of life. • Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.

13. Residents’ Rights Themes Individualized Care

14. Tips for Ombudsman Practice You may need to help staff, residents, and their families understand what these rights mean in everyday life. You can do this by modeling, observing, and asking questions. • Be willing to assist staff and residents in listening to each other and working out solutions that are acceptable to both. • Be alert for opportunities to suggest that residents can exercise choice and have their choices respected. • Help staff think in terms of “How can we. . .” instead of “We can't do that because…” • Use care planning as a problem-solving vehicle to focus everyone’s attention on the resident’s needs, routines, and preferences.

15. Care Plan Meetings Are a forum for • Discussing issues that involve more than one department, • Advocating to have the resident’s routines and preferences respected, and • Accommodating resident participation and decision-making to individualize care. Are an ideal time for residents to exercise their rights!

16. Using the Interpretive Guidelines (SOM) • F-Tags • Regulatory Language • Intent of the requirement • Interpretive guidelines • Procedures • Probes- questions or things to look for during a survey • Definitions • Overview of the issue covered in the regulation • Examples • Investigative protocol • Determinations and criteria for compliance • Potential tags for additional investigation • Deficiency categorization • Endnotes and resources

17. Regulations and Interpretive Guidelines • Understanding the regulations and interpretive guidelines can inform and support your advocacy: • Learn what provisions and guidance applies to specific issues; • Ideas for interview questions and things to observe pertinent to the concern; • Understand what the facility is expected to do; • Enhance communication with surveyors.

18. Emphasis on Person-Centered Care • Focus on the resident as the point of control • Support the resident in making their own choices and having control over their daily lives

19. Resident Preferences and Accommodations The resident has the “right to reside and receive services in the facility with reasonable accommodation of needs and preferences except when to do so would endanger the health or safety of the resident or other residents.”

20. Discharge Planning • Each resident must have discharge plan, which must be updated as needed. • Resident and/or resident’s representative must be involved. • If discharge to community is determined to be not feasible, facility must document who made the determination and why. • 42 C.F.R. § 483.21(c).

21. Explicit Right to Self-Determination • Facility has an affirmative duty to promote and facilitate resident self-determination through support of resident choice • Includes: • Choice of activities, schedules, healthcare, providers • Right to make choices, interact with community members, participate in activities inside and outside the facility • Right to receive visitors • Right to organize and participate in resident and family groups • Right to manage his/her financial affairs

22. Resident Representative • Can only exercise authority given by resident, State or federal law or court • Facility cannot give them “more” authority • The resident retains the right to exercise those rights not delegated to a resident representative • Must consider the resident’s wishes and preferences when exercising the resident’s rights

23. Visitation Rights • Expands some aspects of visitation rights: residents have the right to receive visitors of their choosing at the time of their choosing; receive visitors whom they designate • The facility must: • Have visitation policy • Inform residents of their right to visitors, the policy, and any restrictions • Ensure all visitors have full and equal visitation privileges (subject to resident preferences) • Not discriminate • BUT visits from non-family visitors changed from “reasonable restrictions” to “reasonable clinical and safety restrictions”

24. Personal Property • The facility must: • Provide reasonable care for resident’s personal property • Not waive its liability for loss of resident property • Have a policy indicating circumstances when loss or damage of dentures is the facility’s responsibility and resident won’t be charged for replacement of lost/damaged dentures

25. Grievances • Right to voice complaint without actual or fear of discrimination or reprisal • Complaints can be filed orally, in writing, anonymously • Type of complaints now include complaints related to the behavior of staff and other concerns regarding their LTC facility stay • Right to have a complaint reviewed within a reasonable expected time frame • Right to receive a written decision

26. Grievance Official Role: • Oversee the grievance process • Receive and track grievances • Conduct necessary investigations by the facility • Maintain confidentiality • Issue written grievance decisions to the resident • Coordinate with state and federal agencies as necessary • Must consider the resident’s wishes and preferences when exercising the resident’s rights

