FINAL REPORT

Process Evaluation of the Long-Term Care 

Ombudsman Program (LTCOP) 

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 and 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

Jennifer Scolese, MPP

Sarah Downie, MPP

Kristen Neishi, MA

Kathleen Taylor, MSPH 

Tim Mulcahy, MPP

NORC at the University of Chicago

4350 East-West Highway

Bethesda, MD 20814

(301) 634-9300
NORC | Process Evaluation of the Long-Term Care Ombudsman Program (LTCOP)

FINAL REPORT | I 

Table of Contents 

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

1.1. Background................................................................................................................................... 1

1.2. Overview of the Process Evaluation ............................................................................................. 2

1.3. Highlights of Process Evaluation Findings.................................................................................... 3

1.3.1. Research Question 1: How is the LTCOP structured and how does it operate 

at the local, state, and federal levels?............................................................................. 3

1.3.2. Research Question 2: How do LTCOPs use existing resources to resolve 

problems of individual residents and to bring about changes at the facility and 

government (local, state, and federal) levels that will improve the quality of 

services available/provided?........................................................................................... 7

1.3.3. Research Question 3: With whom do LTCOPs partner, and how do LTCOPs 

work with partner programs?......................................................................................... 14

1.3.4. Research Question 4: How does the LTCOP provide feedback on successful

practices and areas for improvement?.......................................................................... 15

1.4. Recommendations ...................................................................................................................... 17

Chapter 2. Introduction............................................................................................................................. 21

2.1. Background................................................................................................................................. 22

2.1.1. Older Americans Act...................................................................................................... 22

2.1.2. Long-Term Care Ombudsman Program........................................................................ 23

2.2. Overview of the Process Evaluation ........................................................................................... 24

2.2.1. Research Questions...................................................................................................... 24

2.3. Organization of the Report.......................................................................................................... 24

Chapter 3. Process Evaluation Data and Methodology ........................................................................ 25

3.1. Secondary Data Sources............................................................................................................ 25

3.2. Primary Data Sources................................................................................................................. 26

3.2.1. Sample Selection........................................................................................................... 26

3.2.2. Data Collection Procedures and Response Rates........................................................ 28

3.2.3. Interview and Survey Topic Areas................................................................................. 29

3.2.4. Analytic Approach.......................................................................................................... 30

Chapter 4. Research Question 1: How is the LTCOP structured and how does it operate at the 

local, state, and federal levels? ............................................................................................................... 32

4.1. Key Findings ............................................................................................................................... 32

4.1.1. Program Structure and Operations ............................................................................... 32

4.1.2. Reauthorization of OAA and Implementation of the Final Rule .................................... 34

4.1.3. Support from SUA Directors and ACL Central and Regional Offices ........................... 35

4.2. Introduction ................................................................................................................................. 36

4.3. Findings....................................................................................................................................... 36

4.3.1. Federal Law, Regulations, and Ombudsman Program Oversight ................................ 36
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4.3.2. Program Structure at the Federal, State, and Local Levels .......................................... 42

4.3.3. Federal Level – ACL Central and Regional Offices ...................................................... 43

4.3.4. Program Structure and Organizational Placement at the State and Local Levels........ 46

4.4. Recommendations ...................................................................................................................... 56

Chapter 5. Research Question 2: How do LTCOPs use existing resources to resolve 

problems of individual residents and to bring about changes at the facility and governmental 

(local, state and federal) levels that will improve the quality of services available/provided? ........ 57

5.1. Key Findings ............................................................................................................................... 57

5.1.1. Program Resources....................................................................................................... 57

5.1.2. Program Activities.......................................................................................................... 58

5.1.3. Individual Advocacy....................................................................................................... 58

5.1.4. Systems Advocacy ........................................................................................................ 60

5.1.5. Adequacy of Resources ................................................................................................ 61

5.1.6. Strategies to Address Resource Constraints ................................................................ 62

5.1.7. Factors that Facilitate Meeting Program Mandates ...................................................... 63

5.2. Introduction ................................................................................................................................. 64

5.3. Findings....................................................................................................................................... 65

5.3.1. Program Resources....................................................................................................... 65

