Evaluation of the Long-Term Care Ombudsman Program (LTCOP) 

Facility Administrator Survey

PURPOSE OF THE STUDY:

 

NORC at the University of Chicago, with funding from the Administration for Community 

Living/Administration on Aging (ACL/AoA), is conducting an evaluation of the Long-Term Care 

Ombudsman Program. The purpose of the survey is to better understand the relationships between the 

Long-Term Care Ombudsman Program and the facilities. This survey is voluntary and is not part of an 

audit or a compliance review. The information you provide is confidential. We do not include names of 

respondents in any reports or in any discussions with supervisors, colleagues, or ACL/AoA. This survey will 

take approximately __ minutes to complete. Please complete and return this form using the pre-paid 

envelope, or by scanning and emailing it to LTCOPsurvey@norc.org, or by faxing it to 301-634-9582.

Please contact NORC at 1-877-XXX-XXXX or LTCOPsurvey@norc.org if you have any questions or 

concerns.

OMB Control No.:

Expiration Date:

SECTION A: Activities and Interactions

1. How regularly does the Ombudsman visit your facility?

______________________

2. How does the Ombudsman spread awareness of the program among residents and their families? 

{Check all that apply}

 1. Poster in the facility

 2. Brochures and pamphlets in the facility

 3. In-person interaction with residents throughout the facility

 4. In-person interaction targeting new residents

 5. Other (Please specify): __________________________________ 

3. Does your Ombudsman support or assist the development of resident and family councils in your 

facility? 

 1. Yes

 2. No

 97. Don’t know

4. Does the LTCOP participate in the licensing survey conducted by the state licensing and certification 

agency?

 1. Yes

 2. No

 97. Don’t know
2 

SECTION A: Activities and Interactions (continued)

5. Do you personally interact with the following Ombudsman Program representatives? {Check all that 

apply}

 1. Ombudsman staff

 2. Ombudsman volunteer

 3. State Long-Term Care Ombudsman

 4. Other LTCOP staff

 Please note the position of these individuals:___________________________________

 ______________________________________________________________________

 ______________________________________________________________________

6. What form does this interaction take? {Check all that apply}

 1. In person

 2. Phone call

 3. Email

 4. Other (please specify): ____________

7. On average how often do you personally interact with any of the representatives of the LTCOP?

 1. Weekly

 2. Monthly

 3. Quarterly

 4. Less than quarterly

 5. As needed

8. What type of interaction have you had with Ombudsman representatives? {Check all that apply}

 1. Discussion about facility compliance issue

 2. Discussion about specific resident complaint

 3. Discussion about pattern in resident complaints and potential solutions

 4. Discussion about disagreement with a resident or resident’s family/friend 

 5. Discussion about potential training

 6. Information provided

 What was the topic? ______________________________________

 7. Training provided by Ombudsman representative 

 What was the topic? ______________________________________

 8. Other (please specify): ________________________________________ 
3 

SECTION A: Activities and Interactions (continued)

9. Who at your facility interacts with the Ombudsman/Ombudsmen when they visit your facility? {Check all 

that apply}

 1. Nurse practitioners (NPs) 

 2. Registered nurses (RNs)

 3. Licensed practical nurses (LPNs) / licensed vocational nurses (LVNs)

 4. Certified nursing assistants, nursing assistants, home health aides, 

home care aides, personal care aides, personal care assistants, and 

medication technicians or medication aides

 5. Social workers—licensed social workers or persons with a bachelor’s 

or master’s degree in social work

 6. Activities director and activities staff _____________________

 7. Other (please specify): _______________________________

10. Are there areas where you would like more support from the Ombudsman Program? 

 1. Yes

If so, please describe: _________________________

 2. No

11. How could the Ombudsman Program be improved to better serve residents?

________________________________________________________

12. Based on your experience, what are the strengths of the Ombudsman Program?

__________________________________________________________

13. Would you consider the relationship with your primary LTCOP contact to be:

 1. Very effective

 2. Somewhat effective

 3. Somewhat ineffective

 4. Not at all effective

14. Have you ever reported a complaint about an Ombudsman? 

 1. Yes

If so, please describe the complaint: _________________________

 2. No
4 

SECTION B: Program Outcomes

1. To your knowledge, has the Ombudsman Program contributed to changes in your facility’s policies and 

practices?

 1. Yes

 2. No

 97. Don’t know

2. Do you agree with the following statement: Overall, residents benefit from Ombudsman presence in my 

facility?

 1. Strongly agree

 2. Agree 

 3. No opinion

 4. Disagree

 5. Strongly disagree

3. How effectively do Ombudsmen resolve resident complaints in your facility?

 1. Very effectively

 2. Somewhat effectively

 3. Not effectively

 97. Don’t know

SECTION C: Background and Staff Profile

1. How many beds does your facility have? 

__________________________

2. What is the type of ownership of this facility?

 1. Private-nonprofit

 2. Private-for profit

 3. Publicly traded company or limited liability company (LLC)

 4. Government—federal, state, county, or local

3. Is this facility owned by a person, group, or organization that owns or manages two or more long-term 

care facilities?

 1. Yes

 2. No

 97. Don’t know

4. What is the total number of years this facility has been operating at this location?

 1. Less than 1 year

 2. 1 to 4 years

 3. 5 to 9 years

 4. 10 to 19 years

 5. 20 or more years
5 

SECTION C: Background and Staff Profile (continued)

5. For each staff type below, indicate how many full-time employees and part-time employees this facility 

currently has: 

Full-Time Part-Time

a. Nurse practitioners (NPs)

b. Registered nurses (RNs)

c. Licensed practical nurses (LPNs) / 

licensed vocational nurses (LVNs)

d. Certified nursing assistants, nursing 

assistants, home health aides, home care 

aides, personal care aides, personal care 

assistants, and medication technicians or 

medication aides

e. Social workers—licensed social workers or 

persons with a bachelor’s or master’s 

degree in social work 

f. Activities director and activities staff

THANK YOU FOR COMPLETING THIS SURVEY.