What is an Ombudsman

Many facilities dread the call from their local ombudsman, but I am here to tell you they are nothing to be afraid of! In fact, if you develop a solid relationship with the ombudsman, they can help bridge a gap between your residents and your facility leadership by acting as a mediator for difficult situations,
believe me, I have seen it firsthand. These special individuals are typically volunteering and are there solely to protect resident rights and help ensure you and your facility are doing the same. Check out the following regulation on how to work with the Kentucky state ombudsman program:

Section 2. Responsibilities of Kentucky Long-term Care Ombudsman.
(1) The Kentucky Long-term Care Ombudsman Program shall be administered by a full-time ombudsman
operated by DAIL or through a contracted entity.
(2) The Kentucky Long-term Care Ombudsman shall be responsible for the:
(a) Design, implementation, and management of a statewide uniform system for receiving,
investigating, resolving, and reporting complaints on behalf of residents in long-term care facilities and
provide ongoing support to assist in the r
resolution of those complaints;
(b) Investigation of complaints made by or on behalf of residents in long-term care facilities
from areas of the state temporarily without local ombudsman programs if a local backup ombudsman is
not available;
(c) Development and implementation of policies and procedures for operation of the program,
including those related to:
1. Receipt, investigation, verification, and resolution of complaints;
2. Protecting confidentiality of records and identity of complainants;
3. Establishing the right of public access to information regarding conditions in longterm care facilities; and
4. Securing ombudsman access to long-term care facilities, residents, and residents’
personal and medical records;
(d) Development and management of a system for the operation of a statewide network of
district programs, including:
1. Designation of district programs through:
a. Reviewing applications for the designation of district ombudsman contained in
their plans for operating either directly or under subcontract;
b. Providing written confirmation of the designation; and
c. Administration of certification and training requirements;
2. Development of district program operating procedures and reporting requirements;
3. Establishment of a communications link between the Kentucky long-term care
ombudsman and district programs;
(e) Establishment and maintenance of program official files and adoption of procedures to
protect the confidentiality of those files;
(f) Provision of information and education concerning:
1. Program activities;
2. The long-term care system; and
3. The rights and concerns of residents and potential residents of long-term care
facilities;
(g) Provision of assistance to civic organizations, consumer groups, and other interested
community organizations to enhance the rights of residents in long-term care facilities;
(h) Promotion of the development of citizen organizations at the state and local level to
participate in the program;
(i) Use of publicity and outreach efforts directed at long-term care residents and families,
network staff, and the general public about the availability of the program to receive and
investigate complaints;
(j) Review of complaint, case, and issue data submitted by the district programs and analysis for
trends, patterns, and issue identification;
(k) Annual National Ombudsman Reporting System (NORS) report to the Administration on
Community Living;
(l) Assistance to the district ombudsman to establish, develop, and coordinate ombudsman
activities;
(m) Development of agreements and working relationships with relevant agencies to encourage
their cooperation and assistance with the program at the state and local levels;
(n) Development of agreements and working relationships with legal services programs,
particularly those funded by the Older Americans Act of 1965, as amended;
(o) Development and provision of training on an ongoing basis for regional and district
ombudsman program staff and volunteers;
(p) Identification and development of additional funding and staffing resources for the longterm
care ombudsman program;
(q) Support and promotion of the formation of resident councils in long-term care facilities;
(r) Development and provision of testimony and comment on proposed legislation,
administrative regulations, policies, and rule changes affecting the long-term care residents;
(s) Conduction of other activities related to the protection and dignity of residents of longterm
care facilities;
(t) Performance of other activities required by the Administration on Community Living;
(u) Policy that shall require the district ombudsman program to perform the functions and
responsibilities of the ombudsman pursuant to 45 C.F.R. 1324.13 and adhere to the
requirements of section 712 of the Older Americans Act of 1965, as amended;
(v) Policy and procedure clarifying the local ombudsman shall have access to the agencies
programmatic fiscal information; and
(w) Policy and procedure for the receipt and review of grievances received regarding the
determination or action of the ombudsman and representatives.

Pro Tip:
• Build a rapport with your local ombudsman
• Call them when you have questions regarding your policies and protecting resident rights
• Be open and honest with the ombudsman.

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