Ombudsman Policies, Protocols & Procedures


The Aegis “Ombudsman” is an individual who is authorized to receive confidential complaints or questions about alleged acts, omissions and improprieties, as well as systemic problems within the Ombudsman’s defined jurisdiction. Responsibilities include addressing, researching and examining issues independently and impartially, and thereafter facilitating efforts to mitigate and resolve complaints, concerns and conflicts among relevant parties.

“Aegis” includes Aegis Treatment Centers, LLC., Aegis Institute, Inc. and Nationwide Medical Group as well as clinics and programs, which are owned and operated by these three corporations.


Areas of review include:

  • Allegations of unfairness, abuse of power or discretion
  • Discourteous or inappropriate behavior
  • Inappropriate application of law or policy
  • Inefficiency
  • Decision making unsupported by facts
  • Any other breach in Aegis professional, regulatory, and/or ethical standards of Policies, Procedures and Protocols (“PP&Ps”).

The Ombudsman’s scope of service is dedicated to matters related to “Aegis” and its clinics and programs.


The Ombudsman is independent of service provision or management. He will be responsive and assist patients, employees, vendors, governmental agencies and members of the community in resolving concerns or complaints in a timely manner. The Ombudsman will be instrumental in providing education and dissemination of information.


  • Mitigate and resolve conflicts and concerns relating to Aegis
  • Protect patient’s rights as defined by Federal and State laws and regulations
  • Facilitate negotiations among conflicting parties
  • Remedy justified individual grievances
  • Prevent the recurrence of similar complaints
  • Increase responsiveness of administrators by creating awareness of the remedies available to complaints
  • Protect staff members from unfounded criticism. The research and review process will allow determination of valid or invalid complaints.
  • Quarterly and annual reports produced by the Ombudsman will result in identifying and correcting patterns of undesirable PP&P’s.
  • Educate clients, patients, families of addicts, community members, government officials and the general public as to Aegis’ operations and functions as well as the law. Handling complaints allows the Ombudsman the opportunity to educate complainants as to how he might handle the situation, and what functions are being performed by the various Aegis’ departments, and advise them of our limitations of power. Dissemination of information is a vital role of the Ombudsman.
  • Streamline clinic procedures by relieving the sites of complex complaint tasks
  • The Ombudsman acts as a good-will ambassador and serves as the foundation that supports the structure of our corporate endeavors


Satisfaction and success of the people we serve is an integral part of our business. We will handle grievances in a sensitive, honest, confidential and professional manner. People using the Ombudsman services will be treated with respect and feel they are an important part our family, thus adhering to the Aegis Mission.

Enhanced awareness and respect for the treatment of addiction among addicts, their families, government officials and the general public.


In order to measure the effectiveness of the Office of the Ombudsman, objective and subjective observations are required. Statistical reports incorporating this data shall be published.

  • An objective measurement includes the statistics compiled from the cases handled. It is important that data be gathered, analyzed and reported in the manner that is most useful to the process of improving the programs and services provided or the workplace environment.
  • Subjective measurements are also important. The perceived effectiveness among patients, employees, management, administration, health practitioners, community leaders and government officials is directly related to the person’s overall satisfaction, which is related to their success. This data is based on the source point of view and perspectives.


The credibility and effectiveness of the Office of the Ombudsman is to remain independent in its structure, function and appearance. Impartiality and maintaining confidentiality in conducting inquiries and research, communication and negotiation among conflicting parties, are essential characteristics of the Ombudsman.

The Ombudsman will be free from interference in the legitimate performance of duties and independent from control, limitation, or penalties imposed for retaliatory purposes by a judicial or governmental official, official of Aegis, or by a person who may be the subject of the complaint or inquiry.

Structural independence is the foundation upon which the Ombudsman’s impartiality is built. As the Ombudsman is independent from line management and does not have administrative or other obligations or functions, he is able to perform his duty in an impartial manner. The Ombudsman is free from initial bias and conflicts of interest in conducting inquiries and research, and in communications, negotiations and mitigation of conflicts among the parties. Impartiality does not, however, preclude the Ombudsman from developing an interest in securing and implementing the changes that are deemed necessary when the process demonstrates a need for change.


Confidentiality is an essential characteristic, which promotes disclosure from reluctant complainants, elicits candid discussions by all parties, and provides an increased level of protection against retaliation to or by any party. It is also imperative for protecting patient rights and achieving patient confidence in the program. Confidentiality is major factor that distinguishes ombudsmen from others who receive and consider complaints. Confidentiality extends to all communications with the Ombudsman and to all notes and records maintained by the office in the performance of assigned duties. It begins with the initial communication with the Ombudsman, either by scheduling an appointment or sending a complaint or inquiry by telephone, mail, fax or e-mail. The Ombudsman will not reveal the identity of the complainant without that person’s written consent. Anonymous complaints or allegations will not be processed. All information is strictly confidential as described in the Code of Federal Regulations, including but not limited to 42 C.F.R., HIPAA regulations.


