## Long Term Care Ombudsman Annual Report: Fiscal Year1995

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## Part I.Introduction and Summary 

This report highlights the work of state and local ombudsmen,who speak and act on behalf of the approximate 2.4 millionresidents of nursing, board and care and similar adult carehomes. These residents are among the most frail and vulnerable ofthe U.S. population and often are unable to speak and act ontheir own behalf. 

- Working under the ombudsman mandate in the Older        Americans Act (OAA), over 10,000 paid and volunteer        ombudsmen in every state and over 565 local/regional        programs: 
- identify, investigate and resolve complaints made by, or        on behalf of, residents related to action, inaction, or        decisions that may adversely affect the health, safety,        welfare or rights of residents; 
- inform residents and their representatives about how to        obtain needed services; 
- represent the interests of residents before government        agencies and promote policies and practices needed to        improve the quality of care and life in long term care        facilities; and 
- educate both consumers and providers about residents'        rights and good care practices.

[ The above functions are paraphrased from Section 712 of theOlder Americans Act. ] 

Through providing a regular community presence in facilities,volunteer ombudsmen who are trained and certified to assistresidents with their concerns help prevent and reduce theincidence of poor care, neglect, and even abuse of residents.Also, through their presence in facilities and involvement withbeneficiaries, ombudsmen play an important grassroots role indetecting, reducing, and preventing costly fraud against Medicareand Medicaid. 

In FY 1995, ombudsmen investigated over 218,000 complaintsmade by over 162,000 individuals. Nationally, the five mostfrequent nursing home complaints made to ombudsman programs in FY1995 concerned: 

- Accidents, improper handling; 
- Dignity, respect: staff attitudes; 
- Menu: quantity, quality, variation and choice of food; 
- Personal hygiene; and 
- Call lights (unanswered), requests for assistance. 

The five most frequent complaints made by or on behalf ofresidents of board and care and similar adult care facilitiesconcerned: 

- Menu: quantity, quality, variation and choice of food; 
- Equipment/building: disrepair, hazard, poor lighting,        fire safety; 
- Medications: administration, organization; 
- Dignity, respect: staff attitudes; and 
- Cleanliness, pests. 

Over 70% of these complaints were resolved or partiallyresolved to the resident's and/or complainant's satisfaction.Fifteen percent were either withdrawn by the complainant orrequired no action after ombudsmen investigated and providedneeded information on a particular matter. One percent requiredgovernment policy, regulatory change or legislative action toresolve the problem. Of the remainder, only about eight percentwere not resolved to the satisfaction of the resident orcomplainant. These outcomes are discussed more fully on page . 

National totals of FY 1995 ombudsmancomplaint and program data from all 50 states, the District ofColumbia and Puerto Rico are provided in Table 1 below. 

| **Table        1: Selected National Information         FY 1995**    |
|----------------------------------------------------------------------|
| **Complainants        (Cases)**                                      | **162,338** |
| **Complaints**                                                       | **218,455** |
| **Total        Program Funding**                                     | **$40,870,107** |
| **Local        Ombudsman Entities**                                  | **565** |
| **Paid        Program Staff (FTEs)**                                 | **913** |
| **Volunteers**                                                       |
| **Certified        Volunteer Ombudsmen**1                            | **6,421** |
| **Other        Volunteers**                                          | **5,159** |
| **Total        Volunteers**                                          | **11,580** |
| **Licensed Facilities (National        Totals)**                     |
| **Nursing        Facilities**                                        | **Number** | **18,911** |
| **Beds**                                                             | **1,819,069** |
| **Board        & Care/Similar Facilities**2                      | **Number** | **36,904** |
| **Beds**                                                             | **662,199** |
| **All        Facilities**                                            | **Number** | **54,215** |
| **Beds**                                                             | **2,481,268** |
| **Number        of LTC Facility Beds per Paid Program Staff (FTEs)** | **2,718** |

- Individuals who have completed a training course        prescribed by the State Ombudsman and are approved by the        State Ombudsman to participate in the Statewide Ombudsman        Program.
- Includes only those types of facilities which state        ombudsman programs include within their purview under the        requirement of Section 102(34)(D) of the OAA .

State-by-state breakdowns of these figures and selected ratiosof cases/complaints per bed, complaints per case, and beds perpaid ombudsmen are found in Tables A-1 [ Tables numbered A-1 toA-11 are found in Appendix A.] **and A-9.**

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### **OmbudsmanActivities in Addition to Complaint Investigation**

In addition to working on individual complaints, ombudsmen atboth the state and local level: 

- work in a variety of ways to resolve major issues which        impact on large numbers of residents; this includes        working on laws, regulations and government policies; 
- provide training and technical assistance to other        ombudsmen in the statewide program and managers and staff        of long term care facilities; 
- provide information and consultation to individuals        — nationwide, ombudsmen in just 29 states assisted        over 93,000 people in FY 1995; 
- visit residents on a regular basis (not in response to        complaints) — the 27 states which reported this        information reflected visitation rates of 77% of nursing        facilities and 49% of board and care and similar        facilities; 
- participate in facility surveys; 
- work with resident and family councils and provide        community education; and 
- work with the media. 

