Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
Long Term Care Ombudsman Program: 
Overall Capacity 
JUNE GIBBS BROWN 
Inspector General 
MARCH 1999 
OEI-02-98-00351  OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, is to 
protect the integrity of the Department of Health and Human Services programs as well as the 
health and welfare of beneficiaries served by them.  This statutory mission is carried out through a 
nationwide program of audits, investigations, inspections, sanctions, and fraud alerts.  The 
Inspector General informs the Secretary of program and management problems and recommends 
legislative, regulatory, and operational approaches to correct them. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) is one of several components of the Office of 
Inspector General.  It conducts short-term management and program evaluations (called 
inspections) that focus on issues of concern to the Department, the Congress, and the public.  The 
inspection reports provide findings and recommendations on the efficiency, vulnerability, and 
effectiveness of departmental programs. 
OEI's New York regional office prepared this report under the direction of John I. Molnar, 
Regional Inspector General, and Renee Dunn, Deputy Regional Inspector General.  Principal OEI 
staff included: 
REGION  HEADQUARTERS 
Demetra Arapakos, Project Leader  Susan Burbach, Program Specialist

Vincent Greiber

Ellen Vinkey

To obtain copies of this report, please call the New York Regional Office at 212/ 264-2000. 
Reports are also available on the World Wide Web at our home page address: 
http://www.dhhs.gov/progorg/oei  E X E C U T I V E  S U M M A R Y  
PURPOSE 
To describe the overall capacity of State Long Term Care Ombudsman programs to 
promote and monitor quality of care in nursing homes. 
BACKGROUND 
While many studies indicate that changes in law and regulations may have had a positive 
effect on improving the environment and overall health care of nursing home patients, 
recent reports by the Health Care Financing Administration (HCFA) and the General 
Accounting Office have raised serious concerns about patients care and well-being.  The 
Senate Special Committee on Aging held hearings in the summer of 1998 on these results. 
Committee staff requested the Office of Inspector General (OIG) to examine the issue of 
nursing home quality of care.  At the same time, we undertook additional studies aimed at 
assessing the quality of care in nursing homes.  This report examines the capacity of the 
Ombudsman program to monitor and promote quality of care.  Future OIG reports will 
address trends in reported abuse of nursing home residents, the nursing home survey and 
certification process, and the availability of survey results. 
In response to growing concerns about poor quality care in nursing homes and to protect 
the interests of residents,  the State Long Term Care Ombudsman program was 
established in the 1978 Older Americans Act.  The ombudsmen advocate on behalf of 
residents of long term care facilities to ensure they have a strong voice in their own 
treatment and care.  It operates in all fifty States and in hundreds of local communities, 
using both paid and volunteer staff. 
We examined the Ombudsman program in the 10 States with the largest nursing home 
population.  We analyzed 1997 program data from the National Ombudsman Reporting 
System (NORS), reviewed written program procedures, and conducted phone interviews 
with State and local ombudsmen, as well as State Unit on Aging Directors. 
FINDINGS 
The Ombudsman Approach is Distinct From and Complements Other Nursing 
Home Monitoring Programs 
Discussions with State and local ombudsmen, as well as State Aging Unit Directors, 
emphasize the uniqueness of the Ombudsman program.  In contrast to other programs, 
ombudsmen lack enforcement and regulatory oversight authorities.  As independent 
advocates, they work solely on behalf of residents and are able to mediate between these 
residents and nursing home staff on an informal level.  Furthermore, a routine nursing 
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LTC Ombudsman Program: Overall Capacity  OEI-02-98-00351  home presence is essential to the role of the ombudsman since it provides residents with 
the opportunity to develop personal and confidential relationships with ombudsmen staff 
and creates a comfortable environment for registering complaints.  Finally, the program is 
also distinct in its reliance on volunteers. 
The Programs Overall Capacity to Monitor and Promote Nursing Home Care 
Appears Limited 
A number of factors appear to limit the capacity of the Ombudsman program.  First, the 
program is limited by staffing constraints.  Staffing levels among the 10 States vary 
considerably, ranging from a ratio of 5,003 beds per paid staff person in Florida, to 1,115 
beds per paid staff person in California.  Also, a majority of State and local ombudsmen 
(six and seven respectively) identify insufficient program staffing as an obstacle which 
detracts from their programs effectiveness. 
Insufficient program staffing is particularly evident in the limited extent to which 
ombudsmen make regular nursing home visits.  In the nine States that make such visits, 
volunteers are generally assigned to just one home and are able to visit this home on a 
