Department  of Health  and  Human  Services 
ADM  NITRATION  ON  AGING

AND

OFFICE  OF

INSPECTOR  GENERAL

ACTION  PIAN  TO  S1RENGTHEN 
IMPLEMENTATION  OF  TITLE  Ill 
OF  THE  OLDER  AMERICANS  ACT 
APRIL 1993  OEI-02-91-01517
 EXECUTIVE  SUMMARY 
BACKGROUND 
This report  summarizes  the  findings  of a review  of States  implementation  of Title  III 
of The  Older  Americans  Act  (OAA)  and  sets forth  an action  plan  for the 
Administration  on Aging  (AoA). 
In the  summer  of 1992, a joint  AoA/Office  of Inspector  General  (OIG)  review  team 
conducted  compliance  reviews  of States  implementation  of Title  III.  AoA  initiated 
these  reviews  to strengthen  its stewardship  of the  OAA  and  to provide  the 
Commissioner  with up-to-date  information  on implementation  of Title  III.  In April 
1993, AoA  and  OIG  issued  five reports  on the  reviews,  focusing  on the  stewardship, 
targeting,  ombudsman,  nutrition,  and  financial  management  requirements  of Title  III. 
SUMMARY  OF FINDINGS 
The  compliance  reviews  found  that  States  are  generally  successful  in making  area 
agencies  aware  of the  requirements  of Title  III.  They  are,  however,  less successful  in 
assessing  area  agency  compliance.  In some  instances  key requirements  of the  OAA 
were  missing from  assessment  instruments.  Additionally,  only one-third  of the  States 
conduct  annual,  on-site  assessments  of area  agencies.  States  report  that  they  are 
seeking  clearer  and  more  comprehensive  guidance  on many  requirements  of the  O/L%, 
as well as more  skills training  and  information  about  best practices. 
ACTION PLAN 
AoA  has prepared  this action  plan  to address  weaknesses  identified  in the  reviews  and 
to strengthen  the  capacity  of State  and  area  agencies  to provide  services  to  older 
individuals.  It has  three  parts  -- technical  assistance,  training,  and  review. 
Technical assistancewill consist  of the  development  of a system  for,  and 
dissemination  of, policy issuances  and  technical  information. 
Training for State  agencies  will be based  upon  a survey of State  needs  and  will 
employ  a strategy  to use  regional  office  staff  and  Title  IV program  resources  to 
meet  identified  needs. 
Reviews will become  a regular  part  of AoA  stewardship  with  State  self-
assessments  in 1993 and  full AoA  reviews  of States  in 1994. 
i  TABLE  OF  CONTENTS 
EXECUTIVESUMMARY  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .=....i 
INTRODUCTION.  . . . . . . . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . ...==  .......-1 
SUMMARY  OF FINDINGS 
Stewardship  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...=....  3 
Targeting  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .= . ...=..  3 
Ombudsman  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  4 
Nutrition  4 
                           
