REPORT

The Long-Term Care Ombudsman Program 

and the Changing Landscape of Long-Term 

Services and Supports

SEPTEMBER 30, 2019 PRESENTED TO:

Susan Jenkins, PhD

Director, Office of Performance and 

Evaluation

Center for Policy and Evaluation

Administration for Community Living

US Dept. of Health & Human Services

Mary E. Switzer Building 

330 C Street, SW, Rm 1243

Washington DC 20201 

susan.jenkins@acl.hhs.gov

PRESENTED BY:

Kim Nguyen, PhD

Emily White, MA

Kristen Neishi, MA

NORC at the University of Chicago

4350 East-West Highway

Bethesda, MD 20814

(301) 634-9300
NORC | The Long-Term Care Ombudsman Program and the Changing Landscape of Long-Term Services and Supports 

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Table of Contents

Executive Summary....................................................................................................................1

Methodology................................................................................................................................3

Overview of the Long-Term Care Ombudsman Program........................................................4

Growth in Populations in Need of Long-Term Services and Supports and Specialized 

Care..............................................................................................................................................5

Growth in Population in Need of Long-Term Services and Supports (LTSS).......................5

Growth in Diversity of Populations in Need of Specialized Care ..........................................7

Changes in the Provision of Long-Term Services and Supports.........................................11

Growth in Care Options and Shifting Utilization across Facilities .......................................11

Growth in Acuity Levels across Facilities............................................................................19

Growth in Managed Long-Term Services and Supports (MLTSS) .....................................23

New Regulations in Long-Term Care Delivery .......................................................................25

Nursing Home Regulations................................................................................................. 25

Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care 

Facilities that participate in Medicare and Medicaid ......................................25

Home and Community-Based Services (HCBS) Settings Final Rule ................................. 27

Medicaid Home and Community-Based Services Settings Final Rule......................27

Medicaid Managed Care Final Rule ...................................................................................29

Medicaid and Children’s Health Insurance Program (CHIP) Managed Care Final 

Rule ...............................................................................................................29

Updated Legislation and New Regulation for the Long-Term Care Ombudsman 

Program .....................................................................................................................................30

Older Americans Act (OAA) Reauthorization Act of 2016 ..................................................31

State Long-Term Care Ombudsman Programs Final Rule.................................................31

Discussion................................................................................................................................. 34

Glossary of Terms & Acronyms ..............................................................................................36

Bibliography ..............................................................................................................................38
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List of Exhibits

Exhibit 1: Program Funds Expended (NORS)..........................................................................6

Exhibit 2: Number of Long-Term Care Ombudsman Program Paid Staff and Certified 

Volunteers from 1996-2017 (NORS)........................................................................7

Exhibit 3: Number of Nursing Homes and Board and Care Homes from 1996 to 2017 

(NORS) ..................................................................................................................12

Exhibit 4: Percentage of Quarterly Visits Made to Nursing Homes and Board and Care 

Homes from 1996 to 2017 (NORS)........................................................................13

Exhibit 5: Number of Complaints in Nursing Homes and Board and Care Homes from 

1996 to 2017 (NORS).............................................................................................14

Exhibit 6: Effectiveness of Statewide Ombudsman Program’s Relationship with Nursing 

Homes and Board and Care Homes (State Ombudsmen).....................................15

Exhibit 7: Effectiveness of Local Ombudsman Entity’s Relationship with Nursing Homes 

and Board and Care Homes (Lead Local Ombudsmen)........................................15

Exhibit 8: Effectiveness of Local Ombudsmen’s Relationship with Nursing Homes and 

Board and Care Homes (Local Ombudsmen)........................................................15

Exhibit 9: Sufficiency of State Board and Care Home Regulations to Enable State 

Ombudsman Programs to Adequately Serve Residents (State Ombudsmen) ......16

Exhibit 10: Effectiveness of Ombudsman Program’s Relationship with Board and Care 

Homes and Sufficiency of Board and Care Home Regulations (State 

Ombudsmen) .........................................................................................................17

Exhibit 11: LTCOPs with Home Care Responsibility................................................................17

Exhibit 12: Effectiveness of Ombudsman Program’s Relationship with In-Home Service 

Providers (State and Lead Local Ombudsmen) .....................................................19

Exhibit 13: Complaints that are Most Challenging, Time-Consuming, and Effective at 

Resolving in Nursing Homes (State Ombudsmen).................................................21

Exhibit 14: Complaints that are Most Challenging, Time-Consuming, and Effective at 

Resolving in Board and Care Homes (State Ombudsmen)....................................22

Exhibit 15: Top Ten Most Frequent Complaint Types (NORS) ................................................23
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Executive Summary

Since 1978, the Long-Term Care Ombudsman program (LTCOP or Ombudsman program) has promoted 

and protected the health, safety, welfare, and rights of residents living in long-term care (LTC) facilities. 

By responding to resident complaints and advocating for improvements in the long-term care system, the 

program plays a critical role in advancing residents’ rights and supporting residents’ quality of care and 

quality of life. Over the last few decades, however, changes in the policies, service delivery, and 

consumers of long-term services and supports (LTSS) have presented both challenges and opportunities 

to the long-term care delivery system. The populations in need of long-term care as well as the options for 

providing and financing their care have increased dramatically, and these trends are expected to continue

as the U.S. population, and in particular the baby boom generation, ages. 

In response to these developments, new or revised federal regulations for nursing facilities and home and 

community-based services (HCBS) have been implemented. These aim to modernize standards to reflect 

the growth in the older population and the evolving settings where LTSS are delivered, and to improve 

quality of care and safety for LTSS consumers. For the first time, regulations specific to the provision of 

managed LTSS have also been released. These respond to the significant expansion of this delivery 

system model during the interval since Medicaid managed-care rules were last revised. Meanwhile, the 

Ombudsman program itself has been undergoing important new legislative and regulatory changes that 

are designed to strengthen the program by clarifying the scope of its activities and better aligning its 

programs with provisions in the Older Americans Act (OAA). 

Drawing on data collected as part of the Process Evaluation and Special Studies Related to the LongTerm Care Ombudsman Program, this report describes the changing landscape of LTSS in the U.S., and 

the implications of these interrelated developments for current Ombudsman program service delivery. Key 

findings from the study include the following: 

1. The growth and diversity of care settings, service delivery models, and LTSS consumers have 

placed increased demands on Ombudsman programs to assure residents’ quality of care at a 

time when many programs are experiencing fiscal and other resource constraints. The types of 

complaints that the program handles tend to be more complex and challenging than in the past. 

Grievances have moved away from requests for assistance with daily needs to more urgent concerns 

such as involuntary discharges and evictions. Ombudsmen described limitations in their ability to fully 

resolve certain types of complaints, particularly when solutions are ultimately outside the program’s 

control, such as inadequate long-term care facility staffing or lack of available services to address 

residential or care needs. Programs have responded to changes in long-term care utilization, 

availability, and access by directing resources and advocacy efforts to areas of greatest need; and by 

prioritizing individual advocacy over systems advocacy, and visits to nursing homes over board and 

care homes. Against this backdrop, limited programmatic resources have compelled programs to 

increasingly cultivate partnerships with other agencies to support program implementation. 
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2. The last five years have witnessed milestone regulatory reforms not only in the long-term care 

delivery system – with implementation of the revised Nursing Home Regulations, HCBS 

Settings Final Rule, and Medicaid Managed Care Final Rule – but also in the Ombudsman 

program itself, with the State Long-Term Care Ombudsman Programs Final Rule. While each 

regulation is significant individually–each offering an additional tool for programs to advocate for 

residents–their concurrent release and implementation also have tremendous implications for 

Ombudsman program capacity. State Ombudsmen reported that understanding and responding to 

multiple requirements can strain program resources that are needed for ongoing efforts such as 

regular facility visits and resident complaint investigation. The additional responsibilities also mean 

that Ombudsmen must not only be trained on the complex new regulations, but they must then

educate Ombudsman program stakeholders, including consumers, on these developments. 

3. While meeting the requirements of the LTCOP Final Rule, and to a lesser extent the 2016 OAA 

Reauthorization, has been a significant undertaking, there is general agreement that 

investment in these changes will strengthen Ombudsman programs in the long term and 

provide residents with more consistent services and protections. Many federal staff and 

stakeholders reported that the Final Rule provided needed clarification around the role of the 

Ombudsman program and its relationship to other entities that serve older and vulnerable adults. Key 

stakeholders acknowledged that the Ombudsman program operates very differently across and within 

states and territories, and that these differences can lead to misunderstandings among partners and 

program staff at the state and local levels. The 2016 OAA reauthorization, and especially the Final 

Rule, served as useful tools to help educate the broader community about the role and uniqueness of 

the Ombudsman program and its need for independence to carry out mandated activities.

Looking ahead, long-term care stakeholders will continue to focus on implementing provisions that stem 

from this unusually intense period of federal reforms. Although consumers are expected to reap the 

benefits of these efforts, regulations and legislation alone cannot assure quality long-term care without 

sustained advocacy. Implementation of some standards outlined in the Nursing Home Regulations are 

already under threat as CMS has revised the rule around use of pre-dispute arbitration clauses, and has 

proposed revisions to these requirements. 

Most State Ombudsmen reported that considerable work remains to advance resident rights and improve 

residents’ quality of care and quality of life. While the program has historically struggled to meet its 

legislative mandates due to insufficient funding, the combination of demographic, industry, and regulatory 

changes has created additional strain on programs’ capacity. As the long-term care delivery system 

evolves, Ombudsman programs will continue adapting to changing demands, yet they can only do so 

effectively with adequate resources to support full program implementation. To keep pace with changes in 

the long-term care landscape, increased funding is critical for the program to effectively serve a rapidlygrowing population of older adults with more complex needs, who live in a diverse array of non-residential 

and residential care settings.

This report begins with an overview of the study’s methodology and the Ombudsman program. Next, we 

summarize findings on the ongoing changes in long-term services and supports and the program’s 

response to these developments. We then focus on recent legislative and regulatory changes affecting 

both the setting of care as well as Ombudsman programs, and how these changes have shaped program 

operations. A glossary of terms is provided at the end of the report to clarify terms and acronyms used.
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Methodology

In September of 2015, the Administration for Community Living (ACL) contracted with NORC at the 

University of Chicago (NORC) and our partners to conduct a comprehensive process evaluation of the 

Ombudsman program. The NORC research team includes The National Consumer Voice for Quality 

Long-Term Care (Consumer Voice), Resnick, Chodorow & Associates, Associate Professor Brooke 

Hollister, Ph.D. of the University of California, San Francisco, Health Benefits ABCs, and the Human 

Services Research Institute (HSRI).

The overarching goal of the process evaluation is to support program planning and improvement by 

assessing the Ombudsman program’s implementation at the federal, state, and local levels. As part of the 

study, data were collected from federal staff, national stakeholders, State Ombudsmen, local 

Ombudsmen, and volunteers. More detail on the methodology can be found in Final Report: Process 

Evaluation and Special Studies Related to the Long-Term Care Ombudsman Program. The following 

report draws on this data collection, particularly interview and survey data collected from State and local 

Ombudsmen, about trends in LTSS and the Ombudsman programs’ responses to those changes, as well 

as federal staff and national stakeholders’ perceptions of the OAA’s Reauthorization and Long-Term Care 

Ombudsman Programs Final Rule. The report also draws on the Ombudsman program’s administrative 

data, reported in the National Ombudsman Reporting System (NORS). 
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Overview of the Long-Term Care Ombudsman 

Program 

In response to widely reported problems involving poor quality of care in nursing homes, the Long-Term 

Care Ombudsman program (LTCOP or Ombudsman program) was created in 1972 as a Public Health 

Service demonstration project in five states. Envisioned as an independent, person-centered consumer 

protection service, the Ombudsman program aims to provide a voice for long-term care residents. The 

Older Americans Act (OAA) established the Ombudsman program nationwide in 1978, and expanded the 

program’s scope to board and care homes and similar adult care facilities in 1981.1 The 2006 

amendments expanded the definition of board and care to include assisted living facilities.2 To ensure the 

protection of residents’ rights, the OAA defined three key legislative mandates for the program. 

1. The OAA charges the program with serving as an advocate for individual residents of nursing homes 

and board and care homes. In these settings, Ombudsmen identify, investigate, and resolve 

complaints about the care residents receive, focusing on their health, safety, welfare, and rights. 

2. The Ombudsman program is required to advocate for systemic improvements in the long-term care 

system by representing residents’ interests before government agencies and analyzing, commenting 

on, and monitoring regulations, policies, and actions that potentially affect long-term care facilities. 

