1. (1) Each local ombudsman entity shall receive, investigate, and try to resolve any complaint made by or on behalf of a resident.
2. (2) Any person or agency may submit a complaint to a local ombudsman entity.
3. (3) An employee or volunteer of a local ombudsman entity shall initiate a complaint if the employee or volunteer has personal knowledge of an action, inaction, or decision that may adversely affect the health, safety, or rights of a resident.

4. (4) Upon receipt of a complaint, the local ombudsman entity shall determine:

   1. (a) the type of complaint received, using the National Ombudsman Reporting System categorization;
   2. (b) the outcome sought by the complainant;
   3. (c) whether any previous attempt has been made to resolve the complaint;
   4. (d) whether the complaint is appropriate for the ombudsman program to address; and
   5. (e) whether resolution of the complaint would conflict with the rights of another resident.
5. (5) A local ombudsman entity shall respond to a complaint within three business days of receipt of the complaint, or as directed by the state long-term care ombudsman.

6. (6) A local ombudsman entity shall meet with the complainant and discuss:

   1. (a) any alternative for handling the complaint;
   2. (b) any option for the complainant to personally take appropriate action, with assistance from the local ombudsman entity;
   3. (c) an explanation of the local ombudsman entity's role to act in accordance with the resident's wishes; and
   4. (d) any assurance that the local ombudsman entity will maintain the resident's confidentiality.

7. (7) A local ombudsman entity shall meet with the resident for whom a complaint has been submitted and shall discuss:

   1. (a) the resident's perception of the complaint;
   2. (b) the resident's wishes with respect to resolution of the complaint;
   3. (c) the resident's rights;
   4. (d) a plan of action; and
   5. (e) whether the resident consents to the complaint and investigation of the complaint or whether the resident lacks the capacity to consent.
8. (8) If a resident lacks the capacity to consent, the local ombudsman entity shall seek advice from the resident's representative, guardian, power of attorney, spouse, or family member.
9. (9) If the local ombudsman entity has determined that the resident's representative, guardian, power of attorney, spouse, or family member is not acting in the resident's best interest, the local ombudsman entity shall seek evidence to show the resident's wishes and carry out those wishes to the extent possible.
10. (10) A local ombudsman entity is not required to verify a complaint to seek a resolution on behalf of a resident. A resident's perception is a sufficient basis upon which a local ombudsman entity may seek a resolution.

11. (11) Upon investigation of a complaint, a local ombudsman shall complete one or more of the following:

    1. (a) research any relevant regulation, law, rule, or policy;
    2. (b) personally observe and analyze any evidence;
    3. (c) interview any relevant resident and complainant;
    4. (d) interview any relevant staff, administration, other resident, or family;
    5. (e) identify any relevant agency and obtain information from that agency's staff; and
    6. (f) examine any relevant record.
12. (12) A local ombudsman entity shall present official identification to the administration or designated employee of a long-term care facility upon arrival.

13. (13)(a) Upon investigation of a complaint, a local ombudsman entity shall seek credible evidence that supports or refutes the complaint.

    1. (b) A local ombudsman entity may directly observe evidence or gather evidence from statements or information from reliable sources.

14. (14)(a) Upon conclusion of an investigation, a local ombudsman entity shall verify a complaint when the local ombudsman entity determines that the circumstances described in the complaint are substantiated.

    1. (b) In making this determination, the local ombudsman entity shall give the benefit of the doubt to the resident's perspective.

15. (15) If a complaint is verified, the local ombudsman entity shall determine a plan of action to resolve the complaint.

    1. (a) The local ombudsman shall advocate on behalf of the resident in discussing the complaint with the appropriate facility, staff, or other relevant party to develop an agreement that resolves the complaint.
    2. (b) The local ombudsman entity shall try to resolve the dispute directly with the appropriate facility or staff, unless the local ombudsman entity determines another strategy is better.

16. (16) A local ombudsman entity shall submit a referral to another agency on behalf of a resident if one or more of the following applies:

    1. (a) another agency has statutory responsibility to support or assist the resident;
    2. (b) the action to be taken in the complaint is outside of the local ombudsman entity's scope of authority;
    3. (c) the local ombudsman entity needs additional assistance to achieve resolution of the complaint; or
    4. (d) it is determined that additional expertise may benefit the resident.

17. (17)(a) A local ombudsman entity may only submit a referral to another agency on behalf of a resident if the resident or the resident's representative, guardian, power of attorney, spouse, or family member consents.

    1. (b) If the local ombudsman entity determines that the resident's representative, guardian, power of attorney, spouse, or family member is not acting in the resident's best interest, the local ombudsman entity shall seek evidence to show what would be in the resident's best interest and, where such evidence is available, work to carry out what is in the resident's best interest.

18. (18) A complaint or case shall be closed if:

    1. (a) the complaint has been resolved to the satisfaction of the resident;
    2. (b) the local ombudsman entity has determined that the complaint cannot be verified;
    3. (c) further activity by the local ombudsman entity is unlikely to produce a result to the satisfaction of the resident;
    4. (d) the complaint is not appropriate for action from the local ombudsman entity;
    5. (e) the local ombudsman entity anticipates no further response regarding the complaint from the agency to which the referral was made; or
    6. (f) a resident with the capacity to request requests that the local ombudsman entity closes the case.
19. (19) If a local ombudsman entity receives a complaint alleging abuse, neglect, or exploitation of a resident, the local ombudsman entity shall encourage and support the complainant to make a referral to Adult Protective Services or call local law enforcement.
20. (20) If a local ombudsman entity receives a complaint that implicates a resident rights issue, the local ombudsman entity shall provide ombudsman services to the identified resident.
21. (21) A local ombudsman shall enter any complaint and documentation into the local ombudsman entity's electronic case management program.

22. (22) A local ombudsman entity must seek consent from a resident before accessing that resident's facility records.

    1. (a) A resident shall give consent orally, visually, in writing, or through auxiliary aids.
    2. (b) A local ombudsman shall document the date and method of obtaining the consent in the case file.
    3. (c) If a request for consent is denied by the resident or the resident's legal representative, the local ombudsman entity may not access the records.

    4. (d)(i) If a request for consent is unsuccessful for any reason other than specific denial by the resident or the resident's legal representative, the local ombudsman entity may access the records.

       1. (ii) A local ombudsman shall document any reason for not obtaining consent in the case file.

    5. (e)(i) If a request for consent cannot be given by the resident and it is determined that the resident's legal representative is not acting in the resident's best interest, the local ombudsman entity may access the records.

       1. (ii) A local ombudsman shall document the attempt to obtain consent and the reason to believe the resident's legal representative is not acting in the resident's best interest in the case file.

KEY: ombudsman, LTCO

Date of Last Change: October 9, 2025

Authorizing, and Implemented or Interpreted Law: 26B-2-3, 42 U.S.C. 3058g, 45 CFR 1324(A)