. -
\ '
Servces 
Department of Health and Human 

OFFICE OF

INSPECTOR GENERAL

SUCCESSFUL OMBUDSMAN PROGRAMS

Vl. 
Richard P. Kusserow 
INSPECfOR GENERA 
11 
JU 
oIa  1991  , - l' 
OFFICE OF INSPECTOR GENERAL

The mission of the Offce of Inspector Genera 
(OIG), as madated by Public Law 95-452, as
amended, is to protect the integrty of the Depanent of Health and Human Services ' (HHS)
progrs 
as well as the health and welfare of beneficiares served by those progrs. 
This 
statutory mission is cared out though a nationwide network of audits, investigations, and 
inspections conducted by thre OIG operating components: the Offce of Audit Services, the 
Office of Investigations, and the Offce of Evaluation and Inspections. The OIG also infonns the 
Secretar of HHS of progr, and maagement problems, and recommends courses to correct 
them. 
OFFICE OF AUDIT SERVICES 
The OIG' s Offce of Audit Services (OAS) provides all auditig services for HHS, either by
conducting audits with its own audit resources or by overseeing audit work done by others. 
Audits examne the perfonnance of HHS program and/or its grantees and contractors in
caring out their respective responsibilities and 
ar intended to provide independent
assessments of HHS programs and operations in order to reduce waste
, abuse, and
mismanagement and to promote economy and effciency throughout the Depanment. 
OFFICE OF INVESTIGATIONS 
The OIG' s Office of Investigations (01) conducts crmial, civil, and admisttative 
investigations of allegations of wrongdoing in HHS programs or to HHS beneficiares and of 
unjust enrchment by providers. TIe investigative efforts of 01 lead to criminal convictions 
administrative sanctions, or civil money penalties. The 01 also oversees State Medicaid fraud 
control units which investigate and prosecute fraud and patient abuse in the Medicaid program. 
OFFICE OF EVALUATION AND INSPECTIONS 
The OIG' s Office of Evaluation and Inspections (OEI) conducts short-tenn management and 
program evaluations (called tnspections) that focus on issues of concern to the Depanmem
, the
Congress, and the public. The findings and recommendations contaned in these inspection 
repons generate rapid, accurate, and up-to-dte infonnation on the effciency, vulnerability, and
effectiveness of depanmemal programs. This study was conducted in 
the New York Regional 
Offce under the diection of Thomas F. Tully, Regional Inspector General, Region II, Office of
Evaluation and Inspections and Alan S. Meyer, Deputy Regional Inspector General. 
Panicipating in the project were the following people: 
Renee C. Schlesinger  (Project Leader)  Alan S. Levine,
 Headquarters
Demetta Arpakos 
Thomas A. Purvis,  San Francisco 
Nancy Harson 
Raul Manynek  ..'
. ,
Department of Health and Human Servces

OFFICE OF

INSPECTOR GENERAL

SUCCESSFUL OMBUDSMAN PROGRAMS

VlCI. 
Richard P. Kusserow 
INSPECfOR GENERAL 
I' 
~oIa OEI-
02-90-02120  EXECUTIVE SUMMARY

