Form 8620, Long-Term Care Ombudsman Activity Report

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Documents

Effective Date: 9/2019

Instructions

Updated: 10/2019

Certified volunteer ombudsmen are required to submit Form 8620, Activity Report, each month. The report can be submitted electronically or as a paper copy. Submit the report by the due date set by your local long-term care ombudsman program.

Detailed Instructions

Enter your name, the name of your assigned facility to which this report applies, and the month and year you conducted the activities in this report.

Visits

Enter dates and time spent on site. Your local program decides whether you are required to track number of contacts, travel time and mileage.

  • Date – Enter each date you visited.
  • No. of Contacts – Enter the number of separate contacts for resident, family/other (non-relative visitors) and staff. A contact is a meaningful interaction and can be done by phone, e-mail, letter or in person.
  • Time on Site – Enter time spent in the facility and resolving complaints.
  • Travel – Enter time spent traveling to and from the facility.
  • Mileage – Enter miles traveled to and from the facility.

Note to the managing local ombudsman — Determine whether certified ombudsmen are required to track number of contacts, travel time and mileage. When reporting donated hours of service, count time on site, travel time and mileage (if the volunteer is not reimbursed).

Activities

  • Family Council Attended – Enter the date or dates you attended the family council meeting. Only attend if invited by a family council member.
  • Resident Council Attended – Enter the date or dates you attended the resident council meeting. Only attend if invited by a resident council member.
  • Survey Participation – Enter the date or dates of participation in any part of an HHS Regulatory Services annual survey or complaint investigation.
  • Care Plan Meeting – Enter the date or dates you attended the care plan meeting. Only attend if invited by a resident or resident’s legally authorized representative. Enter the name of the resident who was the subject of the care plan meeting.

Information and Assistance

  • Date(s) - Enter the date or dates you provided information and assistance.
  • Topic - Enter the topic of the information and assistance you provided (such as resident rights or the role of the ombudsman.)
  • Name and Role of Person(s) You Gave Information To - Enter the name or names of the person or persons you gave information and assistance to on one topic. Enter the role of the person or persons you gave information and assistance to (such as a resident, a family member, or facility staff.)

Cases and Complaints

  • Date Opened – Enter the date you received or identified the complaint.
  • Resident Name - Enter the name of the resident who is the subject of the complaint. If the complaint involves several residents, enter “several.”
  • Complainant Name and Relationship to Resident - Enter the name of the complainant and how the complainant is related to the resident (such as a friend, family member, legally authorized representative, or staff person.)
  • Who Gave Consent- Select the person who gave consent for the complaint investigation.
    1. Resident - select if the resident gave consent for consent investigation themselves.
    2. LAR - select if the resident’s legally authorized representative gave consent to investigate the complaint. Provide the name of the LAR.
    3. Ombudsman - select if the ombudsman is authorized to investigate the complaint without consent of the resident or legally authorized representative.
  • Complaint Code and Complaint Description (Codes A-1 to L-3) – Enter one code that best matches the complaint. See the attached list of complaint codes. Enter a description of the complaint, including:
    1. Details about the complaint.
    2. What you did to investigate and resolve the complaint.
    3. If part of the complaint investigation was to refer the complaint to another agency, the name of the agency.
    4. If the complaint involves an allegation of abuse, neglect, or exploitation, the name of the alleged perpetrator.
  • Verified – After investigation, mark “Y” if you verified the complaint (through investigation, you found that most or all the facts are true or likely to be true or the complaint is based on the subjective opinion of the resident) or mark “N” if you could not verify the complaint.
  • Disposition – For each complaint, choose a disposition that best describes the outcome after completing the complaint investigation.
    1. Resolved - choose this disposition if the complaint is partially or fully resolved as determined by the resident, resident’s LAR, or complainant.
    2. Withdrawn - choose this disposition if the resident who is the subject of the complaint or the resident’s LAR declines consent for the ombudsman to investigate the complaint; the complaint is withdrawn by the resident or complainant; or the resident died before the resolution of the complaint and you determine that further investigation would not benefit other residents.
    3. Not Resolved - choose this disposition if the complaint was not addressed to the satisfaction of the resident, resident’s LAR, or complainant.
  • Date Closed – Enter the date you closed the complaint because no further action is required.