3. The Ombudsman program is tasked with providing outreach and education to residents, their 

representatives, and facility staff, as well as coordinating with agencies that are relevant to the health, 

safety, well-being, and rights of residents. 

These functions are performed by a State Long-Term Care Ombudsman who heads an Office of the 

State Long-Term Care Ombudsman (Office or Office of the SLTCO) in coordination with a state or 

territorial unit on aging (SUA) in all 50 states, the District of Columbia, Puerto Rico, and Guam. The State 

Ombudsman is responsible for statewide program administration, as well as oversight of designated 

representatives of the Office,

3 including paid staff and volunteers, who help resolve residents' complaints, 

address systemic issues, and provide information to consumers on long-term care services and supports. 

According to NORS, in federal fiscal year (FFY) 2017, 1,319 full-time-equivalent staff (FTEs) and 6,625 

certified volunteer Ombudsman supported the program. 

 

1 To reflect expanded Ombudsman coverage, the program’s name was also changed from the Nursing Home Ombudsman program 

to the Long-Term Care Ombudsman program (LTCOP).

2 The terms “board and care” (including assisted living) and “residential care communities” are being used interchangeably 

throughout the report. 

3 In the OAA, “Ombudsman” refers to the State Ombudsman. All other staff that perform the duties of the Office are “representatives 

of the Office.” In practice, however, local staff and volunteers are typically referred to as Ombudsmen (and not representatives of the 

Office). For the purposes of this research, we refer to both the Ombudsman and representatives of the Office as Ombudsmen, 

unless otherwise noted.
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Growth in Populations in Need of Long-Term Services 

and Supports and Specialized Care

The past several decades have witnessed considerable growth in both the population in need of longterm services and supports (LTSS) and the options for care that are available. In the following two 

sections, we discuss the implications of these complex, interrelated trends for the capacity and 

implementation of Ombudsman programs. 

Growth in Population in Need of Long-Term Services and Supports (LTSS) 

The ongoing transformation of the long-term care landscape has been driven in part by consumers 

themselves. Since at least the middle of the last century, the U.S. has experienced unprecedented growth 

in its older adult population. Between 1950 and 2000, the number of individuals age 65 and older nearly 

tripled, from 12.3 million to 35.1 million (Shrestha and Heisler 2011). In 2016, the number of people age 

65 and older living in the U.S. grew to an estimated 50 million (U.S. Census Bureau, 2016). 

In addition to their large numbers, today’s older adults have longer life expectancies than in prior 

generations, but higher survival rates mean that they are also expected to have higher rates of chronic 

illness (King et al., 2013). This combination of factors—large numbers of older adults with more chronic 

illness–has, and will continue to lead to increased demand for long-term care services. According to the 

National Center for Health Statistics (NCHS), there were 1,347,600 residents in nursing homes, 811,500 

residents in residential care communities, and 4,455,700 individuals receiving home health services in 

2016. By comparison, there were about 1,287,400 residents in nursing homes in 1977 (at that time the 

report did not provide counts for community-based care or home-health services). 

Although the population in need of LTSS has increased dramatically, the number of people who are 

trained to care for them in long-term care facilities has not kept pace. This ongoing workforce challenge is 

driven by several factors. In nursing homes, there has long been a lack of federal standards related to 

staffing levels, despite evidence that these standards are needed to ensure quality care is provided 

(Harrington et al., 2016). The Omnibus Reconciliation Act of 1987 (OBRA 87) required nursing homes to 

have “sufficient” staff, but it failed to define the staffing level needed to meet this definition. Some studies 

show that although the number of licensed practical nurses (LPNs) and nursing assistants (NAs) have 

increased in some facilities, the number of registered nurses (RNs) has decreased. In addition, there is 

considerable variation in staffing across large and small nursing homes, as well as those with for-profit 

and nonprofit ownership (Seblega et al., 2010). 

Furthermore, staff training requirements vary greatly from state to state. For example, 36 states allow 

unlicensed staff to administer medications to residents in residential care settings, and only 24 states 

require residential care staff to complete a course in medication administration (ASPE, 2015). For 

residential care communities, staffing standards are often less well defined, and vary widely by state and 

facility size. Most states choose a “flexible, or as-needed” staffing approach over minimum resident to 

staff ratios (ASPE, 2015).

The shortage of adequately trained workers has important implications for the quality of care that

residents receive. Research has consistently shown a positive relationship between nurse staffing levels 

and quality of care (Harrington et al., 2012; Harrington et al., 2016; Armijo-Olivo et al., 2019; Spilsbury et 

al., 2011; Backhaus et al., 2014), including better clinical outcomes (such as reductions in pressure sores 
NORC | The Long-Term Care Ombudsman Program and the Changing Landscape of Long-Term Services and Supports 

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and use of chemical restraints), resident safety (such as reduction in falls), and fewer nursing deficiencies 

overall. In addition, the Office of the Inspector General (OIG) found that in 2011, 33% of skilled nursing 

facility residents experienced either an adverse event or temporary harm during their stay, 59% of these 

events were either clearly or likely preventable, and 62% of preventable events were due to inadequate 

monitoring or failure to provide necessary treatments (OIG, 2014).

Against the backdrop of staffing and training challenges in long-term care facilities, Ombudsman program

resources to support consumer protections in these settings have also lagged behind growth in the older 

adult population. Programs reported that insufficient resources were a major challenge. Seventy-five 

percent of State Ombudsmen and 73% of local Ombudsmen cited challenges related to insufficient 

funding, and the impact was broad. Funds were perceived to be insufficient with respect to staffing, 

salaries, travel, and data systems. Only 23% of State Ombudsmen and 26% of local Ombudsmen 

reported that their state program’s fiscal resources were sufficient to enable their program to meet federal 

mandates.

Exhibit 1 shows that overall program funding has steadily increased since 1996. However, funding from 

federal sources remained relatively stagnant or declined between 2003 and 2017. Notably, multiple new 

federal regulations were passed that introduced complex new responsibilities for the Ombudsman 

program (described later in this report). Whereas federal funds represented 63% of all program 

expenditures in 1996, the share of federal dollars dropped to 50% in 2017. Programs must increasingly 

seek other sources of funding at the state and local levels to support program operations. However, some 

programs rely on federal sources for the majority of their funding. In 2017, state contributions to overall 

program funding ranged from zero percent to 83%.

Exhibit 1: Program Funds Expended (NORS)4

 . 

$0

$20,000,000

$40,000,000

$60,000,000

$80,000,000

$100,000,000

$120,000,000

Program Funds Expended (in 2017 dollars)

Total, Federal, State and Local Funding Levels from 1996-2017

Federal Funding State Funding

Local Funding Total Program Funding in 2017 dollars

4 Converted to 2017 dollars Using Bureau of Labor Statistics: https://data.bls.gov/cgi-bin/cpicalc.pl
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According to the National Ombudsman Reporting System (NORS; the program’s administrative reporting 

system), staffing for the Ombudsman program fluctuated between 1996 and 2017. In 1996, 847 staff and 

6,622 certified volunteers supported the program. In 2000, the number of staff and volunteers had risen to 

970 and 8,394, respectively. Since that time, the number of staff have continued to grow (1,319) while the 

number of volunteers has decreased by 21% to 6,625 in 2017. The decline in volunteers is especially 

noteworthy because some programs rely heavily on them to maintain an ongoing presence in facilities. 

Exhibit 2: Number of Long-Term Care Ombudsman Program Paid Staff and Certified 

Volunteers from 1996-2017 (NORS) 

In the current study, State Ombudsmen reported challenges in recruiting and retaining both staff and 

volunteers. Twenty-seven percent reported difficulties hiring qualified paid staff, and another 17% 

reported that high turnover of paid staff was a challenge. Challenges with respect to volunteers included 

turnover (30%) and difficulty recruiting and supporting volunteers (73%). While limited funds and staffing 

have characterized the program since its inception, increases in the size of the older population 

exacerbate ongoing challenges in program operations. 

Growth in Diversity of Populations in Need of Specialized Care 

Trends in population aging have been accompanied by key shifts in sub-populations that the long-term 

care provider community serves. These groups include older adults who have specialized or complex 

care needs. In 2014, 50% of nursing home residents and 42% of residential care community residents 

had Alzheimer’s disease or other dementias (Alzheimer’s Association, 2019). Individuals with behavioral 

health concerns encompass those with a wide range of mental health conditions, such as schizophrenia, 

bipolar disorder, and depression, as well as substance use disorders, including alcohol and illicit 

substance use. According to a 2017 report from the National Coalition on Mental Health and Aging, nearly 

50% of long-term care recipients have a mental disorder other than dementia. A report by the Substance 

0.00

1,000.00

2,000.00

3,000.00

4,000.00

5,000.00

6,000.00

7,000.00

8,000.00

9,000.00

10,000.00

Ombudsman Program Paid Staff (FTEs) and Certified Volunteers from 1996 to 

2017

Paid Program Staff (FTEs) Certified Volunteer Ombudsmen
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Abuse and Mental Health Services Administration (SAMHSA) found that the share of people aged 50-59 

who used illicit drugs nearly doubled from 2002 to 2007, increasing from 5.1% to 9.4% (Han et al., 2009). 

As the baby boom generation continues to age, the number of older adults with dementia, mental illness 

and who use illicit drugs is also expected to rise. 

The specialized and complex care that these adults require can be challenging for facilities that lack the 

resources and/or staff knowledge to serve these individuals. For example, the unique characteristics of 

dementia, such as impaired communication, disorientation, confusion, and behavioral challenges, can 

frustrate staff who have not been properly trained to work with these residents (Glister et al., 2018; 

Hazelhof et al., 2016). In some cases, this frustration leads to use of inappropriate methods to manage 

behavior. These methods include physical and chemical restraints, which can increase residents’ risk for 

Parkinsonism, stroke, and even death (Mollot, 2016). Further exacerbating this challenge is the absence 

of federal nursing home regulations addressing staffing requirements for cognitively impaired residents 

(Alzheimer’s Association, 2019). Most states also lack minimum staffing requirements for dementia care 

in residential care settings (Glister et al., 2018; Harrington, 2010; Carder, 2017).

State Ombudsmen described the challenges that they experience in serving individuals with complex care 

needs or special vulnerabilities. These include individuals with Alzheimer’s disease or other dementias;

mental and behavioral health issues; intellectual, developmental, or physical disabilities; and complex 

medical conditions (e.g., tracheostomy or feeding tube). Common challenges that were reported to 

complicate advocacy and complaint resolution for these groups included the following: 

■ State Ombudsmen reported that some facilities may refuse to admit/re-admit individuals with special 

needs due to liability concerns (e.g., alleged violent behavior is perceived to place the safety of staff 

and other residents at risk) or insufficient resources (e.g., lack of training and staff) to meet their 

needs. 

■ Some Ombudsmen indicated that they now serve larger numbers of younger adults with disabilities in 

long-term care facilities. Ombudsmen added that many of these younger adults have mental health 

conditions and/or a history of substance abuse, particularly opioid addictions, and that younger adults 

in long-term care facilities tend to have different psychosocial needs than their older counterparts. 

■ Given the shortage of beds in facilities that specialize in residents with challenging behaviors, 

Ombudsmen are limited in their ability to resolve access issues. Identifying facility placement for 

these residents is often difficult because few options are available. State Ombudsmen reported that 

some individuals who were denied placement were either transported to a facility in another state, 

remained hospitalized until a facility would take them in, or lived with family members who were illequipped to care for them. In some cases, a mental illness or behavioral health problem may have 

been undiagnosed. Assisting these individuals requires staff who have been educated to identify and 

support residents who may be experiencing mental health issues, even if they lack a recognized 

clinical diagnosis. 

■ Of the broad complaint categories, State Ombudsmen reported “admission, transfer, discharge, and 

eviction” to be the most challenging and most time-consuming to resolve in nursing homes (37% and 

54%, respectively) (see Exhibit 13). State Ombudsmen also reported that individuals whose 

behaviors are difficult for staff to handle have high rates of involuntary discharges. For example, 

several noted if a facility does not have sufficient or adequately trained staff capable of meeting the 

service and support needs of cognitively impaired residents, their response may be to involuntary 

discharge or transfer them, stating that they can no longer care for the resident. Similarly, individuals 

with behavioral health disorders are often characterized by emotional distress and functional 

disability, two characteristics that long-term care staff often find challenging. As a result, State 
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Ombudsmen reported that these residents often face difficulty finding a long-term care facility that can 

provide needed care, and once a facility is identified and the resident is admitted, they are more likely 

to face involuntary discharge or transfer. 

