Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

JUNE GIBBS BROWN 

Inspector General 

MARCH 1999 

OEI-02-98-00351 

Long Term Care Ombudsman Program: 

Overall Capacity 
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 
EXECUTIVE SUMMARY 

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 1 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 Program’s 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 program’s 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 program’s 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 2 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 program’s 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 President’s 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 3 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 AoA’s technical 

comments. The full comments are presented in Appendix A. 

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LTC Ombudsman Program: Overall Capacity 4 OEI-02-98-00351 
TABLE OF OF CONTENTS 

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 5 OEI-02-98-00351 
INTRODUCTION 

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 6 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 7 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 8 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 President’s Council on Integrity and Efficiency. 

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LTC Ombudsman Program: Overall Capacity 9 OEI-02-98-00351 
FINDINGS 

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 resident’s 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 program’s 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 10 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 

Homes 

# Paid 

Staff 

Beds per 

Paid Staff 

# Volunteers* Beds per 

Volunteer 

CA 

FL 

IL 

MA 

NJ 

NY 

OH 

PA 

TN 

TX 

1,468 

716 

1,102 

579 

354 

668 

1,456 

807 

352 

1,161 

121 

16 

33 

37 

18 

25 

59 

50 

12 

46 

1,115 

5,003 

3,344 

1,566 

2,752 

4,618 

2,173 

1,946 

3,301 

2,753 

1,691 

214 

314 

328 

64 

600 

200 

276 

211 

761 

79 

374 

325 

177 

774 

192 

641 

354 

184 

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 program’s 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 11 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 

FL 

IL 

MA 

NJ** 

NY 

OH 

PA 

TN 

TX 

100% 

65 % 

88% 

94% 

0% 

100% 

100% 

100% 

100% 

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 program’s success; one says that volunteers 

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LTC Ombudsman Program: Overall Capacity 12 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 State’s 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 13 OEI-02-98-00351 
Table 3 

Other Ombudsman Program Staff Activities, 1997 

State # Community 

Education 

Sessions 

Work w/ Media 

(# Interviews & 

Press Releases) 

Work on 

Laws & 

Govt. Policy1 

# Nursing Home 

Staff Training 

Sessions 

CA 

FL 

IL 

MA 

NJ 

NY 

OH 

PA 

TN 

TX 

1,621 

176 

177 

621 

0 

313 

791 

313 

69 

537 

661 

143 

890 

15 

20 

665 

580 

152 

55 

599 

10% 

27% 

10% 

30% 

20% 

25% 

20% 

20% 

10% 

10% 

484 

134 

114 

94 

170 

204 

437 

602 

64 

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 program’s 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 relate’s her program’s 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 14 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 State’s 

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 they’re 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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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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RECOMMENDATIONS 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 program’s 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 President’s 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 17 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 AoA’s technical 

comments. The full comments are presented in Appendix A. 

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APPENDIX 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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