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### **Major Issues**

Major issues identified in the state reports, barriers toresolving the issues, and ombudsman actions and recommendationsfor resolving the issues are summarized in Part V of the reportand presented extensively in Appendix D. Issues addressed bythree or more states involved: 

- Board and care and similar adult day care facilities; 
- Inadequate state nursing facility regulations and        enforcement, and inadequate state resources to enforce        regulations; 
- Abuse of residents and issues related to state protective        systems, reporting requirements, and the need for abuse        prevention; 
- Staff shortages in general and chronic shortages of well        trained and equitably compensated certified nurse        assistants; 
- Transfer and discharge issues - related to issue # 6; 
- Lack of placement, needed services, and staff training        for those caring for mentally ill and dementia residents;    
- Ensuring that rules and regulations established in the        federal Nursing Home Reform Act (OBRA '87) are continued        and enforced; 
- Subacute care and "distinct parts" (related to        difficulty in finding a bed, issue # 10); 
- Inappropriate and excessive use of chemical and physical        restraints, and related issues; 
- Difficulty in finding a nursing home bed for those in        need — especially for Medicaid-eligible individuals,        those with special care needs, and those with moderate        financial resources (financial discrimination in        admissions); 
- Improving communication and coordination with licensure        and certification agency staff; 
- Medicaid reductions/eligibility delays, denials; 
- Bedhold — nursing facilities sending residents to a        hospital or local mental health center for evaluation or        care and refusing to readmit the resident; 
- Lack of needed services for elderly and disabled; 
- Advocacy through education about rights, benefits and        costs and the residents' perspective on life in a nursing        home; and 
- Ombudsman program coverage (cited by 10 states but        distinguished from the other issues as a program        operation rather than resident/facility issue). 

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### **Sources ofOmbudsman Program Funding**

Funding for statewide ombudsman operations is supplied througha combination of federal, state and local funds, the largestsource of which is the congressional appropriation for Title III[ Title III of the OAA, Grants for State and Community Programson Aging, funds area agencies on aging, supportive services, andnutrition services.] **of the OAA. The OAA permits states to useTitle III dollars to directly fund statewide ombudsman services,and area agencies on aging also support their local ombudsmanprograms with Title III funds which they receive through the OAAintrastate funding formula. As in previous years, state fundswere the second largest source of funding in FY 1995, followed byOAA Title VII** [ Title VII of the OAA, Vulnerable Elder RightsProtection Activities, funds Long-Term Care Ombudsman and ElderAbuse Prevention programs.] **funds. Other non-federal fundsconstituted a fourth important funding source. Figure 1 on pagegives a breakdown on the percentages of total funding supplied byeach of these sources.**

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### **Multi-YearTrends**

When compared with data from previous years, (See Table 2 andTable 3 below), the 1995 figures show that while the numbers oflocal ombudsman programs, complaints, and people filingcomplaints continued to increase as in previous years, totalprogram funding decreased for the first time in the program'shistory — by almost one million dollars. 

This is partly due to a sharp drop in funding in the category *OtherNon-Federal Sources* (primarily local, which includes in-kindcontributions). Due to an increase in Title III funding, federalfunding increased by about $1,000,000, even though funding in thecategories *Title VII, Chapter 3: Elder Abuse Prevention*and *All Other Federal Programs* decreased. 

The findings on funding indicate that since AoA started tocollect ombudsman funding data in FY 1987, there has been adramatic shift in sources of ombudsman program funding. Asreflected in the table below and Figure 2 on the next page, fromFY 1987 to FY 1990 the percentage of federal funding dropped.Beginning in FY 1991 the percentage of federal funding of thetotal funding began to increase [ In FY 1992, the rise was veryhigh; thus the percentage dropped for FY 1993 and 94. However,the trend is still obvious.] **.**

| **Table 2****: Change in Funding:        Federal vs. Non-Federal—FY87-FY95** |
|-----------------------------------------------------------------------------------|
| **Source of Funds**                                                               | **FY87** | **FY88** | **FY89** | **FY90** | **FY91** | **FY92** | **FY93** | **FY94** | **FY95** |
| **Federal (%)**                                                                   | **62.1%** | **59.2%** | **57.1%** | **55.9%** | **56.2%** | **61.8%** | **57.5%** | **61.0%** | **64.8%** |
| **Federal****(in millions)**                                                      | **12.6** | **13.8** | **14.4** | **15.6** | **19.1** | **21.7** | **21.5** | **25.5** | **26.5** |
| **Non-Federal (%)**                                                               | **37.9%** | **40.8%** | **42.9%** | **44.1%** | **43.8%** | **38.2%** | **36.6%** | **39.0%** | **35.2%** |
| **Non-Federal         (in millions)**                                             | **7.7** | **9.5** | **10.8** | **12.3** | **14.9** | **13.4** | **13.7** | **16.3** | **14.4** |

These statistics indicate a significant challenge if thedemand for services continues to increase while financial supportfor ombudsman services becomes static or decreases. Consequenceswould include waiting lists and priority setting for responseswhich would jeopardize the health and safety of residents. 

