FREQUENTLY ASKED QUESTIONS

Long-Term Care Ombudsman Program

March 10, 2020

Preparing for and responding to emergencies to support people living in long-term care facilities requires the work of 

many; and while Long-Term Care Ombudsman programs (Ombudsman programs) are not first responders, they can play 

an important role. Ombudsman programs can resolve complaints, protect rights, and promote access to services for 

residents before, during and after emergencies such as COVID-19. In this difficult time, Ombudsmen must value the 

needs and rights of residents in facilities under quarantine or in which there is risk of exposure, and at the same time 

attend to their own health and safety. 

What is COVID-19?

According to the Centers for Disease Control and Prevention (CDC), a novel coronavirus is a new coronavirus that has not 

been previously identified. The virus causing coronavirus disease 2019 (COVID-19), is not the same as the coronaviruses 

that commonly circulate among humans and cause mild illness, like the common cold.

The new name of this disease is coronavirus disease 2019, abbreviated as COVID-19. In COVID-19, ‘CO’ stands for 

‘corona,’ ‘VI’ for ‘virus,’ and ‘D’ for disease. Formerly, this disease was referred to as “2019 novel coronavirus” or “2019-

nCoV”.

There are many types of human coronaviruses including some that commonly cause mild upper-respiratory tract 

illnesses. COVID-19 is a new disease, caused be a novel (or new) coronavirus that has not previously been seen in 

humans. 

What is the role of the Ombudsman program in responding to residents during a 

COVID-19 outbreak?

The Older Americans Act (OAA) does not authorize Ombudsman programs to serve as first responders in emergencies or 

disasters. While the OAA does not contain any specific provisions regarding activities related to Ombudsman program 

emergency preparedness or response, the OAA and federal regulations (45 CFR 1324) do require the Ombudsman 

program to provide services to assist residents in protecting their health, safety, welfare, and rights, as well as to 

represent the interests of residents before governmental agencies. OAA Section 712(a)(3)(B),(E), 712(a)(5)(B)(iii), (iv); 42 

USC 3058g(a)(3)(B), (E), 3058g(a)(5)(B)(iii), (iv); 45 CFR 1324.13(a)(1),(5), .19(a)(1), (4)

The following information is intended to point state Ombudsmen to existing tools and resources, provided now in the 

context of responding to COVID-19. This information does not replace and is meant to supplement guidance issued by 

the CDC, any state or local health department, or the Centers for Medicare & Medicaid Services (CMS).
ACL COVID-19 Response · LTCO Program FAQ · Page 2

Personal Safety is Paramount

Request that all representatives of the Office carefully review the following fact sheets from the CDC: 

1. What You Should Know

2. What You Should Do If You Are Sick

3. What You Need to Know about Handwashing

Program Preparation Before an Emergency

If your state is not yet affected by COVID-19, use this opportunity to prepare. 

• Add to your policies and procedures using existing materials being disseminated by the National Ombudsman 

Resource Center and other state Ombudsman programs

• Participate in any meetings or training offered by local health departments or your state survey agency, 

encourage representatives to participate as appropriate. 

• Contact the provider associations to learn how their members are preparing.

• Instruct representatives to contact their facilities and inquire about their emergency response plan.

• Ombudsman programs are to serve as a resource and refer individuals to appropriate public health entities, not 

attempt to answer specific questions about COVID-19.

− Inform representatives of state-specific protocols and resources regarding the COVID-19 response and 

prevention. 

− Assist representatives with messaging for community education and information and assistance regarding 

COVID-19 (e.g., provide talking points on residents’ rights regarding visitation, state and local procedures for 

quarantine). 

− Encourage representatives of the Office (representatives) to distribute CDC and related information if visiting 

or through the mail and email.

− Ensure that representatives have the phone number of local health departments or COVID-19 hotlines to 

refer residents, their families and facility staff.

Program Response During an Emergency - Continuity of Operations

Refer to ACL’s Emergency Preparedness and Response: Model Policies and Procedures for State Long-Term Care 

Ombudsman Programs, Section 400, Continuity of Operations in case your program needs to telework. Ensure that you 

and all representatives of your Office have the resources to conduct business remotely including:

• Appropriate technology, laptop, printer, internet access, electronic tablets, cell phones, etc.