weekly basis.  However, most nursing homes in the 10 States do not have volunteers 
assigned to them, and these homes are visited just once or twice a year for no longer than 
one to three hours.  Furthermore, in four States there are nursing homes that never have 
regular visits by volunteers or by paid staff. 
The capacity of the Ombudsman program is additionally limited by the lack of a common 
standard for responding to and resolving complaints; consequently, staff in some States 
are not consistently responding to and resolving complaints in a timely manner. 
Moreover, ombudsman advocacy and outreach efforts in the 10 States are inconsistent, 
and half of State and local ombudsmen say their program lacks adequate support.  Finally, 
while the National Ombudsman Reporting System (NORS) developed in 1995 has 
improved the programs data reporting capacity, it lacks some important performance 
measurement data. 
Collaboration With Other Monitoring Programs Enhances the Capacity of 
Ombudsmen 
Both State and local ombudsmen, as well as State Aging Unit Directors, believe that 
collaboration is crucial to enhancing their capacity to improve the life of nursing home 
residents.  However, ombudsmen would like better collaboration with State surveyors. 
Despite the requirement that they be notified of inspection dates, two ombudsmen say they 
are not notified.  Furthermore, ombudsman and survey and certification data for 1997 
show that ombudsmen staff accompanied surveyors just 61 percent of the time. 
RECOMMENDATIONS 
Ombudsmen, with their unique combination of functions-- visitation, complaint and crisis 
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LTC Ombudsman Program: Overall Capacity  OEI-02-98-00351  response, and advocacy-- play an important role in assuring quality of care in nursing 
homes.  We therefore believe that the program limitations we have identified in this 
inspection must be addressed. 
We recommend that the Administration on Aging work with States to strengthen the 
Ombudsman program.  In particular, we suggest they: 
<	 develop guidelines for a minimum level of program visibility that include 
criteria for the frequency and length of regular visits, as well as a ratio of 
Ombudsman program staff to long term care beds; 
<	 further highlight strategies for recruiting, training, and supervising more 
volunteers; 
<  develop guidelines for complaint response and resolution times; 
<	 continue to strengthen the programs data reporting system, including 
ensuring that all State ombudsmen understand and use the definitions in the 
system and train local ombudsmen and volunteers in standard utilization; 
and 
<	 establish ways in which Ombudsman programs can enhance collaboration 
with the survey and certification agency. 
We recognize that in order to implement these recommendations, and to fulfill the 
Ombudsman program mission as outlined in the Older Americans Act, additional funding 
may be required.  In particular, it may be necessary to find ways to increase the number of 
paid and volunteer ombudsmen.  As noted earlier, the Institute of Medicine recommends 
one full-time equivalent ombudsman staff person for every 2,000 long term care facility 
beds in each State, a standard which not all States meet. 
The Presidents recent nursing home initiative highlights the importance of improving the 
quality of care provided to vulnerable nursing home residents.  We believe that 
strengthening the Ombudsman program will significantly contribute to this important 
effort. 
AGENCY COMMENTS 
We received comments on the draft report from the Administration on Aging (AoA) and 
the Health Care Financing Administration (HCFA).  They concur with our 
recommendations. 
The AoA suggests two modifications to our recommendations.  First, it points out its 
ongoing efforts through training and technical assistance to work with States in the 
effective use of volunteers.  In acknowledgment of these efforts, we have changed the 
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LTC Ombudsman Program: Overall Capacity  OEI-02-98-00351  recommendation to say that AoA should further highlight and promote strategies for 
volunteer programs.  Second, the AoA reports that while they work closely with 
ombudsmen to understand NORS, more could be done to promote a better understanding 
of the system.  We have therefore broadened our recommendation to include the need for 
a common understanding and use of NORS definitions.  We also continue to believe that 
the system could be strengthened by adding performance-based data such as complaint 
response and resolution times. 
Some parts of the report were additionally modified in response to AoAs technical 
comments. The full comments are presented in Appendix A. 
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LTC Ombudsman Program: Overall Capacity  OEI-02-98-00351  T A B L E  O F   O F  C O N T E N T S  
PAGE

EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

FINDINGS

Ombudsman Approach Distinct and Complementary  . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Overall Capacity of  Program Appears Limited . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Collaboration with Other Programs Enhances Capacity  . . . . . . . . . . . . . . . . . . . . . . . . 15