5.3.2. Ombudsman Program Activities.................................................................................... 84

5.4. Recommendations .................................................................................................................... 105

Chapter 6. Research Question 3: With whom do LTCOPs partner, and how do LTCOPs 

work with partner programs? ................................................................................................................ 107

6.1. Key Findings ............................................................................................................................. 107

6.1.1. Role of Partnerships at the Federal Level................................................................... 107

6.1.2. Types of Partnerships and Interactions at the Federal, State, and Local Levels........ 107

6.1.3. Requirements for Coordination with Entities and Perceptions of Effectiveness ......... 107

6.1.4. Benefits and Challenges of Partnerships .................................................................... 108

6.2. Introduction ............................................................................................................................... 108

6.3. Findings..................................................................................................................................... 109

6.3.1. LTCOP Partnerships at the Federal Level .................................................................. 109

6.3.2. OAA and Final Rule Requirements for Coordination .................................................. 110

6.3.3. Activities Supported by Partnering with Other Entities................................................ 113

6.3.5. Sufficiency and Effectiveness of Partnerships ............................................................ 117

6.4. Recommendations .................................................................................................................... 123

Chapter 7. Research Question 4: How does the LTCOP provide feedback on successful 

practices and areas for improvement?................................................................................................. 125

7.1. Key Findings ............................................................................................................................. 125

7.1.1. Training and Technical Assistance.............................................................................. 125

7.1.2. LTCOP Data Collection and Reporting ....................................................................... 126
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7.2. Introduction ............................................................................................................................... 126

7.3. Findings..................................................................................................................................... 127

7.3.1. Training and Technical Assistance for Ombudsmen................................................... 127

7.3.2. Data Collection and Reporting .................................................................................... 135

7.4. Recommendations .................................................................................................................... 139

Appendix A: Acronyms .......................................................................................................................... 140

Appendix B: Glossary of Terms ............................................................................................................ 141
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List of Exhibits

Exhibit 1: Research Questions and Data Sources............................................................................... 25

Exhibit 2: Respondent Classes and Data Collection Method .............................................................. 26

Exhibit 3: States Participating in Local Data Collection ....................................................................... 28

Exhibit 4: Survey Response Rates by Respondent Class ................................................................... 29

Exhibit 5: Effectiveness of Relationship with ACL Central and Regional Offices ................................ 46

Exhibit 6: Program Structure and State Office Organizational Placement........................................... 47

Exhibit 7: Local Ombudsman Entity Organizational Placement by Program Structure ....................... 47

Exhibit 8: Local Ombudsman Entity Autonomy by Program Structure ................................................ 49

Exhibit 9: State Ombudsman Perceptions of Statewide Program Effectiveness by Program 

Structure............................................................................................................................... 49

Exhibit 10: Local Ombudsman Perceptions of Statewide Program Effectiveness by Program 

Structure............................................................................................................................... 50

Exhibit 11: Local Ombudsman Perceptions of Effectiveness of Relationship between Central 

State Office and Local Ombudsman Entity by Program Structure....................................... 50

Exhibit 12: State Office Organizational Placement ................................................................................ 51

Exhibit 13: Autonomy of Ombudsman Program by State Office Organizational Placement ................. 53

Exhibit 14: Ability to Determine Use of Fiscal Resources to Operate LTCOP by State Office 

Organizational Placement.................................................................................................... 53

Exhibit 15: State Ombudsman Perceptions of Statewide Program Effectiveness by State Office 

Organizational Placement.................................................................................................... 53

Exhibit 16: Local Ombudsman Entity Organizational Placement........................................................... 54

Exhibit 17: Support from SUA Director by State Office Organizational Placement ............................... 55

Exhibit 18: Statewide Program Funds Expended ($ in millions)............................................................ 66

Exhibit 19: Minimum, Maximum, and Average Program Expenditures per State* ................................ 66

Exhibit 20: State Offices and Local Ombudsman Entities that Secure Additional Financial 

Resources ............................................................................................................................ 67

Exhibit 21: FFY 2017 Ombudsman Staff and Volunteersa..................................................................... 69