PURPOSE 
The purose of this inspection is to determne the charcteristics of successful State long term 
progrs. 
care ombudsman 
BACKGROUND 
The State Long Term Care Ombudsman progr was established in response to growing 
concern over the poor quality of care in nursing homes. The Act requires each State Unit on 
Aging to establish and operate, either  Ombudsman program. In 
diectly or under conttact, an 
car 
1981, the Ombudsman program was extended to board and  facilities. 
The ombudsman is to be an advocate of the institutionalized elderly to ensure that they have a 
vigorous voice in their own tteatment and care. Some activities include investigating and 
resolving complaints on behalf of elderly residents of long term care facilities, infonning 
residents of their legal rights and providing information on long term care issues to public 
agencies, legislatures and the community-at-large. Most of the State Ombudsman programs 
operate under the diect auspices of their State s Unit on Aging. 
In October 1988, the AoA funded the formation of the National Center for State Long Term Care 
Ombudsman Resources to provide training, technical assistance and information exchange on 
long term car and ombudsmen issues to ombudsmen. 
METHODOLOGY 
This inspection included the following activities: 52 telephone interviews with ombudsmen 
from all States, the Distrct of Columbia (DC) and Puerto Rico (PR); onsite visits with six State 
Ombudsman programs involving interviews with the ombudsman, sub-State program officials, 
- directors of the State Units on Aging, advocacy groups and/or other experts in the field (28). 
Additionally, the State ombudsman programs were rated on their responses to certain criteria for 
visibility and complaint resolution obtained from the telephone interviews. 
FINDINGS 
Twelve programs (CA, CO, DE, DC, KY, LA, MA, MI, NM, OH, OR and TX) were identified 
as the most successful based on the information obtained from telephone surveys, onsite visits 
and the use of scoring criteria.  The Most Successful Programs Are Highly Visible 
Through the use of paid  programs visit facilities very frequently, 
staf and volunteers, these 
typicaly weekly. These visits famliarze residents with the ombudsman personally and the 
progr 
in genera. In conttast, the remaining 39 programs are not nearly as likely to visit as 
often. 
While the successful programs increase their visibility with the assistance of volunteers, nine 
volunteers. Some less successful States have volunteers in some 
other programs have  no 
regions of the State, but not in others. The top States are effective in recruiting, ttaining and 
retaning volunteers. Paid staf playa major role in their efforts to recruit, ttain, supervise and 
maintan volunteers. 
Successful progrs make themselves very visible in the aging community through the use of 
posters or brochures, publicized toll-fre numbers and community outreach efforts. 
progrs 
Successful  respond onsite to potentially life-threatening complaints within 24 hours; 
all but three of the top programs actually respond to all complaints, both life-threatening and non 
life-theatening within 24 hours. In conttast, alost 20 percent of the ombudsmen from the 39 
remaining States require from three days to a week to respond to potentially life-threatening 
complaits. 
Successful Programs Obtain Adequate Funding And Support 
All States link adequate funding with having more professional staf, which allows them to visit 
facilities more frequently; to improve response time to complaints; to ttain and supervise staff 
and volunteers, and to become more involved in legislative planning and decision-makng. Most 
States would give priority to hirng more professional staff if additional funds were made 
available. 
Many successful State ombudsmen enhance their budgets through innovative fund-raising 
techniques. Some use traditional methods such as bake sales, auctions and $100-a-plate dinners, 
while others have developed more sophisticated approaches. 
Strong enabling legislation, legal support, independence and other intangible factors are 
considered important for success. 
Ombudsmen Want Additional Support 
Ombudsman generally feel the National Resource Center is helpful, but would like, the Center to 
get more involved in ttaining, as well as become more active in circulating information about 
best practices and other ombudsman issues. 
Ombudsmen would also like more direct involvement with AoA; including an AoA focal point.  . ,
RECOMMENDATIONS 
The Admisttation on Agig should work with the States in addressing the concerns of the 
ombudsmen by: 
Developing model operational guidelines in aras such as frequency of visits; staff-to-bed 
ratios; volunteer-to-bed ratio; complait response time; complaint resolution percentages; 
recruitment, trning and retention of staff and volunteers; and program publicity. 
Providing technical assistace regarding the use of volunteers, fund-raising, obtaining 
legal support, confidentiality and other areas of concern. 
Assuring that information about successful program and effective techniques (including 
that obtained in this inspection) is dissemiated to States in a systematic and detailed way 
with recommendations for implementation. 
Responding to the concerns of ombudsmen about sttengthening the role of the Resource 
Center. 
COMMENTS 
Comments received from AoA were generally supportve of our findings and recommendations. 
However, AoA is concerned that we do not acknowledge the extent to which the National 
Resource Center is involved in supporting the Long Tenn Car Ombudsman Program. We 
should note that it was not within the scope of our study to evaluate the Center, itself, but rather 
to obtain the sentiments of the ombudsmen regarding the Center. We have added AoA' 
information about the Center to the background of the report. It may be helpful for AoA to 
communicate more fully with ombudsmen about the activities of the Resource Center. 
The comments of AoA essentially respond to the study recommendations. These comments are 
in Appendix A.  ................. .. ..... ..... ........ . ........................................... .. .......................................... ................. ... .......................... ................ .......... ........................ ......
" , .................. ...................... .. 
TABLE  OF CONTENTS

EXECUTIV SUMMARY 
INTRODUCTION.......... ...... 
Purpose................................................................................. 

Background.................................................................................... ......................

Methodology........................................................................................................ 3

FINDINGS................................................................................................................. 

