(A) The SLTCO shall conduct a regular program review, no less frequently than every three years, to determine whether the regional program may continue its designation as a regional long-term care ombudsman program. In addition to the regular program review, the SLTCO may conduct additional program reviews whenever service delivery problems occur within the region served by a regional program.
The AAA having jurisdiction in the designated region may participate in the program review.
Nothing in this rule shall prohibit the AAA from conducting a unit audit independent of the SLTCO's program review, except that the AAA shall inform the SLTCO of the results of any such audit.
(1) When conducting any program review, the SLTCO shall review:
(a) The program's continued compliance with the structural standards set forth in paragraph (B) of rule 173-14-21 of the Administrative Code;
(b) The program's continued compliance with all state and federal laws, regulations, policies, and procedures governing the office of the SLTCO;
(c) The program's continued compliance with the requirements pertaining to the maintenance of program policies and procedures as set forth under paragraph (B)(7) of rule 173-14-21 of the Administrative Code;
(d) The program's complaint case records to determine the quality of the program's complaint-handling efforts and to determine whether the program is acting in accordance with the case handling protocol set forth in rule 173-14-16 of the Administrative Code;
(e) The program's attainment of the outcomes and objectives provided for under its current ombudsman plan;
(f) The program's ombudsman plan for the ensuing year. The plan shall be prepared in accordance with paragraph (A) of rule 173-14-23 of the Administrative Code;
(g) The program's performance on quality measures established by the SLTCO with input from regional program directors; and,
(h) The program's advocacy and information service.
(2) In the event the AAA chooses to participate in a program review, the AAA may take the lead in conducting the reviews required under paragraphs (B)(1)(a) to (B)(1)(c) of this rule and the SLTCO may be present and offer comments. The SLTCO shall take the lead in conducting the reviews required under paragraphs (B)(1)(d) to (B)(1)(f) of this rule and the AAA may be present and offer comments, except that the AAA may not be present or offer comments during the review provided for under paragraph (B)(1)(d) of this rule.
(3) The SLTCO or the AAA conducting the program review shall have access to all necessary program administrative records and the SLTCO shall have access to all necessary complaint records. Program administrative records include, but are not limited to, governing board minutes; conflict of interest screening forms; quality assurance documents; client satisfaction surveys; and professional development documents.
(4) When conducting reviews under paragraph (B)(1)(d) of this rule, the SLTCO shall review a minimum of fifteen cases, drawn from a random sampling of cases documented by the regional program. By January first of each year, the SLTCO, in consultation with directors of regional programs, shall determine standard case, advocacy and general information selection criteria for the ensuing year of program reviews. The established criteria will apply to all regular program reviews during that year and one or more may be determined to apply to the entire three-year cycle of program reviews.
(C) If appropriate, upon the completion of any program review the SLTCO shall develop a technical assistance plan (TAP) for the regional long-term care ombudsman program. The TAP shall be developed in accordance with paragraph (E) of rule 173-14-23 of the Administrative Code.
(1) Within twenty business days of completing any program review, the SLTCO shall provide the regional program and the AAA having jurisdiction in the designated region with written notification of the results. The date of notification shall begin the new designation period which shall not exceed three years.
(2) If the SLTCO withdraws the regional program's designation or grants the regional program only provisional designation status, the SLTCO and the AAA shall follow the notice and hearing requirements set forth in Chapter 119. of the Revised Code. The sponsoring agency may appeal the SLTCO's decision.