■ State Ombudsmen reported that the types of complaints and issues raised by individuals with mental 

health or behavioral issues tend to be more complicated, and time consuming for Ombudsmen to 

resolve. In some cases, particularly when residents’ complaints are caused by a general deficit in 

needed services, such as access to mental health supports, Ombudsmen are unable to effectively 

resolve the issue. 

State Ombudsmen described efforts to better serve individuals with special needs, including:

■ Providing more targeted education and training for Ombudsmen and long-term care facility staff to 

better inform them on how to assist and advocate for special populations. 

► State Ombudsmen reported reaching out to and coordinating with professionals from national, 

state, and local entities that specialize in working with special populations. Some of these entities 

include: behavioral health units/agencies, public health departments, universities, police 

departments, corrections and rehabilitation departments, legal services, and disability rights

organizations. For example, Ombudsmen in one state participate in a national program called 

Mental Health First Aid, an eight-hour course that provides training on how to identify and assist 

people who may be experiencing mental health issues. Another program worked with partners to 

develop a curriculum explaining residents’ rights concerning discharges. In another state, some 

Ombudsmen are certified trainers for a program designed to educate the community about caring

for people who exhibit signs and symptoms of Alzheimer’s disease or related dementias. These 

Ombudsmen then deliver this training to the staff at facilities across their state. 

► A few State Ombudsmen described approaches to improve service for lesbian, gay, bisexual, or 

transgender (LGBT) residents. These efforts include working with their state’s LGBT council or 

advocacy group to improve the experience of residents who identify as LGBT; leading seminars 

and presentations on providing care and services for an aging LGBT population; promoting 

models of organizational inclusivity for facilities, and developing training for Ombudsmen on how 

to provide better advocacy for LGBT consumers. One State Ombudsman noted that identifying

appropriate services and supports for transgender individuals can be especially challenging. As 

awareness about the needs of the transgender community evolve, additional staff training for both 

facility staff and Ombudsmen may be needed to support the unique needs of this population. 

► In response to CMS’s National Partnership to Improve Dementia Care in Nursing Homes, one 

Ombudsman program partnered with organizations in their state to reduce antipsychotic drug use

among residents with dementia. The partnership’s education and training efforts emphasize 

person-centered care and non-pharmacological interventions. Activities include a Music and 

Memory Project, direct-care staff training, resident and family education, and a mentoring 

program in which nursing homes with low antipsychotic utilization rates serve as mentors to 

facilities with higher rates. The State Ombudsman reported that the state’s nursing homes have 

been among the country’s most improved in reducing use of antipsychotics, even surpassing the 

goals set by CMS in establishing this initiative. 

■ Organizing/participating in multidisciplinary/multiagency coalitions, councils, work/community groups, 

and meetings to identify and advocate for solutions to improve the quality of long-term care services 

for special populations. 
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► One State Ombudsman reported regular participation in a work group of representatives from law 

enforcement, hospitals, the Department of Health and Welfare, emergency medical services, and 

Adult Protective Services (APS) to strategize on ways to prevent discharges, particularly among 

residents with dementia-related behaviors that are difficult to manage. In another state, a medical 

parole program was implemented that allows for the Department of Corrections to place a paroled

inmate in a long-term care facility. The State Ombudsman developed a communications 

agreement with the Department of Corrections stipulating that the Ombudsman be notified when 

a former inmate is placed in a skilled nursing facility and the conditions of their parole. This 

agreement ensures that any Ombudsmen advocacy on the individual’s behalf is consistent with 

those conditions. 

► To support advocacy for populations with special needs, Ombudsmen reported working with 

various agencies with expertise in these areas. For example, 54% of State Ombudsmen and 45% 

of local Ombudsmen reported working with Behavioral and Mental Health Departments in 

carrying out their work. In addition, 53% of State Ombudsmen discussed efforts to promote 

person-centered care (culture change) in long-term care facilities.

► Some State Ombudsmen provide or anticipate providing more services to veterans, and are 

working to establish and cultivate partnerships with the Veterans’ Administration (VA). One 

Ombudsman explained that they were asked to provide advocacy services to veterans residing in 

a community living center (i.e., nursing home) in a state VA hospital. While State Ombudsmen 

are interested in providing services to these veterans, implementation involves considerable 

coordination with the VA to establish appropriate protocols and lines of authority (e.g., access to 

records and confidentiality).

■ Proposing legislation to address gaps and problems affecting special populations. 

► One State Ombudsman reported working with a disability council to testify on laws to improve the 

lives of individuals with disabilities in long-term care (e.g., testifying on financial exploitation and 

abuse). 
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REPORT | 11 

Changes in the Provision of Long-Term Services and 

Supports 

Growth in Care Options and Shifting Utilization across Facilities

Over the last several decades, board and care homes (also known residential care communities, 

including assisted living facilities) have proliferated in response to growing numbers of older adults, longer 

life expectancy, and consumer demand for alternatives to nursing homes. While nursing homes have 

traditionally served as the setting for individuals requiring skilled nursing care or assistance with activities 

of daily living, older adults have long preferred to “age in place,” either in their homes or within their 

communities, if they can access the necessary supportive services. 

Against the backdrop of these larger trends, a number of federal and state initiatives have been 

introduced to promote consumer choice and independence, as well as to rebalance LTSS provision 

toward more cost-effective HCBS instead of institutional care. As the nation’s primary payer of institutional 

and community-based LTSS for low-income Americans, Medicaid has played a significant role in these 

rebalancing efforts. These mechanisms have developed in a somewhat piecemeal fashion over time. 

Beginning in the early 1980s, states began taking steps to develop alternatives to institutional care 

through use of the Medicaid section 1915(c) waiver program. This allows states to offer a wide range of 

HCBS to beneficiaries who would otherwise qualify for institutional care. The shift was further stimulated 

in the 1990s by the Supreme Court’s Olmstead decision as well as states’ obligations to integrate people 

with disabilities into the community under the Americans with Disabilities Act. 

More recently, states have been afforded new or expanded opportunities under the Affordable Care Act 

(ACA) to improve access to, and delivery of, Medicaid LTSS. HCBS options include the Balancing 

Incentive Program (BIP), the Money Follows the Person (MFP) Rebalancing Demonstration Program 

(originally enacted under the Deficit Reduction Act of 2005 (DRA)), the Section 1915(i) HCBS State Plan 

Option, the Section 1915(k) Community First Choice (CFC) State Plan Option, the Home Health State 

Plan Option, and the Financial Alignment Demonstration for Dual-Eligible Beneficiaries. Each program 

has different eligibility and service provision requirements and may be used alone, or in combination with 

other programs. Because state-based implementation of these Medicaid HCBS options is discretionary, 

there is enormous state-level variation in the size and scope of HCBS programs. However, 2013 marked 

the first year that many states devoted a greater percentage of Medicaid LTSS spending to HCBS than to 

institutional services (Wenzlow et al., 2016), indicating a meaningful shift in the overall balance of how 

and where LTSS are provided. 

Exhibit 3 depicts the shift in LTSS from nursing homes to board and care homes using NORS data. 

Between 1996 and 2017, the number of nursing homes declined by about 18%, while the number of 

board and care homes rose by 55%. More than half of the latter are relatively small—between four and 25 

beds—although larger facilities (over 50 beds) house a majority of long-term care residents (ASPE, 

2015). 
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Exhibit 3: Number of Nursing Homes and Board and Care Homes from 1996 to 2017 (NORS)

Decreases in nursing home usage have been particularly evident in states with large rural areas. 

According to NCHS (2016), more than a third of nursing home beds in Illinois, Nebraska, Oklahoma, and 

Utah were empty in 2015. The national occupancy rate for nursing homes in the same year was 80%. 

While some facilities closed for health and safety standard violations, far more appear to have closed in 

response to financial pressures from policies that encouraged people to choose community-based 

options (Healy, 2019).

Because the Ombudsman program is federally mandated to cover both nursing homes and board and 

care homes, the increase in the older adult population and the growth of board and care homes or 

residential care communities have important operational implications for the program. Over time, the 

Ombudsman program has had to provide services to larger numbers of consumers who live in a wide

variety of settings. Whereas nursing homes house a relatively large number of residents, board and care 

homes, assisted living, and similar communities typically house smaller number of residents, and some 

settings house as few as two residents. This creates practical challenges for resident advocacy because 

it can take many more visits to board and care homes to reach the same number of people that reside in 

a single nursing home. 

Although many State Ombudsmen agree that a non-institutional setting is preferred if the resident’s care 

needs are properly met, over a quarter of State Ombudsmen also reported that increasing utilization of 

board and care homes has impacted the program’s work. Some raised concerns about the quality of 

some of the less regulated care homes, providers’ lower awareness of the Ombudsman program, and the 

obstacles to making regular visits to these small, but numerous residential settings. In addition to the 

smaller number of people living in board and care homes compared to nursing homes, board and care 

homes are often geographically dispersed throughout the state, making them difficult to visit regularly – 

especially for programs experiencing staffing and funding challenges. 

0

10000

20000

30000

40000

50000

60000

70000

Number of Facilities from 1996 to 2017

Nursing Homes Board and Care Homes
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Coverage of rural areas presents special challenges for Ombudsman programs. State Ombudsmen 

report that long travel distances and the costs to reach rural facilities make routine visits challenging, 

particularly for those facilities that are located in remote regions with poor-quality roads or areas that are 

only accessible by plane. In addition, several State Ombudsmen reported that the long-term care 

community in less populated areas cope with very few options for specialty care (such as dementia or 

mental health care) and attracting qualified staff to work in very rural regions is difficult. Moreover, 

recruiting staff in rural areas is a challenge not only for providers, but also for Ombudsman programs. 

In response to these challenges, State Ombudsmen reported prioritizing nursing home visits over board 

and care visits, particularly when resources are limited. As shown in Exhibit 4, Ombudsman programs 

have largely focused on nursing home visits relative to board and care homes, even as the number of 

board and care homes continues to grow. In FFY 2017, there were over twice as many Ombudsman 

quarterly visits to nursing homes (68%) than to board and care homes (30%). As discussed above, the 

larger share of visits to nursing homes arises at least in part because nursing homes tend to be larger, 

and therefore nursing home visits can be more efficient in reaching a greater number of residents. 

Exhibit 4: Percentage of Quarterly Visits Made to Nursing Homes and Board and Care 

Homes from 1996 to 2017 (NORS)

When asked about activities that cannot be fully carried out due to a lack of resources, 50% of State 

Ombudsmen reported that regular nursing home visits fell into this category. The percentage is even 

higher for board and care homes, where 69% of State Ombudsmen reported that regular visits to these 

settings are not fully carried out because of resource limitations. When resources are constrained, State 

Ombudsmen also reported prioritizing individual advocacy activities over systems advocacy activities. 

Whereas 23% of State Ombudsmen reported being unable to fully carry out complaint investigation and 

resolution activities due to lack of resources, 48% reported not being fully able to facilitate public 

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Percentage of Facilities Visited Quarterly from 1996 to 2017

Nursing Homes Board and Care Homes
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comments on proposed legislation, laws, regulations, policies and actions. In addition, State Ombudsmen 

reported not being fully able to conduct research and policy analysis to inform systems advocacy work 

(42%) and analyze and monitor federal, state, and local laws, regulations, and other government policies 

and actions (38%).

Exhibit 5 shows the number of complaints that Ombudsman programs handle by facility type between 

1996 and 2017. Historically, Ombudsmen have addressed more complaints in nursing homes than in 

board and care homes, due in part to their greater frequency in visiting nursing homes. In FFY 2017, 

there were over two and a half times more nursing home complaints (144,003) than board and care 

complaints (53,984). 

Exhibit 5: Number of Complaints in Nursing Homes and Board and Care Homes from 1996 to 

2017 (NORS)

In a landscape characterized by increasing program demands, State and local Ombudsmen reported 

important differences in their ability to have effective relationships with nursing home and board and care 

home staff, as shown in Exhibits 6 through 8. State and lead local Ombudsmen (those identified as 

having managerial responsibilities), were asked about the effectiveness of their statewide programs and 

local Ombudsman entities, respectively. Local Ombudsmen (those without managerial responsibilities) 

were asked about their individual relationships with the two types of providers. Overall, State, lead local,

and local Ombudsmen were more likely to report effective relationships with nursing homes, compared to 

board and care homes. This finding is consistent with the observation that a greater share of Ombudsmen 

visits are dedicated to nursing homes than board and care homes. While local Ombudsmen tended to 

report higher levels of effective relationships with both types of providers than did State Ombudsmen, 

State Ombudsmen were asked to report on their statewide program (rather than local Ombudsman 

entities or their individual relationships with providers). Comparisons between respondent groups, then, 

should be interpreted with caution because of these differences in question wording. 

