.Department  of  Health  and Human  Services
1 
ADMIN  STRATION  ON  AG  NG 
AND 
OFFICE  OF 
INSPECTOR  GENERAL 
STATE  IMPLEMENTATION  OF  THE 
OMBUDSMAN  REQUIREMENTS  OF 
THE  OLDER  AMERICANS  ACT  ADMINISIIU130N  ON AGING 
The Administration on Aging (AoA)  isthe principal Federal  agency designed to carry out the 
provisions of the Older Americans Act (OAA).  It advises the Secretary of Health  and Human 
Setices  and other Federal agencies on the characteristics, circumstances and needs of older 
individuals.  Further,  it develops policies, plans, and programs designed to promote  their 
welfare. 
AoA administers three grant programs under the Older Americans Act.  The largest program -
- Title III of the Act -- consist of formula grants to States to establish State and community-
based programs for older individuals with the purpose of preventing the premature 
institutionalization  of older individuals. The second program --Title VI -- consists of 
discretionary grants with the same purpose as Title III, but to meet the unique needs of older 
Native Americans.  The third program --Tkle IV -- is also discretionary.  Its purpose is to fund 
research, demonstration,  and training activities to elicit knowledge and techniques  to improve 
the circumstances of older Americans.  (The 1992 Amendments to the OPA  created  a fourth 
program -- Title VII --which provides funds for State activities to protect  the rights of 
vulnerable older people.  Prior to the 1992 Amendments, Title III of the OAA provided the 
funds for these activities.) 
OFFICE  OF INSPECIOR GENERAL 
The mission of the Office of Inspector General  (OIG), as mandated by Public Law 95-452, 
as 
amended,  is to protect  the integrity of the Department  of Health  and Human Semites (HHS) 
programs as well as the health and welfare of beneficiaries sewed by those programs.  This 
statutory  mission is carried out through a nationwide network of audits, investigations, and 
inspections conducted by three OIG operating components:  the Office of Audit Services, the 
Office of Investigations, and the Office of Evaluation and Inspections.  The OIG also informs 
the Secretary of HHS of program and management problems and recommends courses to 
correct  them. 
The OIGS Office of Evaluation  and Inspections (OEI) conducts short-term  management  and 
program evaluations (called inspections) that focus on issues of concern to the Department. 
the Congress, and the public.  The findings and recommendations contained  in these inspection 
reports generate  rapid, accurate, and up-to-date  information on the efficiency, vulnerability, 
and effectiveness of departmental  programs. 
THIS  REPORT 
This report  is the result of a joint effort between AoA  and OIG/OEI  to assess the 
implementation  of Title III of the Older Americans Act.  OIG staff in the New York and 
Dallas regional offices provided technical support to the joint project.  AoA staff in New York 
and Dallas directed  the project with all regional offices participating in the development  of 
instruments and data collection. 
For additional information, please contact: 
AoA  John Dia~  Regional Program Director-Dallas 
OIG  Jack Molnar, Project Leader-New York  Department  of  Health  and Human  Services 
ADMINISTRATION  ON  AGING

AND

OFFICE  OF

INSPECTOR  GENERAL

STATE  IMPLEMENTATION  OF  TI= 
OMBUDSW  REQUIREMENTS  OF 
THE  OLDER  AMERICANS  ACT 
APRIL  1993  OEI-02-91-01516
 EXECUTIVE  SUMMARY 
PURPOSE 
To  review  State  Units  on Aging  (SUA)  implementation  of the  ombudsman 
requirements  of Title  III of the  Older  Americans  Act  (OAA). 
BACKGROUND 
In an effort  to strengthen  its stewardship  of the  0~  the  Commissioner  of 
Administration  on Aging  (AoA)  requested  technical  assistance  from  the  Office  of 
Inspector  General  (OIG)  in designing  a review  of their  primary  Title  III grantees  --
SUAS.  After  reviewing  traditional  and  current  ombudsman  activities  and  discussing 
potential  approaches  for future  efforts,  we agreed  that  a review  of individual  States 
would  be  instituted  in such  a way as to provide  the  Commissioner  with  an  overview  of 
how States  are  implementing  key components  of Title  111. Since  this review  was 
conducted,  the  Long-Term  Care  Ombudsman  Program  has been  moved  from  Title  III 
to Title  VII  of the  OAA.  All references  in this report  are  to the  program  as it was 
defined  under  Title  III, prior  to the  enactment  of the  1992 Amendments  of the  OAA. 
In order  to conserve  limited  travel  funds  the  reviews would  be  conducted  on a sample 
of States  and would  focus  on only five programmatic  areas  -- stewardship> targeting> 
ombudsman,  nutrition,  and  financial  management. 
This report  on Ombudsmen  addresses  the  requirement  that  States  establish  an Office 
of Ombudsman  to investigate  and  resolve  complaints  regarding  older  individuals 
residing  in long-term  care  facility.  It focuses  on issuing guidance  on and  monitoring 
implementation  of the  key ombudsman  requirements  of Title  III of the  OAA, 
including  the  area  planning  process. 
METHODOLOGY 
The  reviews  were  conducted  in a stratified,  random  sample  of 20 States  based  upon 
the  population  of individuals  over  60 years  of age  in each  State.  In the  first step  of 
the  sampling  process,  States  were  divided  into  four  strata  based  upon  the  number  of 
older  individuals  in each  State.  In the  second  step,  five States  were  selected  from 
each  stratum.  This  stratified,  random  sample  permits  USto generalize  findings  from 
the  20 sample  States  to the  Nation. 
FINDINGS 
while  l%e  ~anization  of  State  ()/&x  Of (hnbudwnan  Vati  Only  S@@&, Sta@g 
Varies  Greatly 
Most  Ombudsmen  are  located  in the  State  agency,  use  sub-State  offices,  and  have 
 
laws establishing  their  authority 
Professional  staffing  is directly  proportional  to the  population  of older  Americans 
 
i  Coordination Between  ombudsmen  And  Other  State  Agencies  Ex&ts, But  Wtih A  Fm 
I%obkms 
Most  Ombudsman  use joint  meetings,  referrals,  and written  agreements  to 
 
coordinate  activities  with other  agencies 
One-quarter  report  coordination  problems,  usually with  adult  protection  services 
 
or the  legal  services  developer 
WhiZe Ombudkman  Authodies  To P~orm  llieu  Jobs Axe Based  In State Law, 
Regukztibq  Or Ikmdi.ue;  Zkere Are  Some  l%oblems 
Some  Ombudsmen  lacking  a State  law, rely on the  Older  Americans  Act  for 
 
authority  to perform  their  duties 
Half  of the  Ombudsmen  have  reported  difficulty with gaining  access  to LTC 
 
facilities 
Long-Term  Care  Facility  Vitation  Varies  Si&zificantly,  Possib&  Due  TO Sta@g 
Concentrations 
Only half  of the  Ombudsmen  visit all of their  nursing  homes  annually 
 
