Health and Human Services

Ombudsman (Office of)

Rule 4: Congregate Care Ombudsman Program

Effective Date: 07/30/2026

Admin. Code Reference: R500-4

Rule Type: Current Rule

NOTICE OF SUBSTANTIVE CHANGE

TYPE OF FILING: CPR (Change in Proposed Rule)

Filing ID: 57747

Rule or section number:

R500-4

Date of previous publication (only for CPRs):

01/15/2026

1. Agency Information

Title catchline:

Health and Human Services, Ombudsman (Office of)

Building:

Multi-Agency State Office Building

Street address:

195 N 1950 W

City, state:

Salt Lake City, UT

Mailing address:

PO Box 142003

City, state and zip:

Salt Lake City, UT 84114-2003

2. Contact Persons

Name:

Phone:

Email:

Sofia Latham

801-440-6775

slatham1@utah.gov

Angie McCourt

385-505-3502

amccourt@utah.gov

Mariah Noble

385-214-1150

mariahnoble@utah.gov

Please address questions regarding information on this notice to the persons listed above.

3. General Information

A. Rule or section catchline:

R500-4. Congregate Care Ombudsman Program

B. Purpose of the new rule or reason for the change:

HB 383, passed in the 2026 General Session, amended Section 26B-2-124.2 to give rulemaking authority to the Department of Health and Human Services (department) to implement and enforce that section.

Therefore, it is appropriate to file this change in proposed rule (CPR) to reflect the updated statutory authority.

Additionally, based on public comment from the initial filing, the department determined it is appropriate to clarify the definition of a guardian, provider resolution exceptions, implementation plans after an ombudsman recommendation investigation timeline, and the ombudsman recommendation appeal process through this CPR.

Furthermore, based on internal discussion and direction from department leadership, this filing removes executive director involvement from the appeals process and clarifies that the Division of Customer Experience director will receive appeals, rather than the Office of Ombudsman director.

C. Summary of the new rule or change:

This CPR updates the statutory authority for this rule to Section 26B-2-124.2.

Additionally, this filing clarifies the definition of a guardian, provider resolution exceptions, implementation plans after an ombudsman recommendation investigation timeline, and the ombudsman recommendation appeal process.

This filing also removes executive director involvement from the appeals process and replaces "office director" with "division director" in Section R500-4-5.

(EDITOR'S NOTE: The original proposed new rule upon which this change in proposed rule (CPR) was based was published in the January 15, 2026, issue of the Utah State Bulletin, on page 34. Underlining in the rule below indicates text that has been added since the publication of the proposed new rule mentioned above; strike-out indicates text that has been deleted. You must view the CPR and the proposed new rule together to understand all of the changes that will be enforceable should the agency make this rule effective.)

4. Legislative Action Information

A. Are any changes in this filing because of state legislative action?

Changes are because of legislative action.

B. If yes, any bill number and session:

HB 383 (2026 General Session)

5. Fiscal Information

Provide an estimate and written explanation of the aggregate anticipated cost or savings to:

A. State budget:

There is no anticipated fiscal impact to the department as a result of this filing because changes to the rule text clarify existing processes and do not add to, modify, or remove responsibilities or restrictions for the Office of Licensing and the Office of Ombudsman.

While this filing removes the involvement in the appeals process of the department's executive director, whose title was updated to commissioner by HB 384 of the 2026 General Session, and updates the recipient of appeals from "office director" to "division director" in Section R500-4-5, this change is not anticipated to result in a cost or savings to the department.

B. Local governments:

This filing is not anticipated to impact local governments' revenues or expenditures because local governments do not provide congregate care services and, therefore, are not affected by this rule.

C. Small businesses ("small business" means a business employing 1-49 persons):

This filing is not anticipated to result in a cost or savings for small businesses providing congregate care services because changes to the rule text clarify existing processes and do not add to, modify, or remove responsibilities or restrictions for small businesses providing congregate care services.

D. Non-small businesses ("non-small business" means a business employing 50 or more persons):

This filing is not anticipated to result in a cost or savings for non-small businesses providing congregate care services because changes to the rule text clarify existing processes and do not add to, modify, or remove responsibilities or restrictions for non-small businesses providing congregate care services.

E. Persons other than small businesses, non-small businesses, state, or local government entities ("person" means any individual, partnership, corporation, association, governmental entity, or public or private organization of any character other than an agency):

This filing is not anticipated to result in a cost or savings to persons other than small businesses, non-small businesses, state, or local governments, as it applies only to the department and congregate care providers.