RECOMMENDATIONS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  17

APPENDIX

Comments  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

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LTC Ombudsman Program: Overall Capacity  OEI-02-98-00351  I N T R O D U C T I O N  
PURPOSE 
To describe the overall capacity of the State Long Term Care Ombudsman program to 
promote and monitor quality of care in nursing homes. 
BACKGROUND 
While many studies indicate that changes in law and regulations may have had a positive 
effect on improving the environment and overall health care of nursing home patients, 
recent reports by the Health Care Financing Administration (HCFA) and the General 
Accounting Office have raised serious concerns about patients care and well-being.  The 
Senate Special Committee on Aging held hearings in the summer of 1998 on these results. 
Committee staff requested the Office of Inspector General (OIG) to examine the issue of 
nursing home quality of care.  At the same time, we undertook additional studies aimed at 
assessing the quality of care in nursing homes.  This report examines the capacity of the 
Ombudsman program to monitor and promote quality of care.  Future OIG reports will 
address the trend in reported abuse of nursing home residents, the nursing home survey 
and certification process, and the availability of survey results. 
In 1987, Congress passed major nursing home reform legislation with the Omnibus 
Reconciliation Act of 1987 (OBRA 1987).  This legislation required nursing homes with 
Medicare and Medicaid residents to comply with specific quality of care standards by 
providing services and activities to attain or maintain the highest practicable physical, 
mental, and psychosocial well-being of each resident.  More than a decade later, concerns 
still exist about the quality of care provided in nursing homes. 
Ombudsman Program 
A nursing home is a long term care residential facility for individuals with physical or 
mental impairments that prevent them from living independently.  A nursing home provides 
its residents with a room, meals, assistance with daily living activities, and medical care. 
According to data provided in State ombudsman reports, in 1996 there were 18,066 
nursing homes and 1,845,791 nursing home beds.  Medicaid payments to nursing homes 
that year totaled $29.6 billion, while Medicare payments totaled $10.6 billion. 
In response to growing concerns about poor quality care in nursing homes and to protect 
the interests of residents,  the State Long Term Care Ombudsman program was established 
in 1978 in the Older Americans Act.  The ombudsmen advocate on behalf of residents of all 
long term care facilities, including nursing homes, to ensure they have a strong voice in 
their own treatment and care. 
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LTC Ombudsman Program: Overall Capacity  OEI-02-98-00351  The Ombudsman program operates in all fifty States, the District of Columbia, and Puerto

Rico, and in hundreds of local communities, and uses both paid and volunteer staff.  The

program receives funding from Federal, State and local levels, and is overseen by the

Administration on Aging (AoA).  Most State ombudsmen operate within the State Unit on

Aging (SUA), some of which are independent while others are part of a larger State

umbrella agency.  The remaining State Ombudsman programs are located organizationally

outside of the SUA.  These programs are operated by non-profit organizations or legal

services agencies, or they are freestanding Ombudsman programs. 

State Ombudsman programs have multiple functions that are mandated by law, many of

which are closely tied to ensuring quality care for long term care residents.  They include:

C  identifying, investigating, and resolving complaints;

C  protecting the legal rights of patients; 

C  advocating for systemic change; 

C  providing information and consultation to residents and their families; and,

C  publicizing issues of importance to residents

Several national associations have been established to support State Ombudsman programs. 

One of these, the National Long Term Care Ombudsman Resource Center, was established

in 1993.  This Center is funded by AoA and is run by the National Citizens Coalition for

Nursing Home Reform (NCCNHR) in cooperation with the National Association of State

Units on Aging (NASUA).  It serves as a clearinghouse for information on the national

Ombudsman program.  One of its functions is to identify issues of significance to the

Ombudsman program, including ways the ombudsman can improve quality of care in

nursing homes; it also trains ombudsmen and provides technical assistance.  Additionally,

the National Association for Long Term Care Ombudsman Programs (NASOP) was

established by State ombudsmen to provide a common voice for all State programs and

promote the sharing of ideas and experience among ombudsmen.