• Contact information for the Ombudsman, representatives of the Office (both staff and volunteer), legal counsel, 

agency leadership, other State Ombudsmen

• Copy of Ombudsman laws, regulations, program policies and procedures, including emergency preparation and 

response policies and procedures

• Ombudsman program training manual

• Business cards

• Ombudsman program brochures and/or other outreach materials

• Ombudsman program forms, such as consent to access and disclosure forms

• Relevant contact information of other entities as described in 400.7.

Consider alternative formats to ensure that CDC guidance is widely available to all representatives of the Office (i.e.,

mailing hard copies for those representatives who are not typically online).

Consider gathering resident and family contact information now. See below, Communication with Residents 

and Families.
ACL COVID-19 Response · LTCO Program FAQ · Page 3

Alternative Methods to Conduct Ombudsman Program Work During Quarantine

Refer to ACL’s Emergency Preparedness and Response: Model Policies and Procedures for State Long-Term Care 

Ombudsman Programs Section 600 – Ombudsman Program Services Related to Emergencies to determine if there is a 

need to make adjustments in response to an outbreak of COVID-19. Such adjustments may include temporary changes 

to procedures or standards concerning facility coverage through visits to residents, alternative formats to conduct 

resident communication, such as through video conferencing, or phone calls, and suspension of some activities, as 

appropriate.

Communication with Residents and Families

Be proactive and ensure that your state policies and procedures require that representatives routinely obtain a resident 

census list. If one is not available and visits are prohibited, instruct representatives to call the facility and ask for the list.

Outreach to Residents – Start with the Telephone

States may want to develop a script and brief questionnaire when contacting residents to ensure some consistency. Use 

introductory language and questions typically asked during routine visits. Additionally:

• Ask residents if they have access to a computer, tablet or has a smart phone and if they are interested in video 

chats or conferences.

• Ask residents if they have email addresses and if they would like to receive email updates or correspond through 

email.

• Ask residents if they prefer that you contact a representative for on-going communication. 

Reminder about Ombudsman Communications: All communications with residents, complainants, others, via 

email or other methods are considered Ombudsman program information and disclosure provisions apply. Ensure 

that your program has technology in place to protect the privacy of email correspondence. 

Resident Councils

Ensure that your state policies and procedures require that representatives routinely obtain the contact 

information of resident council leadership, including phone numbers and email addresses. 

• If this was not in your policies and procedures, consider activating this requirement for future visits.

• Do not wait for an outbreak of COVID-19. Instruct representatives to call the facility and ask for information now.

• Contact the resident council president – assess the level of technological capacity to hold resident council 

teleconferences

• Seek facility staff support to establish this meeting format, if necessary.

Resident Representatives, Families and Family Councils

• Ensure that your state policies and procedures require that representatives routinely obtain resident 

representative or family contact information, including phone numbers and email addresses.

− If this was not in your policies and procedures, consider activating this requirement.

− Do not wait for an outbreak of COVID-19 – instruct representatives to call the facility and ask for resident 

representative or family contact information now.

− Create and send an email introduction, which includes how to contact the program.

• Ombudsman programs may want to consider activating family councils where they do not exist or holding family 

teleconference meetings. This type of meeting creates an opportunity to introduce the program before a crisis 

occurs. Establishing communication may be more difficult when the facility is in the middle of a crisis. 
ACL COVID-19 Response · LTCO Program FAQ · Page 4

• If a family council exists, ensure that representatives contact the president and ask to be invited to their meeting, 

if not already involved.

Additional Communication Approaches When a Facility is Under Quarantine

• Post Ombudsman program contact information on front door.

• Make brochures available outside by the front door, if practical.

• Mail brochures and other information to the facility and ask the administrator to distribute program brochures.

• Consider issuing a press release to remind the public that the program is a resource.

• Contact elected officials to remind them that the program is a resource for their constituents.

Complaint Processing 

Refer to ACL’s Emergency Preparedness and Response: Model Policies and Procedures for State Long-Term Care 

Ombudsman Programs Section 600.2 Complaint Processing

Assess complaint intake, response, investigation, referral, and resolution procedures and standards applicable under 

normal operating conditions and determine if adjustments are necessary. 

• Ensure that the complaint process during emergencies continues to reflect the primacy of the resident’s goals, 

wishes and determination of satisfaction with the resolution, as required by 45 CFR 1324.19(b).

• Ensure consistency of complaint processing practices regarding disclosure of resident or complainant identifying 

information, as required by 45 CFR 1324.19(b). The program continues to obtain informed consent to the 

greatest extent possible with consideration of the specific circumstances of this emergency. 