The most successful programs are highly visible................................................. 
progrs 
Successful  obtain adequate funding and support ................................ 
Ombudsmen want additional support.... 
RECO MMENDA TIO NS 
Comments.......................................................................................................... l 0

....................................... A

APPENDIX A: COMMENTS TO DRAFT REPORT 
 , ,
INTRODUCTION

PURPOSE 
The purpose of this inspection is to determne the charcteristics of successful State long term 
progrs. 
care ombudsman 
BACKGROUND 
History 
The State Long Term Care Ombudsman program was established under the Older American 
Act (OAA) in response to growing concern over the poor quality of car in nursing homes. The 
ombudsman was to be an advocate of the 
institutionalzed elderly to ensure that they have a 
vigorous voice in their own treatment and care. The Ombudsman program is modeled after a 
progr 
similar  in Scandiavian countres. 
car 
In 1972, the Admnistrtion on Aging (AoA) awarded seven States conttacts to  out long 
term care ombudsman demonstration projects. In 1975, amendments to the OAA authorized 
AoA to make grants for all States to have ombudsman projects. Further amendments in 1978 
required each State Unit on Aging to establish and operate, either directly or under contract, an 
Ombudsman program. In 1981 , the Ombudsman program was extended to board and care 
facilities. 
Prior to FY 1987 the OAA required States to spend at least one percent of their supportive 
services allotment under Title Ill-B of the OAA or $20,00, whichever was greater, to support 
statewide ombudsman activities. Based on amendments in 1987 States must in the future spend 
at least as much on the Ombudsman program as they did in FY 1987, as long as Federal 
allotments continue above 1987 levels. 
Role of ombudsman 
Ombudsmen conduct a varety of activities in the long-term care community. They investigate 
and resolve complaints on behalf of elderly residents of long term car facilities concerning 
matters that may adversely affect their health, safety, welfar or rights. They also inform 
residents of their legal rights and provide information on long term care issues to public 
trn 
agencies, legislatures and the community-at-large. They  volunteers and promote the 
development of grass roots organizations to assist long term care residents. Additionally, they 
monitor the development and implementation of Federal, State and local laws relating to long 
term care. 
Most of the State Ombudsman programs operate under the diect auspices of their Stare s Unit on 
Aging, which assures that OAA requirements are met. Most States also have sub-State  . ,
progrs 
Ombudsman progrs. These are  in varous aras of the State that have ombudsman 
ar 
responsibilties. These  either managed directly by the State or are sponsored by a 
varety of 
organizations, including Ara Agencies on Aging, other sub-State governmental units, citizen 
advocacy committees and private, non-profit organizations. 
National Center for State Long Term Care Ombudsman Resources 
In October 1988, the AoA funded the formation of the National Center for State Long Term Care 
Ombudsman Resoures (caled the Resource Center). The center is admnistered by cooperative 
agreement with the National Association of State Units on Aging (NASUA), which operates it 
cooperatively with the National Citizens Coalition for Nuring Home 
Reform. The Center 
provides ttning, technical assistance and information exchange on long term care and 
ombudsmen issues. 
The goal of the Center is to enhance the capacity of the nation s State Units on Aging in the 
design, development and admnistrtion of Statewide Ombudsman Programs. The Center
priar 
focus is on building Statewide systems of ombudsman services to address the issues 
facing older residents in long term car facilties. 
Durg 
its fIrst two years, the center initiated a number of activities including: development of a 
State Ombudsman Resource Manual; multi-regional teleconferences for information sharng 
with and among States; a National Traning Conference for Ombudsman and State staff; training 
modules for States to use in ttaining local ombudsmen; simplified guides to OBRA legislation; a 
bi-monthly Center newsletter called the "Ombudsman Reporter ; and, the production of a video 
to inttoduce the Ombudsman Progrm to the genera public that wil also serve as viable 
recruitment tool. 
National Association of State Long Term Care Ombudsman Programs 
The National Association of State Long Term Care Ombudsman Programs, established to 
provide a common voice for all S tate Ombudsman programs, informs ombudsmen of 
opportnities available through Federal sources, panicularly the AoA. It also promotes the 
sharng of ideas and experiences among State ombudsman staf. 
Prior Studies 
The National Center for State Long Term Care Ombudsman Resources recently completed two 
studies on the Ombudsman program. The first surveyed all State ombudsmen regarding their 
use 
of volunteers and found the recruitment of volunteers to be the most difficult management task. 
The second study, which examined ombudsmen involvement in board and care found it 
insufficient. It reported that the degree to which ombudsmen work with board and care is 
dependent upon the number of total licensed facilities and the number of paid and volunteer staff 
in the State.