Ombudsman Data 
States have recently started to collect and report data under a new system.  In 1995, States 
began to systematically collect and report data under the National Ombudsman Reporting 
System (NORS).  Prior to NORS, States reported data to AoA which was of limited use 
due to the lack of common definitions for key data elements.  The NORS was created in 
response to earlier recommendations made by the General Accounting Office and the 
Office of Inspector General and was developed by the ombudsmen themselves.  It includes 
more specific data elements than were reported before NORS.  For example, it separates 
complaints by type and distinguishes between complaints and complainants.  In 1995, 29 
States reported under NORS, and all States did so annually beginning in 1996. 
The first Long Term Care Ombudsman Program Annual Report was also published in 
1995.  This report utilizes NORS data for 29 programs and pre-NORS data for the other 
23 programs, and describes the operation of Ombudsman programs nationwide.  The report 
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LTC Ombudsman Program: Overall Capacity  OEI-02-98-00351  also describes the broad range of ombudsman activities, including training and technical 
assistance programs, visitations, and community relations activities.  The 1996 report, 
which provides complaint data for all states, was issued in January 1998. 
Prior Studies 
Many studies have reported on the progress and impact of the Ombudsman program.  One 
of the most recent, Real People, Real Problems, published in 1995 by the National 
Academy of Sciences Institute of Medicine, reported on State compliance, conflicts of 
interest, effectiveness, resources, and the need for future expansion of the program.  It 
found that, overall, the Ombudsman program is effective.  It also reported lack of access to 
ombudsman services by residents and their families,  disparities in ombudsman visitation 
patterns and service provisions, and uneven availability of ombudsman legal services. 
Additionally, the Inspector General issued several reports on the Ombudsman program in 
1991 and 1992.  First, Successful Ombudsman Programs, (OEI-02-90-02120), the main 
report in a series, found that successful programs are highly visible and obtain adequate 
funding and support.  Furthermore, State Implementation of the Ombudsman 
Requirements of the Older Americans Act, (OEI-02-91-01516), found, among other 
things, that State program staffing and long term care facility visitation varies significantly, 
and that ombudsmen use many methods to increase their visibility. 
In July, 1998, the Secretary of the Department of Health and Human Services released a 
report to Congress on nursing home care.  While the report found that some progress had 
been made in nursing home care, particularly in the more appropriate use of physical 
restraints and drugs, it also indicated that further improvements were needed.  In 
conjunction with this report, the President announced a new nursing home initiative to 
provide enhanced protection to residents and target needed improvements in care. 
Also in July, 1998, the General Accounting Office (GAO) released a report on California 
nursing homes.  This report found that care problems still exist, despite Federal and State 
oversight.  Among problems described are poor nutrition, dehydration, and pressure sores. 
METHODOLOGY 
We used three methods for this inspection.  First, we analyzed 1997 data from the National 
Ombudsman Data Reporting System (NORS) in order to determine the extent of 
Ombudsman program staffing and activities.  Second, we reviewed written Ombudsman 
program procedures to assess program processes and standards.  Third, we conducted 
telephone interviews with State and local ombudsmen, as well as with State Unit on Aging 
Directors, to obtain their perspectives on  program strengths and weaknesses. 
Sample Selection 
We selected a purposive sample of 10 States for this inspection.  These ten States are New 
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LTC Ombudsman Program: Overall Capacity  OEI-02-98-00351  York, California, Texas, Ohio, Illinois, Pennsylvania, Massachusetts, Florida, New Jersey, 
and Tennessee. They represent 55.8 percent of total skilled nursing beds and 53 percent of 
all Ombudsman program complaints nationally for 1996.  They also account for nearly half 
(43 percent) of all Ombudsman programs nationwide and half of all program funding. 
Procedures Review 
We obtained and reviewed written procedures for all 10 State Ombudsman programs. 
Using a structured review guide, we examined these procedures to determine the different 
processes used by ombudsmen to monitor and promote quality of care in nursing homes. 
We also looked for any standards mandated for these processes, such as complaint 
response times, and discussions of linkages with other nursing home programs in the State. 
Interviews 
We conducted a total of 30 structured interviews for this inspection.  In each of the 10 
States we spoke with the State ombudsman, one local program ombudsman, and the 
Director of the State Unit on Aging (except for one State, when we interviewed the Deputy 
Director).  We selected these three groups of respondents to obtain their different 