Financial  Management  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  5 
ACTION PLAN 
Technical  Assistance  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  6 
Training  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  7 
Review  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  7 
Action  Plan  Timetable  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  9  INTRODUCTION 
BACKGROUND 
In the  summer  of 1992 the  Administration  on Aging  (AoA)  and  Office  of Inspector 
General  (OIG)  conducted  reviews  of State  Units  on Agings (SUA)  implementation  of 
Title  III of the  Older  Americans  Act  (OAA).  AoA  initiated  these  reviews  to 
strengthen  its stewardship  of the  OAA  and  to provide  the  Commissioner  with  up-to-
date  information  on the  implementation  of Title  III.  The  reviews  focused  on SUAs 
responsibility  for stewardship,  targeting,  ombudsman,  nutrition,  and  financial 
management  requirements  of Title  III.  AoA  and  OIG jointly  published  five reports  in 
April  1993 which  contain  the  findings  from  the  reviews.  Based  on those  findings  AoA 
plans  to undertake  a number  of actions  which  are  outlined  in this plan. 
Under  the  0~  the  AoA  serves  as the  principle  Federal  advocate  for  older 
individuals  and  monitors  SUA  implementation  of Title  III.  Through  Title  III, AoA 
encourages  and  assists SUAs  and  area  agencies  on aging  (AAAs)  to implement  a 
system  of community-based  services  to prevent  the  premature  institutionalization  of 
older  individuals.  In FY  1992, AoA  distributed  approximately  $787 million  in formula 
grants  to States  based  on the  population  60 years  and  older  within  each  State.  The 
SUAs  use  5 percent  of the  grant  on administration  and  fund  AAAs  who,  in turn, 
contract  for  the  supportive  services,  nutrition  services  and  multipurpose  senior  centers. 
However,  AoAs capacity  to carry  out  its stewardship  responsibilities  declined 
substantially  during  the  1980s due  to a significant  reduction  in resources.  More 
specifically,  AoA  sustained  a 47 percent  reduction  in staff  and  a 75 percent  reduction 
in travel  funds.  (Each  regional  office had  only $2,000 annually  for travel.)  These 
reductions  limited  AoAs ability to effectively  monitor  SUAS implementation  of Title 
III. 
METHODOLOGY 
The  stratified,  random  sample  of 20 States  was based  upon  the  population  of 
individuals  age  60 and  older  in each  State.  These  are  the  same  data  used  to allocate 
Title  III funds  among  States.  In the  sampling  process,  we first divided  States  into  four 
strata  based  upon  the  number  of older  individuals  in each  State  and  then  selected  five 
States  from  each  stratum.  This  sample  permits  us to generalize  findings  from  the  20 
sample  States  to the  nation.  We  also used  sampling  techniques  during  site visits to 
each  State  for the  reviews  of specific  area  plans,  assessments,  and  audits. 
The  data  collection  was conducted  in two phases  -- an AoA  Regional  Office  desk 
review  and  an on-site  review  at the  SUA.  In the  desk  reviews,  we reviewed  sample 
SUAs guidance  to,  and  assessment  instruments  for, AAAs.  We  also reviewed  their 
program  participation  data  and waiver  requests.  During  the  site visits, we interviewed 
1  SUA  staff  on their  implementation  of the  requirements  of Title  III, and  reviewed 
samples  of area  plans,  assessment  reports,  and  audits.  Data  from  reviews  are 
weighted  to reflect  the  sampling  plan  so that  the  percentages  in the  five reports 
represent  the  nation. 
2  SUMMARY  OF  FINDINGS 
STEWARDSHIP 
Stewardship  is the  States  process  of directing  and  monitoring  AA%  A key part  of 
that  process,  the  area  planning  process,  works well for those  SUAS using it to 
implement  State  as well as Federal  initiatives.  However,  the  requirements  for 
coordinating  with  mental  health  and  long term  care  facilities,  and  for  conducting 
annual  evaluations  of outreach  are  often  not  addressed.  Further,  these  same  three 
criteria  were  often  missing from  assessment  instruments.  More  importantly,  one-third 
of SUAS do not  conduct  annual,  on-site  assessments  of AAAs.  Some  of these  SUAS 
want  to, but  can  not  because  of resources  limitations;  others  were  unclear  about  this 
requirement. 
Only half  of the  SUAS reported  that  all AAAs  conduct  the  required  evaluation  of 
outreach.  This  is probably  due  to the  lack  of guidance  and  assessment  from  the 
SUAS.  Further,  authorized  waivers  for AAA  services  are  common,  but  do not  always 
follow required  procedures  established  by AoA. 
SUAS provide  training  and  technical  assistance  to AAAs  to address  noted  deficiencies. 
This  assistance  most  frequently  focuses  on planning,  monitoring,  reporting,  and 
financial  management.  They  note  that  AA/k  still have  unmet  needs  and  States  are 
seeking  training  and  technical  assistance  from  Ao/& including  clearer  guidance  on 
program  requirements  and technical  assistance  on monitoring,  data  collection,  cost 
sharing,  and  managing  with declining  resources. 
TARGETING 
Virtually  all SUAS conduct  targeting  activities  to identify  and  serve  individuals  with  the

greatest  economic  or social  need.  These  activities  most  frequently  include

coordinating  with  other  organizations  and  conducting  conferences  and  meetings.  They

also include  providing  guidance  and  technical  assistance  to AAAs  and  monitoring  their

targeting  efforts.  Half  of SUAS have  established  program  participation  goals  for

AAAs.  Only one-quarter  of SUAS have  altered  their  intra-state  funding  formula,

despite  AoAs efforts  to promote  it as a useful  targeting  technique.