Three recent OIG studies have touched upon the activities of the Ombudsman program
, one 
entitled "Board and Care Homes" (OEI-02-89-0l860) and two others entitled "Resident Abuse  in Nursing Homes" (OEI-06-88-00360 and OEI-06-88-O361). The fIrt found varability in the 
level of service delivery among Ombudsman progrs; the latter two identifed weakesses in 
State complaint-reportng systems and reponed that ombudsmen consider many areas of patient 
abuse and neglect to be serious problems in nursing homes. 
The Genera Accounting Offce (GAO) and the House Select Commttee on Agig have issued 
reports on board and car homes which address the role of the ombudsman in those facilities; 
both found that the ombudsman does not always get involved when abuse and neglect occur in 
board and car homes. 
The ombudsmen from Louisiana and Massachusetts presented a repon at a conference in June 
1990 to the Senate Special Commttee on Aging entitled "Capacities of the State Long Term 
Care Ombudsman Progrs." Their conclusions were that: (1) Federa funds are distrbuted to 
the States according to a formula that does not correspond to the number of clients ombudsmen 
serve; (2) stafng levels between State Ombudsman program var; and (3) Ombudsmen believe 
they are severely limited by fiscal and personal constraints. 
The Ohio State ombudsman presented a paper at the same conference identifying three barers 
to effective advocacy: (1) the unspecified role of Area Agencies on Aging in monitoring the 
Ombudsman progrm; (2) difficulty in maintaining confidentiality; and (3) the limited provision 
of legal representation to ombudsmen. 
METHODOLOGY 
This inspection was conducted in three phases. Firt, ombudsmen from all States, the Distrct of 
Columbia (DC) and Pueno Rico (PR) were interviewed by telephone and asked to identify some 
programs they felt were the most successful across the countr and best practices for certain 
ombudsman activities. They were also asked to suggest criteria for successful progrs;
describe and assess the dissemination of such information; and to recommend the most effective 
way to use ombudsman funds. 
Second, based on the above discussions, on the results of a literature review and on the 
recommendations of expens in the field, six State Ombudsman progrs (CA, DC, MA, MI, NJ 
and OH) were selected for onsite visits. Four (CA, MA, MI, OH) received the most votes from 
other ombudsmen as representing a model program. The other two (DC, NJ), also well regarded. 
were selected primarly because of their unique featurs: the NJ progr is one of the few that is 
located in an independent State agency and has a sttong enforcement focus; DC conttacts out all 
its services to the American Association of Retied Persons (AARP). Discussions were held 
during onsite visits with the State Ombudsman, sub-State program offcials, directors of the State 
U nits on Aging, advocacy groups and/or other experts in the field. These discussions provided 
information on why these State programs are effective and how they overcame barers. In all 
28 interviews were conducted onsite. 
Additionally, 51 State ombudsman programs (one was not included due to lack of information) 
were rated on their responses to certain criteria for visibility and complaint resolution which  were obtained from the telephone interviews. Visibility crteria included the frquency of visits 
to each facilty annually, the ratio of professional staf to the number of long term care facility 
beds, and the ratio of volunteers to beds. 
Based on the frequency distrbution of each, every State s perfonTance was scored from high to 
low. The same was done with complaint resolution criteria which dealt with response time to 
both life thatening and less serious complaints, and the percentage of complaints resolved. The 
number of votes each State program received from other ombudsmen as being a model State was 
incOIporated into the score. All the scores were then totalled to obtain a final score for each 
State.  FINDINGS

Twelve programs (CA, CO, DE, DC, KY LA, MA, MI, NM, OH, OR and TX) were 
identifed as the most successful based on the informtion obtained from 
telephone surveys, onsite visits and on the use of scoring criteria.  most
The  12 
successful programs included the top four selected for onsite visitation. This is 
not to say that there are not some very goodfeatures in other programs. In fact 
scored as least successful. In 
25 scored as moderately successful, while  14 
discussing the findings, however, the moderate and least successful are grouped 
together when contrasts are mae to the successful programs. Thefollowing 
findings characterize the key features of  most successful programs.
the  12 
Additionally, an indepth case study analysis of the onsite visits 
wil be reported in 
a subsequent inspection report. 
THE MOST SUCCESSFUL PROGRAMS ARE HIGHLY VISIBLE 
They visit 
facilties very frequently. 
Through the use of both paid staff and an extensive volunteer program, these programs typically 
make weekly visits to all nursing homes in their States. These visits  in nature and 
ar proactive 
are intended priarly to familarze residents with the ombudsman personally and the program 
in general. During these visits the ombudsmen speak to residents and staff and identify 
complaits. The hope is that their presence may prevent futu problem situations. As one 
ombudsman said, "the ombudsman concept is to be omnipresent in facilties." An ombudsman 
from New England stated, "Our regular presence has had enonnous impact on the qualty of care 
in facilities. We effect change, accomplish systematic change which reflects a good program. 
One local program assigns a volunteer to each facilty in its region to provide this regular 
presence. 
In contrst, the remaining 39 programs ar not nearly as likely to visit as often. Nineteen (49 
percent) visit nursing homes only four times a year or less, while six programs (15 percent) 
respond to complaints only, bUt do not make routine visits. In those States there are many 
residents who never see an ombudsman. A total of nine (23 percent) of the less successful States 
make monthly visits and five (13 percent) report visitig al nursing homes weekly. As an 
ombudsman from a small rural State said, "When we get to homes we do really good work, but 
we are not in homes as much as I want to be." 
While the successful programs are able to increase their visibilty with the assistan e of 
volunteers, nine other  volunteers. One ombudsman from the Midwest
progrms have  no 
Our Legislature has mandated we not use 
reported, " volunteers." States without volunteers 
appear to be more limited in their ability to make routine visits. Five visit one to four times a 
year, three only respond to complaints and the last makes monthly visits. 
Some less successful 
States have volunteers in some regions of the State, but not in others. An ombudsman from the  , "