perspectives of the program and looked for consensus among the groups in our analysis. 
In selecting ombudsmen from local programs to interview, we chose individuals from a 
variety of local program structures.  Five of the local programs represented are operated by 
Area Agencies on Aging (AAAs), while the other five are operated by non-profit or legal 
service agencies.  Furthermore, five of the local programs are rural and five are urban. 
During our interviews with the ombudsmen, we discussed the processes their programs use 
to impact quality of care in nursing homes, as well as their opinions on which processes are 
most effective.  Additionally, we discussed the factors that either facilitate or hinder their 
effectiveness.  In this report, to differentiate between respondent groups, we will refer to 
State ombudsmen and local ombudsmen. We will use the term ombudsman to refer 
to both the Ombudsman program and the individual. 
During our interviews with the Directors of State Units on Aging, we discussed ways in 
which the Ombudsman program is linked to other nursing home programs.  This discussion 
included both programs within the Aging Unit and programs outside the Unit. 
Data Analysis 
We analyzed 1997 NORS data, looking specifically at data on program staffing, visitation 
rates, advocacy activities, and coordination with survey and certification agencies. 
This inspection was conducted in accordance with the Quality Standards for Inspections 
issued by the Presidents Council on Integrity and Efficiency. 
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LTC Ombudsman Program: Overall Capacity  OEI-02-98-00351  F I N D I N G S  
The ombudsman approach is distinct from and complements 
other nursing home monitoring programs 
The Ombudsman program has several functions to promote and monitor quality of care in 
nursing homes.  First, ombudsman staff identify and resolve complaints, typically by 
contacting the complainant and informally mediating with residents and nursing home staff 
to reach some resolution.  Second, ombudsmen also make regular visits to nursing homes, 
during which they speak with residents and make themselves available to answer questions 
and listen to concerns.  Lastly, ombudsmen engage in a variety of different activities to 
advocate for improved nursing home care. 
Discussions with State and local ombudsmen, as well as State Aging Unit Directors, 
emphasize the uniqueness of the Ombudsman program.  In contrast to other programs, 
ombudsmen lack enforcement and regulatory oversight authorities.  As independent 
advocates, they work solely on behalf of residents and are often the only voice these 
residents have in their own care.  Says one State ombudsman, her program is the only 
certified, unrestricted organization that can go into a nursing home on a residents behalf. 
Furthermore, by taking the concerns and complaints of residents directly to nursing home 
staff, they are able to mediate between both parties on an informal and amicable level. 
Unlike many other programs, an ongoing, routine nursing home presence  is essential to 
the role of the ombudsman.  In fact, most State ombudsmen (six) believe this presence is 
the most important part of their program.  This presence provides residents with the 
opportunity to develop personal and confidential relationships with ombudsmen.  It also 
gives ombudsmen the chance to identify and address individual issues before they become 
larger, systemic problems and creates a comfortable environment for registering 
complaints.  The Ombudsman program is also distinct from other programs in its reliance 
on volunteers, who are needed to achieve an ongoing presence in nursing homes. 
The programs overall capacity to monitor and promote 
nursing home care appears limited 
The program is limited by staffing constraints 
Staffing levels among the 10 States vary considerably, as shown in Table 1 below. 
Ombudsman staff cover from as many as 5,003 nursing home beds per paid staff person in 
Florida, to as few as 1,115 beds in California (these numbers do not include licensed board 
and care and similar facilities for which the Ombudsman programs are also responsible). 
Due to its relatively high number of volunteers, California also has the lowest ratio of beds 
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LTC Ombudsman Program: Overall Capacity  OEI-02-98-00351  per volunteer (79 to 1) among the 10 States.  These numbers do not reflect actual nursing 
home coverage, however, since most State programs assign each volunteer to just one 
nursing home or one board and care home; therefore, not all nursing home beds are 
covered by volunteers. 
Table 1 
Ombudsman Program Staffing, 1997 
State  # Nursing  #  Paid  Beds per  # Volunteers*  Beds per 
Homes  Staff  Paid Staff  Volunteer 
CA  1,468  121  1,115  1,691  79 
FL  716  16  5,003  214  374 
IL  1,102  33  3,344  314  325 
MA  579  37  1,566  328  177 
NJ  354  18  2,752  64  774 
NY  668  25  4,618  600  192 
OH  1,456  59  2,173  200  641 
PA  807  50  1,946  276  354 
TN  352  12  3,301  211  184 
TX  1,161  46  2,753  761  166 
*Includes both certified and other volunteers  Source: 1997 NORS data 