Complainants must agree that any communication with the Office of the Ombudsman, whether written or oral, cannot be subpoenaed or otherwise discovered for any purpose, legal or otherwise. They will not, at any time, attempt to compel Ombudsman to testify on their behalf or for any other reason, nor will they, at any time; attempt to compel disclosure of records, files, documents or any information in the control of the Ombudsman.

The complainants must acknowledge that the Ombudsman shall not be liable for any indirect, special or consequential damages, or any damages arising out of or in connection with the use or performance of this information, advice, or service. It must be further agreed that use of the services of the Ombudsman is entirely at complainants own risk, and that the Ombudsman services are provided without warranty of any kind, either express or implied, including without limitation any warranty for information, services, counseling, uninterrupted access, or products and services provided.


The Ombudsman:

  • has the right to initiate an action without receiving a complaint or question
  • may determine that a complaint is without merit
  • may receive a complaint or question on a specific topic and conduct an inquiry on a broader or different scope
  • will conduct steps toward resolution by fair procedures in each complaint
  • will have access to all information relevant to a complaint or question and will have authority to access all relevant information
  • be responsible for protecting the rights of those seeking assistance from or providing information to the Ombudsman from personal, professional, or economic retaliation, loss of privacy, or loss of relationships
  • will prepare a statistical report of results and recommendations resulting from information received from a review or inquiry. The Ombudsman will generally consult with and obtain advice from the relevant professionals (i.e., physicians, lawyers, and others) regarding matters requiring such advice. Additionally, he will consult with an individual or group prior to issuing a report critical of that individual or group, and include their comments with the report. He will communicate the outcome, conclusion or resolution of a complaint or an inquiry to the complainant and may also communicate with other concerned entities or individuals.
  • processes should include: conducting an inquiry; research and review, examination, communication and reporting findings; developing, evaluating, and discussing the options which may be available for remedies or redress; facilitating, negotiating, and mediating; making recommendations for the resolution of an individual complaint or a systemic problem to those persons who have authority to act on them; identifying complaint patterns and trends; and educating.


  • Ombudsman will not assume practices performed in accordance to statute or other governmental agency rule, or unlawful practices, but rather will refer these cases to the appropriate and relevant persons.
  • The Ombudsman will terminate the process should the complainant file a lawsuit.
  • The Ombudsman will not conduct an inquiry that has not proceeded through the prerequisite grievance resolution processes.
  • The Ombudsman will not process, review or otherwise become involved with anonymous complaints or allegations.


The Ombudsman works outside of line management structures and has no direct power to compel any decision. The Ombudsman cannot make, change or set aside a policy or administrative decision, nor can he directly compel Aegis or any person to implement those changes. The Ombudsman is independent and has the power to mediate and recommend, but has no power of enforcement and therefore cannot require or ensure any action or outcome.

The Ombudsman shall not take up a specific issue that is pending in a legal forum without the concurrence of the parties and the presiding officer.

The Aegis Office of the Ombudsman DOES NOT:

  • Give legal advice
  • Provide psychological counseling
  • Provide medical advice
  • Make decisions on issues
  • Represent Aegis or the client in formal hearings or proceedings


An Ombudsman program requires that the office and the organization maintain two essential elements: confidentiality and neutrality. The Ombudsman role is one that emphasizes personal relations and good communications skills. The Ombudsman should be a person of recognized knowledge, judgment, objectivity, and integrity. Personality traits and specific credentials are important in selecting an Ombudsman


The Office of the Ombudsman is an independent office. In order to maintain a high level of independence, the Ombudsman is in an affiliated position with Aegis Treatment Centers, LLC. President & CEO, rather than a subordinate position.


The Ombudsman is not an employee, but an independent contractor whose service contract is reviewed for renewal each year and may be terminated by either the Ombudsman or Aegis with 30 days written notice.


The Office of the Ombudsman was created as an enhancement to the other grievance mechanisms available at Aegis. The Office of the Ombudsman differs from the Quality Assurance Department, Office of General Counsel, Department of HR, and the Patient Advisory and Advocacy Group (“PAAG”) where established procedures currently exist regarding the application of rules, policies, procedures, or interpretations. The Ombudsman may direct the complaint to the appropriate office, department or organization. The Ombudsman’s Office is not intended to be an appeals forum for unpopular decisions made in other forums or an arbitrary alternative to the program that already exists. The Ombudsman may assist in identifying the appropriate method of resolving problems or complaints outside those matters handled by the Ombudsman’s office. Complementary mechanisms are a source of support for the Ombudsman office rather than sources of competition.


Educating the public, clients, patients, addicts and their families, judicial and governmental officials, and employees about the existence and function of the office is vital to the success of the Ombudsman program.