Southwest said, "In the facilties where we have volunteers we ar making a dent, there s a lot 
out there we ar not addrssing. 
Top States are effective in recruiting, 
training and retaining volunteers. 
In these States good recruitment involves targeting the right audience at both the State and local 
levels, with an excellent source being the elder network. These programs often tap the services 
of the AARP, which helps State ombudsmen by mailing volunteer information to its members 
and asking people to join the ombudsman effort. Another effective source is the word-of-mouth 
curnt 
recruitment efforts of their  volunteers who ar able to communicate to others the realities 
of the job. When successful ombudsmen recruit volunteers, they are honest about the demands 
of the work from the beginning. One successful State program is able to recruit lawyers who 
donate their services. 
These top States consider extensive ttning and staf support vital in order for volunteers to be 
effective. Several have detailed volunteer training manuals. One State has incorporated its 
volunteer training guidelines in legislation. It also employs a tiered approach with increased 
ttning hours linked to increased responsibilty levels, a way to build a career ladder. 
Paid staf playa major role in the volunteer effort. One ombudsman said  If you don t have 
paid sta, you don t have a volunteer program. " Many ombudsmen feel that volunteers need as 
much, if not more, supervision and backup as other staff members. Some ombudsmen express 
the need for additional staff in order to recruit, ttn, supervise and maintain volunteers. One 
reflected the feelings of others when she said, " We rely heavily on volunteers but we need good 
staf to supervise them.

progrs 
Good volunteer  retain workers by recognizing their worth. They treat the volunteers 
the same as the paid staff, have the same expectations of them and honor them with special 
awards and ceremonies. 
The best programs are highly publicized. 
Successful programs make themselves very visible in the aging community through the use of 
posters or brochures, publicized toll-free numbers and community outreach efforts. Other 
techniques include informing all residents about the ombudsman program upon admission 
media exposure, such as radio or television spots, and in-service trining for staf of the facilities 
on the ombudsman program. 
In contrast, only approximately half of the remaining 39 progrms make themselves available in 
a similar fashion to the successful ones. 
Successful programs handle complaints expeditiously. 
All but one of the top States respond onsite to potentially life-threatening complaints within 24 
hours. These complaints involve abuse or neglect which may seriously jeopardize a person  well-being. Moreover, al but the of the top progrs actually respond to all complaints, both 
life-theatening and non life-theatening within 24 hour. 
In contrst, almost 20 percent of the ombudsmen frm the 39 remaining States require from 
thee days to a week to respond to potentially life-theatening complaints; 46 percent take four 
days or more to respond to non life-threatening complaits. One State taes months before 
being able to respond to some complaints; others report not being able to respond for several 
weeks. 
Almost all successful State ombudsmen report at least three-quarers of their complaints being 
resolved to the point of closur within 12 months, although they, and other ombudsmen, report 
some inconsistencies in how they define complaints resolved. 
Approximately half (56 percent) of the remaining 39 States similarly report coming to closure on 
75 percent or more of their complaints in a 12-month period; 21 percent close between 65 and 75 
percent of complaints; and 21 percent come to closur on less than 65 percent of their complaints 
in a 12 month period. Of these, one State with limited staf and no volunteers reports coming to 
closure on only 25 percent of their complaints in a given year. One State does not even keep this 
statistic. 
SUCCESSFUL PROGRAMS OBTAIN ADEQUATE FUNDING AND SUPPORT 
States report innovative fund-raising techniques.