27. Grievance Written Decisions • Must include: • Date the grievance was received • Summary statement of the resident’s grievance • Steps taken to investigate the grievance • Summary of the pertinent findings or conclusions regarding the resident’s concern(s) • Statement as to whether the grievance was confirmed or not confirmed • Any corrective action or to be taken by the facility as a result of the grievance • Date the written decision was issued

28. Freedom from Abuse • Right to be free from abuse, neglect, misappropriation of resident property, and exploitation • Free from physical or chemical restraints Facility must: • Prohibit and prevent • Investigate allegations • Include training for staff, volunteers, contractors

29. Resident Councils are… • both a community gathering and an opportunity for residents to provide input on their care. Community/activity Resident councilQuality of Life Input • a group of residents with a purpose. • a forum whose purpose is to create opportunities for residents to execute meaningful decisions. • a working combination of process, task selection, and task completion.

30. What Are the Benefits? • Resident Councils offer benefits to residents, staff, and the facility when they are structured properly. • A forum for their voice • Safety in numbers • Contributing to quality of life and care in their community • Involved residents are healthier

31. What Do The Revised Nursing Home Regulations Say? Located in Resident Rights Section! F565 483.10(f)(5) – Resident has right to organize and participate in resident groups • (i) – Facility must provide a private space and must take reasonable steps (with the approval of the group) to make residents aware of upcoming meetings • (ii) – Group must approve staff, visitors, or other guests to attend meetings • (iii) – Designated staff person that the resident group approves responsible for providing assistance and responding to written requests that result from group meetings • (iv) – Facility must consider views of a resident group and act promptly upon the grievances and recommendations of such groups • (A) – Facility must be able to demonstrate their response and rationale for such response • (B) – Facility does not need to implement every request from resident groups

32. What Does the LTCOP Rule Say? • 1324.13(a)(9) – Functions and responsibilities of the State Long-Term Care Ombudsman. • “Promote, provide technical support for the development of, and provide ongoing support as requested by resident and family councils to protect the well-being and rights of residents; and” • 1324.19(a)(6) – Duties of the representatives of the Office. • “Promote, provide technical support for the development of, and provide ongoing support as requested by resident and family councils; and”

33. Homework • What examples do you have of times when you either have been empowered or have empowered someone else? • Jot a few notes about ways to empower representatives of the Office as you discuss casework and support their advocacy?

34. In reviewing NORS data for your state, look at facility visitation, work with family councils, and work with resident councils. How does your state compare to the national data in these areas? • What training, support, and resources do you provide to representatives of the Office regarding addressing residents’ rights issues in assisted living facilities/board or care/or similar facilities? • What is the primary residents’ rights focus for the year for your program? • What was the basis for this decision?

35. Resources

36. NORC Resources • Residents’ Rights Issue page: https://ltcombudsman.org/issues/residents-rights • Webinar recordings • Consumer education materials • Ombudsman program examples • Upcoming – • Residents’ Rights In-Service Powerpoint • Residents’ Rights Prezi Presentation and On-Line Training Course

37. Consumer Voice Resources • Resident’s Rights https://theconsumervoice.org/issues/recipients/nursing-home-residents/residents-rights • Residents’ Rights Fact Sheet in six languages https://theconsumervoice.org/issues/recipients/nursing-home-residents/residents-rights#Other-Languages • Residents’ Rights posters available for purchase

38. 2019 Residents’ Rights Month (October) • Resident’s Voice Challenge • Promotional Materials • Activity Suggestions • Resources https://theconsumervoice.org/events/2019-residents-rights-month

39. Surviving the First year Speaker: Mike Milliken, Florida State LTC Ombudsman

40. Q&A with the mentors

41. The National Long-Term Care Ombudsman Resource Center (NORC) www.ltcombudsman.org Connect with us: The National LTC Ombudsman Resource Center @LTCombudcenter This project was supported, in part, by grant number 90OMRC0001-01-00, from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy.