ABC’s of the LTCOP for Ombudsmen Ethical Considerations, Core Principles, and the Strengths of the Role of the Program November 2, 2016

Moderator and Presenter Carol Scott, Ombudsman Specialist, NORC Presenters Becky Kurtz, Director, Office of Long-Term Care Ombudsman Programs, Administration for Community Living Lynn B. McCamie, Ombudsman Program Manager, Baltimore County Department of Aging, Maryland  Denise Kennedy, Bluegrass District Ombudsman, Nursing Home Ombudsman Agency of the Bluegrass, Inc., Kentucky 

Who are YOU? Name Town/state How long have you been in the LTCOP One sentence describing your favorite part of the job

Agenda 3:20 – 3:35 Stretch Break

Elevator Speech Turn to your neighbor: tell him/her what the LTC Ombudsman Program is and what it does (assume the person knows nothing about the program) You have 30 seconds.

Ombudsman: ɑmbədzmən https://www.youtube.com/watch?v=mTKvBxRypbc A LTCO is an advocate for residents of nursing homes, board and care homes, and assisted living facilities. Ombudsmen provide information about how to find a facility and what to do to get quality care. They are trained to resolve problems. They also represent the perspective of residents in monitoring laws, regulations, and policies.

Roles of the LTCO Advocate Educator Investigator Resolver of complaints Mediator

Video from New York      That's So New York: New York Foundation for Senior Citizens - Ombudsman Program: https://youtu.be/Ylb9LrKtYZQ

How the LTCOP Began What federal legislation in 1965 created the nursing home “industry?” Medicare/Medicaid Who’s idea was it to create the Ombudsman Program? Dr. Arthur Fleming Why? Poor care provided, and wanting communities to get involved The early nationwide program stressed reliance on…..what? Volunteers

Volunteer Management Listserv This group is a private listserv for Ombudsmen that manage volunteers. The purpose is to promote discussion among your peers and share challenges and successes regarding Ombudsman volunteer management. NORC staff will respond to questions and highlight resources, as appropriate. To join the listserv, send an email to cscott@theconsumervoice.org

Ombudsman perspective on the job: “The greatest experiences I have had working as an ombudsman are listening to people and treating them as a valued human being; working with citizens to become volunteer ombudsmen, and facilitating staff, residents, and families to communicate with each other.” Vivian Omagbemi, Maryland Local LTCO

A Self-Evaluation and Continuous Quality Improvement Tool for Local LTCOP: Mini-Tool BENEFITS OF THE TOOL Completing this self-evaluation tool can help the Local Ombudsman: ⇒ Develop an action plan tailored to address the particular needs of his/her local program ⇒ Set priorities for the local program ⇒ Establish benchmarks for the local program ⇒ Meet the requirements of the Older Americans Act ⇒ Identify ombudsman program best practices ⇒ Identify training needs ⇒ Gain a greater understanding of the ombudsman program if the Local Ombudsman is new

Program Access 1. The local ombudsmen and certified volunteers have large print business cards that identify them as being with the local ombudsman program. 2. The local program initiates opportunities in the community to educate others about its services (e.g. at trainings, presentations, or discussions organized by other organizations/agencies; at service clubs or meetings of religious organizations, etc.). 3. Complaints are received from a variety of sources including: residents, families/friends, non-relative guardian/legal representative, governmental and non-governmental agencies, facility staff and ombudsman observation.

Systems Advocacy 1. The local program develops an identifiable local systems advocacy agenda to address an issue or issues faced by residents in the program’s service area. (NOTE: systems advocacy includes advocacy to resolve systemic problems with care at the individual facility level or within facilities owned by a particular corporation, as well as efforts to improve laws, regulations and policies affecting residents.) 2. The local program is unencumbered in carrying out its local systems advocacy agenda and the state systems advocacy agenda (when a state agenda exists) and in responsibly representing the concerns and interests of long-term care residents (for example, the LO, and LTCOs when directed by the LO, are able to take issues affecting residents directly to legislators and other policymakers).

Systems Advocacy Continued 3. The local program educates residents, their families, citizens’ groups and the public about, and involves them, in the local systems advocacy agenda and the state systems advocacy.

Relationships with Agencies/Entities/ Individuals/Citizen Groups/Others 1. The local program develops and maintains relationships with a wide range of agencies, individuals and entities outside of the ombudsman program (e.g. regional/local surveyors, local adult protective services investigators, regional Medicaid Fraud Control Unit investigators, regional legislators, the media, etc.). 2. The local program fulfills all pertinent commitments made under any memorandum of understanding established between the office of the state ombudsman and another agency or entity. 3. The LO or LTCO designated by the LO serves on local committees, councils, workgroups and other groups that are involved in issues related to residents of long-term care facilities within the program’s service area.

Becky’s slides

3:20 – 3:35 Stretch Break

So, What Makes LTCO Unique? Long-Term Care Ombudsmen are Advocates. • LTCO carry the message for residents. • LTCO are - impartial in gathering information. - advocates for residents in seeking resolution.

The Long-Term Care Ombudsman Program • Operated by Office of the LTCO, headed by a State LTCO, responsible for a statewide program • Has more strict confidentiality provisions • Has specific conflict of interest provisions • Pursues administrative, legal, and other remedies on behalf of residents • Is protected from willful interference • Has legal counsel available that is free of conflict of interest

The LTCOP is unique in OAA because it • Addresses concerns of individual residents • Calls upon others to fulfill their responsibilities to residents • Gives a public voice to residents’ needs by working for legislative and regulatory changes. • Individual Concerns Systems Issues Laws, Regulations, Policies • How facts are used can be different with LTCO. LTCOP gather information to resolve issue to resident’s satisfaction. Others determine if a law, standard, or regulation has been violated.

Standards Of Evidence in Investigation • LTCO gather evidence to - understand what must be addressed, - resolve problem to resident’s satisfaction. • Other agencies gather evidence to - determine if legal standards have been violated and - take official action if indicated.

Ethics http://ltcombudsman.org/omb_support/pm/ethics Ethics is the principles of right and wrong conduct A set of moral principles  a theory or system of moral values  the principles of conduct governing an individual or a group  a guiding philosophy Ethics is about the process as well as what you do. It is about how you get there.  Good ethics begins with good facts.  There is always a range of morally acceptable actions. Glover, 2001 presentation to LTCO

Quick Reference Guide for LTCO Practice: Ethical Guidance for Long-Term Care Have I taken reasonable actions to: respect and maintain the confidentiality of the resident; ascertain what the resident wants; identify the underlying issue/problem; verify the complaint; identify as many solutions as possible; seek the assistance of other resources as appropriate; consult with the resident throughout the process; follow the resident’s desires, not my determination of the best interest of the resident; encourage the resident to exercise self-advocacy; discuss with the resident the potential ramifications of this course of action, or of taking no action; engage in advocacy, not just accept the explanations of others as to what “has to be”? http://ltcombudsman.org/uploads/files/support/Quick-Reference-Guide-Ethics.pdf

NALLTCO Code of Ethics http://nalltco.org/codeofethics.html The Ombudsman provides services with respect for human dignity and the individuality of the client unrestricted by considerations of age, social or economic status, personal characteristics or lifestyle. Respects and promotes the client’s right to self-determination. Makes every reasonable effort to ascertain and act in accordance with the client’s wishes. Acts to protect vulnerable individuals from abuse and neglect.

NALLTCO Code of Ethics continued Safeguards the client’s right to privacy by protecting confidential information. Remains knowledgeable in areas relevant to the long term care system, especially regulatory and legislative information, and long term care service options. Will provide professional advocacy services unrestricted by his or her personal belief or opinion. Participates in efforts to promote a quality long term care system. Participates in efforts to maintain and promote the integrity of the long-term care ombudsman program.

NALLTCO Code of Ethics continued Supports a strict conflict of interest standard which prohibits any financial interest in the delivery or provision of nursing home, board and care services, or other long-term care services which are within the scope of involvement Shall conduct him or herself in a manner which will strengthen the statewide and national ombudsman network.

Case Studies For all of your answers, explain your rationale. In all of these scenarios, you are considered to be the ombudsman.

1. A nursing home social worker calls you requesting assistance. 2. The legal representative of a resident calls you asking for help.

How do you respond to the social worker? Explain the role of Ombudsman: it’s not to tell the home WHAT to do. It IS to help get the staff thinking of possible solutions. Highlight ethical issues Framing questions as an advocate Resources: Mental Health Issues Individualized care

What do you do when the legal representative of a resident calls you asking for help? Meet with the resident, legal representative and facility staff. Goal is to see if there is any way the resident can/will change their behavior. You are the advocate for ALL residents, so you have to be concerned about the welfare of the other residents. Read the discharge notice and make sure it contains all the required information. If no, point those items out to the legal representative and have him/her request a discharge hearing, pointing out to the hearing officer what is deficient about the notice. That will buy some time for the discharge, as the hearing officer will “throw the notice” out and the facility will need to re-write the notice and the clock will start again. If there is another more appropriate facility for the resident to move to, or if there are other resources available (therapy, behavior management, etc.), this information can be provided to the legal representative.

3. While making a routine monitoring visit, a resident shares that she is very scared. Last night a staff person told her if she keeps ringing the call light she will be punished by being discharged from the facility.  The resident is totally bedfast and needs constant assistance from staff. She has no other place to go. The resident tells you not to do anything to assist her because she fears retaliation and no one will be able to protect her.   Should you report this? If so, to whom? Would your actions change if you overheard the staff person threatening the resident? If so, how?

Should you report this? NO. Ombudsman are not mandated reporters. One thing you could do is talk to the resident about WHY she was ringing the call light. Did no one respond? Does she ring the call bell every night? Is there something different happening: new staff at night; new need to go to the bathroom often; is she on a new medication, etc.? By finding out this information, you may be able to visit with other residents and see if any of them use the call light at night. If so, do they also experience difficulties getting assistance? Will THEY give you permission to investigate? Try to find out the name of the staff person. When talking to other residents, see if they mention this same staff person. You can visit the resident as often as possible to develop a trusting relationship. Share information about requirements regarding discharge notification and her rights.

Would your actions change if you overheard the staff person threatening the resident? If so, how? Why the role is what it is…. Resident directed (person centered care) LTCOP Rule regarding witnessing abuse The procedures for disclosure, as required by §1324.11(e)(3), shall provide that, if the Ombudsman or representative of the Office personally witnesses suspected abuse, gross neglect, or exploitation of a resident, the Ombudsman or representative of the Office shall seek communication of informed consent from such resident to disclose resident-identifying information to appropriate agencies; [1324.19 (b)(8)] *Information regarding the LTCOP Rule http://ltcombudsman.org/library/fed_laws/ltcop-final-rule 

Lynn and Denise

The National Long-Term Care Ombudsman Resource Center (NORC) www.ltcombudsman.org This project was supported, in part, by grant number 90OM002, 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.