Exhibit 22: Motivation to Work for the LTCOP ....................................................................................... 70

Exhibit 23: Staff Tenure with Ombudsman Program.............................................................................. 70

Exhibit 24: Held Previous Positions in the LTCOP ................................................................................ 71

Exhibit 25: State Ombudsman Ability to Determine use of Resources to Operate the 

Ombudsman Program at the State Level............................................................................. 72

Exhibit 26: Ability of State Ombudsmen with Decentralized Programs to Approve 

Allocation of Federal and State Funds to Local Programs .................................................. 73
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Exhibit 27: Time Dedicated to the LTCOP............................................................................................. 74

Exhibit 28: Management Functions Performed by Local Ombudsmen.................................................. 74

Exhibit 29: Activities Performed by Local Ombudsmen ......................................................................... 74

Exhibit 30: Activities Performed By Volunteer Ombudsmen.................................................................. 76

Exhibit 31: Sources of Legal Counsel .................................................................................................... 78

Exhibit 32: Scope of Legal Assistance Available to the Office of the SLTCO ....................................... 79

Exhibit 33: Legal Counsel Knowledge ................................................................................................... 80

Exhibit 34: Effectiveness of Legal Assistance........................................................................................ 81

Exhibit 35: Resources Sufficient to Enable the Program to Meet Federal Mandates............................ 82

Exhibit 36: Ombudsman Program Activities Not Carried Out Fully Due to Lack of Resources............. 83

Exhibit 37: Statewide Program Goals for Visiting Facilities ................................................................... 85

Exhibit 38: Statewide Average Frequency of LTCOP Visits to Most or All Facilities ............................. 86

Exhibit 39: Frequency of Local and Volunteer Ombudsman Visits to Long-Term Care Facilities ......... 86

Exhibit 40: Decisions Made About Facility Visits ................................................................................... 87

Exhibit 41: Average Amount of Time Local and Volunteer Ombudsmen Spent in Facility for 

Each Routine Visit................................................................................................................ 87

Exhibit 42: Visits to Nursing Homes or Board and Care Homes............................................................ 88

Exhibit 43: Ombudsman Visits to Long-Term Care Facilities – Type of Visit and Facilities Assigned .. 89

Exhibit 44: Frequency of Problems Accessing Residents in Long-Term Care Facilities ....................... 90

Exhibit 45: Top Ten Most Frequent Complaint Types (FFY 2017) ........................................................ 91

Exhibit 46: Type of Complainant and Number and Percentage of Cases Closed (FFY 2017).............. 92

Exhibit 47: Complaints Handled by Local Ombudsmen and Volunteer Ombudsmen ........................... 93

Exhibit 48: Effectiveness of Ombudsman Program’s Relationship with Nursing Homes and 

Board and Care Homes (State Ombudsmen)...................................................................... 94

Exhibit 49: Effectiveness of Local Ombudsman Entity’s Relationship with Nursing Homes and 

Board and Care Homes (Lead Local Ombudsmen) ............................................................ 94

Exhibit 50: Effectiveness of Relationship with Nursing Homes and Board and Care Homes 

(Local Ombudsmen)............................................................................................................. 94

Exhibit 51: Effectiveness of Relationship with Nursing Homes and Board and Care Homes 

(Volunteer Ombudsmen)...................................................................................................... 94

Exhibit 52: Sufficiency of State Board and Care Home Regulations to Enable State Ombudsman 

Programs to Adequately Serve Residents ........................................................................... 96

Exhibit 53: Responsibility for Systems Advocacy Work......................................................................... 98

Exhibit 54: Systems Advocacy Activities Performed by Local Ombudsmen .......................................... 99

Exhibit 55: Education/Outreach Activities Performed by Local Ombudsmen ...................................... 105

Exhibit 56: Regular Interaction with Entities Enumerated in the OAA and LTCOP Final Rule............ 111
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Exhibit 57: Other Entities with whom the State and Local Ombudsmen Programs Coordinate .......... 112

Exhibit 58: State and Local Level Work Groups .................................................................................. 113

Exhibit 59: Organizations with whom Ombudsmen Partner to Advance Individual Advocacy Goals.. 114