Most  Ombudsman  include  licensed  board  and  care  facilities  in their  visitation 
 
program 
Ombudsmen  Have  Many  Method  To Increase  l%eir  Vibility 
Virtually  all Ombudsmen  use posters  in LTC  facilities  and  the  media  to increase 
 
their  visibility 
Complaints  usually  come  to Ombudsmen  from  family  and  friends,  or during  visits 
 
Some  States  Gte Roblenw  With  Legal  Counsel 
One-third  of Ombudsmen  report  problems  with availability  of legal  counsel 
 
Ombudsmen  must  compete  with other  State  agencies  for State  attorneys  or 
 
contract  out  for legal  services 
ii  TABLE  OF  CONTENTS 
PAGE 
EXECUTIVE  SUMMAR r    0.....  .  ..0.00  .  ...**.    ******    **    11  
INTRODUCIION  . . . . .   *.....  . . . . . .. .O*O*OO    ******    *0*      1 
Organization  OfState  Offices  Of Ombudsman  Is Similar  . . . . . . . . . . . . . . . . . . 4 
Most  Ombudsmen  Coordinate  With  Other  State  Agencies  . . . . . . . . . . . . . . . . .  6 
Ombudsmen  Have  Power  To  Perform  Their  Jobs  . . . . . . . . . . . . . . . . . . . . . . .  7 
Nursing  Home  Visitation  Varies  Significantly  . . . . . . . . . . . . . . . . . . . . . . . . . . .  9 
Ombudsmen  Seek  To  Increase  Their  Visibility  . . . . . . . . . . . . . . . . . . .  . . .  10 
   
Some  Ombudsmen  Report  Problems  With  Legal  Counsel  . . . . . . . . . . . . . . . .  10 
APPENDICES 
A  Appendix  A  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..  A-l  INTRODUCTION 
PURPOSE 
To review  State  Units  on Aging  (SUA)  implementation  of the  ombudsman 
requirements  of Title  III of the  Older  Americans  Act  (OAA).  (Since  this report  was 
conducted,  the  1992 Amendments  to the  OAA  have  moved  the  Ombudsman  program 
from  Title  III to Title  VII  of the  OAA.)  In this report,  the  term  ombudsman  refers 
to the  requirement  that  States  establish  an Office  of Ombudsman  to investigate  and 
resolve  complaints  regarding  older  individuals  residing  in long-term  care  facilities. 
BACKGROUND 
Under  the  0~  the  Administration  on Aging (AoA)  servesas the  principal  Federal 
advocate  for  older  individuals,  providing  national  leadership  in the  development  of 
programs  to  address  their  needs.  Through  Title  III of OAA  (Grants  for State  and 
Community  Programs  on Aging),  AoA  encourages  and  assists SUAS and  area  agencies 
on aging  (&lAs)  to implement  a system  of coordinated  community-based  services  to 
prevent  the  premature  institutionalization  of older  individuals  by allowing  them  to 
remain  in their  own community. 
Under  Title  III, AoA  distributes  approximately  $765 million  in formula  grants  to States 
based  on the  age  60+  population  within  each  State.  The  SUAS use  about  5 percent 
of the  grant  on administration  and  then  fund AAAs,  who then  contract  for the 
supportive  services,  nutrition  services  and  multipurpose  senior  centers.  The  single 
largest  component  of Title  III, the  nutrition  program,  provides  approximately  $450 
million  for congregate  and  home-delivered  meals.  Other  key program  components 
include  supportive  services  (i.e., access  services,  in-home  services  and  legal  assistance) 
and  the  Ombudsman  Program  which  serves  as an advocate  for residents  in long term 
care  facilities. 
One  of AoAs major  administrative  responsibilities  is to provide  stewardship  over  the 
States  implementation  of the  Title  III program.  I-Iowever, 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  75 percent  reduction  in travel  funds.  Each  regional  office  had 
only $2,000 annually  for travel.  Because  they  could  not  monitor  SUAS, AoA  became 
further  and  further  removed  from  the  activities  of the  SUAS and  their  area  agencies 
on aging. 
In efforts  to strengthen  its stewardship  of the  OAA,  the  Commissioner  of AoA 
requested  technical  assistance  from  the  Office  of Inspector  General  (OIG)  in 
designing  a review  of their  primary  Title  III grantees  -- SUAS.  In response  to the 
Commissioners  request,  OIG  staff met  with key AoA  headquarters  and  regional  staff 
to identi~  traditional  and  current  stewardship  activities  and  to discuss potential 
1  approaches  for future  efforts.  As a result,  we agreed  that  the  review  of individual 
States  would  be  instituted  in such a way as to provide  the  Commissioner  with  an 
overview  of how States  are  implementing  key components  of Title  III.  The  OIG 
agreed  to  assist AoA  in developing  national,  standardized  review  instruments  for key 
components  of Title  III and  in writing  a report  summarizing  States  implementation  of 
the  Act.  We  also  agreed  that  in order  to conserve  limited  travel  funds  the  reviews 
would  be  conducted  on a sample  of States  and would  focus  on only five programmatic 
areas  -- stewardship,  targeting,  ombudsman,  nutrition,  and  financial  management. 
Designing  the  review  began  with  the  meeting  of a review  team  of OIG  and  selected 
AoA  regional  staff.  They  brainstormed  approaches,  identified  Federal  reporting  and 
operating  requirements  for SUAS and  AAAs,  and  drafted  instruments  containing  the 
review  questions  and  criteria.  The  draft  instruments  were  shared  with AoA 
headquarters  staff  and  each  regional  office  for comments,  and  then  revised  to reflect 
comments. 
The  OIG/AoA  review  teams  pre-tested  the  instruments  and  data  collection 
methodology  by conducting  reviews  for  each  of the  five instruments  in six States 
located  in four  different  Federal  regions.  The  pre-test  identified  that  a great  deal  of 
time  was lost explaining  criteria  (interpreting  law and  regulation)  and  searching  for 
documentation.  Accordingly,  the  review  team  modified  each  of the  instruments  and 
changed  the  data  collection  methodology.  The  most  significant  change  to the 
methodology  required  the  sharing  of the  review  instruments  with  the  States  prior  to 
the  site visit in the  belief  that  if States  are  aware  of and  understand  the  review  criteria 
being  used  during  the  review,  they will be better  prepared  to provide  required 
documentation  and  to discuss specific  issues. 
METHODODGY 
The  reviews  were  conducted  in a stratified,  random  sample  of 20 States  based  upon 
the  population  of individuals  over  60 years  of age  in each  State.  These  are  the  same 
data  used  to  allocate  Title  III funds  among  States.  In the  first step  of the  sampling 
process,  States  were  divided  into  four  strata  based  upon  the  number  of older 
individuals  in each  State.  In the  second  step,  we selected  five States  from  each 
stratum.  This  stratified,  random  sample  permits  us to generalize  findings  from  the  20 
sample  States  to the  Nation.  Table  I indicates  those  States  selected  for the  review 
process  (See  Table  I). 
2  TABLE  I 
SAMPLE  STATES 
Stratum 1  Stratum 2  Stratum 3  Stratum 4 
California  Michigan  Wisconsin  New Hampshire 
Pennsylvania  Indiana  Colorado  North  Dakota 
New York  Massachusetts  Oklahoma  Nevada 
Texas  Georgia  Maine  District 
Florida  North  Oregon  of Columbia 
Carolina  Montana 
The  data  collection  was conducted  in two phases  -- an AoA  regional  office  desk 
review and  an on-site  review  at  the  SUA.  During the desk review phase,  we looked  at 
program  instructions.  Following  the  desk  review,  each  State  was sent  a proposed 
agenda  for the  site visit, copy of the  ombudsman  review  instrument  (Appendix  A),  and 
the  findings  from  the  desk  review  to be  discussed  during  the  site visit.  The  review 
instrument  focused  on the  nature  and  operation  of the  Office  of Ombudsman  and  on 
key requirements  of Title  III.  The  instruments  also focus  on the  issues  of SUA 
operating  procedures  and  on training  and  technical  assistance  activities. 
We  entered  data  from  the  ombudsman  review  instruments  into  one  database  that 
contained  the  responses  to the  open- and  closed-ended  questions  on the  instrument. 
The  percentages  cited  in this report  are  based  on the  responses  to specific  questions 
contained  in the  review  instrument.  The  responses are weighted to reflect  the  sampling 
plan  and  are  projected  to the  Nation.  The  precision  at the  90-percent  confidence 
intervals  vary for each  question  from  plus  or minus  6 to 21 percent  based  upon  the 
nature  of the  question  (categorical  or continuous)  and  the  number  of respondents  to 
each  question. 
3  FINDINGS 
WHILE THE  ORGANIZATION  OF STATE  OFFICES  OF OMBUDSMAN 
VARIES  ONLY  SLIGHTLY,  STAFFING  VARIES  GREATLY 
States  have  taken  similar  approaches  in setting-up  their  Offices  of Ombudsman.  Most 
Ombudsman  offices  are  located  in the  SU~  while  18 percent  are  located  in either 
independent  agencies  or in other  agencies  with their  relationship  to the  State  Agency 
established  in a contract  or memorandum  of understanding. Most Ombudsman  offices 
are  not  located  in the  agency  responsible  for licensinglong-term care  (LTC)  facilities. 
Only four  percent  of States  are  in a licensing  agency.  In these  instances,  the  licensing 
agency  is an umbrella  human  service  agency. 
States(76 percent)  that  utilize  sub-State  Ombudsmen  have  different  organizational 
approaches  in establishing  these  offices.  Half  of the  State  Ombudsmen  who  use  sub-