AAA  targeting  activities  most  often  include  outreach,  specialized  services,  and  site and

provider  selection.  However,  there  are  weaknesses  in implementing  the  requirements

for evaluating  the  effectiveness  of outreach,  and  for identifjhg  areas  with  substantial

numbers  of older  individuals  with limited  English-speaking  ability.  Also,  there  are 
little  data  to document  the  effect  of targeting  initiatives. 
SUAS note  that  targeting  causes  them  to attempt  to increase  services  to selected 
populations  in a period  of level funding.  Accordingly,  they  are  seeking  guidance  and 
3  technical  assistance  from  AoA.  In particular,  they want  to learn  about  best practices 
and  to obtain  better  data  on low-income  populations. 
OMBUDSMAN 
While  States  have  similarly  structured  their  offices  of ombudsman,  their  staffing  varies 
greatly.  Most  ombudsmen  are  located  in the  same  agency  as the  SU~  use  sub-state 
offices,  and  are  authorized  by State  law.  However,  professional  staffing  range  from  1 
to over  130 and volunteers  range  from  3 to  1,300.  Most  often  professional  staffing  is 
directly  proportional  to the  population  of older  individuals;  this is not  so for 
volunteers.  One-fifth  of States  do not  use volunteers  because  State  law precludes 
them  or because  SUAS and  AAAs  doubt  the  abilities  of volunteers. 
Ombudsmen  are  generally  successful  in meeting  the  requirements  of the  OAA.  Most 
have  the  authority  needed  to carry  out  all their  responsibilities  and  have  coordinated 
their  activities  with  other  agencies,  as required.  Half  the  ombudsmen  visit all of their 
nursing  homes  annually,  while  most  of the  others  visit at least  70 percent  of them. 
Virtually  all ombudsmen  include  licensed  board  and  care  facilities  in their  visitation 
program.  About  one-third  report  problems  in getting  adequate  legal  counsel. 
NUTRITION 
While  States  have  been  generally  successful  in implementing  the  nutrition

requirements  of the  O%  some  weaknesses  were  noted  in the  SUAS guidance  to and

assessments  of AAAs.  The  weaknesses  are  eligibility  criteria  for home-delivered

meals,  the  requirements  for use of USDAS cash/commodity  option,  and  the  provision

of nutrition  related  services  other  than  meals.

Virtually  all States  assess  performance  of AAAs nutrition  programs,  but  only 56

percent  of these  report  that  they conduct  the  assessments  annually.  Individuals  who

perform  assessments  of the  nutrition  program  have  a range  of expertise  and

qualifications;  a registered  dietitian  or individual  with  dietetic  qualifications  or

education  is used  by 58 percent  of the  States.  Through  the  assessment  process,  States

identified  inadequate  staff, lack of resources,  and  sanitation  problems  as the  most

common  problems  faced  by the  nutrition  programs.  All States  have  procedures  to act

on deficiencies  identified  by assessments.

The  majority  of States  provide  technical  assistance  or training  to  address  deficiencies

identified  in AAA  assessments.  The  subjects  ranged  from  management  and

administration  procedure  training  to meals  related  issues  such as preparation  and

other  nutrition  services  such as nutrition  education.  Further,  many  States  seek  to

control  nutrition  program  costs and  utilize  a variety  of methods  to help  reduce  costs of

required  or nece;sa~  services,  to improve  access  to services,  or to improve  or increase

services.  States  also discussed  their  reasons  for choosing  the  USDA  options  for  cash