All States link adequate funding with having more professional staf, which allows them to visit 
facilities more frequently; to improve response tie to complaints; to train and supervise staff 
and volunteers, and to become more involved in legislative planning and decision-making. Most 
States would give priority to hirng more professional  funds were made 
staf if additional 
available. An ombudsman from a rural western State stated, "There is a direct correlation 
between funding and effectiveness, it allows for more sta. 
Many successful State ombudsmen enhance their budgets through innovative fund-raising 
techniques. Some use ttaditional methods such as bake sales, auctions and $100-a-plate dinners, 
while others have developed more sophisticated approaches. 
One Western State imposes a $3 surcharge on nursing home and board and care licensing fees, 
thus raising about $140,000 a year. Deposited into a special fund controlled by the State Board 
progr 
on Aging, this money is given to the Ombudsman  for use in education, 
parcularly the 
ttaining and organizing of resident s councils. Another top State has a similar bed tax which 
goes to the Ombudsman program. 
A local program in a Southern State has a budget of $250,000 with only $30,000 coming from 
the Federal and State governments through the AAA. Not housed in any State or local 
government agency, it is able to secure funds from the United Way, mayors and other 
organizations. Its dynamic distrct director spends much of her time raising funds, a task she  , "

, , ' .
feels is made easier because the agency is private and non-profit. A State or local government 
agency would have a diffcult time getting such donations. The fund raising is seen as having 
the additional benefit of enhancing community education and outreach for the ombudsmen 
progr. 
Other programs sell their knowledge to generate income. For instance, one program has 
developed a game called "Resident Bingo," which is sold nationally to long term care facilties 
to help famliarze residents with their rights and with how to refer problems to ombudsmen. A 
progr 
Midwestern  is located outside of the State government so it can charge facilities, such 
as nuring homes and hospitals, for in service 
trning, mileage, and materials such as brochures. 
A local ombudsman in this State said, "We take full advantage of the language in the OAA which 
mentions the ' opportunity to donate 
Strong enabling legislation and legal support strengthen programs. 
Five of the top programs were cited by other ombudsmen for their strong enabling legislation 
which is comprehensive, succinct and easy to understad. One such statute gives the 
ombudsman immunity from liabilty when acting in good faith. AnOther State s legislation 
allows the ombudsmen to grant confidentiality and immunity to all complainants and issue 
subpoenas for documents or testimony. 
Strong legal support is also cited as important. Several successful programs have ombudsmen 
progr 
who ar lawyers. One large  in the West reports that each one of its 35 local programs 
has access to legal support. Other top programs contract with an attorney or a law firm for legal 
support. 
Independence and other intangible factors make a difference. 
Many ombudsmen consider progrm independence importnt for success. Several programs 
contrct with outside agencies for ombudsman services in order to obtain such independence. 
One ombudsman reflected the feeling of others when he said  Ombudsmen should be 
independent to avoid conflict of interest. " AnOther said, "We should be independent.. .location of 
progr 
the  is the real issue...advocacy and service delivery don t combine. 
The Office of Ombudsman in a Northeastern State is independent and exempt from conttol or 
supervision by any deparent of the State government by statute. The Offce reports directly to 
the Governor and Legislature. This administrtive autonomy allows the ombudsman to act 
quickly and effectively, responding in 24 hours or less. Another advantage is a high 
profie and a 
certn amount of clout because of its close association with the Governor. 
Other intagible factors involved in successful performance include: the personality and 
leadership style of the State ombudsman (when respondents recommended model programs they 
often mentioned this as an important factor); the ability of the program to influence legislation or 
change policy ( as one very successful State ombudsman said "We have systematic impact, we 
solve problems through .regulatory reform ), and the relationship of the ombudsman program 
with other State agencies and providers. A successful ombudsman said, "We are widely  recognized and respected by the provider community." Another remarked, "We have an 
excellent relationship with major agencies, an excellent image in the State. 
OMBUDSMEN WANT ADDITIONAL SUPPORT 
More than hal, 54 percent, of the State respondents say that they ar not kept informed about 
best practices. Only 25 percent of the ombudsmen report receiving this information from the 
National Resource Center. They report this information is not circulated systematically. Best 
practices may be highlighted in the Resource Center s newsletters, a newsletter from a State 
progr 
Ombudsman  or in material received from other soures. 
Ombudsman generally feel the Resource Center is helpful. One said, "I would like to see the 
Resource Center continued." Other ombudsman recommend that the Resource Center get 
involved in ttaiing as well as more active in cirulating infonnation about best practices and 
other ombudsman issues. 
Over half of the ombudsmen report receiving infonnation diectly from the AoA, but consider it 
limited and not always helpful. Many (40 percent) would like more direct involvement with 
AoA. Some mentioned a designated AoA focal point. One ombudsman said, "We need more 
Federal diection." Another requested, "n. more guidace from AoA on how the program should 
be admnistered, more Federal guidelines. " And another agreed saying, "We need clear 
regulations and model guidelines.  RECOMMENDATIONS