0

50000

100000

150000

200000

250000

300000

Number of Complaints by Facility Type from 1996 to 2017

Nursing Homes Board and Care Homes
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Exhibit 6: Effectiveness of Statewide Ombudsman Program’s Relationship with Nursing 

Homes and Board and Care Homes (State Ombudsmen)

Overall, how would you rate the effectiveness of your 

statewide program’s relationship with the following types of 

facilities and providers?

Nursing Homes 

N=51

Board and Care 

Homes 

N=51

A majority of the relationships are effective 51% 39%

Some of the relationships are effective 47% 49%

A few of the relationships are effective 2% 12%

None of the relationships are effective 0% 0%

Missing=1

Exhibit 7: Effectiveness of Local Ombudsman Entity’s Relationship with Nursing Homes and 

Board and Care Homes (Lead Local Ombudsmen)

Overall, how would you rate the effectiveness of your local 

program’s relationship with the following types of facilities 

and providers?

Nursing Homes 

N=188a

Board and Care 

Homes 

N=173b

A majority of the relationships are effective 68% 53%

Some of the relationships are effective 29% 37%

A few of the relationships are effective 3% 9%

None of the relationships are effective 0% 1%

a Missing=1; b

 Missing=7, Not applicable=9 

Exhibit 8: Effectiveness of Local Ombudsmen’s Relationship with Nursing Homes and Board 

and Care Homes (Local Ombudsmen)

Overall, how would you rate the effectiveness of your 

relationship with the following types of facilities and 

providers?

Nursing Homes 

N=295a

Board and Care 

Homes 

N=279b

A majority of the relationships are effective 66% 59%

Some of the relationships are effective 28% 36%

A few of the relationships are effective 5% 4%

None of the relationships are effective 0% 1%

a

 Missing=3, Not applicable=10 ; b Missing=6, Not applicable=23 

In open-ended follow-up questions, Ombudsmen were asked to describe factors that informed their 

assessments of effectiveness. Although all types of Ombudsmen reported that a regular presence in 

facilities and positive working relationships as key factors, the salience of these two factors varied by 

roles. Whereas 20% of State Ombudsmen and 22% of lead local Ombudsmen reported that a regular 

presence was important for effective relationships, 12% of local Ombudsmen reported maintaining a 

regular presence as important. Much larger percentages of lead local and local Ombudsmen (32% and 

47%, respectively) reported that establishing positive working relationships with facility staff are major 

contributing factors. Eleven percent of lead local Ombudsmen also reported that relationships are more 

effective if facility staff view the Ombudsman program as a resource, whether that involves reporting 

issues before they become complaints, seeking training, or connecting residents to available resources. 
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Another 19% of local Ombudsmen reported that the knowledge, confidence, and experience level of the 

Ombudsman is an important factor in the effectiveness of relationships with facility staff. 

Other contributors to effectiveness depended on provider setting. With respect to board and care homes, 

15% of State Ombudsmen reported that the strength of the state’s regulations for these facilities is a 

major driver of the effectiveness of the program’s relationships. Indeed, a key difference between nursing 

home and board and care homes that affects resident advocacy concerns the source and stringency of 

regulatory oversight. Whereas nursing homes are regulated at the federal level and provide greater 

protections for residents, board and care homes are licensed and regulated at the state level, and 

regulations vary widely. For example, many states have regulations concerning training for direct-care 

workers, but the number of hours of required training can range from one to 80 (ASPE, 2015). 

Given state-level variation in staffing and other standards, State Ombudsmen differed in their perceptions 

of the extent to which state regulations facilitated efforts to advocate for board and care home residents. 

Exhibit 9 shows that 43% of State Ombudsmen reported that regulations for board and care homes in 

their state were sufficient. Another 45% found them sufficient in some circumstances and settings, while 

12% felt that they are not sufficient for any setting type. These results suggest that more than half of State 

Ombudsmen (57%) have difficulty serving residents in at least some residential care settings due to a 

lack of strong state regulations to support their advocacy work. 

Exhibit 9: Sufficiency of State Board and Care Home Regulations to Enable State 

Ombudsman Programs to Adequately Serve Residents (State Ombudsmen)

Do the state regulations that govern board and care homes and similar facilities 

provide sufficient provider guidance to enable your statewide program to advocate for 

residents of those settings?

State 

Ombudsmen

N=51

Yes, they do provide sufficient guidance to advocate for residents in those settings 43%

A mix, depending on the type or size of the setting 45%

No, they are not sufficient for any setting type 12%

Missing=1

In interviews, about one-quarter of State Ombudsmen reported that lack of strong regulations for board 

and care homes makes serving those residents more challenging compared to nursing home residents. 

Whereas nursing home federal regulations enable programs to refer facilities to requirements they must 

follow, states’ assisted living regulations are relatively less stringent, making it harder for programs to 

protect residents and resolve their complaints. One State Ombudsman noted weaknesses in regulations 

for the required level of care in assisted living facilities, particularly for special needs populations, such as 

those with Alzheimer’s disease or other dementias. This ambiguity allows board and care, assisted living 

and similar homes to accept residents for whom they may not be able to provide adequate care. Other 

reported weaknesses may result from board and care regulations that attempt to cover a wide range of 

facility sizes. One State Ombudsman noted that their state’s regulation is written to address both the 

small, six-bed homes, as well as the larger assisted living facilities. Further, notions of adequate staffing 

may differ between providers and residents. Lastly, one State Ombudsman noted that movement from 

one type of residential setting to another can be confusing to residents who expect the same resident 

protections and rights to apply in all settings. 

Consistent with these observations, Exhibit 10 shows the relationship between State Ombudsmen’s 

perceived effectiveness in board and care homes and their perceptions concerning the adequacy of 

regulatory guidance for board and care homes in their states and territories. State Ombudsmen who 
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reported sufficient guidance were more likely to report that the majority of their statewide program’s 

relationship with board and care homes are effective. 

Exhibit 10: Effectiveness of Ombudsman Program’s Relationship with Board and Care Homes 

and Sufficiency of Board and Care Home Regulations (State Ombudsmen)

Overall, how would you rate the 

effectiveness of your statewide 

program’s relationship with providers of 

board and care homes?

State regulations 

for board and care 

homes provide 

sufficient guidance 

to advocate for 

residents

N=22

Sufficiency of 

state regulations 

for board and care 

homes depends 

on the type or size 

of the setting

N=22

State regulations for 

board and care

homes are not

sufficient for any 

setting type

N=6

A majority of the relationships are effective 64% 18% 17%

Some of the relationships are effective 27% 64% 83%

A few of the relationships are effective 9% 18% 0%

None of the relationships are effective 0% 0% 0%

Missing=2 

In addition to federally-mandated responsibilities for nursing homes and board and care homes under the 

OAA, 17 State Ombudsmen reported having authority to serve in-home consumers receiving LTSS. 

Under state statutes or other provisions, these states and territories expanded Ombudsman services to 

individuals who receive HCBS in their own homes or communities, outside of facilities. Exhibit 11 lists 

these states and territories. 

Exhibit 11: LTCOPs with Home Care Responsibility

State/Territory

Colorado Iowa Rhode Island

District of Columbia Maine Vermont

Delaware Minnesota Virginia

Georgia Ohio Wisconsin 

Idaho Pennsylvania Wyoming

Illinois Puerto Rico

It should be noted that although programs are not prohibited from providing services to individuals beyond 

those defined in the OAA, they must use resources other than those appropriated through federal law

(such as general state revenues or other funds) to support this work (AoA, 2015).

Responsibility for home-care advocacy has existed almost since the program’s inception, with the earliest 

report of in-home services from the Wisconsin Ombudsman program in 1981. While states and territories 

may gain or lose authority for home-care advocacy (and for this reason, the composition of states with 

this authority may change over time), the overall level of responsibility has steadily increased over the last 

40 years, with the loss of authority in some states and territories offset by gains in others. Based on 

available historical data, approximately eight states were responsible for home care in the 1980s. The 

number increased to 10 in the 1990s (data were first collected by the National Long-Term Care 

Ombudsman Resource Center in 1994 and again in 1999), 12 in 2007, and 14 in 2013. In the current 

study, 17 State Ombudsmen reported having authorization to serve in-home consumers in 2017. 
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Across programs with authority for in-home advocacy, the scope, funding, and implementation of these 

requirements varies widely. According to two reports prepared by NASUA5 (first in 2001 and updated in 

2007), a majority of programs have responsibility for investigating complaints regarding HCBS under 

Medicaid waivers but they may also serve individuals covered by other services (alone or in combination). 

These services include state-funded home care, home health agency services, OAA home care 

programs, private pay home care, adult foster care, adult day services, hospice and public housing, and 

relocation follow-up. Other differences in scope may pertain to whether programs engage exclusively in 

complaint handling or if systems advocacy is included as part of their responsibilities. Funding for these 

activities come from a variety of sources (such as state general funds, Medicaid administrative funds, 

provider fees, and grants) or it may be absent altogether. As of the 2007 report, state legislatures of 

Indiana and Virginia provided no additional funding to support their mandated home care advocacy 

activities. In terms of implementation, programs vary in staffing for home care complaint handling (use of 

any Ombudsman, dedicated staff, and/or volunteers), training requirements, policies and procedures, and 

use of formal agreements (such as memoranda of understanding) with other agencies (e.g., APS, 

Medicaid waiver programs) to address home care advocacy. 

It should be noted that there are instances where Ombudsman programs without responsibility for home 

care advocacy also investigate complaints regarding home care services. This may occur during periods

of resident transitions – whether the complaint concerns identifying a new residence or needs related to 

health care. For example, some programs provide advocacy for individuals moving from one setting to 

another (e.g., transitioning to the community from nursing homes) or for long-term care facility residents 

who receive additional home care services that are arranged by facilities to supplement care needs. 

Overall, home-care complaints represent a very small percentage of total complaints handled by the 

Ombudsman program. According to NORS in FFY 2017, 25 Ombudsman programs reported handling 

1,277 home-care complaints (one percent of all complaints addressed by the program).6 Of this number, 

10 programs did not have explicit state level authority to serve consumers of in-home services. Only 10 

programs handled more than 10 home care complaints, only one of which did not have state level 

authority to serve consumers of in-home services. Among the 17 programs authorized to serve 

consumers of in-home services, 88% reported handling any home-care complaints, ranging from one 

complaint to 281 complaints.

Exhibit 12 presents State and lead local Ombudsmen’s reports of their program’s effectiveness in home 

care. Most State and lead local Ombudsmen reported that some to a majority of the program’s

relationships are effective, although a greater percentage of State Ombudsmen felt this way (81% 

compared to 66%). Compared to State Ombudsmen, lead local Ombudsmen were more likely to report 

that a few of the relationships with in-home service providers are effective, and seven percent of lead 

local Ombudsmen reported that none of the relationships are effective. As a reminder, State Ombudsmen 

are responding to questions in the context of their statewide programs and lead local Ombudsmen are 

reporting on their local entities. 

 

5 The reference to the National Association of State Units on Aging (NASUA) reflects the name of the organization when the report 

was published. In 2010, NASUA subsequently changed its name to the National Association for States United on Aging and 

Disabilities (NASUAD). In August of 2019, NASUAD changed its name to ADvancing States. 

6 In NORS, in-home complaints are reported within the larger category of “Other Non-Facility Settings.”
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Exhibit 12: Effectiveness of Ombudsman Program’s Relationship with In-Home Service 

Providers (State and Lead Local Ombudsmen)

Overall, how would you rate the effectiveness of your 

state/local program’s relationship with in-home service 

providers?

State Ombudsmen 

N=16 a

Lead Local 

Ombudsmen 

N=28 b

A majority of the relationships are effective 25% 28%

Some of the relationships are effective 56% 38%

A few of the relationships are effective 19% 28%

None of the relationships are effective 0% 7%

a Missing=1; b

 Missing=4 

In open-ended questions, Ombudsmen were asked to describe factors that informed their assessments of 

effectiveness. Among State Ombudsmen who reported that a majority of their relationships with in-home 

service providers are effective, many explained that they had been serving this population for many years 

and had developed good communications and a strong understanding of this service population. They 

reported having success in resolving issues for these programs’ consumers, noting that providers 

responded adequately to their recommendations concerning consumer rights. Among those who reported 

that some of their relationships with in-home service providers are effective, some explained that program 

limitations (such as time or resources) prevented them from establishing strong relationships with 

providers, and that there were inconsistencies in the quality of in-home care provided to consumers. One 

State Ombudsman noted that the lack of a comprehensive provider association in their state made it 

difficult to facilitate effective communication. The main reasons for rating only a few of the relationships as 

effective included the newness of in-home care as part of the Ombudsman’s jurisdiction, the rapid growth 

and closure of in-home service providers, and lack of program resources to establish regular contact with 

providers. Exacerbating these challenges is the nature of complaints that arise in non-institutional 

settings. One State Ombudsman reported that compared to nursing homes, consumer complaints 

initiated at home or in the community can be more complex and labor-intensive to investigate because of 

the number of providers with whom they need to consult and coordinate (such as a specialist or home 

health aide), who may not work together in the same setting. 