State  Ombudsmen  contract  out  to the  area  agencieson aging(AA/is) to act  as the

sub-State  Ombudsman.  Twenty-nine  percent  of the  time  they  contract  with  other

community-based  organizations.  Some  States  (18 percent)  do not  contract  out.  For

these,  State  employees  act as the  sub-State  Ombudsmen.

All Offices  of Ombudsman  have  State  laws that  outline  their  responsibilities  and

authorities.  Also,  all of the  State  Ombudsmen  work  full-time  as the  Ombudsman.

However,  in one  instance,  two part-time  employees  share  the  full-time  position.

The  staffing  levels  for each  State  differ  greatly.  Total  statewide  staffing  (professional,

support  and  volunteer)  ranges  from  3 to  1323, for an  average  of 216.  The  median

number  of staff is 58, which  indicates  most  are  smaller  than  the  average.  Full-time

professional  staff range  from  1 to 65, with an average  of 14.  Each  State  has  an

average  of 16 part-time  professional  staff, with a range  from  1 to  131.  On  the  whole,

Ombudsman  offices  do not  have  many  support  personnel.  They  average  only 2.5

clerical  or support  staff.  Lastly,  45 percent  of Ombudsmen  rely on full-time  staff  and 
55 percent  on part-time  staff. 
Stafmg  Levelk  Vary By Popzdation 
The  number  of professional  statewide  staff tends  to correlate  with  the  60-plus 
population  of the  State,  with  a few exceptions.  Generally,  States  with  a smaller 
number  of older  individuals  have  a lower  number  of professional  staff.  States  whose 
60-plus  population  is under  half  a million  have  six or less full-time  professional  staff 
members.  Those  with  an older  population  of over  a million  employ  at least  ten  full-
time  professionals.  One  State,  with  one  of the  largest  older  populations,  has  65 full-
time  professionals.  However,  two States  are  an exception  to this pattern.  They  show 
three  and  four  professional  staff members  respectively  but  have  older  populations  of 
2.4 and  .9 million. 
4  The  number  of volunteers  statewide  does  not,  however,  correlate  with  the  60-plus 
population  of a State.  Unlike  the  relationship  between  professional  staff  and  60-plus 
population,  some  States  that  have  older  populations  under  half  a million  have  more 
volunteers  than  States  with  older  populations  of over  1.5 million.  One  State,  with  a 
60-plus  population  of slightly over  a million  has the  most  volunteers  (1323).  Another 
State  which  has  a 60-plus  population  of 3.2 million  has  only 455 volunteers.  One  State 
has  50 volunteers  and  a 60-plus  population  of 102,984, while  another  State  has  59 
volunteers  and  an  older  population  of 1.5 million. 
Sta~g  Leveik  Do  Not  Effect  Visitation  Rates 
The  size of a States  staff does  not  insure  that  all its nursing  homes  will be visited 
annually.  States  that  visited  100 percent  of the  nursing  homes  in their  States  varied 
greatly  in the  amount  of professional  staff  and volunteers.  One,  which visited  all 
nursing  homes,  has  22 professional  staff  (full and  part-time  included)  and  1,300 
volunteers.  Another,  with  three  professional  staff members  and  no volunteers,  also 
visited  all its nursing  homes.  This  State  contracts  with its AAAs to provide  sub-State 
Ombudsman  programs;  these  programs  visit the  nursing  homes.  Some  States  with 
large  staffs  do not  visit all of their  nursing  homes  annually.  One  only visited  half  of its 
nursing  homes  although  it has  57 professionals  and  455 volunteers. 
As with  nursing  homes,  the  size of the  staff does  not  insure  that  all of a States 
licensed  board  and  care  facilities  will be visited.  States  are  not  currently  required  to 
visit these  facilities  (unless  a complaint  against  a facility is received  by the 
Ombudsman),  but  most  make  some  visits.  The  States  that  visited  all their  board  and 
care  facilities  had  some  of the  smaller  professional  staffing  levels  (3 to 54 members). 
In contrast,  some  States  with larger  staffs  did not  visit any board  and  care  facilities. 
Volunteem 
Eighty  percent  of the  States  use volunteers  in their  Ombudsman  program.  The 
number  of volunteers  range  from  3 to  1,300, for  an average  of 246.  While  all States 
that  use volunteers  train  them,  nineteen  percent  do not  formally  certify  them. 
Generally,  volunteers  are  certified  after  they  received  training  and  after  it has been 
determined  that  they  do not  present  a conflict  of interest.  Some  must  pass  a written 
exam, while  others  sign contracts  stating  that  they  understand  their  responsibilities. 
Ombudsmen  who  use volunteers  would  like more  volunteers  and  believe  a more  active 
recruitment  and  screening  process  is needed.  The  States  also mention  the  need  for 
better  supervision  over  and  better  retention  tactics  for volunteers.  They  feel  that 
more  training  may help  to improve  retention.  Also, having  funds  for administrative 
support  and  for  reimbursement  of expenses  that  the  volunteers  incur  (i.e., mileage  to 
and  from  the  LTCS, lunch)  would  help.  Finally,  some  of the  States  that  do not  certi@ 
volunteers  believe  a certification  process  would  improve  the  quality  of volunteers. 
5  The  use  of volunteers  has helped  Ombudsman  programs.  Most  States  indicate  that 
volunteers  allow for more  visits to LTCS.  They  help  to handle  more  resident 
complaints  in a cost effective,  timely  manner.  The  increased  visitation  to the  LTCS 
has helped  give the  Ombudsman  programs  greater  visibility with  the  residents  and 
staff.  This,  in turn,  has helped  both  groups  to better  understand  residents  rights. 
The  States  that  do not  use volunteers  (20 percent)  offer  three  reasons:  their  State 
legislatures  prohibit  the  use  of volunteers;  their  AAAs  are  not  convinced  that 
volunteers  can  do the job;  or they  believe  it is too  difficult  to train  and  manage 
volunteers. 
COORDINATION  BETWEEN  OMBUDSMEN  AND  OTHER  STATE AGENCIES 
EXISTS, BUT  WITH A FEW PROBLEMS 
Coordination 
The  Older  Americans  Act  requires  the  Ombudsman  Program  to coordinate  activities 
with  other  agencies  and  individuals.  These  include  protection  and  advocacy  agencies 
for individuals  with  developmental  disabilities  and  mental  illness,  adult  protective 
services,  long term  care  licensing  agencies,  and  the  Legal  Service  Developer.  The 
Ombudsmen  rely on a few approaches  to meet  these  requirements;  in many  situations 
they  use more  than  one  of these  approaches  to facilitate  coordination.  Some  of the 
more  common  approaches  for coordination  are joint  meetings,  joint  training, 
memoranda  of understanding  (MOU),  and  referrals. 
Joint  meetings  (37 percent)  and  MOUS  (33 percent)  are  the  most  often  used  methods 
of coordination  between  the  Ombudsmen  and  the  protection  and  advocacy  agency  for 
individuals  with  developmental  disabilities  and  mental  illness.  Joint  training  between 
the  agencies  is used  about  a quarter  of the  time.  Eighteen  percent  of the 
