26 Tex. Admin. Code § 88.107 - Desk Review Monitoring of a Local Ombudsman Entity
(a) The Office conducts a desk review of a
local ombudsman entity to determine if the local ombudsman entity:
(1) is in compliance with §
88.305(a)(3) and (c)(2)
of this chapter (relating to Complaints) and
§
88.307(a) of
this chapter (relating to Requirements Regarding LTC Facility Visits and
Submitting Information to the Office);
(2) is making progress toward meeting:
(A) performance measures required by §
88.405(a)(3) -
(6) of this chapter (relating to Performance
Measures); and
(B) performance
measure projections required by §
88.405(b) of
this chapter; and
(3)
has conducted at least one visit to each LTC facility in the ombudsman service
area each quarter of a federal fiscal year as required by the Ombudsman
Policies and Procedures Manual.
(b) The Office:
(1) conducts at least one desk review of a
local ombudsman entity every three months; and
(2) may conduct a desk review of a local
ombudsman entity at any time.
(c) If the Office identifies a finding from a
desk review, the Office provides to the local ombudsman entity and the host
agency a written report that contains the finding and may include
recommendations.
(d) If a local
ombudsman entity or host agency receives a written report described in
subsection (c) of this section, the host agency, within 14 days after receipt
of the report, must submit a written plan of correction to the Office that
describes:
(1) the action that will be taken
to correct each finding in the report; and
(2) the date by which each action will be
completed.
(e) Within 14
days after the date the Office receives the plan of correction required by
subsection (d) of this section, the Office notifies the local ombudsman entity
and host agency of whether the plan is approved or requires modification. If
the Office approves the plan, the local ombudsman entity must complete the
actions contained in the plan of correction by the dates in the plan. If the
Office determines that the plan requires modification, the host agency must
submit a modified written plan of correction within a time period determined by
the Office for approval by the Office.
(f) To determine if the local ombudsman
entity has completed the actions in accordance with an approved plan of
correction or approved modified plan of correction, the Office takes one or
more of the following actions:
(1) reviews
information in the ombudsman database;
(2) requests that the local ombudsman entity
submit evidence of correction to the Office; and
(3) visits the local ombudsman
entity.
(g) If the
Office determines that the local ombudsman entity did not complete an action in
accordance with an approved plan of correction or a modified plan of
correction:
(1) the Office may allow the local
ombudsman entity additional time to complete the action;
(2) HHSC may impose a Level Two sanction in
accordance with §
213.5 of this title (relating to
Compliance with Contractor Responsibilities, Rewards and Sanctions);
or
(3) the State Ombudsman may
remove the designation of the local ombudsman entity as described in §
88.104(c)(2)(B)
of this subchapter (relating to Designation of a Local Ombudsman
Entity).
(h) If the
Office allows a local ombudsman entity additional time to complete an action as
described in subsection (g)(1) of this section and the Office determines that
the local ombudsman entity did not complete the action within the time allowed:
(1) HHSC may impose a Level Two sanction in
accordance with §
213.5 of this title; or
(2) the State Ombudsman may remove the
designation of the local ombudsman entity as described in §
88.104(c)(2)(B)
of this subchapter.
(i)
Upon request by a local ombudsman entity or host agency, the Office provides
technical assistance to a local ombudsman entity or host agency regarding
developing a plan of correction.
Notes
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