With respect to lead local Ombudsmen, 34% reported that the small number of complaints from these 

settings resulted in limited overall contact with providers and this hindered relationship building. 

Seventeen percent described having collaborative or “working” relationships with in-home service 

providers, while 10% reported that the Ombudsman program is seen more as an adversary or a 

“nuisance.” A few lead local Ombudsmen also noted staff turnover or shortages, as well as weaker 

regulations in in-home care settings as contributing factors to less effective relationships.

Growth in Acuity Levels across Facilities

The distinction between nursing homes and other residential care communities has become somewhat 

blurred over time as residents’ level of acuity has increased across settings (Han et al., 2016; Carlson, 

2014). Han et al.’s (2016) analysis of the 2010 National Survey of Residential Care Facilities found that 

more than half of assisted living facilities admitted residents with considerable health care needs, 

including some who needed nursing-level care for transfers, medication, and eating or dressing. Staffing 

for these facilities mostly consisted of resident care aides, however, with only half utilizing higher-level 

licensed providers such as registered nurses. In fact, the Han et al. report showed that smaller facilities 

tended to admit residents with higher care needs despite having fewer licensed nurses than larger 
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facilities. Additional data from Caffrey et al. (2012) showed that almost 40% of residents in residential 

care facilities received assistance with three or more activities of daily living (ADLs), more than 40% had 

Alzheimer’s disease or other dementias, and nearly 75% had been diagnosed with at least two of 10 

common chronic conditions such as high blood pressure and heart disease.

Nearly 21% of State Ombudsmen described increasing resident acuity in residential care settings and, in 

some cases, in nursing homes as well. While some nursing homes may prioritize short-term rehabilitation 

residents, State Ombudsmen seemed particularly concerned with residential care settings that admit

residents who require high levels of nursing care without having adequately trained or appropriately 

licensed staff to provide needed care. Ombudsmen are finding that residential care facilities are home to 

some residents whose frailty and complex medical needs require the type of skilled nursing care that is 

characteristic of a nursing home. Some Ombudsmen also noted that residential care communities are 

becoming default mental health institutions. 

Some issues related to increased resident acuity are reflected in State Ombudsmen’s reports of 

complaints they find most challenging and time-consuming to address. Of the 16 broad types of 

complaints,7 State Ombudsmen reported complaints relating to nursing home admission, transfer, 

discharge, and eviction were both the most challenging and most time-consuming to resolve (Exhibit 13). 

These types of complaints include transitions resulting from facility closures and emergency relocations. 

Perhaps due to their frequency, 20% of State Ombudsmen also reported that their programs are most 

effective at resolving complaints related to admission, transfer, discharge, and eviction. Additionally, 79% 

of State and local Ombudsmen reported that their programs have expertise in addressing involuntary 

discharges and transfers. 

Other notable findings concern resident care and staffing. Care-related issues were generally not 

perceived to be particularly difficult to resolve, but were reported to be time-consuming when they arose. 

In contrast, one-fourth of State Ombudsmen reported that staffing problems were among those most 

difficult to resolve, but none reported that these issues were the most time-consuming. This may be partly 

due to the limitations in Ombudsmen’s ability to address staffing issues. 

In interviews, one-third of State Ombudsmen reported that their programs were receiving an increasing 

number of complaints related to staffing, such as insufficient staffing levels, inadequate training, and high 

staff turnover. Several State Ombudsmen reported inadequate staffing as the underlying source of quality 

problems in long-term care facilities. Because facility staffing is largely outside the program’s control, 

however, there is little that Ombudsmen can do to handle this issue, other than to pursue more systemic 

reform. For example, one State Ombudsman reported establishing a workgroup to develop legislation to 

improve the state’s staffing standards in nursing homes. The move was prompted by increasing 

complaints from nursing home residents about staff and direct appeals from certified nursing assistants to 

the Ombudsman program. Among other requirements, the legislation removed incentives for facilities to 

keep lower staffing levels, established minimum staffing requirements based on resident acuity, and 

required that direct care staff be available at all times. To develop this legislation, Ombudsman program 

staff met with residents, family members, nursing home staff, legislators, and other stakeholders to 

ensure that recommended staffing changes were informed and well-supported. The legislation was 

passed in 2009. Although there have been periodic threats to the legislation’s staffing standards, the 

Ombudsman program has successfully advocated to protect the standards by encouraging stakeholders 

 

7 When reporting complaint data in NORS, programs record complaints that they handle using 16 broad complaint codes and 133 

detailed complaint codes. The study’s survey used NORS’ 16 broad complaint categories when asking Ombudsmen about the types 

of complaints that their programs resolve.
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to call legislators, testify when the opportunity arises, and write letters to the state’s commission that 

examines rate setting. 

Exhibit 13: Complaints that are Most Challenging, Time-Consuming, and Effective at Resolving

in Nursing Homes (State Ombudsmen)

Complaint Category

Most 

Challenging to 

Resolve 

N=52

Most Time 

Consuming to 

Resolve 

N=52

Most Effective 

at Resolving 

N=51a 

Abuse, gross neglect, exploitation 10% 4% 6%

Access to information by resident or resident’s 

representative

0% 0% 10%

Admission, transfer, discharge, eviction 37% 54% 20%

Autonomy, choice, preference, exercise of rights, privacy 4% 13% 39%

Financial, property (except for financial exploitation, which 

is included in the first response option)

6% 2% 0%

Care 6% 23% 18%

Rehabilitation or maintenance of function 2% 0% 0%

Restraints – chemical and physical 2% 0% 0%

Activities and social services 2% 0% 0%

Dietary 0% 0% 2%

Environment 0% 0% 2%

Policies, procedures, attitudes, resources 4% 0% 4%

Staffing 25% 0% 0%

Certification/Licensing agency 0% 0% 0%

State Medicaid agency 0% 0% 0%

System/Others 4% 4% 0%

a Missing=1

With respect to board and care homes, State Ombudsmen similarly reported that complaints relating to 

admission, transfer, discharge, and eviction were most challenging to resolve, although a smaller 

proportion of respondents found them particularly time-consuming to address, as seen in Exhibit 14. 

Other issues that were particularly challenging or time-consuming for Ombudsmen to resolve in board 

and care homes included policies, procedures, attitudes, and resources; and issues relating to resident 

care. Almost one-fifth of State Ombudsmen considered policies and related issues for board and care 

homes to be particularly difficult to resolve, compared with only four percent who found these issues to be 

challenging to address in nursing homes. This may reflect the greater specificity of regulations for nursing 

home policies and procedures in most states. With respect to the effectiveness of Ombudsman programs 

in resolving complaints, over half of State Ombudsmen (54%) reported that their programs were most 

effective at resolving complaints related to autonomy, choice, preferences, exercise of rights, and privacy. 

These types of complaints can often be resolved by coordinating with facility staff and are generally 

focused on an individual resident. Some states also have residents’ rights outlined in state law or 

regulation for board and care homes which provide Ombudsmen additional tools to advocate on behalf of 

residents. 

 
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Exhibit 14: Complaints that are Most Challenging, Time-Consuming, and Effective at Resolving 

in Board and Care Homes (State Ombudsmen)

Complaint Category

Most 

Challenging 

to Resolve 

N=52

Most Time 

Consuming 

to Resolve 

N=52

Most 

Effective at 

Resolving 

N=52

Abuse, gross neglect, exploitation 4% 6% 2%

Access to information by resident or resident’s representative 0% 0% 10%

Admission, transfer, discharge, eviction 40% 31% 8%

Autonomy, choice, preference, exercise of rights, privacy 8% 31% 54%

Financial, property (except for financial exploitation, which is 

included in the first response option)

4% 4% 0%

Care 13% 15% 12%

Rehabilitation or maintenance of function 0% 0% 0%

Restraints – chemical and physical 0% 0% 0%

Activities and social services 0% 0% 4%

Dietary 0% 2% 4%

Environment 0% 2% 0%

Policies, procedures, attitudes, resources 19% 8% 4%

Staffing 12% 0% 0%

Certification/Licensing agency 0% 0% 2%

State Medicaid agency 0% 0% 0%

System/Others 0% 2% 2%

State Ombudsmen also reported that the complaints that Ombudsman programs handle are currently 

more complex and challenging than they were in the past, moving away from requests for assistance with 

daily needs to more urgent concerns such as discharges and evictions. Exhibit 15 shows the top 10 most 

frequent complaints by facility type in FFY 2017. These complaints reflect the detailed complaint codes 

(rather broad complaint categories presented in Exhibits 13 and 14) used in NORS. For residents of both 

nursing homes and board and care homes, the most frequent complaint pertained to “discharge/eviction – 

planning, notice, procedure, implementation, including abandonment.” According to historical NORS data, 

the most common type of complaint addressed by Ombudsmen in nursing homes between 1997 and 

2010 were failures to respond to requests for assistance (such as transfers to chairs/bed), followed by 

discharge/eviction. For the last seven years, discharge/eviction topped the list of the most frequently 

reported complaints handled by the program. As described earlier, of the broader complaint categories, 

those related to “admission, transfer, discharge and eviction” were reported to be the most challenging 

and time-consuming to resolve.8 In board and care homes, the most common complaints addressed by 

Ombudsmen in recent years (2017, 2016, and 2014) were discharges and evictions. Prior to that time, the 

most frequent complaints concerned medications or food service (1996-2013, 2015).

 

8 According to NORS, “discharge/eviction – planning, notice, procedure, implementation, including abandonment” is one of seven 

types of complaints that falls under the broad complaint code of “admission, transfer, discharge, and eviction.”
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Exhibit 15: Top Ten Most Frequent Complaint Types (NORS)

Complaint 

Ranking Nursing Homes Board and Care Homes

1 Discharge/eviction-planning, notice, procedure, 

implementation, including abandonment

Discharge/eviction-planning, notice, procedure, 

implementation, including abandonment

2 Failure to respond to requests for assistance Medications – administration, organization

3 Dignity, respect – staff attitudes Food service - quantity, quality, variation, choice, 

condiments, utensils, menu

4 Medications – administration, organization Dignity, respect – staff attitudes

5 Resident conflict, including roommates Equipment/building - disrepair, hazard, poor 

lighting, fire safety, not secure

6 Personal hygiene (includes nail care & oral 

hygiene) and adequacy of dressing & grooming Cleanliness, pests, general housekeeping

7 Food service - quantity, quality, variation, 

choice, condiments, utensils, menu Resident conflict, including roommates

8 Care plan/resident assessment - inadequate, 

failure to follow plan or physician orders

Accidental or injury of unknown origin, falls, 

improper handling

9 Symptoms unattended, including pain, pain not 

managed, no notice to others of changes in 

condition

Personal property lost, stolen, used by others, 

destroyed, with-held from resident

10 Accidental or injury of unknown origin, falls, 

improper handling

Care plan/resident assessment - inadequate, 

failure to follow plan or physician orders

Growth in Managed Long-Term Services and Supports (MLTSS) 

Adding momentum to the movement toward HCBS is the growing interest among states in capitated 

managed long-term services and supports (MLTSS) delivery systems. Under MLTSS, managed care 

organizations (MCOs) act as the state’s agents to negotiate contracts with providers and arrange 

beneficiary services. In this arrangement, MCOs absorb full financial risk and agree to deliver covered 

services for a fixed amount. By contracting with MCOs to deliver health care services to Medicaid and/or 

Medicare beneficiaries, states hope to reduce program costs and better manage health service utilization. 

Over time, an increasing number of states have implemented MLTSS programs. In 2009, only six states 

operated MLTSS programs (Anthony and Nevitt, 2016). By 2015, 22 states operated these programs, and 

11 more were in the planning stages. By 2016, nearly three-quarters of Medicaid beneficiaries were 

enrolled in Medicaid managed care (MMC) programs (Anthony and Nevitt, 2016), and this growth has 

included increased use of MLTSS. 

MLTSS programs vary by state, differing in the populations served (e.g. younger people with disabilities, 

people that are only Medicaid-eligible, Medicare/Medicaid dual-eligibles), and the services covered (e.g. 

HCBS, supported employment services) (National Health Policy Forum, 2012). The transition from feefor-service to a managed care system has broad implications for enrollees in terms of their ability to 

navigate the system, access services, and understand their rights. 