Exhibit 60: Organizations with whom Ombudsmen Partner to Advance Systems Advocacy Goals ... 115

Exhibit 61: Organizations with whom Ombudsmen Partner to Advance Education/Outreach Goals.. 117

Exhibit 62: Relationship with Entities Enables Ombudsman Program to Meet Residents’ Needs ...... 118

Exhibit 63: Effectiveness of Relationship with Facilities and Providers – Nursing Homes .................. 118

Exhibit 64: Effectiveness of Relationship with Facilities and Providers – Board and Care Homes ..... 119

Exhibit 65: Visit Frequency and Effectiveness of Facility Relationships – Nursing Homes 

(Lead Local Ombudsmen).................................................................................................. 120

Exhibit 66: Visit Frequency and Effectiveness of Facility Relationships – Board and Care 

(Lead Local Ombudsmen).................................................................................................. 120

Exhibit 67: Orientation, Training, and Support Provided for Ombudsmen........................................... 127

Exhibit 68: Ongoing Training and Support for Ombudsmen ................................................................ 128

Exhibit 69: Training and Assistance on Documentation of Ombudsman Program Activities............... 129

Exhibit 70: Frequency of Local Ombudsmen’s Performance Reviews ................................................ 129

Exhibit 71: Volunteer Ombudsman Receipt of Performance Reviews................................................. 129

Exhibit 72: Sufficiency of Resources Provided by the Resource Center for Carrying Out 

Program Responsibilities ................................................................................................... 130

Exhibit 73: Sufficiency of Resources Provided by the Resource Center for Carrying Out 

Individual Ombudsman Work............................................................................................. 130

Exhibit 74: Perceived Helpfulness of National, State, and Local Resources (State Ombudsmen)..... 131

Exhibit 75: Perceived Helpfulness of National, State, and Local Resources (Local Ombudsmen)..... 131

Exhibit 76: Perceived Helpfulness of National, State, and Local Resources (Volunteer 

Ombudsmen)...................................................................................................................... 132

Exhibit 77: Ombudsmen’s Perceived Effectiveness of their Orientation Training................................ 133

Exhibit 78: Ombudsmen’s Perceptions of Whether Other Training Would Have Been 

Helpful during Orientation Period....................................................................................... 134

Exhibit 79: Ombudsmen’s Interest in Additional Types of Training and Support................................. 135

Exhibit 80: Adequacy of Statewide Program’s Data Collection System for Annual Reporting ............ 136

Exhibit 81: Frequency of Report Submission....................................................................................... 137

Exhibit 82: Ease of Collecting Data and Submitting Reports............................................................... 137

Exhibit 83: Use of NORS Data............................................................................................................. 138
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List of Tables

Table A: Program Structure and Organizational Placement.................................................................... 150

Table B: Program Expenditures by Source – Federal, State, Local and Total Funds (FFY 2017).......... 152

Table C: Program Data – Totals and by State/Territory........................................................................... 154

Table D: Program Data, Continued – Totals and by State/Territory ........................................................ 156

Table E: Complaint Dispositions – All Facilities (Nursing Homes and Board and Care Homes)............. 158

Table F: Complaint Dispositions – Nursing Homes.................................................................................. 160

Table G: Complaint Dispositions – Board and Care Homes.................................................................... 162
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Chapter 1. Executive Summary

1.1. Background

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

Care Ombudsman program (LTCOP, or Ombudsman program) began in 1972 as a Public Health Service 

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

service, the program aims to provide a voice for long-term care residents. The Older Americans Act 

(OAA, or the Act) 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. The 2006 OAA amendments 

expanded the definition of board and care to include assisted living facilities. Today the Ombudsman 

program is administered by the Administration on Aging (AoA), within the Administration for Community 

Living (ACL) of the United States Department of Health and Human Services (DHHS). Through grants to 

states and territories, the Ombudsman program operates in all 50 states, as well as the District of 

Columbia, Puerto Rico, and Guam. 