The Ombudsman program may be the complainant when there is difficultly accessing resident, for example, or if there 

are general concerns about care or infection control and similar circumstances. Remind representatives to document all 

activities (e.g., complaints, information and assistance, community education) using appropriate NORS codes. Document 

these complaints in your state’s software; this includes activities and complaint work conducted by the state 

Ombudsman.

Ombudsman Program Authority

The Ombudsman program has authority to access residents and their representatives although during this crisis the 

method may change.

• 45 CFR 1324.11(e)(2)(iii) Access to the name and contact information of the resident representative, if any, where 

needed to perform the functions and duties set forth in §§1324.13.

• 1324.19 (e)(2)(vii) Reaffirmation that the Health Insurance Portability and Accountability Act of 1996 (HIPAA) 

Privacy Rule, 45 CFR part 160 and 45 CFR part 164, subparts A and E, does not preclude release by covered 

entities of resident private health information or other resident identifying information to the Ombudsman 

program, including but not limited to residents' medical, social, or other records, a list of resident names and 

room numbers, or information collected in the course of a State or Federal survey or inspection process.

Review your state’s Memorandum of Understating (MoU) with your state survey and certification agency to ensure 

that lines of communication are consistent with the MoU. Advocate for the program to be included in any 

statewide task force and that the program is involved in applicable conference calls, etc.

Legal counsel – ensure that your legal counsel is activated to help if you are having difficulty accessing residents or 

their representatives and for consultation on complaints and other programmatic issues related to COVID-19.
ACL COVID-19 Response · LTCO Program FAQ · Page 5

Facility Emergency Preparedness and Response Requirements

Nursing homes are to have an emergency preparedness plan – see §483.73 - Emergency preparedness.

The LTC facility must comply with all applicable Federal, State and local emergency preparedness requirements. The 

LTC facility must establish and maintain an emergency preparedness program that meets the requirements of this 

section. The emergency preparedness program must include, but not be limited to, the following elements:

(a) Emergency plan. The LTC facility must develop and maintain an emergency preparedness plan that must be 

reviewed and updated at least annually. The plan must do all of the following:

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an allhazards approach, including missing residents.

(2) Include strategies for addressing emergency events identified by the risk assessment.

(3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has 

the ability to provide in an emergency; and continuity of operations, including delegations of authority and 

succession plans.

(4) Include a process for cooperation and collaboration with local, tribal, regional, State, or Federal emergency 

preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation.

The policies and procedures require the nursing home to maintain an emergency communication plan that specifically 

includes contain contact information for the Office of the State LTC Ombudsman Program. 42 CFR § 483.73(c)2)(iii).

Resident Rights: 42 CFR § 483.10(f)(4)(i)

(4) The resident has a right to receive visitors of his or her choosing at the time of his or her choosing, subject to the 

resident's right to deny visitation when applicable, and in a manner that does not impose on the rights of another 

resident. (i) The facility must provide immediate access to any resident by—

(C) Any representative of the Office of the State long term care ombudsman, (established under section 712 of the Older 

Americans Act of 1965, as amended 2016 (42 U.S.C. 3001 et seq.). 42 CFR § 483.10(f)(4)(i)(C).

Again, the method of communication with the resident may not be in a personal visit but this does not mitigate the 

responsibility of the nursing home to facilitate resident communication (by phone or other format) with the 

Ombudsman program or any other entity listed in 42 CFR § 483.10(f)(4).

Residential Care Communities

Review your state requirements for emergency preparedness requirements. Reports of assisted living residents and staff 

with COVID-19 indicate that they will need to prepare and respond.

Resources

Administration for Community Living (ACL) COVID-19 Page

Centers for Disease Control and Prevention (CDC) – Check the CDC website for the most timely, comprehensive 

information about the national response to the outbreak. 
ACL COVID-19 Response · LTCO Program FAQ · Page 6

Centers for Medicare & Medicaid Services (CMS)

• CMS recently issued guidance for surveyors (QSO-20-12-All) and a call to action to long-term care providers 

(QSO-20-14-NH) and hospitals to assist in preventing the spread of COVID-19.

National Ombudsman Resource Center (NORC)

• Coronavirus Prevention in LTC Facilities: Information for State Long-Term Care Ombudsmen (password

protected SLTCO site) 

• Infection Control issue page