(a) The Office conducts an onsite visit of a local ombudsman entity and a host agency to monitor:
  (1) the performance of functions of the Ombudsman Program by a representative of the Office;
  (2) the compliance by a local ombudsman entity with Subchapter D of this chapter (relating to Requirements of a Local Ombudsman Entity);
  (3) the compliance by a host agency with Subchapter E of this chapter (relating to Requirements of a Host Agency); and
  (4) the compliance by a local ombudsman entity and a host agency with Subchapter G of this chapter (relating to Grievances).
(b) The Office conducts at least one onsite visit every three years. An onsite visit includes:
  (1) observing and evaluating a visit of a managing local ombudsman to an LTC facility; and
  (2) reviewing information regarding a local ombudsman entity's compliance with Subchapter D of this chapter, including documentation regarding:
    (A) the training of representatives of the Office;
    (B) identification of individual conflicts of interest; and
    (C) expenditures for the Ombudsman Program, such as timesheets and evidence supporting mileage reimbursement for representatives of the Office.
(c) The Office:
  (1) selects a date for an onsite visit in consultation with the managing local ombudsman;
  (2) notifies the host agency of a scheduled onsite visit at least 30 days before the visit; and
  (3) within 45 days after the Office completes an onsite visit, provides to the local ombudsman entity and the host agency a written report that may contain findings and recommendations from the visit.
(d) The host agency must, within 45 days after receipt of the written report described in subsection (c)(3) of this section that contains one or more findings, submit a written plan of correction to the Office that describes:
  (1) the action that will be taken to correct each finding; and
  (2) the date by which each action will be completed.
(e) Within 45 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 or host agency 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 or host agency submit evidence of correction to the Office; and
  (3) visits the local ombudsman entity.
(g) If the Office determines that the local ombudsman entity or host agency did not complete an action in accordance with an approved plan of correction or an approved modified plan of correction:
  (1) the Office may allow the local ombudsman entity or host agency 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 or host agency 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.

Source Note: The provisions of this §88.106 adopted to be effective May 22, 2024, 49 TexReg 3566