Since its inception, the Ombudsman program has played a unique role in protecting and promoting longterm care residents’ health, safety, welfare, and rights – the program’s services are not duplicated by any 

other federal agency. To fully represent residents’ interests and improve the quality of their lives and care, 

the OAA delineated program responsibilities at both the individual and systems levels. At the individual 

level, Ombudsmen1 assist residents by resolving complaints about their care, and help ensure that their 

rights are protected. In addition to investigating and resolving problems, Ombudsmen play a sentinel role 

through the facility and resident visits they routinely conduct. Serving as the “eyes and ears” of the 

program, Ombudsmen help address residents’ concerns before they rise to the level of complaints 

requiring intervention by preventing actions or inactions that unfavorably impact residents’ care, rights, 

and quality of life. At the systems level, Ombudsmen advocate at the local, state, and federal levels for 

improvements in the long-term care system that benefit residents. These activities are not limited to 

legislative advocacy, but include coalition-building, speaking to the media, and other strategies that 

broadly advance residents’ rights and well-being. To help build capacity for both individual and systems 

advocacy, the program also carries out education and outreach activities. These activities include 

providing information and consultation to facilities, residents and their families, collaborating with other 

agencies, supporting family and resident councils, developing citizen organizations, and empowering 

residents as well as their families and caregivers to be effective advocates. 

Ombudsman program functions are performed by a State Long-Term Care Ombudsman who heads an 

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

territorial unit on aging (SUA). The State Ombudsman is responsible for statewide program administration 

and oversight of designated representatives of the Office, including paid staff and volunteers. In federal 

fiscal year (FFY) 2017, 1,319 full-time equivalent staff (FTEs) and 6,625 designated volunteer 

Ombudsmen supported the program. 

To enhance the skills, knowledge, and management capacity of LTCOPs, the National Long-Term Care 

Ombudsman Resource Center (Resource Center) was established in 1992. Hosted since 1994 by The 

 

1 In the OAA and Final Rule, “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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National Consumer Voice for Quality Long-Term Care (Consumer Voice), in cooperation with the National 

Association of States United for Aging and Disabilities (NASUAD),

2 the Resource Center supports 

programs by providing training, technical assistance, and information dissemination. The LTCOP’s work is 

also enhanced by membership organizations, including the National Association of State Long-Term Care 

Ombudsmen Programs (NASOP) at the state level, and the National Association of Local Long-Term 

Care Ombudsmen (NALLTCO) at the local level. These affiliations provide professional and educational 

opportunities, information sharing, and advocacy support to members.

Over the years, various aspects of the Ombudsman program have been studied, but the only national 

evaluation of the program was carried out in 1995 by the Institute of Medicine (IOM). In the more than two 

decades since the IOM evaluation, the Ombudsman program has come to operate under a very different 

long-term care landscape. The rapid aging of the U.S. population, growing consumer preference for 

receipt of home and community-based services (HCBS), both at home and in other residential settings, 

and changes in the delivery and financing of post-acute care and long-term services and supports (LTSS) 

have had a substantial impact on the program’s service delivery. These trends pose challenges as well as 

opportunities for Ombudsman programs at a time when significant new regulatory actions have been 

introduced. With the 2016 reauthorization of the OAA and implementation of the State Long-Term Care 

Ombudsman Programs Final Rule (hereafter, Final Rule), states have been newly tasked with ensuring 

that the structure and implementation of their Ombudsman programs are compliant with these provisions. 

Concurrent changes in both the landscape of long-term care service provision and the program itself 

present an opportunity to understand how the Ombudsman program is progressing toward achieving its 

legislatively-mandated goals. To assess and strengthen the program’s ability to meet its mandates, ACL

contracted with NORC at the University of Chicago (NORC) and our partners to conduct a comprehensive 

process evaluation of the LTCOP. The NORC research team includes Consumer Voice, Resnick, 

Chodorow & Associates, Associate Professor Brooke Hollister, Ph.D. of the University of California, San 

Francisco, Health Benefits ABCs, and Human Services Research Institute (HSRI). The following report 

summarizes findings from the process evaluation and based on those analyses, offers recommendations 

for improving Ombudsman program practices.

