Guidance from ACL’s Office of Long-Term Care Ombudsman Programs

Recommendations for Ombudsman program advocacy related to states’ work on the HCBS Settings Rule

Long-Term Care Ombudsman Role

Home and Community-Based Services (HCBS) Settings Rule

Background

In 2014, the Centers for Medicare and Medicaid Services (CMS) published a rule that established that home 

and community-based settings (HCBS) must exhibit specific qualities to be eligible sites for delivery of HCBS. 

Implementation of the rule required states to evaluate such settings for compliance. Then, CMS published a 

toolkit that allowed Ombudsman representatives to conduct site-specific evaluations. 

In 2015, ACL’s Office of Long-Term Care Ombudsman Programs responded to an inquiry about the 

Ombudsman role, stating that it would be consistent with the Ombudsman duty to provide information to state 

personnel to assist with their evaluation of settings’ compliance – even though Ombudsman programs do not 

perform regulatory functions and cannot determine whether a particular setting meets the settings rule 

requirements. The following guidance builds on the 2015 letter by providing specific actions Ombudsman 

programs can take.

Ombudsman Actions

• Identify state agency lead.

• Educate state agency about the Ombudsman role and data.

• Read the approved State Transition Plan.

• Respond to opportunities for public comment on the State Transition Plan.

• Develop/adapt educational materials about residents’ rights and rights of HCBS waiver consumers.

• Define the Ombudsman role in the case of facility non-compliance leading to resident disenrollment or

transition to a compliant setting.

• Request a list of affected providers and their compliance status, if known.

• Train Ombudsman representatives on the state’s evaluation process and key observations to make

during regular visits.

• Facilitate local educational meetings between Ombudsman representatives and local entities such as

case managers for residents of waiver facilities.

• When scheduling regular presence visits, consider prioritizing visits to waiver providers.

• Collaborate with the Protection & Advocacy (P&A) system when both the P&A and Ombudsman

program have visited a setting.

• Respond to opportunities for public comment on Heightened Scrutiny packages.
ACL | Long-Term Care Ombudsman Role: HCBS Settings Rule | Page 2

Examples from State Transition Plans

Excerpts from State Plans

• Alaska: Request and encourage Ombudsman to volunteer for training due to presence in HCBS 

settings in regular course of duties. 

• Arizona: Planning meetings include information about Ombudsman. 

• Arkansas: Providers required to cooperate with Ombudsman on transition; on-site visit prior to 

termination. 

• District of Columbia: Training on rights, risks in transitions; participation in review group. 

• Maine: Member of stakeholder advisory committee. 

• Minnesota: Ombudsman information included in consumer letters about transition; member of advisory 

group. 

• New Hampshire: Member of advisory task force; assistance with participant surveys; complaint 

process; Ombudsman role included in training; process for analyzing complaint data. 

• North Dakota: Quarterly visits; trained in criteria; help educate and advocate for consumers rights; 

report systemic issues. 

• Ohio: Adapt resident satisfaction survey; facilitate transition team. 

• Oregon: Input to selection of Heightened Scrutiny facilities; assign volunteers to facilities determined to 

need additional oversight; received HCBS 101 training. 

• Rhode Island: Administer HCBS survey questions to residents; share information with state team 

regularly. 

• South Carolina: Stakeholder review; invited to webinar. 

• South Dakota: Ongoing monitoring by Ombudsman after transition plan period. 

• Tennessee: Support for resident transition. 

• Vermont: Ombudsman information in handbook. 

• Wisconsin: Assist consumers with appeals. 

Resources

• Final Rule Fact Sheet

• Medicaid Letter Extending Timeline

• Requirements Compliance Toolkit

• CMS HCBS Training Series

• HCBS Advocacy Coalition

• Autistic Self Advocacy Network’s Plain Language Toolkit

• HCBS Technical Assistance for States