Reporting the activities of the office is necessary to measure effectiveness and gain support for the program. By publicizing (at managers meetings and on bulletin boards) the percentages of justified and unjustified complaints, the Ombudsman may provide a means that protects departments and individuals involved while convincing clients, patients and employees that they would get a fair hearing because a substantial percentage of the complaints appear to be justified.

Colleges with an Addiction Studies program, Ombudsman meetings, CAADE conferences, Federal, State and local governmental agencies or officials including judges, public defenders, district attorneys, parole and probation officers, employees, patients, other providers, medical and mental health professionals, Chamber of Commerce luncheons, Community Action program meetings, and other groups should be approached regarding the benefits of having an Ombudsman program.

Means to create awareness and availability of the Ombudsman services.

  • Brochure (See attachment # 1)
  • Web page: plus a link from the Aegis home page.
  • Article in the company newsletter
  • Posters in the clinic lobby areas and in staff break rooms (See attachment # 2)


  • Quality of staff: It is important that the staff be conscientious and competent to handle difficult cases. Staff must be able to compile facts adhering to the rules and regulations relative to the case. Careful preparation will result in a clear disposition of the case prior to the informal conference.
  • Case Assignment: Cases will be handled on a first come basis rather than developing specializations.
  • Referral: Complex legal issues that cannot be handled by the Office of the Ombudsman will be referred to the Office of General Counsel for legal advice and opinions.


  1. The Office of the Ombudsman receives the Grievance Form (either through the mail, by fax or by email) or receives a letter. (See Attachment # 3)
  2. Grievances are sorted as: 1) no jurisdiction; 2) informational request; 3) complaint/allegation.
  3. If no jurisdiction, then it is referred to the appropriate jurisdictional person, if known. If informational request, the request is researched and the information forwarded to the requesting party, within 5 business days. The Ombudsman can relay the correspondence to the relevant department director, clinic, and program manager with the information requested. They should respond within 5 business days. If complaint, the staff member opens a file and sends a letter to the complainant informing them that the Ombudsman has received their concern and will be contacting them within 5 business days to begin the research and review process. Preliminary review of policy, procedures, laws, rules and regulations takes place in advance of interview in order to develop the proper approach.
  4. Within five (5) days of receipt of the complaint, an inquiry is sent to the appropriate department director or agency as well as the relevant clinic or program manager for information and documentation. This correspondence also informs them that a complaint has been registered against their clinic, program and/or department. They are requested to respond within five business days.
  5. A copy of the correspondence is sent to the complainant, so they have an opportunity to check allegations and make corrections if anything is incorrect. If necessary, an amended inquiry is sent to the relevant department director and clinic or program manager.
  6. Documents are reviewed by the Ombudsman after the department director, clinic/program manager responds, If there is a discrepancy in the facts, he will verify the facts by further research, interview or review of records.
  7. The Ombudsman continues research into internal PP&Ps as well as the laws, rules and regulations and all areas that would be helpful in evaluating the complaint. He may at this time schedule a conference with the Complainant, the department director and the clinic or program manager in order to facilitate and mediate negotiations and the solution process. Complainants may wish to maintain their right to confidentiality by not attending this conference in person.
  8. Following the Ombudsman examination of the case, opinions and recommendations are developed.
  9. If the complaint is deemed unjustified, the Complainant and the department Director and Clinic or Program Manger are sent notice of the opinion and the reasons, and the case is closed. If the complaint is deemed justified, an informal conference with the department director and the clinic or program manager is scheduled at which time the Ombudsman informs them of the facts and conclusions and his proposed recommendation.
  10. If the department director, clinic or program manager voluntarily rectifies the complaint, the Complainant is notified and the case may be closed with the approval of the complainant. Follow-up includes a phone call to both parties within ten business days to verify the resolution was implemented, and mailing a "Satisfaction Survey" postcard.
  11. If the department director, clinic or program manager does not voluntarily rectify the complaint, the Ombudsman will prepare a final written recommendation to the department director, clinic or program manager with time limitations for response.
  12. The department director, clinic or program manager responds. If they refuse to implement the recommendation, they must state their reasons for refusal.
  13. Ombudsman reevaluates the case in light of reasons given by the department director, clinic or program manager.
  14. If the department director, clinic or program manager’s reasons are sound, the Ombudsman will notify Complainant and close the case.

If the reasons are determined not to be sound, the Ombudsman will report the case to the C.E.O. and the Board of Directors for their recommendations.


  • All records will be maintained to ensure confidentiality. Names will not be used, only case numbers, with a cross-reference by topic or type of complaint.
  • Statistics regarding the type, source and frequency of complaints, will be available for use in evaluating and improving the program.
  • Development of a computer database will automate the reporting process.
  • A "Satisfaction Survey" card will be mailed to complainants to determine the level of service. The postcard will be anonymous only using the case number as a reference.