(a) The Office conducts a desk review of a local ombudsman entity to determine if the local ombudsman entity:
  (1) is in compliance with §88.305(a)(3) and (c)(2) of this chapter (relating to Complaints) and §88.307(a) of this chapter (relating to Requirements Regarding LTC Facility Visits and Submitting Information to the Office);
  (2) is making progress toward meeting:
    (A) performance measures required by §88.405(a)(3) - (6) of this chapter (relating to Performance Measures); and
    (B) performance measure projections required by §88.405(b) of this chapter; and
  (3) has conducted at least one visit to each LTC facility in the ombudsman service area each quarter of a federal fiscal year as required by the Ombudsman Policies and Procedures Manual.
(b) The Office:
  (1) conducts at least one desk review of a local ombudsman entity every three months; and
  (2) may conduct a desk review of a local ombudsman entity at any time.
(c) If the Office identifies a finding from a desk review, the Office provides to the local ombudsman entity and the host agency a written report that contains the finding and may include recommendations.
(d) If a local ombudsman entity or host agency receives a written report described in subsection (c) of this section, the host agency, within 14 days after receipt of the report, must submit a written plan of correction to the Office that describes:
  (1) the action that will be taken to correct each finding in the report; and
  (2) the date by which each action will be completed.
(e) Within 14 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 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 submit evidence of correction to the Office; and
  (3) visits the local ombudsman entity.
(g) If the Office determines that the local ombudsman entity did not complete an action in accordance with an approved plan of correction or a modified plan of correction:
  (1) the Office may allow the local ombudsman entity 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 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 §88.107 adopted to be effective May 22, 2024, 49 TexReg 3566