Ombudsman  offices  report  that  they  refer  cases  to the  protection  and  advocacy 
agency.  (Thirteen  percent  of the  Ombudsmen  are  actually  located  within  the  same 
agency  that  houses  the  protection  and  advocacy  agency). 
Most  Ombudsmen  (58 percent)  report  using referrals  in their  coordination  with  adult 
protective  services.  Almost  half  (46 percent)  use joint  training  to accomplish 
coordination,  and  27 percent  have  MOUS  that  establish  the  relationship  between  the 
two agencies. 
Sixty-four  percent  of the  Ombudsmen  use joint  meetings  to coordinate  operations  with 
long term  care  (LTC)  licensing  agencies.  Other  methods  are  referrals  (26 percent), 
MOUS  (23 percent),  and joint  training  (19 percent). 
The  Ombudsmen  use  a few methods  to coordinate  with the  Legal  Service  Developer 
(LSD).  For  10 percent  of the  States  the  LSD  is the  Ombudsmans  attorney,  and  for 
28 percent  the  Ombudsman  and  the  LSD  are  co-located  in the  Ombudsman  programs. 
6  For  those  Ombudsmen  not  co-located  with the  LSD, joint  training  is frequently  used 
(32 percent)  to achieve  coordination. 
State  Ombudsmen  also coordinate  with citizen  advocacy  groups. This  coordination  is 
achieved  mostly  by public  education  by the  Ombudsmen  (43 percent).  The 
Ombudsmen  also hold joint  meetings  with such groups  (32 percent).  Citizen  groups 
serve  as advisory  committees  to  30 percent  of the  States.  Often  these  two groups 
meet  to discuss  nursing  home  reforms.  This type  of coordination  on legislative  matters 
has  reportedly  helped  form  a good working  relationship  between  the  two groups. 
tibkms 
One  quarter  of all Ombudsmen  report  problems  with  coordination.  They  tend  not  to 
have  formal  agreements  with  the  developmental  disabilities  protection  and  advocacy 
systems  and,  therefore,  find coordination  difficult.  Some  report  making  referrals  by 
phone  and  then  not  receiving  return  calls.  One  State  is particularly  frustrated.  Its 
Ombudsman  feels  that  the  protection  and  advocacy  agency  has  the  funds  to actively 
work  in the  nursing  homes,  but  chooses  not  to since the  agency  feels  there  are  not 
many  developmentally  disabled  and  mentally  ill residents. 
Some  Ombudsmen  (14 percent)  report  problems  with  coordination  with  adult 
protective  services.  A common  complaint  is that  adult  protective  services  in some  of 
these  States  do not  have  enough  funds  to conduct  investigations  in nursing  homes. 
Nursing  homes  are  not  a priority  because  adult  protective  services  focuses  on family 
abuse.  Since  these  States  lack formal  agreements  with  adult  protection  semices,  it is 
hard  to make  LTC  facilities  a priority.  One  Ombudsman  believes  that  the  adult 
protective  service  program  in &  State  does  not  consider  nursing  homes  to be  part  of 
its domain.  Protective  Sexvices believes  that  the  nursing  homes  should  deal  with 
questions  of abuse. 
Twenty-three  percent  of the  Ombudsmen  report  they  have  no LSD  in their  State. 
They  consider  the  lack  of a LSD  a problem. 
WHILE  OMBUDSMAN  AUTHORITIES  TO PERFORM  THEIR  JOBS ARE 
BASED  IN STATE  LAW, REGULATION,  OR PROCED~,  THERE  ARE 
SOME  PROBLEMS 
The  OAA  requires  the  Ombudsmen  to have  certain  authorities.  These  authorities 
help  them  to perform  their  duties  by resolving  conflicts  of interest,  protecting  staff 
from  law suits, and  by giving staff  access  to LTC  facilities  and  LTC  residents  files. 
Ombudsmen  tend  to use State  laws, procedures  and  regulations  to meet  the 
requirements  of the  OAA.  However,  some  report  problems  in meeting  these 
obligations. 
The  OAA  requires  that  the  State  ensure that  no individual  involved  in the  designation 
of the  LTC  ombudsman  or that  no officer,  employee,  or other  representative  of the 
7  (Ombudsman)  Office  is subject  to a conflict  of interest.  To guarantee  no conflict,  the 
Ombudsmen  use  State  procedures,  which  may include  employees  filing forms  stating 
they have  no conflict  of interest  (43 percent  of the  time).  The  remaining  States  have 
passed  State  regulations  (31 percent)  and  State  laws (17 percent)  to cover  this 
provision. 
A representative  of the  Ombudsman  office  cannot  be held  liable  for  actions  while 
acting  in good  faith  in performing  their  official  duties.  Most  States  (80 percent)  have 
passed  laws to protect  employees  from  liability.  However,  seven  percent  lack  such 
protection  and  use insurance  policies  to protect  Ombudsman  staff.  Thirteen  percent 
of the  Offices  report  problems  with this issue,  mainly  the  lack  of a State  statute 
specifically  protecting  Ombudsmen.  Some  of these  States  report  State  employees  are 
covered  simply because  they  are  State  employees,  but  the  status  of volunteers  is 
questionable. 
Seventy-three  percent  of the  States  have  laws that  make  it unlawful  for any person  to 
willfully interfere  with  a representative  of an Ombudsman  office.  However,  five 
percent  of the  States  dont  have  a State  law and  rely on the  OAA  to protect  staff from 
interference.  Many  States  (22 percent)  have  had  problems  with this provision.  Some 
States  simply do not  have  laws or regulations  that  would  prevent  willful interference. 
Other  States  use  community  access  laws that  do not  provide  as much  protection  as the 
OAA  requires. 
Ombudsman  representatives  are  required  to have  full access  to facilities  and  files to 
perform  their  duties.  Eighty  percent  of the  States  have  laws that  specifically  ensure 
access.  Other  States  use State  regulations  to guarantee  access.  The  laws and  the 
regulations  have  not  guaranteed  easy access  for Ombudsmen.  Forty-eight  percent  of 
the  States  reported  incidents  where  they  have  had  difficulty with gaining  access  to a 
LTC  facility.  In a few cases,  Ombudsmen  used  their  sanction  authority  which  resulted 
in fines  for the  facility.  Fines  ranged  from  $500 to $1,000.  Following  the  fine,  the 
Ombudsman  was allowed  into  the  facility.  The  local  law enforcement  agency  has had 
to be  brought  in to gain  access  in some  States.  Ombudsmen  have  also talked  to the 
administrator  and,  after  explaining  the  Ombudsmans  authority,  gained  access. 
Both  residents  and  the  staff  of LTC  facilities  need  to be  protected  from  retaliation  for 
reporting  a case  to an Ombudsman.  State  laws (70percent)  and  State  regulations  (18 
percent)  prohibit  retaliation  on residents  and  staff of LTC  facilities  who report 
violations  to the  Ombudsman.  Further,  Ombudsmen  do not  identi~  any complainant 
without  their  permission  (and  without  due  cause).  State  laws (46 percent),  State 
procedures  (26 percent),  and  State  regulations  (11 percent)  guarantee  a complainants 
confidentiality.  There  have  been  instances  when  complainants  have  been  identified. 
Thirty-seven  percent  of the  States  report  incidents  where  they  have  identified 
complainants  due  to abuse,  fraud,  or court  cases. 
8  A residents  and  Ombudsmans  files are  also  confidential  information.  Fifty-seven