4  and/or  commodities.  In general  the  reason  for choosing  commodities  is the  bonus 
items,  however  for some  States  the  problems  of storage,  transportation  or lack  of 
variety,  make  choosing  commodities  less desirable. 
FINANCIAL MANAGEMENT 
While  SUAs  are  meeting  a majority  of financial  management  requirements,  some 
vulnerabilities  exist.  Three-fifths  of SUAS do not  include  in their  assessment  standards 
the  limits on AAA  administrative  expenditures.  Yet,  only four  percent  spend  more 
than  the  authorized  amount  for SUA  or A&4  administration.  We  also found  that 
most  SUAS lack  proper  documentation  on rural  expenditures,  and  that  one-fifth 
exceed  limits  for program  development  and  coordination. 
SUAS have  implemented  audit  requirements.  They  require  grantees  to budget  for 
audits  and  to submit  completed  audits  to the  SUA.  SUAS have  follow-up  procedures 
to address  weaknesses  identified  in audits  and  they provide  training  and  technical 
assistance  to address  deficiencies.  The  most  common  deficiencies  are  weaknesses  in 
internal  controls  and  accounting.  SUAS also requested  training  and  technical 
assistance  from  AoA  on federal  requirements  and  audits. 
5  ACTION  PLAN 
State  and  area  agencies  on aging have  been  generally  successful  in implementing  the 
requirements  of Title  III.  However,  the  AoA/OIG  review  of SUAS has  identified 
weaknesses  in States  implementation.  AoA  has  made  SUAS aware  of these 
weaknesses.  In order  to take  corrective  action,  SUAS are  seeking  technical  assistance 
and  training  from  AoA.  More  specifically,  the  States  want  clearer  and  more 
comprehensive  guidance  on many  requirements  of the  OAA  and  related  federal  laws 
and  regulations,  as well as on skills training  and  information  about  best practices. 
AoA  has prepared  this action  plan  to address  those  SUA  and  AAA  needs.  The  action 
plan  is intended  to strengthen  the  capacity  of SUAS and  AAAs  to provide  services  to 
older  individuals.  The  plan  identifies  three  areas  -- technical  assistance,  training,  and 
review  -- which will be  the  primary  focus  of this capacity-building  initiative.  As a 
result  of this effort,  AoA  will increase  its direct  guidance  to States  on the  OAA  and 
related  laws and  regulations;  provide  additional  training  in key programmatic  and  skill 
areas;  and  conduct  periodic,  standardized  reviews  of SUA  and  AAA  implementation 
of Title  III and  the  new Title  VII  programs. 
TECHNICAL ASSISTANCE 
In the  course  of the  reviews  AoA  noted  varying  State  interpretations  and 
implementation  of the  OAA  and  related  regulations.  In response,  SUAS requested 
that  AoA  provide  clarification  and  definition  of specific  Federal  requirements  in a 
more  timely  manner.  Currently,  AoA  issues Program  Instructions  (PI) when  it 
believes  there  is a need  to clarify a point  of law or to initiate  a new policy.  At  this 
time,  AoA  does  not  have  a system  that  allows for archiving  and  subject-area  retrieval. 
Accordingly,  AoA  will strengthen  its system  for providing  guidance  to SUAS. 
AoA  will strengthen  its formal  guidance  to SUAS and  AAAs  by instituting  the 
following: 
Policy Archiving and Subject-Area Retrieval System. AoA will issue  a one-time 
 
compilation  of responses  to specific  needs  for policy clarification  identified  in 
the  course  of the  AoA/OIG  review.  In addition,  AoA  will develop  a policy 
archiving  and  subject  area  retrieval  system. 
Disseminationof Policy Issuancesand Technical Information. A compendium 
 
of PIs and  Informational  Memoranda  will be widely disseminated  and  updated 
semi-annually.  Most  issuances  will have  automatic  expiration  dates.  Also, AoA 
will explore  additional  methods  of dissemination,  such  as a national  electronic 
bulletin  board  or other  electronic  communications  systems. 
6  *  Prompt Response to Requests for Policy Clarification. AoA  will respond  to 
most  requests  for policy clarification  within  30 days.  The  majority  of responses 
will most  likely address  State-specific  issues.  However,  if AoA  believes  that  the 
issue has national  significance,  it will issue a Program  Instruction. 
Pro posals  for Amendments to EliminateOutdated or Ineffective Requirements 
 