This report is one of seven products that have been developed as part of the NORC team’s process 

evaluation of the Ombudsman program. Other products include a report on the relationship between the 

Ombudsman program and the changing landscape of LTSS and five research briefs. The latter focuses

on the following topics: (1) understanding the uniqueness of the Ombudsman program in the context of 

the aging network, (2) resident complaint handling, (3) systems advocacy and organizational placement, 

(4) use of volunteers, and (5) promising practices. Looking ahead, an outcome evaluation of the 

Ombudsman program is currently being implemented. That study will offer additional findings on the 

effectiveness of Ombudsman programs. 

1.2. Overview of the Process Evaluation

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

assessing the LTCOP’s implementation at the federal, state, and local levels. To that end, this report 

examines the program’s structure and operations, use of resources to carry out its legislative mandates, 

the nature of Ombudsman program partnerships, and program quality assurance activities. Four research

questions form the basis of the process evaluation, including: 

 

2 In August 2019, NASUAD changed its name to ADvancing States.
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1. How is the LTCOP structured and how does it operate at the local, state, and federal levels?

2. How do LTCOPs use existing resources to resolve problems of individual residents and to bring 

about changes at the facility and governmental (local, state, and federal) levels that will improve 

the quality of services available/provided?

3. With whom do LTCOPs partner, and how do LTCOPs work with partner programs?

4. How does the LTCOP provide feedback on successful practices and areas for improvement?

The study also includes sub-questions that ask who the program serves, how is it staffed, and what data 

are collected about activities and outcomes. 

To address these four main research questions and sub-questions, we collected qualitative and 

quantitative data from primary and secondary data sources. Existing data sources included the National 

Ombudsman Reporting System data (NORS; the program’s administrative data collection tool) as well as 

the Resource Center’s training and technical assistance materials. 

For research questions that could not be addressed by existing data sources, we obtained information 

from program staff at the federal, state, and local levels, as well as national stakeholders who were 

positioned to provide input on LTCOP activities and operations. Primary data collection included 

telephone interviews and surveys (both web- and paper-based). Based on input and priorities from ACL, 

five ACL Central and Regional staff members, three representatives from other federal agencies, and 16 

stakeholders participated in the evaluation. These respondents were purposefully selected because each 

had a unique perspective and was able to provide important information concerning the intra- and interagency relationships that were of interest to the study. 

All 53 State Ombudsmen were invited to participate in the evaluation. This decision was driven by the 

considerable variability across programs in how the LTCOP is administered, and the importance of 

understanding the programmatic implications of this variability. 

For the local data collection, a multistage, stratified sampling approach was used. To ensure that every 

ACL region was represented, sampling began with stratifying programs by the 10 ACL regions. Within 

each region, at least two states were selected randomly. We identified a sample of 27 states to capture 

the diversity of Ombudsman program structures and organizational placements. In sampled states, all 

local Ombudsmen were invited to participate in the study, and half of volunteer Ombudsmen were 

randomly sampled and invited to participate. 

1.3. Highlights of Process Evaluation Findings

1.3.1. Research Question 1: How is the LTCOP structured and how does it operate at the local, 

state, and federal levels? 

Program Structure and Operations

1. The Older Americans Act (OAA) and the Long-Term Care Ombudsman Programs Final Rule 

(Final Rule) provide legislative and regulatory guidance and requirements for the structure and 

operations of Long-Term Care Ombudsman programs (LTCOPs). 

2. Long-Term Care Ombudsman programs are administered by the Administration on Aging (AoA), 

within the Administration for Community Living (ACL) of the United States Department of Health 

and Human Services (DHHS). As the chief federal agency charged with helping to maximize the 
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independence of older adults and individuals with disabilities, ACL issues OAA grants to State 

agencies, known as state or territorial units on aging (SUAs). These designated, state-level 

agencies are responsible for developing and administering multi-year state plans for OAA 

activities and programs, including the Long-Term Care Ombudsman program.