No minimum staffing ratios are required by law.  However, a 1995 Institute of Medicine 
study on the Ombudsman program recommends a standard staffing ratio of 1 paid 
ombudsman staff person per 2,000  long term care facility beds (including both nursing 
home and board and care home beds).  Only 1 of the 10 sample States, Massachusetts, 
meets this standard when counting both nursing home and board and care beds. 
A majority of State and local ombudsmen identify insufficient program staffing as an 
obstacle which detracts from their programs effectiveness.  Six State and seven local 
ombudsmen believe their program does not have enough paid staff.  Similarly, seven of 
each say they have an insufficient number of volunteers.  Finally, many ombudsmen also 
say they would like better supervision and training of the volunteers they have. 
Extent of regular visits is limited 
Insufficient program staffing is particularly evident in the limited extent to which 
ombudsmen make regular nursing home visits, as illustrated in Table 2 below.  First, while 
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LTC Ombudsman Program: Overall Capacity  OEI-02-98-00351  9 of the 10 States make regular visits, in 4 States there are nursing homes that are never 
visited by paid staff or volunteers.  Second, despite AoA instructions which define regular 
visits as weekly, monthly, or quarterly, most nursing homes in these 9 States are usually 
visited only once or twice a year and for no longer than 1 to 3 hours.  While volunteers do 
visit homes more frequently since they are generally assigned to just one nursing home and 
visit this home on a weekly basis, there are not enough volunteers to cover all nursing 
homes. 
It is notable that Florida, which has the highest number of beds per paid staff, also has the 
lowest percentage of regular nursing home visits.  Additionally, Florida has the lowest 
program funding among the 10 States, with approximately five dollars spent per long-term 
care bed (compared to the 10 State average of almost 18 dollars). 
Table 2 
Nursing Homes Visited Annually, 
Not in Response to a Complaint, 1997 
State  % Nursing Homes 
Visited At Least 
Once a Year* 
CA  100% 
FL  65 % 
IL  88% 
MA  94% 
NJ**  0% 
NY  100% 
OH  100% 
PA  100% 
TN  100% 
TX  80% 
C  Most visits last from 1 to 3 hours 
**	 While New Jersey does not make regular nursing home 
visits, staff do make periodic, surprise visits when 
warranted. 
Source: 1997 NORS data 
Ombudsman programs in the sample States rely on volunteers primarily to make regular 
nursing home visits.  Due to this reliance on volunteers, ombudsmen generally agree that a 
strong volunteer component is crucial to their programs success;  one says that volunteers 
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LTC Ombudsman Program: Overall Capacity  OEI-02-98-00351  act as her eyes and ears in nursing homes. 
In all 10 States, ombudsman staff make more frequent visits to nursing homes that are 
chronically substandard, where residents are routinely poorly treated.  Several ombudsmen 
mention that an ongoing presence in substandard homes is particularly important since 
problems in these homes are often cyclical; they tend to fall in and out of compliance. 
Ombudsman programs lack a common standard for response and resolution 
times 
Only 2 States procedures specify any  kind of standard at all.  Without such a standard, 
ombudsman staff in some States are not consistently responding to complaints in a timely 
manner.  Typically, once a complaint is received, ombudsman staff initially respond by 
contacting the complainant.  Two ombudsmen say it takes them an average of five days to 
respond to a complaint, two say they take four days, and another five say they respond to 
complaints in just one or two days.  In contrast, the remaining ombudsman says that it 
takes an average of 30 days for her program staff to respond to complaints. 
All States, however, use a separate process for handling life-threatening complaints such 
as physical abuse.  Ombudsmen do not investigate these complaints but instead usually 
refer them directly to the adult protective services and/or the survey and certification 
agencies.  Most States procedures mandate that this referral take no more than 24 hours. 
Complaint resolution time also varies somewhat among the 10 States.  In most States, 
ombudsmen resolve complaints by working informally with the resident and nursing home 
staff to reach an agreement between both parties.  While 6 State ombudsmen report that 
complaints are typically resolved in a week or less, 2 State ombudsmen say they take an 
average of 90 days to resolve complaints.  (The two remaining State ombudsmen are 
unable to specify an average resolution time).  Only one States written procedures 
mandate a standard resolution time, saying that all cases should be closed within 60 days. 
In four States, ombudsmen report that certain complaints are eventually closed without a 
resolution being reached. 
Outreach and advocacy efforts are inconsistent 
As Table 3 below shows, ombudsman staff devote varying amounts of time to outreach 
and advocacy activities, with some spending relatively little time on community education, 