percent  of the  States  protect  the  confidentiality  of files through  State  law.  Other

States  use  State  procedures  (22 percent)  and  State  regulations  (11 percent).

The  OAA  requires  the  State  to provide  Ombudsmen  with sanction  authority  if any of

these  provisions  are  violated.  Eighteen  percent  of the  Ombudsmen  report  they  do not

have  State  authorized  sanction  authority.  They  consider  this as a significant  problem

and  feel  they  have  no muscle  backing  them  Up if necessary.  For  those  who have  this

authority,  the  authority  is either  legislated  (58 percent)  or regulated  (18 percent).

Thirty  percent  of Ombudsmen  do report  using their  sanction  authority.

LTC VISITATION  VARIES  SIGNIFICANTLY,  POSSIBLY  DUE  TO  STAFFING

CONCENTRATIONS

Some  Ombudsmen  do not visit all of their  LTC  facilities.  Only half  of the

Ombudsmen  report  visiting  all of their  nursing  homes  annually.  Regarding  these

States,  38 percent  visit at least  annually  and  53 percent  visit at least  quarterly.  Another

9 percent  manage  to visit all facilities,  but  only because  all facilities  had  residents  who

issued  complaints  that  the  Ombudsmen  had  to respond  to.  Among  the  States  which

do not  visit all of their  nursing  homes  annually,  most  (69 percent)  visit at least  70

percent  of them.  The  remaining  States  visit from  a quarter  to half  of their  facilities.