There are no other persons affected by this rule filing.

F. Compliance costs for affected persons:

There are no anticipated compliance costs for affected persons, identified as the department and small and non-small businesses providing congregate care services, because changes to the rule text clarify existing processes and do not add to, modify, or remove responsibilities or restrictions for affected persons.

While this filing removes department executive director involvement in the appeals process and updates the recipient of appeals from "office director" to "division director" in Section R500-4-5, that change is not anticipated to result in any compliance cost.

6. Regulatory Impact Summary Table

Enter the cost or savings in the relevant cell. If there is no cost or savings, enter, "$0." If a cost or savings is inestimable, enter, "inestimable."

Fiscal Cost

FY2027

FY2028

FY2029

FY2030

FY2031

State Budget

Local Governments

Small Businesses

Non-Small Businesses

Other Persons

Total Fiscal Cost

Fiscal Benefits

FY2027

FY2028

FY2029

FY2030

FY2031

State Budget

Local Governments

Small Businesses

Non-Small Businesses

Other Persons

Total Fiscal Benefits

Net Fiscal Benefits

7. Regulatory Impact Analysis Approval

The Commissioner of the Department of Health and Human Services, Tracy S. Gruber, has reviewed and approved this regulatory impact analysis.

8. Family Impact Information

A. The agency has considered this rule's impact on family health, stability, and formation:

☒

9. Citation Information

Provide citations to the statutory authority for the rule. If there is also a federal requirement for the rule, provide a citation to that requirement:

Section 26B-1-202

Section 26B-2-124.2

11. Public Notice Information

The public may submit written or oral comments to the agency identified in box 1.

A. Comments will be accepted until:

07/01/2026

12. Effective Date Information

This rule change MAY become effective on:

(NOTE: This is the date the agency anticipates making the filing effective. It is NOT the effective date)

07/08/2026

13. Agency Authorization Information

Agency head or

designee and title:

Tracy S. Gruber, Commissioner

Date:

05/13/2026

R500. Health and Human Services, Ombudsman (Office of).

R500-4. Congregate Care Ombudsman Program.

R500-4-1. Authority and Purpose.

(1) Sections 26B-1-202 and 26B-2-124.2 authorize[s] this rule[, and Section 26B-2-124.2 establishes the congregate care ombudsman].

(2) This rule outlines the structure, roles, functions, and operational procedures for the Congregate Care Ombudsman Program.

R500-4-2. Definitions.

(1) "Complaint" means the same as "report" is defined in Subsection 26B-2-124.2(1)(b).

(2) "Complainant" means a person who initiates a complaint.

(3) "Department" means the Department of Health and Human Services.

(4) "Division" means the Division of Customer Experience under the department.

(5) ["Executive director" means the executive director of the department, or a designee.]"Guardian" means a person or entity, including a

legal custodian or designee or placing authority or designee, legally responsible for the care and management of a child.

(6) "Ombudsman" means the congregate care ombudsman, described in Section 26B-2-124.2, or a designee.

(7) "Office" means the Office of the Ombudsman within the division under the department.

(8) "Office director" means the director of the office.

(9) "Preliminary investigative review" means the second phase of the ombudsman complaint resolution process, which is initiated if a complaint has merit and remains unresolved after the complainant has attempted to resolve the issue directly with the provider.

(10) "Provider" means an entity that provides a congregate care program, as defined in Subsection 26B-2-101(12).

R500-4-3. Receiving and Processing Complaints.

(1)(a) For a complaint to be accepted by the ombudsman, a complainant must file a complaint with the ombudsman no later than nine months from the date of any alleged circumstance that led to the complaint.

(b) If the office director determines that there is a legitimate complaint filed more than nine months after the alleged circumstance, the office director may direct the ombudsman to accept and investigate the complaint.

(2) The complainant may file a complaint by:

(a) filling out and submitting the online complaint form at dhhs.utah.gov/office-of-ombuds/congregate%20care%20ombuds/;

(b) emailing the complaint to dhhscustomerexp@utah.gov;

(d) mailing the complaint to:

Multi-Agency State Office Building, Utah Department of Health and Human Services, Office of Ombudsman - 1st Floor

195 N. 1950 West, Salt Lake City, UT 84116

(3) Each complaint shall include:

(a) a summary of any alleged circumstance that led to the complaint;

(b) the name of any person involved in the complaint;

(d) the anticipated outcome the complainant is seeking.