work with the media, work on laws and policy, and nursing home staff training.  Overall, 
California appears to be the most active of the ten States in outreach and advocacy, and 
New Jersey and Tennessee the least active.  Despite the variation in time devoted these 
activities, all 10 ombudsmen stress the importance of advocating for systemic change in 
order to improve nursing home care. 
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LTC Ombudsman Program: Overall Capacity  OEI-02-98-00351  Table 3 
Other Ombudsman Program Staff Activities, 1997 
State  # Community  Work w/ Media  Work on  # Nursing Home 
Education  (# Interviews &  Laws &  Staff Training 
Sessions  Press Releases)  Govt. Policy1  Sessions 
CA  1,621  661  10%  484 
FL  176  143  27%  134 
IL  177  890  10%  114 
MA  621  15  30%  94 
NJ  0  20  20%  170 
NY  313  665  25%  204 
OH  791  580  20%  437 
PA  313  152  20%  602 
TN  69  55  10%  64 
TX  537  599  10%  631 
1 Percent of State-level efforts of total paid staff time only.  Source: 1997 NORS data 
Ombudsmen say their program lacks adequate support 
Half of State and local ombudsmen believe their programs lack of support in the State 
diminishes its capacity and limits their ability to influence nursing home policies.  One 
State ombudsman believes that the limited visibility of her program curtails her regulatory 
ability and impacts her overall effectiveness to resolve complaints; another believes that 
restrictions from her umbrella agency on activities such as publishing statements and 
serving on committees limit her overall effectiveness.  On the local level, one ombudsman, 
expressing the opinion of others, notes that due to changing priorities within the Area 
Agency on Aging (AAA), there are multiple demands at the regional level that distract 
from the effectiveness of the program.  Another relates her programs lack of support to 
a diminished impact on the survey and certification process, because the surveyors are not 
sure how much weight to place on the information provided by the ombudsman. 
Ombudsman data reporting systems are still being improved 
The Administration on Aging (AoA) and State ombudsmen are working to improve the 
Ombudsman data reporting system.  Prior to 1995, the reporting system consisted of only 
30 data elements and lacked common definitions.  The new system, called the National 
Ombudsman Reporting System (NORS), has over 200 data elements and standard 
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LTC Ombudsman Program: Overall Capacity  OEI-02-98-00351  definitions. 
Ombudsmen in the 10 sample States are still getting accustomed to the new reporting 
format.  However, ombudsmen generally evaluate NORS highly:  six rate it excellent or 
good for comprehensiveness, accuracy, and usefulness.  Two in particular say that there 
are still grey areas and that they are not always sure how to report certain data. 
Exemplifying this concern, we found that the 10 ombudsmen still do not all count 
complaints the same way.  Half  say they count a complaint when it is completely resolved, 
and another half when it is first received. 
While NORS appears to have improved the data reporting capacity of the Ombudsman 
program and includes comprehensive data on complaints, it does lack other important 
performance measurement data.  For example, no data are collected on response and 
resolution times.  Furthermore, despite the decision of Ombudsmen to collect data on 
cases only after they are closed, the number of cases that remain open at the close of one 
year are not reported into the next, making it difficult to determine the number of cases 
that are currently open. 
Collaboration with other monitoring programs enhances the 
capacity of ombudsmen 
Collaboration with other programs is seen as important 
Both State and local ombudsmen, as well as State Aging Unit Directors, believe that 
collaboration is crucial to enhancing their capacity to improve the life of nursing home 
residents.  In fact, several of the States written program procedures have charts and/or 
descriptions of how the ombudsman is linked with other long term care programs.  Four 
State ombudsmen specifically cite collaboration with and support from other agencies as 
one of the main strengths of their program.  Similarly, State Aging Unit directors believe 
that while different  programs may have different perspectives, all share the same agenda 
of ensuring good nursing home care. 
All State and local ombudsmen report collaborating with a number of organizations on a 
regular basis to promote quality care in nursing homes.  First, all work with their States 
survey and certification agency to identify and eliminate nursing home problems. 
Ombudsmen also collaborate with legal support groups for advice on complaint cases. 
Additionally, all have an ongoing relationship with Adult Protective Services, who they 
work with on abuse cases.  Most also report working with senior citizen groups to 
advocate for resident rights, as well as with Medicaid and Medicare program 
representatives, to ensure residents get the benefits that theyre entitled to have.  Finally, 
in six States ombudsmen refer cases where they suspect health care fraud to the Attorney 
General. 
However, ombudsmen would like better collaboration with State surveyors 