Some  Ombudsmen  say that  visitation  rates  are  a function  of staffing  and  that  staffing

varies  across  their  State.  Accordingly,  there  are  States  that  do not  visit  100 percent  of

their  nursing  homes,  but  the  homes  they  do visit are  visited  frequently.  One  large

State  only visits half  its nursing  homes  at least  annually,  but  they visit these  half

weekly.  Another  visits 70 percent  of its nursing  homes  weekly,  but  does  not visit the

remaining  30 percent  at all.  Ombudsmen  report  that  variation  of staff  across  a State

(i.e., some  areas  of the  State  are  fully staffed  while  other  parts  are  partially  staffed)

makes  it possible  for some  areas  to get weekly visits while  other  areas  are  not  visited.

While  Ombudsmen  are  not  currently  required  (unless  a complaint  is brought  against  a

facility)  to visit licensed  board  and  care  facilities,  many  do make  such visits.  Eighty-

nine  percent  include  licensed  board  and  care  facilities  in their  visitation  programs.  Of

those  who  include  these  facilities  in their  visits, 29 percent  visit all of them  and  13

percent  visit at least  90 percent.  Most  of the  remaining  Ombudsmen  visit less than  a

third  of their  board  and  care  facilities.

Some  Ombudsman  patterns  of visitation  to licensed  board  and  care  facilities  mirror

their  patterns  of visitation  to nursing  homes.  Some  visit some  of their  licensed  board

and  care  facilities  frequently,  while  not visiting others  at  all.  One  Ombudsman  office

visits 28 percent  of these  facilities  weekly,  but  does  not  visit the  remaining  72 percent

at all.  Another  visits 20 percent  weekly, while  not visiting the  other  80 percent.  Like

nursing  homes,  some  Ombudsmen  attribute  this pattern  of visitation  to the  various

staffing  levels  across  a State.  Most  of a States  Ombudsman  staff may be  concentrated 
9  around  certain  key cities,  so certain  areas  of a State  have  a  100 percent  visitation  rate 
and  other  areas  are  not visited  at  all. 
OMBUDSMEN  HAVE  MANY  METHODS  TO INCREASE  THEIR  VISIBILITY 
Many  methods  are  used  to make  residents  and  staff of LTC  facilities  aware  of 
Ombudsman  programs.  The  most  commonly  used  method  is the  placement  of posters 
in facilities  (91 percent).  Half  of the  Ombudsmen  use the  media  to make  facility  staff 
and  residents  aware  of their  programs.  Site visits by Ombudsmen  (20 percent)  and 
hotlines  (11 percent),  a phone  line  to a Ombudsman  office,  are  other  ways.  Other 
frequently  mentioned  methods  include  pamphlets,  Residents  Bill of Rights,  and 
attending  LTC  conferences. 
Complaints  are  most  often  brought  to the  attention  of the  Ombudsman  from  family 
and  friends  (50 percent)  of the  residents  of LTC  facilities  and  through  site visits by a 
representative  of an  Ombudsman  (51 percent).  Residents  also bring  forth  complaints 
(45 percent).  Many  complaints  come  over  the  phone  (27 percent),  often  over  hotlines. 
Seventy-seven  percent  of the  Ombudsmen  prioritized  complaints.  In these  States,  all 
use life threatening  as a criterion.  Fifteen  percent  also list threat  of discharge. 
SOME  STATES  CITE PROBLEMS  WITH LEGAL  COUNSEL 
Thirty  percent  of the  Ombudsman  report  problems  with  the  availability  of legal 
counsel.  Many  of these  States  mention  a lack of funds  for an attorney  as a major 
barrier  to legal  counsel.  The  high price  for legal  services  puts  a strain  on budgets. 
Another  problem  cited  is the  competition  for limited  legal  staff.  For  the  Ombudsman 
programs  that  use their  State  attorney  general  or an attorney  in an  umbrella  agency, 
they must  often  compete  with  other  agencies  and  concerns.  They  do not  have  a 
lawyer  they  can  count  on.  They  must  follow the  schedules  or workloads  of people 
outside  of their  office.  In these  instances,  the  bare  minimum  of litigation  is handled. 
Also,  attorneys  from  outside  the  Ombudsman  programs  often  do not  understand  the 
Ombudsman  program  and  its problems. 
Legal  counsel  for the  Ombudsman  most  often  (44 percent)  comes  from  an attorney  in 
their  agency.  In some  cases  the  attorney  is the  Legal  Service  Developer.  Thirty-four 
percent  use their  State  Attorney  General.  Others  contract  out for  legal  services  or 
accept  pro  bono  counsel. 
10  o  OMBUDSMAN  COMPLIANCE  REVIEW 
Department  of Health  and Human  Services 
Administration  on Aging 
State  Date 
Primary  Respondent  Telephone 
Review  Team Leader  Telephone 
--------- ----------- ------- ------- -------- ------- ----------
1.  Is the Office of the Long-Term  Care  ombudsman  located  in the State Agency  on Aging? 
(Hereafier  the  St&e  Agency  on Aging  will  be  referred  to as  the  State  Agency) 
Yes  (IJ Yes,  go  to question  2) 
B.  No  (If 1~0): 
(1)  Where  is it located? 
(2)  Is there  a contract  between  this agent y and the State Agent y? 
(a)  Yes (If  Yes,  get  copy) 
(b)  No 
(c)  Dont Know  (Check  if applicable) 
2.  Is the agency  that sponsors  [houses) the ombudsman  responsible  for licensing  long-term 
care  (LTC)  facilities  or an association  affiliated  with LTC  facilities? 
a.  Yes (If  Yes,  discuss): 
b.  No 
A-1  3.  Is there  a State law governing  the Ombudsman  Program? 
a.  Yes (If  Yes,  get  copy) 
b.  No 
c.  Dont Know  (Check  if applicable) 
4.  Does the Office of the Long-Term  Care  Ombudsman  utilize  sub-State  ombudsmen? 
Yes  (If  Yes,  go  to question  5) 
::  No  (If No,  go  to question  7) 
5.  Describe  the organizational  relationship  between the sub-State  ombudsmen  and the State 
Office  of the Ombudsman. 
6.  Are  there  an~ reporting  or operations  problems  with sub-State  ombudsman?  (Probe  both) 
A-2  3.  Is there  a State law governing  the Ombudsman  Program? 
Yes  (If  Yes,  get  copy) 
:;  No 
c.  Dont Know  (Check  Zyapplicable) 
4.  Does the Office  of the Long-Term  Care  Ombudsman  utilize  ombudsmen? 
a.  Yes  (If  Yes,  go  to  question  5) 
b.  No  (If No,  go  to  quest-ion  7) 
5.  Describe  the organizational  relationship  between  the sub-State  ombudsmen  and the State
Office of the Ombudsman. 
6.  Are there  any reporting  operations  problems  with  sub-State ombudsman?  (Probe  both)  7.	 How  does the State Agency  solicit comments  and recommendations  from area  agencies, 
older  individuals,  and provider  agencies  regarding  the planning  and operation  of the 
ombudsman  program?  [Sec. 307(a) (12)(E)] 
8.	 Does the State Ombudsman  (Do you) work full-time  on ombudsman  responsibilities  as 
outlined  in the Older  Americans  Act?  [Sec. 307(a) (12)(A)] 
a.  Yes 
b.  No,  Why  not? 
c.  Dont Know  (Check  if applicable) 
9.	 What  is the total  number  of staff in the State office  of the Ombudsman,  including  any sub-
State program?  Include  in the total  number,  clerical  and administrative  personnel  as well as 
full-time,  part-time,  and volunteer  staff. 
a.  (Indicae  total  number) 
b.  Dont Know  (Check  if applicable) 
A-3
 10*  Of that total  (number  provided  in  question  9),  how many professional  and support  staff are: 
(Complete  question  using  a,  b,  and  c) 
PROFESS1ONAL  SUPPORT  DONTKNOW 
(Indicate  Number)  (Indicate  Number)  (Check  inapplicable) 
a.  Full-time  employees? 
b.  Part-time  employees? 
c.  Volunteers? 
If the  respondent  indicties  no  volunteers  are  used,  ask  question  11.  Otherwise  skip  to  question 
12. 
11.  Why arent  volunteers  used to meet the requirements  of the Older Americans  Act?  (Probe 
forjidl  explim~on.  For  example,  if the  respondent  indicates  no  volunteers  are  used 
because  a state  law prohibits  use  of  volunteem,  get  an  explan~on  of th~  sttie  lhw.) 
12?.  What procedures  are  in place  to assure  that Ombudsman  employees  and volunteers,  if any, 
are qualified  and trained  prior  to investigating  complaints?  [See. 307(a)( 12)(K)] (Probe for 
stanhzis  for  both  employees  and  volunteers,  where  approptie) 
A-4  13.  Does the Ombudsman  program  formally  certify  volunteers?