### **Figure 1****: Sources ofFunding—FY 1995****Long-Term Care Ombudsman Program**

### **Figure 2****:Sources of Funds—FY1987 to FY1995****Federal vs.Non-Federal**

| **Table 3:****Trends in the Ombudsman Program—FY87–95** |
|-------------------------------------------------------------------|
|                                                              | **FY87** | **FY88** | **FY89** | **FY90** | **FY91** | **FY92** | **FY93** | **FY94** | **FY95** |
| **Total Number Local Programs**                                   | 557 | 578 | 570 | 578 | 551 | 571 | 549 | 559 | 565 |
| **Local Programs in AAA's****1**                                  |  |  | 435 | 412 | 395 | 406 | 386 | 414 | 374 2 |
| **Total Number Complainants (in        thousands)****3**          |  |  |  |  | 159.4 | 144.0 | 154.4 | 152.1 | 162.3 |
| **Total Number Complaints [Cases]        (in thousands)**         | 110.4 | 129.0 | 134.5 | 154.1 | 174.3 | 177.3 | 197.8 | 207.4 | 218.5 |
| **Funding (in millions        of dollars)**                       |   |
| **Title III-B Funding**4                                          |  |   |   |   |   |   |   |   |   |
| **Allotted by State & Area        Agencies**                  | 11.6 | 12.7 | 13.6 | 14.5 | 15.4 | 15.6 | 16.5 | 17.4 | 19.8 |
| **Allotted by State Agencies**                                    |  |  |  |  |  |  |  |  | 9.7 |
| **Allotted by Area Agency**                                       |  |  |  |  |  |  |  |  | 10.1 |
| **Title III Ombudsman Allotment**5                                |  |  |  |  | 2.0 | 3.3 | .6 |  |  |
| **Title III-G Abuse Prevention**5                                 |  |  |  |  | .8 | 1.8 |  |  |  |
| **Title VII Chapter 2**                                           |  |  |  |  |  |  | 3.5 | 4.2 | 4.4 |
| **Title VII, Chapter 3**                                          |  |  |  |  |  |  | 2.1 | 2.9 | 1.9 |
| **All other Federal**                                             | 1.0 | 1.1 | .8 | 1.1 | .9 | 1.0 | .9 | 1.0 | 0.4 |
| **All State**6                                                    | 7.7 | 9.5 | 7.1 | 7.4 | 8.1 | 8.3 | 7.9 | 8.2 | 8.9 |
| **All Other Non-Federal**                                         |  |  | 3.7 | 4.9 | 6.8 | 5.1 | 5.8 | 8.1 | 5.5 |
| **Total Funding**                                                 | 20.3 | 23.3 | 25.2 | 27.9 | 34.0 | 35.1 | 37.4 | 41.8 | 40.9 |

- This information was not collected prior to FY 1989.
- The reduced number in Area Agency on Aging-sponsored        programs may be due to more refined definitions in the        NORS rather then to an actual drop in the number of        programs located in AAAs.
- There was no clear distinction between        "complaint," "complainant," or        "case" until the implementation of the NORS in        FY1995, but numbers of "people presenting        complaints" were collected each year. These are        generally comparable to "case" (i.e.        "Complainants") in the NORS.
- A breakdown on the source of Title III funding between        State and Area Agencies on Aging was one of the        enhancements included in NORS.
- These allotments were provided for FY 1991-92. They were        replaced by Title VII allotments in FY 1993.
- Data in FY 1987-8 not collected separately for All State        and All Other Non-Federal

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### **The NationalOmbudsman Reporting System**

FY 1995 is the first year for which all of the data presentedin Table 1 has been available at the national level. In FY 1995states began to collect and report information required in thenew National Ombudsman Reporting System (NORS). The NORS providesnational statistics and narrative which have not been availablepreviously on types of complainants and complaints, complaintverification and disposition, major issues affecting long-termcare residents, host agencies of local ombudsman programs,numbers of facilities and beds, program coverage, staff andvolunteer levels, Title III funds provided by state and areaagencies, and a variety of ombudsman activities in areas otherthan complaint investigation. FY 1995 will serve as the base yearfor this type of program information in the future. 

The NORS was initiated by AoA in 1991 in response to

- ombudsman reporting requirements in the then-pending FY        1992 amendments to the Older Americans Act and reports by        the General Accounting Office and
- the Department of Health and Human Services' Office of        the Inspector General recommending that standard        definitions be established and comparable data on        complaints filed with ombudsman programs and other        program activities be documented and analyzed. 

Later, the Institute of Medicine Committee which evaluated theeffectiveness of the Ombudsman Program also stressed theimportance of collecting detailed, comparative information onombudsman complaints, other activities, and program operations. 

For the FY 1995 transition year from the previous reportingrequirements to the new requirements, states were afforded anoption of providing all of the NORS data, or only modified data.Twenty-nine states submitted most of the NORS data. The remaining23 states provided the modified data required. This informationis presented Parts III through V of this report. 

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For questions about the LTC Ombudsman Program, contact Sue WheatonHypertext conversion by Saadia Greenberg,June 20, 1997