Form 8619, State Long-Term Care Ombudsman Program Case Record

Instructions

Updated: 9/2010

Certified ombudsmen collect data on HHSC Form 8619 to enter in OmbudsManager. It can be collected while onsite. The form is optional. If used, retain the document as a record.

Ombudsman — Enter the certified staff managing the case.

Reference title for the case — Briefly describe the subject. Focus on the most significant complaint.

Date — Enter the date you

• received or identified the first complaint within a case.
• initiated work on the case.
• closed the case because no complaints required further action.

Intake Summary — Enter basic initial information, including the presenting problem expressed by the resident or complainant. Mark whether the resident or complainant requested anonymity.

Consent to —

• work on a resident's behalf. Mark Yes or No. With consent, work to resolve complaints; without consent, consult the managing local ombudsman. Leave this box unchecked only in situations where you initiate the complaint or the complaint is not widespread enough to require individual resident consent.
• review records. Mark Yes or No. If yes, mark oral or written.

Complainant — Enter applicable information or use Anonymous if not known. Complainant roles include:

1. resident
2. relative/friend
3. guardian/legal rep
4. ombudsman
5. facility staff
6. medical staff
7. social/health agency
8. unknown/anonymous
9. bankers, clergy, law enforcement, public officials, etc.

Facility — Mark nursing facility or assisted living facility and enter the name.

Resident — Enter the resident's name as applicable or use Anonymous, if not known. If the resident has a legally authorized representative, enter that name and mark the type of authority.

Complaints

Code (001-132) — Enter the code that best matches the complaint. See Attachment 1 for a list of codes.

Notes — Enter information to describe the complaint.

Verified? — After investigation, mark Yes if you verified the complaint or found it to be generally accurate. If not, mark No. A certified ombudsman may work to resolve a complaint, regardless of verification.

Actions (Journal) — Enter comments about a case. It is unnecessary to duplicate documentation made in the intake summary or complaint table.