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LTC Ombudsman Program: Overall Capacity  OEI-02-98-00351  While ombudsmen in all 10 States believe collaboration with State surveyors is important, 
many believe this collaboration can be improved.  One of the main ways ombudsmen 
work with surveyors is to participate in annual nursing home inspections.  However, 
despite the requirement that they be notified of inspection dates, two ombudsmen say they 
are not consistently notified.  Furthermore, ombudsman data for 1997 show that they 
participated in a total of approximately 5,100 surveys in that year; survey and certification 
data, however, indicate that in 1997 around 8,400 surveys were conducted in the 10 
States.  Thus, ombudsmen accompanied surveyors just 61 percent of the time. 
Ombudsmen say their relationship with survey and certification staff is most productive 
when they are routinely given advance notice about upcoming inspections, and when they 
are asked for their input about the quality of care being provided at facilities.  They also 
believe it is important to work with the surveyors during their inspection and to attend exit 
conferences held with facility administrators at the end of the inspection. 
Ombudsmen characterize their  relationship with State survey and certification staff in 
different ways.  Four say this relationship is one in which they are currently working out 
problems.  Four others indicate that the relationship is basically a good one.  Furthermore, 
some ombudsmen also say that there is a healthy tension and mutual respect between the 
two functions. 
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LTC Ombudsman Program: Overall Capacity  OEI-02-98-00351  R E C O M M E N D A T I O N S  
S 
Ombudsmen, with their unique combination of functions-- visitation, complaint and crisis 
response, and advocacy-- play an important role in assuring quality of care in nursing 
homes.  We therefore believe that the program limitations we have identified in this 
inspection must be addressed. 
We recommend that the Administration on Aging work with States to strengthen the 
Ombudsman program.  In particular, we suggest they: 
<	 develop guidelines for a minimum level of program visibility that include criteria 
for the frequency and length of regular visits, as well as a ratio of Ombudsman 
program staff to long term care beds; 
<	 further highlight and promote strategies for recruiting, training, and supervising 
more volunteers; 
<  develop guidelines for complaint response and resolution times; 
<	 continue to strengthen the programs data reporting system, including ensuring 
that all State ombudsmen understand and use the definitions in the reporting 
system and train local ombudsmen and volunteers in standard utilization; and 
<	 establish ways in which Ombudsman programs can enhance collaboration with the 
survey and certification agency. 
We recognize that in order to implement these recommendations, and to fulfill the 
Ombudsman program mission as outlined in the Older Americans Act, additional funding 
may be required.  In particular, it may be necessary to find ways to increase the number of 
paid and volunteer ombudsmen.  As noted earlier, the Institute of Medicine recommends 
one full-time equivalent ombudsman staff person for every 2,000 long term care facility 
beds in each State, a standard which not all States meet. 
The Presidents recent nursing home initiative highlights the importance of improving the 
quality of care provided to vulnerable nursing home residents.  We believe that 
strengthening the Ombudsman program will significantly contribute to this important 
effort. 
AGENCY COMMENTS 
We received comments on the draft report from the Administration on Aging (AoA) and 
the Health Care Financing Administration (HCFA).  They concur with our 
recommendations. 
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LTC Ombudsman Program: Overall Capacity  OEI-02-98-00351  The AoA suggests two modifications to our recommendations.  First, it points out its 
ongoing efforts through training and technical assistance to work with States in the 
effective use of volunteers.  In acknowledgment of these efforts, we have changed the 
recommendation to say that AoA should further highlight and promote strategies for 
volunteer programs.  Second, the AoA reports that while they work closely with 
ombudsmen to understand NORS, more could be done to promote a better understanding 
of the system.  We have therefore broadened our recommendation to include the need for 
a common understanding and use of NORS definitions.  We also continue to believe that 
the system could be strengthened by adding performance-based data such as complaint 
response and resolution times. 
Some parts of the report were additionally modified in response to AoAs technical 
comments. The full comments are presented in Appendix A. 
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LTC Ombudsman Program: Overall Capacity  OEI-02-98-00351  A P P E N D I X  A  
In this appendix, we present in full the comments from the Administration on Aging and 
the Health Care Financing Administration. 
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