The Administration on Aging should work with the States to address the concerns of the 
ombudsmen by: 
Developing model operational guidelines in aras such as frquency of visits; staf-to-bed 
ratios; volunteer-to-bed ratio; complait response time; complaint resolution percentages; 
progr 
recruitment, trning and retention of staf and volunteers; and  publicity. 
Providing technical assistace regarding the use of volunteers, fund-raising, obtaning 
legal support, confidentiality and other areas of concern. 
Assurng that information about successful programs and effective techniques (including 
that obtained in this inspection) is disseminated to States in a systematic and detailed way 
with recommendations for implementation. 
Respondig to the concerns of ombudsmen about sttengthening the role of the Resource 
Center to provide information about best practices and model States in a more systematic 
way and provide trning on a regular basis. 
COMMENTS 
Comments received from AoA were generaly supportive of our findings and recommendations. 
However, AoA is concerned that we do not acknowledge the extent to which the National 
Resoure Center is involved in supportng the Long Term Car Ombudsman Progrm. We 
should note that it was not within the scope of our study to evaluate the Center, itself, but rather 
to obtain the sentiments of the ombudsmen regarding the Center. We have added AoA' 
information about the Center to the background of the report. It may be helpful for AoA to 
communicate more fully with ombudsmen about the activities of the Resource Center. 
The comments of AoA essentially respond to the study recommendations. These comments are 
in Appendix A.  APPENDIX A

The Draft Report 
Comments  To  ~~~
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TO:	 Richard P. Kusserow

Inspector General

FROM:	 u. s. Commissioner on Aging 
SUBJECT:	 OIG Draft Report "Successful Ombudsman Programs,

OEI-02-90-02120

Recently youdr orffaicef rteq ureseted pthaot trhe tA.dm inistration on Aging

(AoA) review and provide comments as appropriate on the above-

ref erenced 
AoA staff have reviewed the draft and, while we do not fully

support all the conclusions, we believe that it contains a great

deal of useful 
information. The draft certainly describes 
effective operational models and should prove to be a useful tool 
in compiling information on exemplary ombudsman programs and 
practices. Our specific comments are outlined briefly below. 
A numer of the concerns raised in the draft focus on the 
National Center for State Long Term Care Ombudsman Resources. 
Sumary 
and page 
Recommendations 2-4 on p. iii of the Executive 
10 of the draft report are particularly relevant to the work of 
Center. 
the National  Indeed, recommendation # 4 specifiI csa lrolyle . 
refers to the perceived need to "strengthen" the Center 
In general, we believe that the Center has been more active and
aggress i ve in supporting the Ombudsman Program than the draft
suggests. 
As the draft indicates, the Center is operated by the National 
Association of State units on Aging in cooperation with the 
has 
Reform. AoA 
National citizens Coalition for Nursing Home 
support. In each 
provided the Center with considerable financial 
of the first two years of operation (FY' s 1988 and 1989), the 
Center for State Long Term Care Ombudsman Resources received more 
Title IV funds ($387, 488 in FY 88, $500, 000 in FY 89) than any of 
supported. 
the other National Aging Resource Centers which AoA 
1990. 
The Center also received $500, 000 in Title IV funding in FY 
The goal of the National Center for state Long Term Care 
I s 
Ombudsman Resources is to enhance' the capacity of the nation 
state Agencies on Aging in the design, development and 
Programs. 
administration of statewide long term care Ombudsman  ' .
P. Kusserow