(4) If a complaint does not include the information in Subsection (3), the ombudsman shall attempt to contact the complainant to request more information.

(5) The ombudsman shall prioritize any complaint alleging any:

(a) act or omission that places a child's health or safety at risk; or

(b) behavior that could cause serious emotional or bodily harm to any person.

R500-4-4. Conducting an Investigation.

(1) The ombudsman shall make an effort to contact the complainant within three business days of receiving a properly filed complaint to confirm receipt of the complaint and gather additional information as needed.

(2) If the complainant has not attempted to resolve the complaint with the provider before filing the complaint, the ombudsman may refer the complainant back to the provider to attempt to resolve the complaint before the ombudsman takes further action, except when the complaint

alleges:

(a) abuse, neglect, sexual misconduct, or trafficking;

(b) retaliation or intimidation;

(d) any circumstance where referring the complainant back to the provider could reasonably deter reporting or compromise safety.

(3) If the complaint remains unresolved after the complainant attempts to resolve the complaint with the provider and the complaint has merit, the ombudsman may initiate a preliminary investigative review and contact the provider to discuss the complaint.

(4) If the complaint remains unresolved after the ombudsman's efforts to facilitate resolution during the preliminary investigative review, the ombudsman shall determine whether further investigation is warranted based on the merits of the complaint.

(a) If the ombudsman decides to escalate the complaint and conduct a formal investigation, the ombudsman shall provide written notification of that decision to:

(i) the provider;

(ii) the complainant; and

(iii) the parent or guardian of any child mentioned in the complaint, including the complainant if the complainant is a child.

(b) If the ombudsman determines that further investigation is not warranted, the ombudsman shall notify the complainant and the provider of the reason for the decision.

(5) If the ombudsman determines a formal investigation is warranted, the investigation may include the ombudsman:

(a) interviewing the complainant and gathering information necessary to determine the validity of the complaint;

(b) interviewing any child admitted to the provider;

(d) interviewing any provider staff member;

(e) accessing, copying, or inspecting a provider's records related to the complaint;

(f) entering, inspecting, or observing any physical area of a provider's facility.

(6) At the end of the formal investigation, the ombudsman shall:

(a) document the findings of the investigation; and

(b) make recommendations as needed to the provider to address any complaint found to be valid.

(7)(a) The ombudsman shall complete any investigation within [180]90 days from the date the complaint was filed, unless there are

extenuating circumstances, such as the complexity of a case or workload.

(b) If the ombudsman cannot complete the investigation within [180]90 days, the ombudsman shall notify the complainant in an accessible

format suitable to the complainant, of the reason why the final decision is delayed and the additional time needed to reach a final decision.

(8) The ombudsman shall provide written notification of the completion of an investigation and any recommendations to:

(a) the provider;

(b) the complainant; and

(c) the parent or guardian of any child mentioned in the complaint, including the complainant if the complainant is a child.

R500-4-5. Recommendation Compliance or Appeal.

(1) If the ombudsman makes recommendations upon completion of an investigation, the provider shall, within ten business days of receipt of the written recommendations:

(a) agree to comply with the recommendations by submitting a written implementation plan that includes:

(i) each specific step the provider will take to implement each recommendation;

(ii) the timeline for completion; and

(iii) staff responsible; or

(b) if the provider does not agree with the recommendations, file a written appeal with the [office]division director that:

(i) includes why the provider does not agree with the recommendations; and

(ii) requests that the recommendations be amended.

(2)(a) The [office]division director shall issue a written final decision to the provider on any appeal no later than 15 business days after

receiving the provider's appeal.

(b) If the [office]division director's final decision on an appeal amends the original recommendations, the [office]division director shall

also provide written notification of the final decision to:

(i) the complainant; and

(ii) the parent or guardian of any child mentioned in the complaint, including the complainant if the complainant is a child.[

(3) The provider may submit a written appeal of the office director's decision to the executive director within ten business days of

receiving the office director's decision.

(4)(a) The executive director shall issue a written final decision to the provider within 15 business days of receiving the appeal.

(b) If the executive director's final decision on an appeal amends recommendations, the executive director shall also provide written

notification of the final decision to:

(i) the complainant; and

(ii) the parent or guardian of any child mentioned in the complaint, including the complainant if the complainant is a child.

(5) If the executive director cannot reach a final decision within 15 business days, the executive director shall notify the provider in writing

and inform the provider the additional time needed to reach a final decision.]

R500-4-6. Processing Records Requests.