To ensure that Ombudsman programs’ staff and volunteers are knowledgeable about the complexities of 

their state’s MLTSS program, some state Ombudsman programs have developed intensive MLTSS 

training programs. Thirty-seven percent of State Ombudsmen, 38% of lead local Ombudsmen, and 35% 

of local Ombudsmen reported partnering or coordinating with MCOs in carrying out their work. Four State 
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Ombudsmen mentioned collecting data on activities related to managed care, including the quantity and 

types of managed care complaints received by the program. 

Additionally, as consumers continue to move toward managed LTSS options, some Ombudsman 

programs’ roles have expanded to cover MCO members. For example, Iowa has a Managed Care 

Ombudsman Program that is a division of the Office of the SLTCO. The Managed Care Ombudsman 

Program “advocates for the rights and needs of...Medicaid managed care members who live or receive 

care in a health care facility, assisted living program or elder group home, as well as members enrolled in 

one of Medicaid’s seven home and community-based services waiver programs” (Iowa Department on 

Aging, 2016). The Managed Care Ombudsman Program provides education and information regarding 

members’ rights, advocacy, and complaint resolution when members are unable to resolve an issue with 

their MCO. It also assists with appeals when members are dissatisfied with MCO decisions. 

Furthermore, recent changes in delivery of LTSS require that the program provide educational 

opportunities to MCOs. Because MCOs typically operate under a medical model, Ombudsmen must 

educate them on issues such as self-determination and basic rights that may not be familiar to these 

providers or easily translated into practice or routine workflows.

In some states, Ombudsman programs for managed care settings are separate from the LTCOP. For 

example, Minnesota has an Ombudsman for Public Managed Health Care Programs which “helps 

enrollees get needed health care and resolve billing problems...[and] provides information and assistance 

with the managed care grievance and appeal process available through the health plan and the state” 

(Minnesota Department of Human Services, 2017). From an operational point of view, this administrative 

separation may require the Ombudsman program to work with the Managed Care Ombudsman to ensure 

residents receive the support they need from the appropriate Ombudsman entity.

Nineteen percent of State Ombudsmen reported that their states had implemented managed long-term 

care programs. Some described positive relationships while others expressed concern that these 

programs limit coverage for people who need LTSS in ways that a non-managed care system would not. 

Additionally, other Ombudsmen described an impact on workload as they familiarized themselves with 

managed care regulations and other recent federal and state directives related to long-term care. They 

noted that because consumers often look to the Ombudsman program as a resource on these issues, 

Ombudsmen must quickly educate themselves on these topics. Eleven percent noted that while their 

states do not currently have managed long-term services and supports, they anticipate these changes in 

the near future and expect that they will impact their states’ long-term care landscape and Ombudsman 

program.
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New Regulations in Long-Term Care Delivery 

In response to the growth and increasing diversity of populations and settings, significant new regulations 

have been implemented for both institutional and residential settings that aim to improve oversight and 

quality of care. On October 4, 2016, the Centers for Medicare & Medicaid Services (CMS) published the 

first major revision to federal nursing home standards in over a quarter of a century. The nursing home 

regulations are authorized by the Nursing Home Reform Act, passed as part of the Omnibus Budget 

Reconciliation Act of 1987 (OBRA 87). OBRA 87 is widely considered to be landmark legislation because 

it led to sweeping reforms that improved quality of care and established resident rights in nursing facilities 

that accepted payment from CMS. 

In March of 2014, CMS published the first regulations to establish standards for facility-based settings 

that are funded through Medicaid HCBS. As states come into compliance with the regulations, CMS is 

taking an active oversight role to ensure compliance with the settings standards, in addition to any 

existing state laws and regulations.9 

Released in 2016, CMS specifically addressed the provision of managed LTSS for the first time in its 

Medicaid and Children’s Health Insurance Program (CHIP) Managed Care Final Rule. Inclusion of 

managed LTSS in the rule reflects states’ expansion of this delivery system model since the last revision 

to Medicaid managed care regulation. 

While the impact of each of these regulations is far reaching for states and long-term care providers, the 

changes also affect the Ombudsman program, albeit to varying degrees. Because the Ombudsman 

program serves settings affected by CMS’s regulations, it needs to be familiar with any updated 

provisions regarding the financing or other aspects of LTSS service delivery. Ombudsman program staff

must at minimum be trained on the complexities of all final rules because of the program’s role as a 

consumer advocate. In this section, we discuss the relationship between recent regulatory developments 

and Ombudsman program service delivery.

Nursing Home Regulations

Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care 

Facilities that participate in Medicare and Medicaid

In September of 2016, CMS issued the “Medicare and Medicaid Programs; Reform of Requirements for 

Long-Term Care Facilities that participate in Medicare and Medicaid” (hereafter referred to as the 

“Nursing Home Regulations”). Despite significant changes in the nursing home industry over the past 

several decades, this was the first comprehensive revision to existing nursing home regulations since 

they were first issued in 1991. The new regulations reflected an evolution in the theory and practice of 

long-term care service delivery and safety, and they implemented important provisions of the Affordable 

Care Act (ACA) (Tritz et al., 2016). The 2016 nursing home regulations addressed five major themes:

■ Person-centered care: maintaining and improving existing protections, choices, care and discharge 

planning

■ Quality: quality of life and quality of care, including quality assurance and performance improvement

 

9 Previously, oversight of HCBS settings was limited to requirements in states’ Medicaid plans, while residential care settings had 

been governed almost entirely by state laws and regulations (ASPE, 2015).
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■ Facility assessment and competency-based approach: accounting for diversity in populations and 

facilities, and focusing services on individual needs

■ Alignment with current HHS initiatives: reducing unnecessary hospital readmissions and 

healthcare-acquired infections, improving behavioral healthcare, and safeguarding residents against 

unnecessary use of psychotropic medications

■ Implementation of legislation: This includes ACA provisions related to compliance and ethics 

programs, quality assurance and performance improvement programs, and dementia care and abuse 

awareness training, as well as provisions of the Improving Medicare Post-Acute Care 

Transformations (IMPACT) Act, such as discharge planning requirements for skilled nursing facilities 

(SNFs).

Implementation of the 2016 nursing home regulations is being carried out in three phases, with full 

compliance required by November 28, 2019 (however, on July 16, 2019, CMS proposed to delay 

implementation of certain Phase 3 requirements for one year). Although these changes are expected to 

have an impact on nursing home quality of care, the full effect is unlikely to be evident for some time. 

However, some of the new regulations are already impacting the Ombudsman program and its effort to 

serve nursing home residents. The National Consumer Voice for Quality Long-Term Care (2017a, b, c) 

summarized the changes that are likely to have the greatest influence on Ombudsman programs: 

■ A copy of a resident’s transfer/discharge notice must be sent to a representative of the Office of the 

SLTCO. CMS subsequently clarified the type of notices that are required to be sent under this 

provision; 

■ Prohibition of pre-dispute binding arbitration agreements, and subsequent suspension of that 

prohibition (described further below); 

■ A requirement that nursing homes provide immediate access to any resident by “any representative 

of the Office of the State Long-Term Care Ombudsman (Office of the SLTCO).” Previously, the 

regulations only provided immediate access to the State Ombudsman;

■ Facilities must allow representatives of the Office of the SLTCO to examine a resident’s records in

accordance with state law;

■ Facilities must not prohibit or discourage residents from communicating with federal, state, or local 

officials, including federal and state surveyors and representatives of the Office of the SLTCO; 

■ Facilities must have sufficient nursing staff with the appropriate competencies and skill sets to provide 

nursing and related services to assure resident safety and attain or maintain the highest practicable 

physical, mental, and psychosocial well-being of each resident. A sufficient staffing level is 

determined by resident assessments and individual plans of care and considering the number, acuity, 

and diagnoses of the facility’s resident population in accordance with the facility assessment required 

in §483.70(e);

■ Nursing homes must post contact information for the Office of the SLTCO; and

■ Nursing homes that are closing must notify the Office of the SLTCO.

Arguably, changes in resident discharge and transfer provisions have had the most impact on 

Ombudsman programs. Among the 74% of State Ombudsmen who reported the new nursing home 

regulations as a major federal policy change that impacts the Ombudsman program, 64% specifically 

mentioned the requirement for facilities to send notices of involuntary transfers and discharges to the 

Ombudsman program. Because the regulation did not specify whether notification was limited to the 

nature of the discharge, facility staff widely interpreted this requirement to include all transfers and 

discharges, regardless of reason. This resulted in an influx of notices received by many Ombudsman 

programs (particularly in those states that did not already have notification requirements), diverting staff 

attention to managing the flood of paperwork.
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CMS later issued a clarification that only notices of involuntary (or facility-initiated) transfers or discharges 

must be provided. Despite this clarification, some Ombudsmen reported continuing to receive a large 

number of unnecessary notifications and needing to dedicate staff time to verify that the notices were in 

fact related to involuntary discharges. Given the influx of notices, some State Ombudsmen developed 

new processes or procedures to address the tremendous increase of notices. They also reported 

providing training and education to nursing home staff to help them understand the requirements and 

reduce unnecessary work for both nursing home staff and Ombudsmen. Many also reported that 

involuntary nursing home discharges and the effort to find placements for discharged residents

represented a large share of their workload, particularly in areas with large numbers of nursing home 

closures.

Initially, the Nursing Home Regulations included a prohibition against forced pre-dispute binding 

arbitration agreements. These require prospective residents to agree to settle disputes without turning to 

the court system as a condition of admission to a facility. A lawsuit brought by the American Health Care 

Association (AHCA; the largest nursing home provider association), however, resulted in suspension of 

this requirement (Collier 2019). A few State Ombudsmen expressed concern that this suspension would 

weaken protections for nursing home residents who wish to bring a claim of abuse, neglect, or other 

quality of care issues against a nursing home.

Multiple State Ombudsmen noted disappointment about the vagueness of the requirement for nursing 

homes to have “sufficient” staff, with appropriate competencies and skill sets. While they noted that the

current requirement is a step in the right direction, they pointed out that it lacks specificity and strength to 

compel facilities to establish minimum staffing requirements, such as standards based on minimum 

numbers of direct care hours for each resident. Some states are advocating for stronger state-level 

requirements to address the federal regulation’s limitations. 

Provisions of the Nursing Home Regulations that address access for both Ombudsmen and residents are 

widely viewed as a positive change that will enhance the program’s ability to serve residents. Some 

Ombudsmen also highlighted the requirement for nursing homes to notify the program of an impending 

closure, noting that this allows programs to coordinate with other partners in the aging network to ensure 

that residents have safe, coordinated transitions to new homes.

Home and Community-Based Services (HCBS) Settings Final Rule

Medicaid Home and Community-Based Services Settings Final Rule

Medicaid-funded HCBS provide LTSS that allow low income older adults and persons with disabilities to 

remain integrated in their communities (Edwards, 2014). In January of 2014, CMS issued the Medicaid 

Home and Community-Based Services Settings Final Rule (CMS-2249-P2). These regulations addressed 

several sections of Medicaid law that stipulate how states may use federal Medicaid funds to pay for 

HCBS, and they established quality requirements for provider settings that are eligible for reimbursement 

for Medicaid HCBS. States and care settings must comply with the new requirements by March 2022. 

In the HCBS Settings Final Rule, CMS required settings that qualify as home and community-based to: 

■ Be integrated in and supports full access to the greater community;

■ Be selected by the individual from among several setting options;

■ Ensure individual rights of privacy, dignity, respect, and freedom from coercion and restraint;

■ Optimize autonomy and independence in making life choices, and

■ Facilitate choice regarding services and who provides them.
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The Final Rule specifies additional requirements for provider-owned or controlled HCBS residential 

settings that serve individuals who receive Medicaid-funded HCBS:

■ The individual must have a lease or other legally-enforceable agreement providing similar protections;

■ The individual must have privacy in the unit and lockable doors, choice of roommates, and freedom to 

furnish or decorate the unit;

■ The individual must control their own schedule, including access to food and visitors at any time; and

■ The setting must be physically accessible.

These HCBS setting requirements exclude nursing facilities and other institutions from serving as 

Medicaid-funded home and community-based settings. The requirements also outline characteristics of 

care settings that are presumed not to be home and community-based. These include settings in the 

same building as a facility that provides inpatient treatment, settings on the grounds of, or immediately 

adjacent to a public institution, and settings that isolate individuals. Providers must show evidence that 

they meet the HCBS setting requirements to continue providing services under Medicaid HCBS 

programs.