of The OAA.  When  AoA  notices,  or when  SUAS or AAAs  bring  to its 
attention,  contradictory  language  which  affects  implementation  of the  program, 
AoA  will seek  an amendment  or provide  a clarifying  regulation.  A frequently 
cited  example  from  the  reviews  is the  requirement  that  current  expenditures  in 
rural  areas  exceed  105 percent  of the  1978 expenditures. 
TRAINING 
In the  course  of the  reviews  AoA  noted  that  SUAS lacked  selected  skills needed  to 
carry  out  requirements  of the  OAA.  Many  SUAS agreed  and  noted  that  AAAs  also 
need  skills training.  AoA/OIG  staff, along  with the  SUAS, identified  a number  of key 
skill areas  during  the  review  process.  These  areas  include  accounting,  financial 
management,  assessment,  reporting,  and  contracting.  Examples  of training  needs  for 
programmatic  areas  included  targeting,  cost-sharing  and  managing  voluntary 
contributions,  obtaining  adequate  legal  counsel  for ombudsmen,  recruiting  and 
managing  volunteers,  and  nutrition  program  issues. 
AoA  will strengthen  its commitment  to provide  training  to  the  network  by undertaking 
the  following: 
Surveyof States.The  survey will ask SUAS to identify  key administrative  and 
 
programmatic  skills needed  to implement  the  OAA. 
TrainingStrategy. This strategy  will include  the  developing  a priority  listing of 
 
training  needs,  identifying  appropriate  training  approaches,  and  identifying  of 
knowledgeable  and  skilled  individuals  to conduct  the  training.  AoA 
headquarters  and  regional  staff, as well as Title  IV Discretionary  Program 
resources,  will be  used  to implement  this strategy.  Additionally,  AoA  will 
conduct  special  training  on the  implementing  regulations  for  the  1992 
Amendments  within  90 days of the  final  rule. 
REVIEW 
The  AoA/OIG  reviews  provided  up-to-date  and  reliable  information  on State 
compliance  with  requirements  of the  Act.  They  also found  that  States  were  unclear 
about  AoAs expectations  in a variety  of program  activities  and,  therefore,  failed  to 
address  some  requirements  of the  OAA.  Accordingly,  AoA  will continue  to  conduct 
regular  reviews  of the  implementation  of Title  III and  the  new Title  VII. 
7  Future  reviews will use the  tools  developed  for this initiative.  AoA  will use 
standardized  instruments  and  a process  that  will include  pre-testing.  The  instruments 
will be  published  and  made  available  to SUAS in advance  of site visits.  Baseline 
reviews  will be  conducted  in all States,  and  subsequent  reviews will focus  on specific 
problem  areas. 
In  1993, AoA  will take  the  following two steps: 
State Self-Assessments. During  the  spring  of 1993, AoA  will ask all States  that 
 
did not  participate  in the  1992 reviews  to self-assess.  Regional  offices will 
conduct  follow-up  site visits to clarify information  and  to discuss weaknesses. 
1994 Reviews.  AoA will modi~  the  review  instruments  to include  changes  in 
 
requirements  as a result  of the  implementation  of the  1992 Amendments,  and 
will conduct  reviews  in the  spring  of 1994. 
8  DUE DAm 
AC-
Technical  Assistance 
  Implement  a policy  archiving  and  July  1993 
subject  area  retrieval  system 
  Disseminate  compendium  of policy  July  1993 
issuances  and  technical  information 
Implement  system  to respond  to requests 
 
for policy clarification  within  30 days  April  19% 
of receipt 
Implement  policy to seek  amendments  to 
 
eliminate  outdated  or ineffective  July  1993 
requirements  of the  OM 
Training 
September  1993 
Conduct  a survey  of States  training  needs 
 
December  1993 
Complete  training  strategy 
 
Conduct  training  on regulations  within 
 
90 days of final rule 
Reviews 
  Issue  copy of State  assessment  April  1993 
instrument  to  all other  States 
Complete  regional  office follow-up  to 
  October  1993 
State  self-assessments 
December  1993 
Issue  AoA  1994 assessment  guidance 
 
January  - August  1994 
Conduct  1994 reviews 
 
December  1994 
Report  of 1994 review 
 
9