(1) In accordance with Subsection 26B-2-124.2(4)(e), the ombudsman may access, copy, or inspect a program's records that are relevant to a complaint, investigation, or review concerning a child, including any:

(a) clinical file;

(b) medical records;

(d) progress notes;

(e) incident report;

(f) audio file;

(g) video file;

(h) behavioral plans; and

(i) other records that pertain to the care, treatment, or well-being of the child in the provider's program.

(2) The ombudsman shall submit a written request for records to the provider and specify in the request:

(a) the purpose of the request;

(b) the name of any child whose records are being requested; and

(3)(a) Upon receipt of the ombudsman's written request, the provider shall provide the requested records to the ombudsman within three business days, unless a shorter timeframe is required for an urgent or expedited investigation, as described in Subsection (3)(d).

(b) The provider shall give the ombudsman access to the requested records without requiring a release of information or consent from the child or the child's legal guardian when:

(i) the ombudsman requests the records as part of the ombudsman's official duties; and

(ii) the records are related to a specific complaint or investigation.

(c) The provider shall deliver the records to the ombudsman in a secure, confidential manner to protect the child's privacy, such as through a secure electronic portal, encrypted email, or secure physical delivery.

(d) If the ombudsman determines that a delay in receiving records would jeopardize the child's health, safety, or welfare, the ombudsman may make an expedited request for records.

(i) The ombudsman shall clearly mark any expedited request as "Expedited" and include an explanation of the immediate need for the records.

(ii)(A) Upon receipt of an expedited request, the provider shall provide the requested records within 24 hours.

(B) If the request is received after regular business hours, the 24-hour period shall begin at the start of the next business day.

(4)(a) If a provider cannot provide the requested records to the ombudsman within the timeframe specified in this section, the provider shall immediately contact the ombudsman to explain the reason for the delay and provide a firm date by which the records will be provided.

(b) Any provider's delay in providing requested records, as described in Subsection (4)(a), may only be the result of unforeseen and exceptional circumstances and may not be a matter of routine practice.

R500-4-7. Child Access to Contact with the Ombudsman.

(1) A provider shall ensure that each child in the provider's program has reasonable and confidential access to the ombudsman.

(2) A provider shall promptly accommodate a child's request to contact the ombudsman and may not impede or discourage a child from contacting the ombudsman.

(3)(a) If a child requests to contact the ombudsman during a scheduled program activity, including an educational class, group therapy, or recreational activity, the provider shall make a reasonable effort to facilitate contact between the child and the ombudsman without undue delay.

(b) If the child expresses an urgent or immediate need to speak with the ombudsman, the provider shall facilitate contact between the child and the ombudsman as soon as it is safe and practical to do so.

(4) A child's ability to contact the ombudsman may not be contingent on the child's behavior, therapeutic progress, or any other factor.

(5) If a child requests to contact the ombudsman after the posted business hours, the provider shall allow the child to call the ombudsman and leave a voicemail.

R500-4-8. Confidentiality.

(1) The office may only disclose records maintained by the Congregate Care Ombudsman Program in accordance with Title 63G, Chapter 2, Government Records Access and Management Act.

(2) The ombudsman may not disclose the identity of a complainant or entity named in the complaint unless:

(a) the complainant or the legal representative of the complainant consents verbally or in writing;

(b) a court orders disclosure; or

(i) has statutory responsibility:

(A) for the complainant;

(B) over the action alleged in the complaint; or

(ii) can assist the ombudsman to achieve resolution of the complaint; or

(iii) can provide expertise that would benefit the complainant.

(3) The ombudsman may only be required to testify in court with respect to confidential matters when a court finds the ombudsman's testimony necessary to enforce this section.

R500-4-9. Complaints Regarding the Congregate Care Ombudsman Program.

(1) If a complaint is made to the ombudsman about the ombudsman, the ombudsman shall immediately notify the office director.

(2)(a) The office director, or a designee, shall investigate the complaint within ten business days of the office director receiving the complaint.

(b) The office director, or a designee, shall document the nature of the complaint and investigation.

(3)(a) The office director, or a designee, shall provide a response to the complainant within ten business days of completing the investigation.

(b) The office director, or a designee, shall document that response.

(4)(a) A complainant may file a written request for reconsideration of findings or recommendations with the division director.

(b) The division director shall review the request and investigative findings within ten business days.

KEY: residential treatment

Date of Last Change: 2026

Authorizing, and Implemented or Interpreted Law: 26B-1-202; 26B-2-124.2

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