One-third of State Ombudsmen reported the HCBS Settings Final Rule to be a major change affecting 

their programs. Included in Ombudsman programs’ coverage of board and care homes are a number of 

settings that are affected by the settings rule, such as assisted living facilities. Other than what is required 

in states’ Medicaid plans, there has been virtually no federal oversight of HCBS settings, and residential 

care settings have been governed almost entirely by state laws and regulations (ASPE, 2015). For this 

reason, the regulation is especially important for programs in states where LTSS provision favors HCBS 

over nursing homes. For several of these State Ombudsmen, the regulation is viewed as a positive 

development that will benefit residents who utilize Medicaid. The 2014 HCBS setting requirements 

established a regulatory framework that provides the Ombudsman program with additional remedies 

when resolving complaints in these settings, and it also provides additional opportunities for systems 

advocacy to support improvements to state HCBS systems. In general, Ombudsmen perceived the new 

regulatory requirements as tools that programs can use to advocate on behalf of consumers. 

As states evaluate their HCBS settings for compliance with the 2014 regulations, State Ombudsmen 

described needing to familiarize themselves with the complexities of the regulation and to serve as a 

resource to stakeholders. Part of this challenge involves determining whether a facility is communitybased in order to participate in the Medicaid program. One State Ombudsman noted that because 

assisted living facilities are often physically attached to nursing homes, whether a facility is an assisted 

living facility or nursing home is sometimes not readily evident. For facilities that do not qualify as meeting 

the settings rule, the State Ombudsman reported that the program will need to help transition residents to 

other facilities that are not deemed institutional. Ombudsmen report that this is expected to be a hard and 

painstaking process, both for residents and for programs. 

In addition, one consequence of the HCBS Settings Final Rule is that some providers may not be able to 

comply with the requirements, thereby forcing service recipients in those settings to move elsewhere, or 

to find an alternative source of funding (other than Medicaid) to continue receiving services in their current 

setting. In these situations, Ombudsmen may be called upon to provide information and complaint 

resolution assistance with transitions, or they may need to work with other agencies if a facility closes due 

to loss of Medicaid funding. Given that many state and local Ombudsman programs struggle to conduct 

regular visits to HCBS settings (National Long-Term Care Ombudsman Resource Center, 2015), 

programs may have limited capacity to respond to all complaints if a state determines that many existing 

care settings do not meet the new HCBS settings requirements. 
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Medicaid Managed Care Final Rule

Medicaid and Children’s Health Insurance Program (CHIP) Managed Care Final 

Rule

In April of 2016, CMS released its Medicaid and Children’s Health Insurance Program (CHIP) Managed 

Care Final Rule. The Final Rule included Medicaid MLTSS, which are delivered through capitated 

Medicaid managed-care programs instead of fee-for-service arrangements. Key goals of these 

regulations included advancing delivery system reform and improving accountability and transparency. 

The managed-care regulations became effective in July 2017, but some provisions will be phased in over 

three years (Center for Medicaid and CHIP Services, n.d.). This reform was implemented in part because

of the growth in managed care described earlier, the rules for which were last updated in 2002. 

In states that operate MLTSS programs, State Ombudsmen reported the need to quickly educate 

themselves as well as staff and volunteers on the regulations in order to effectively advocate for 

consumers. As with the HCBS Settings Final Rule, other agencies and consumers turn to the 

Ombudsman program as a resource. For this reason, staff must be trained on the regulations to interpret 

them for members and provide guidance on how to best respond. State Ombudsmen also reported that 

any rule that affects the population the Ombudsman program serves also means that the program must 

monitor the regulation’s release and participate in commenting on federal requirements. 
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Updated Legislation and New Regulation for the LongTerm Care Ombudsman Program

As outlined in the OAA, states must meet specific requirements for Ombudsman programs but also 

exercise considerable discretion in fulfilling program functions in a manner that best serves their older 

adult populations. States can expand program responsibilities (e.g., supporting recipients of in-home 

services) and administer their programs in multiple ways (e.g., organizational location at both the state 

and local levels). This flexibility, as well as differing interpretations of the Act in the absence of formal 

guidance, has resulted in considerable state-level variation in the structure, operation, and effectiveness 

of Ombudsman programs. 

To address variability in 

Ombudsman program service 

delivery and effectiveness 

across and within states and 

territories, two recent legislative 

and regulatory activities were

undertaken. In 2015, ACL 

promulgated the State LongTerm Care Ombudsman 

Programs Final Rule (made 

effective in 2016), the first 

regulation focused specifically 

on States’ implementation of the 

Ombudsman program. 

Coinciding with the regulation’s 

implementation period, 

Congress renewed its 

commitment to providing 

services to older adults and 

reauthorized the OAA in 2016. 

Together, the LTCOP Final 

Rule and the provisions relating 

to Ombudsman programs in the 

reauthorized Act sought to 

protect vulnerable adults by 

strengthening Ombudsman 

programs. 

This section describes the 

experiences of Ombudsman 

programs in meeting the 

requirements of the updated 

legislation and new regulation. 

2016 Reauthorization of the Older Americans Act

The reauthorization of the OAA in 2016 included the following important 

changes and clarifications to the LTCOP:

■ Authorized Long-Term Care (LTC) Ombudsman programs to serve all 

LTC facility residents, regardless of their age. [Section 711(6)] 

■ Clarified that the State LTC Ombudsman is responsible for the fiscal 

management of the Office of the State LTC Ombudsman. [Section

712(a)(2)] 

■ Clarified that LTC Ombudsman programs may work to resolve complaints 

on behalf of residents unable to communicate their wishes, including 

those lacking an authorized representative. [Section 712(a)(3)(A)(i)& 

(a)(5)(vi)] 

■ Required State LTC Ombudsmen to ensure that residents have private, 

unimpeded access to the program. [Section 712(a)(3)(D)] 

■ Required LTC Ombudsman programs to actively encourage, and assist in 

the development of resident and family councils in long-term care 

facilities. [Section 712(a)(3)(H)(iii) & (a)(5)(vii)] 

■ Authorized LTC Ombudsman programs to serve residents transitioning 

from a LTC facility to a home-care setting, when feasible. [Section

712(a)(3)(I)] 

■ Clarified that the LTC Ombudsman program is considered a “health 

oversight agency” for purposes of the Health Insurance Portability and 

Accountability Act (HIPAA). [Section 712(b)(3)] 

■ Applied OAA disclosure provisions to all LTC Ombudsman program 

information (rather than only “files and records”) and clarified exceptions 

for disclosure of information relating to residents unable to communicate 

their wishes, including those lacking an authorized representative. 

[Section 712(d)(2)(c)] 

■ Provided specific examples of individual and organizational conflicts of 

interest, requiring remediation or removal of such conflicts. [Section

712(f)] 

■ Required that each State LTC Ombudsman or designee participate in 

training provided by the National Ombudsman Resource Center. [Section

712(h)(4)] 

■ Required the Director of the Office of Long-Term Care Ombudsman 

Programs to collect and analyze promising practices related to 

responding to elder abuse, neglect, and exploitation in long-term care 

facilities. [Section 201(d)(3)(M)]
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Older Americans Act (OAA) Reauthorization Act of 2016 

On April 19, 2016, the Older Americans Act Reauthorization Act of 2016 was signed into law to further 

promote the dignity and independence of older adults in their homes and communities and protect 

residents in long-term care facilities and other settings from abuse, neglect, and exploitation (see text 

box). To improve and strengthen the Ombudsman program’s effectiveness, the reauthorization focused 

on key clarifications and changes related to the service population (which now includes all long-term care 

residents, regardless of age), responsibilities for fiscal management of the program, disclosure of 

information, and remedying individual and organizational conflicts of interest. To help bring consistency to 

program service delivery, the reauthorization also included provisions related to training and development 

of resident and family councils. 

State Long-Term Care Ombudsman Programs Final Rule

ACL embarked on an historic undertaking in 2015 by promulgating the State Long-Term Care 

Ombudsman Programs Final Rule (hereafter, Final Rule) to clarify OAA provisions, particularly those that 

are unique to the program. First published February 11, 2015, and made effective July 1, 2016, the Final 

Rule focused its regulatory guidance on areas of greatest inconsistency in program implementation. Key 

provisions of the Final Rule focused on the following areas:

■ State Agency Policies (45 CFR §1321.11)

■ Establishment of the Office of the State Long-Term Care Ombudsman (45 CFR §1324.11)

■ Functions and Responsibilities of the State Long-Term Care Ombudsman (45 CFR §1324.13)

■ State Agency Responsibilities Related to the Ombudsman Program (45 CFR §1324.15)

■ Responsibilities of Agencies Hosting Local Ombudsman Entities (45 CFR §1324.17)

■ Duties of the Representatives of the Office (45 CFR §1324.19)

■ Conflicts of Interest (45 CFR §1324.21)

To help bring programs into compliance with the new regulation, ACL’s Central and Regional Offices and 

the National Long-Term Care Ombudsman Resource Center provided training and technical assistance to 

programs through conferences, webinars, and by providing a Frequently Asked Questions (FAQs) 

document. During the study’s data collection (2017-2018), programs were still actively working toward

meeting Final Rule requirements. Given this schedule, this report offers early findings on State 

Ombudsmen’s as well as stakeholders’ perceptions of the impact of implementing the Final Rule and the 

reauthorized OAA on program operations. The clarifications that State Ombudsmen discussed as most 

salient for the program included: 

■ The Office of the State Long-Term Care Ombudsman must be a distinct entity, separately identifiable 

within the state or territorial unit on aging (SUA) or other agency or organization in which it is housed

or connected; 

■ The State Ombudsman must be able to carry out mandated systems advocacy activities, making 

independent determinations and establishing positions of the Office, without representing the 

positions of the State agency or other entity housing the Office; and

■ Examples of individual and organizational conflicts of interest, and the requirement to remedy these 

conflicts through policies and procedures, or if necessary, changes to state statutory language or 

program location.
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Most federal staff, national stakeholders, and State Ombudsmen reported that implementation of the 

reauthorized OAA and Final Rule were positive developments that will eventually strengthen the 

program’s service delivery. Given the historic nature of the regulation, in many ways, the Final Rule

eclipsed changes that were outlined in the OAA reauthorization in terms of its impact on programs. 

Ombudsmen and stakeholders reported that they allocated considerable effort to understand and 

implement the Final Rule as well to educate entities with which they coordinate. 

Many federal staff and stakeholders reported that the Final Rule provided needed clarification around the 

role of the Ombudsman program and its relationship to other entities that serve older and vulnerable 

adults. Key stakeholders acknowledged that the Ombudsman program operated very differently across 

and within states and territories, and that these differences can lead to misunderstandings among 

partners and program staff at the state and local levels. The OAA reauthorization, and especially the Final 

Rule, served as useful tools to help educate the broader community about the role of the program and its 

staff. 

Given that State Ombudsmen frequently reported challenges with effectively communicating the role and 

uniqueness of the Ombudsman program and its need for independence to host agencies as well as 

entities with which they coordinate, many expressed appreciation for having its autonomy more clearly 

defined in the Final Rule. The Final Rule’s description of the Office of the State Long-Term Care 

Ombudsman when established in a state agency as “a distinct entity, separately identifiable and located 

within or connected to the State agency” underscored the OAA’s vision of the Ombudsman program’s 

independence. The regulation also clarified the State Ombudsman must be free to comment on policies 

and legislation without obtaining prior approval from the State agency. It additionally clarified that state 

policies and procedures must exclude the State Ombudsman and local staff from any state lobbying 

prohibitions that are inconsistent with the OAA in order for Ombudsmen to engage in mandated systems 

advocacy activities. 

Despite provisions to ensure program independence, however, political or bureaucratic pressures can still 

prevent State Ombudsmen from having the freedom to engage in systems advocacy. A few State 

Ombudsmen noted that their SUA or state government host agencies struggled to understand the need 

for programmatic independence, and another explained that in practice, advocating for independence can 

be challenging when the State agency is responsible for hiring, firing, and evaluating the State 

Ombudsman’s performance. Some State Ombudsmen also noted similar difficulties for local Ombudsmen 

whose host agencies have been slow to recognize that the role of an Ombudsman extends beyond 

individual advocacy. Having these programmatic elements more clearly defined in the Final Rule helped 

Ombudsmen communicate these long-standing requirements to other entities. 