Page 2 - Richard 
The Center I s primary focus is on building statewide systems of 
ombudsman services ftaoc ialdidtireesss.  the issues facing older residents 
in long term care 
numer of 
years, the Center initiated a 
During its first two 
acti vi ties including: development of a state Ombudsman Resource 
Manual; mUlti-regional teleconferences for information sharing 
wi th and among states; a National Training Conference for 
Ombudsman and state staff; training modules for stateles gtios lautsieo nin;
training local ombudsmen; simplified guides to OBRA 

a bi-monthly Center newsletter called the "Ombudsman Reporter"

and, production of a video to introduce the Ombudsman Proqram to

ttoheo gle.n eral public that will also serve as a revisapbolne sribecirliutii tmenfot
r 
Center' s 
In addition to the Resource 
states, the Center 
technical assistance and training for 
volunteers. 
conducted a study of ombudsman services to residents of board and 
section of this study is devoted to use of

care facilities. One 
AoA fully intends to continue to provide on-qoing support to the

Ombudsman Proqram. On April 29, 1991, we issued a Program 
Announcement (AoA-91-2) for awards authorized under Titles II and 
IV of the Older Americans Act to establish a series of "National 
" to work in cooperation with the National

Eldercare Institutes
Eldercare Campaign. A portion of the funds awarded under this

announcement will be expended to provide for the continuation of

a national focal point for the ombudsman support activities

currently provided by the.  wNaittihoinna lt hCiesn ter for state Long Term

framework issues to be
Care Ombudsman Resources  include: 
addressed pertaining to the ombudsman program will 

legislation;
Identification of relevant Federal 

Dissemination of best practice models;

trends; and,

Analysis of program develop 
Examination of changes needed to improve program

effectiveness . 
March, 1991, AOA convened a
Finally, let me note that, in  Representatives

National Roundtable on the Ombudsman Program. 

from state and local programs and from national organizsaetrivoicnse sm,
et

ombudsman, model 
with the AOA to discuss roles of the  nationwide. 
and future directions for the ombudsman program
useful. If 
you have any
I hope that you will find these comments

know. 
information, please let me 
questions or need further 

Thank you.  with representatives of the aging network. In a series of 
focus groups, Administration on Aging and National Association 
of state Units on Aging staff discussed these issues with a 
sample of state and Area Agencies on Aging and service 
providers. The Administration on Aging will be following up 
The 
on several of the ideas generated in these discussions. 
establishment of the Eldercare Volunteer Corps and our 
thinking about expansion of the Corps, builds upon ideas
discussed during these sessions. 
The Administration on Aging will be working closely with state 
and Area Agencies on Aging toi naistsiiastti vyoeu.  in the implementation 
of this important volunteer  Further information 
forthcoming. 
regarding the Eldercare Volunteer Corps will be 
A press release regarding this announcement is enclosed for

your information. 
INQUIRIES:	 Inquiries should be addressed to Regional 
Program Directors on Aging, HHS Regional
Off ices 
Attachment  -,,'-II
Of  Se-.y 
DEPARTMENT OF HEALTH. HUMAN SERVICES	 of th 
l. 
W88ton. D.
Administration on Aging	 C. 20201 
APR 2 3 1991 
INFORMTION MEMORADUM

AOA-IM-91-22 
AR 
STATE AND  AGENCIES ADMINISTERING 
PLAS UNDER TITLE III OF THE OLDER 
AMERICANS ACT OF 1965, AS AMDED 
SUBECT	 Older Americans Act Eldercare Volunteer 
Corps 
LEGAL AND RELATED

REFERCES	 Older Americans Act, as amended 
Recently I announced the establishment of the Older Americans Act

Eldercare Volunteer Corps. Volunteers have been the backbone of the

Older Americans Act service system since its inception in 1965 and

000 volunteers providing services 
curren  ly there are nearly 500, 
and assistance to older persons across the Nation, many of them at 
independence. 
risk of losing their 
The National Eldercare campaign seeks to broaden the base of 
support and  vulnerable elderly 
commitment to our Nation' 
population by reaching out to organizations and individuals and
invi ting 
them to participate in solutions to the problems facing 
many of our older citizens. The Eldercare Volunteer Corps provides 
an opportunity for young and old alike to support the National 
and 
Eldercare Campaign by contributing a portion of their time 
effort to 
improve the lives of older persons, especially those 
independence. 
vulnerable elderly who are at risk of losing their 
TEhledsee racta-rries kc aemldperaliyg,n ,t hcea bnen esfuibcisatrainest iaanldly f obceusn eoff itth ef rNoamtio nthael 
contributions made by volunteers.

the 
The Eldercare Volunteer Corps is designed to build upon 
existing efforts of State and Area Agencies on Aging and service 
providers to promote and support volunteer acti vi ties in Older 
Amer icans Act programs. Recrui tment, retention, training and 
and, 
supervision are critical components of any volunteer program 
strengthening 
in order to determine the most effective means of 
consulted 
current efforts, the Administration on Aging recently