a.  Yes (If  Yes,  go  to  question  14)

b.  No (If No,  go  to  question  15)

14.  What  are the requirements  for certification?

15.  What  are the most significant  accomplishment(s)  of your use of volunteers?

16.  What  improvements,  if any,  are  needed  in the use of volunteers?
 17.  Did staff training,  conducted  in the last year,  include  topics  such as: 
Yes  No  Dont  Know  (Check  applicable  response) 
a.  Federal  laws,  regulations,  and policies  regarding  LTC 
facilities,  (If No): When  was the last time training  was 
conducted? 
b.  State laws,  regulations,  and policies  regarding  LTC 
facilities,  (If No):  When  was the last time  training  was 
conducted? 
c.  Local  laws,  regulations,  and policies  regarding  LTC 
facilities,  (If No):  When  was the last time training  was 
conducted? 
d.  Investigative  techniques,  (Zf No): When  was the last 
time training  was conducted? 
18.  Is there  a formal  (written)  in-service  training  curriculum  for employees? 
a.  Yes  (If  Yes,  get  copy) 
b.  No  19.  What  are examples  of the types of training  provided  in the last year to:  (Complete  question 
using  a,  b,  and  c) 
a.  paid  full-time  staff? 
b.  paid part-time  staff? 
c.  volunteers? 
20.  HOW  do yOU  activities  with the protection  and advocacy  systems for  individuals 
with developmental  disabilities  and mental  illness?  [Sec. 307(a)( 12)(H)(v)]  (Get examples) 
, 
21.  How do you coordinate  activities  with adult protective  services?  (Get  examples) 
22.  How do you coordinate  with the State agency  responsible  for licensing  and ceflifying  LTC  facilities? 
23.  How do you coordinate  activities  with the legal services  developer? 
\ 
24.  How do you encourage  the participation  by citizen  organizations  in the Ombudsman 
program?  [307(A) (12)(A) (ii)] 
A-8  25.  How does the State Agency  identify  and resolve  any potential  conflicts  of interest  affecting 
the Ombudsman,  or any employee  or representative  of the Office of the Ombudsman? 
[Sec.  307(a) (12)(F) (i), (ii), (iii)] 
26.  How  does the State ensure  that no representative  of the Office of the Ombudsman  will be 
held liable  for the performance  of official  duties?  [Sec. 307(a) (12)(I)] 
27.  How does the State ensure  that willful  interference  with representatives  of the Office of the 
Ombudsman  in carrying  out their duties  shall be considered  unlawful? 
[Sec.  307(a) (12)(J)(i)]  28.  What  steps has the State  undertaken  to prohibit  retaliation  and reprisals  by a LTC facility 
on any resident  or employee  for fding  a complaint  or for providing  information  to the Office 
of the Ombudsman?  [Sec. 307(a) (12)(J) (ii)] 
29.  What  State sanction  authority  is in place  regarding  interference,  retaliation,  and reprisals? 
[Sec. 307(a) (12(J) (iii)] 
30.  Have  any sanctions  ever  been  toany individual  or entity? 
a.  Yes  (If  Yes): 
Describe  the circumstances,  the sanction applied,  and the results of the sanction. 
--
CIRCUMSTANCES  SANCTION  RESULTS  OF 
APPLIED  SANCTION 
(1) 
(2) 
(3) 
@) 
(If adiiitional  space  is required,  use  the  back  of the previous  page) 
b.  No 
A-10  31.  How do you ensure  residents  of LTC  facilities,  throughout  the State,  are made aware  of the 
Office of the Ombudsman? 
32.  What percent  of the nursing  homes inthe  State are visited  annually? 
(Indic&e  percentage) 
::  Dont Know  (Check  if applicable) 
33.  How often are nursing  homes visited? 
a.  regularly;  How many times per  year? 
b.  in response  to a complaint  only 
c.  other  (Speci~  and  obtain  frequency) 
34.  What  percent  of the licensed  board and care  faciliti~  in the State are visited annually? 
a.  (Indictie  percentage) 
 
(If more  than  5%):  How often are licensed board  and care  facilities  visited? 
(1)  regularly;  How  man y times per  year? 
(2)  in response to a complaint  only 
(3)  other  (Specifi  and  obtain  j7equency) 
b.  Dont know  (Check  inapplicable)  -
r  A-n 
 
.  35.  Who  routinely  performs  the annual visits to licensed  board  and care  facilities? 
36.  List,  in order,  the most prevalent  ways in which complaints  are brought 
the Office of the Ombudsman. 
37.  Do you prioritize  complaints? 
a.  Yes (1! Yes), How are complaints  prioritized?  (Probe for  process,  definitions 
used,  etc.) 
b.  No 
38.  How do you ensure  your staffs  access  to LTC  facilities,  residents.  and residents  records? 
 