Many State Ombudsmen also praised the additional guidance and clarification regarding individual and 

organizational conflicts of interest. As a result of these provisions, State Ombudsmen and SUA Directors 

were, at minimum, required to consider whether their program’s placement within a state agency was 

appropriate, mitigate or remedy any organizational conflicts, and where prohibited conflict existed, 

remove the conflict (i.e., some State Offices and local Ombudsman entities relocated to a different host 

agency to eliminate organizational conflicts). State Ombudsmen also were required to report their 

conflicts, remedies, and removals in NORS which is then reviewed by ACL for compliance. Other State 

Ombudsmen implemented new policies and procedures, developed MOUs, or secured separate legal 

counsel to mitigate existing conflicts. State Ombudsmen also discussed working with their SUAs and 

state legislatures to update statutes to enable compliance with the new regulations.
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Although many State Ombudsmen perceived that the Final Rule will strengthen and bring consistency to 

the Ombudsman program’s service delivery, they also reported challenges associated with implementing 

the new regulations, for both Ombudsman programs and entities with which they coordinate. Some 

stakeholders expressed concern about the provision that Ombudsmen cannot be mandatory reporters for 

abuse or neglect. One respondent viewed this as an ethical issue, and another was concerned about 

potential gaps in service in states where APS does not serve nursing home residents. Although other 

regulatory agencies such as the state survey agency may serve as the lead investigator, one State 

Ombudsman noted that Ombudsmen are often the primary intake for responses to cases of resident 

abuse or neglect. These scenarios required partnering agencies to review their own practices to 

determine if changes were needed to address potential gaps. Another stakeholder was concerned about 

privacy issues related to residents’ personal information, especially in the case where small town 

residents and their families may know the Ombudsman outside of their role in the program and may not 

want to share their information. It is important to note that the Final Rule clarified requirements regarding 

disclosure of resident identifying information and requires policies to identify, remedy, and remove 

individual conflicts of interest because of concerns shared by the stakeholder. 

One point of agreement among federal staff, stakeholders, and State Ombudsmen is that promulgation 

and implementation of the Final Rule were significant undertakings for all parties that support 

Ombudsman program operations. In developing the Final Rule, ACL invested heavily in working with, and 

obtaining buy-in from numerous federal staff, State Ombudsmen, and stakeholders in the aging network 

to ensure that the regulation addressed common concerns and areas of confusion. As one federal staff 

member described it, ACL sought “more consensus on the front-end, for more ownership on the backend.” ACL’s Central and Regional Office staff spent considerable time working with State Ombudsman 

programs to examine program structure, laws, regulations, organizational placement, and policies and 

procedures to help the programs understand areas that needed to be addressed, and to develop 

compliance plans. State Ombudsmen and program staff, in turn, dedicated substantial effort to 

understanding and implementing the regulation. 

Although the Final Rule went into effect on July 1, 2016, not all states were compliant at the time data 

were collected for this study. As of March, 2017, ACL had approved plans submitted by a majority of 

states that outlined the steps they would take to come into compliance, as well as timelines for completing 

those steps. Some programs were already compliant and simply needed to put their policies and 

procedures into writing. Others needed to make structural changes such as relocating the Office out of 

the state agency to eliminate conflicts of interest, or to secure changes to their state statutes. Because 

programs are subject to the schedule of state legislative sessions, programs' ability to make the required 

updates varied considerably – from months to years.
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Discussion

In response to both consumer preference and the rising need for LTSS over the last few decades, HCBS 

options have grown significantly. The expansion of care options has been accompanied by federal and 

state initiatives that encourage use of home and community-based care settings. For the Ombudsman 

program, the increasing number and diversity of populations and settings present important challenges 

and opportunities for service delivery. The Ombudsman program is not only required to advocate for a 

larger number of residents overall with more complex needs and special vulnerabilities, but programs 

must adapt to these expanding demands with resources that have not kept up with the program’s 

operational needs. 

Over time, the types of complaints that the Ombudsman program handles have become more complex 

and difficult. According to historical NORS data, the most common type of complaint addressed by 

Ombudsmen in nursing homes between 1997 and 2010 were failures to respond to requests for 

assistance (such as transfers to chairs/bed), followed by discharges and evictions. For the last seven 

years, “discharge/eviction – planning, notice, procedure, implementation, including abandonment” have

topped the list of the most frequently reported complaints handled by the program. Of the broader types 

of complaints, those related to “admission, transfer, discharge and eviction” are the most challenging and 

time-consuming to resolve. Part of these trends stem from increasing numbers of people with complex 

care needs and high acuity, including individuals with dementia and behavioral health issues. 

Compounding these issues are the challenges that occur when these special populations move across 

settings or between facilities. Ombudsmen in our study, as well as results from earlier research, indicate 

that facilities are more likely to involuntarily discharge a resident when care needs become challenging. 

Ombudsmen described limitations in their ability to fully resolve certain types of complaints, particularly 

when problems ultimately reside outside the program’s control, such as regulations that result in 

inadequate staffing or geographic considerations that preclude delivery of services to address special 

residential or care needs. 

In addition to the changing nature of complaints that programs handle, Ombudsmen must provide 

advocacy services to residents living in larger numbers of settings than in the past. Although the growth in 

less-restrictive settings is viewed by many as a positive development, this shift comes with important

challenges, including ensuring regular facility visits and effective advocacy against the backdrop of 

considerable variability in state-level regulations. 

These changes in the long-term care landscape compel programs to direct resources and advocacy 

efforts to areas of greatest need. At a time when many programs are experiencing fiscal and other 

resource constraints, programs have prioritized individual advocacy over systems advocacy and visits to 

nursing homes over board and care homes. Limited resources also compel programs to cultivate 

partnerships with other state and local agencies to support program implementation. State Ombudsmen 

are also turning to new regulatory reforms to help promote quality of care and protect resident rights and 

safety. 

Indeed, although the growth in the older population and the diversification of long-term care settings have 

been underway for several decades, only more recently have changes in legislation and regulations been 

implemented to support better oversight and care for consumers. Within just two years, CMS released 

three major regulations to modernize oversight of nursing homes and HCBS settings, and ACL published 

the first Ombudsman program regulation. The revised Nursing Homes Regulations, HCBS Settings Final 
NORC | The Long-Term Care Ombudsman Program and the Changing Landscape of Long-Term Services and Supports 

REPORT | 35 

Rule, Medicaid Managed Care Rule, and State Long-Term Care Ombudsman Programs Final Rule were 

all released between 2014 and 2016. 

While each regulation represents a milestone in reforming long-term care service delivery and provides 

the Ombudsman program with additional tools to advocate for residents, the concurrent implementation of 

these regulations within a short period of time has strained program resources. To varying degrees, each 

regulation requires that Ombudsman programs expend considerable effort to respond to the changing 

regulatory environment. This is especially true for meeting the requirements of the LTCOP Final Rule. 

While some states were already in compliance and only needed to formalize current practices and 

policies, other states needed to relocate programs and/or revise state statutes, policies, and procedures. 

This may take months to years, depending on each state’s legislative schedule. 

The last five years have witnessed an unusually intense period of regulatory and legislative activity in the 

long-term care delivery system, and consumers are expected to reap the benefits of these collective 

investments over time. Regulations and legislation alone, however, cannot assure quality long-term care 

without sustained advocacy. Indeed, implementation of some standards outlined in the recent Nursing 

Home Regulations are already under threat, as CMS has revised the rule around use of pre-dispute 

arbitration clauses and has proposed revisions to the 2016 requirements. 

Most State Ombudsmen report that considerable work remains to advance resident rights, quality of care, 

and quality of life. While the Ombudsman program has long struggled to meet its legislative mandates 

due to lack of sufficient funding, the combined impact of demographic, industry, and regulatory changes 

has created additional strain on programs’ capacity. As the long-term care delivery system evolves, 

Ombudsman programs will continue adapting to changing demands, yet they can only do so effectively 

with adequate resources that support full program implementation. To keep pace with changes in the 

long-term care landscape, increased funding for the program is critical to serve an ever-growing 

population of older adults with more complex needs who live in a diverse array of residential and nonresidential care settings.
NORC | The Long-Term Care Ombudsman Program and the Changing Landscape of Long-Term Services and Supports 

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Glossary of Terms & Acronyms

Aging network – The OAA established a national network of federal, state, and local agencies to plan 

and provide services that help older adults to live independently in their homes and communities. 

Collectively, this structure of agencies is referred to as the aging network. The national aging network is 

headed by the Administration on Aging and includes 56 state and territorial units of aging (SUAs), 622 

Area Agencies on Aging (AAAs), and over 260 Title VI Native American aging programs (AoA, 2019).

Area Agency on Aging (AAA) – AAAs are public or private nonprofit agencies designated by a state to 

address the needs and concerns of older persons at the regional and local levels. AAAs are primarily 

responsible for a geographic area (e.g. a planning and service area or PSA), that is either a city, a single 

county, or a multi-county district (ACL, 2019). 

Board and care homes – These homes include residential care facilities, adult congregate living 

facilities, assisted living facilities, foster care homes, and other adult care homes similar to a nursing 

facility or board and care home which provide room, board, and personal care services to a primarily 

older residential population. See also “residential care community/facility.”

Home and community-based services (HCBS) – HCBS refers to types of person-centered care 

delivered to individuals with functional limitations who need assistance with everyday activities (such as 

getting dressed or bathing) in their home or community. HCBS are often designed to enable people to 

remain in their homes, rather than moving to a facility for care and generally fall into two categories – 

health services and human services. HCBS programs may offer a range of services from one or both 

types of services (CMS, 2019: https://www.cms.gov/Outreach-and-Education/American-Indian-AlaskaNative/AIAN/LTSS-TA-Center/info/hcbs).

Long-term services and supports (LTSS) – LTSS encompasses the broad range of paid and unpaid 

medical and personal care assistance that people may need when they experience difficulty completing 

self-care tasks as a result of aging, chronic illness, or disability. Long-term services and supports include, 

but are not limited to, nursing facility care, adult daycare programs, home health aide services, personal 

care services, transportation, supported employment, and assistance provided by a family caregiver 

(Reaves & Musumeci, 2015). 

National Association of States United for Aging and Disabilities (NASUAD) – Founded in 1964, 

NASUAD is a non-profit association representing the nation’s 56 officially designated state and territorial 

agencies on aging (SUAs). Their mission is to design, improve, and sustain state systems delivering 

home and community-based services and supports for people who are older or have a disability, and their 

caregivers (NASUAD, 2019). In August of 2019, NASUAD changed its name to ADvancing States.

National Long-Term Care Ombudsman Resource Center (Resource Center) – The Resource Center 

provides support, technical assistance and training to the 53 State Long-Term Care Ombudsman 

Programs and their statewide networks of local Ombudsman entities. Funded by ACL, the Center is 

operation by Consumer Voice, in cooperation with NASUAD. The Center’s objectives are to enhance the 

skills, knowledge, and management capacity of the State programs to enable them to handle residents’ 

complaints and represent resident interests in both individual and systems advocacy (Resource Center, 

2019).
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National Ombudsman Reporting System (NORS) – NORS is the administrative data collection tool for 

the LTCOP. Used by Ombudsman programs since 1996, NORS provides national and state-specific data 

on programmatic efforts, including facility visits, complaint types and resolution, consultations, resident 

and family councils, community education and program information such as funds expended and 

numbers of program staff. States report aggregated data annually to the Administration for Community 

Living (ACL), 

Nursing homes – Also referred to as nursing facilities, these homes are licensed by the state to offer 

residents personal care as well as skilled nursing care on a 24-hour/day basis. These include skilled 

nursing facilities. Services provided include nursing care, personal care, room and board, supervision, 

medication, therapies and rehabilitation (ASPE, n.d.).

Residential care community/facility – Similar to board and care homes, a residential care community 

refers to a type of long-term care facility, regardless of setting, that provides at a minimum, room and 

board, around-the-clock on-site supervision, and help with personal care such as bathing and dressing or 

health-related services such as medication management. Facility types include but are not limited to: 

assisted living; board and care home; congregate care; enriched housing programs; homes for the aged; 

personal care homes; adult foster/ family homes and shared housing establishments that are licensed, 

registered, listed, certified, or otherwise regulated by a state (NORS OMB#0985-0005).

State Unit on Aging (SUA) – State or territorial units on aging (SUAs) are designated state-level 

agencies that are responsible for developing and administering multi-year state plans that advocate for 

and provide assistance to older residents, their families, and in many states, for adults with physical 

disabilities. The SUA is the grantee of the federal funds designated for the LTCOP, and as a result, has 

certain responsibilities to the LTCOP (e.g. providing personnel supervision and management for the State 

Ombudsman and representatives of the Office who are employees of the SUA) (ACL, 2019).

The National Consumer Voice for Quality Long-Term Care (Consumer Voice) – The Consumer Voice 

is the leading national voice representing consumers in issues related to long-term care, helping to 

ensure that consumers are empowered to advocate for themselves. They are also a primary source of 

information and tools for consumers, families, caregivers, advocates, and Ombudsmen to help ensure 

quality care for individuals (Consumer Voice, 2019).
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