[Sec. 307(a) (12)(B),QQ]  39.  Have  any incidents  occurred  when the Ombudsman  has attempted  to gain access to a facility 
or to obtain  residents  records? 
a.  Yes (If  Yes),  What  were the incidents  which occumed  and what  did the 
. 
Office of the Ombudsman  take? 
INCIDENT  ACTION  TAKEN 
J 
(1) 
(2) 
(3) 
 
I  I  II 
(4) 
(If additional  space  is required,  use  the  back  of the previous  page) 
b.  No 
40.  How  do you protect  the confidentiality  of residents  records  and Ombudsman  files? 
[Sec.  307(a) (12)(B),(D)] 
A-13 
.
.4.!  ~- 41.  How do you ensure  that the identity  of any  complainant  or resident  of a facility  will not be 
disclosed?  [Sec. 307(a) (12)(D)] 
42.  Has your Office  had to identify  the complainant  or resident  of a facility  without 
permission? 
a.  Yes  (If  Yes),  Please  discuss  the circumstances  and under  what grounds  the 
OffIce disclosed  this information. 
b.  No 
43.  HOW is legal counsel  made available  to  the  Office of the Ombudsman? 
A-14  44.  In the past year,  have there been any problems  with the availability  of legal counsel? 
a.  Yes (If  Yes):  What  were  these obstacles,  and how were they overcome? 
b.  No 
45.  In the past year,  what type of issues and cases required  legal counsel? 
46.  Describe  your statewide  uniform  reporting  system.  elements  and  procedures) 
A-15  47.  What  was the date of your last annual  report? [Sec. 307(a)(12)(H)] 
/ / 
(?i$e  annual  repoti  petiains  to  Ombudsman  repoti  as per  Sec.  307(a) (12MU 
48.  Were  policy,  regulatory,  and legislative  recommendations  made  in this report? 
a.  Yes 
b.  No 
49.	 Was the annual  report  submitted  to the State agency  responsible  for licensing  or certifying 
LTC  facilities? 
a.  Yes 
b.  No 
50.  Was  it submitted  to the State legislature? 
a.  Yes 
b.  No 
51.  In general,  who else routinely  receives  the report? 
A-16  52.  What  has the State Agency  done to ensure  that the Ombudsman  has the ability to pursue 
administrative,  legal,  and other  remedies  on behalf of LTC  residents? 
[Sec. 307(a) (12)(G) (ii)] 
53.  Are there  any Federal  requirements  causing  you operational  or financial  problems?  (Probe 
both) 
/INTERVIEW  COMPLETED] 
A-17  Department  of  Health  and Human  Services 
ADMIN  STRATION  ON  AG  NG

AND

OFFICE  OF

INSPECTOR  GENERAL

STATE  IMPLEMENTA~ON  OF= 
OMBUDSW  REQUIREMENTS  OF 
THE  OLDER  AMERICANS  ACT 
APRIL  1993
 ADMINISTRATION ON  AGING 
The Administration on Aging (AoA) k the principal Federal agency designed to carry out the 
provisions of the O1der Americans Act (OPA).  It advises the Secretary of Health  and Human 
Semites  and other  Federal agencies on the characteristics, circumstances and needs of older 
individuals.  Further,  it develops policies, plans, and programs designed to promote  their 
welfare. 
AoA administers three grant programs under the Older Americans Act.  The largest program -
- Title III of the Act --consist of formula grants to States to establish State and community-
based programs for older individuals with the purpose of preventing the premature 
institutionalization  of older individual.  The second program --Title VI -- consists of 
discretionary grants with the saxne purpose as Title Iu,  but to meet the unique needs of older 
Native Americans.  The third program --Title IV -- is also discretionary.  Its purpose is to fund 
research, demonstration,  and training activities to elicit knowledge and techniques to improve 
the circumstances of older Americans.  (The 1992 Amendments  to the OAA created  a fourth 
program -- Title VII --which provides funds for State activities to protect  the rights of 
vulnerable older people.  Prior to the 1992 Amendments, Title III of the OAA provided the 
funds for these activities.) 
OFFICE  OF INSPECTOR  GENEIWL 
The mission of the Office of Inspector General  (OIG), as mandated by Public Law 95-452, as 
amended, k to protect  the integrity of the Department  of Health  and Human Services (HHS) 
programs as well as the health and welfare of beneficiaries sexved by those programs.  This 
statutory  mission is carried out through a nationwide network of audits, investigations, and 
inspections conducted by three OIG operating components:  the Office of Audit Sewices, the 
Office of Investigations, and the Office of Evaluation and Inspections.  The OIG also informs 
the Secretary of HHS of progrmn and management problems and recommends courses to 
correct  them. 
The OIGS Office of Evaluation and Inspections (OEI) conducts short-term  management  and 
program evaluations (called inspections) that focus on issues of concern to the Departrncnt, 
the Congress, and the public.  The findings and recommendations  contained  in these inspection 
reports generate  rapid, accurate, and up-to-date  information on the efficiency, vulnerability, 
and effectiveness of departmental  programs. 
THIS  REPORT 
This report  is the result of a joint effort between AoA and OIG/OEI  to assess the 
implementation  of Title III of the O1der Americans Act.  OIG staff in the New York and 
Dallas regional offices provided technical support to the joint project.  AoA staff in New York 
and Dallas directed  the project with ail regional offices participating in the development  of 
instruments and data collection. 
For additional information, please contact: 
AoA  John Dia~ Regional Program Director-Dallas  214-767-2971 
OIG  Jack Molnar, Project Leader-New York  212-264-1998