3. Within ACL, Central and Regional Offices3 provide critical support to State Long-Term Care 

Ombudsman programs.

a. The Office of Long-Term Care Ombudsman Programs (Central Office) includes the 

Director of the Long-Term Care Ombudsman Programs and the Ombudsman Program 

Specialist who together support States’ implementation of OAA grants for their LongTerm Care Ombudsman programs. In addition to administrative duties, the OAA requires 

that the Director of the Long-Term Care Ombudsman Program advocate on behalf of 

residents of long-term care facilities within DHHS and other departments, agencies, and 

instrumentalities of the federal government. This advocacy includes all federal policies 

affecting populations that are covered by the Ombudsman program. 

b. The Office of Regional Operations (Regional Office) serves as the focal point for the 

development, coordination, and administration of ACL programs across ACL’s 10 

regions. The Regional Office is also the local point of contact for SUAs. 

4. SUAs are responsible for establishing an Office of the State Long-Term Care Ombudsman (Office 

or Office of the SLTCO) that is distinct, and separately identifiable from the SUA. The OAA also 

requires that SUAs ensure that Ombudsman programs have sufficient resources and protections 

to carry out their legislatively mandated functions. This includes establishing or ensuring policies 

and procedures; monitoring local programs (where applicable); ensuring Ombudsmen have 

private and unimpeded access to residents; providing disclosure of information provisions; 

ensuring freedom from individual and organizational conflicts of interest; assigning adequate legal 

counsel, and managing personnel functions if programs are organizationally located within the 

SUA. 

5. The Office of the SLTCO is headed by a full-time State Ombudsman who is responsible for the 

leadership and management of the State Long-Term Care Ombudsman program in coordination 

with the SUA, and where applicable, any other host agency that implements the Ombudsman 

program. Key duties of State Ombudsmen include statewide program administration and 

oversight of representatives of the Office at the state and local levels.

6. The OAA affords broad flexibility to State agencies in how they administer Ombudsman 

programs. This administration is defined by both the program’s structure and its organizational 

placement. 

a. A program’s structure can be described as either centralized or decentralized. In a 

centralized structure, all program staff are employees of the agency housing the Office of 

the SLTCO. In a decentralized structure, the Office of the SLTCO is housed in a state 

agency or contracted entity, but local Ombudsman staff are employed by another 

contracted entity designated by the State Ombudsman as a local Ombudsman entity. 

b. Organizational placement refers to the location of the program. At both the state and local 

levels, programs can be “hosted” by (or housed within) the SUA, or with another agency 

or entity that is under contract with the SUA to administer the Ombudsman program. 

These placements include other state or local government agencies, independent 

 

3 As of June 2019, the Regional Office became the “Center for Regional Operations.”
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agencies within state government, or within nonprofit organizations, including freestanding Ombudsman programs. 

7. There are 21 state Ombudsman programs with a centralized program structure. Of these, eight

programs have Offices that are housed within SUAs, and the remaining 13 are housed outside of 

SUAs. By definition, centralized programs do not have local entities. However, some centralized 

programs have offices located outside of the State Office that facilitate statewide access to the 

program. 

8. There are 32 state Ombudsman programs with a decentralized program structure. Of these, 25 

programs have Offices that are housed within SUAs, and the remaining seven are housed 

outside of SUAs. 

a. Decentralized state Ombudsman programs have local Ombudsman entities located 

within a number of different organizational placements, although most are housed within 

Area Agencies on Aging (AAAs) or nonprofit social service agencies. 

9. Ombudsman programs’ structure offer notable advantages and disadvantages.

a. State Ombudsmen whose programs are characterized by a centralized structure reported 

that they could ensure consistency in their program’s implementation across all program 

staff. This was partly attributed to having greater direct access to, and communication 

with staff that facilitates coordination of activities. At the same time, a few State 

Ombudsmen reported that increased oversight can be difficult to manage when staff are 

geographically dispersed throughout the state. 

b. State Ombudsmen with decentralized programs reported greater ability to carry out 

systems advocacy and higher levels of local program autonomy in setting priorities, 

compared to their counterparts who lead centralized programs. However, State 

Ombudsmen with decentralized programs were also more likely to report fragmentation in 

service delivery across local programs and conflicts with local host agencies concerning 

personnel management. They also described challenges managing fiscal resources due 

to lack of access to detailed budget information at the local level. 

10. Ombudsman programs’ organizational placement at the state and local levels offer notable 

advantages and disadvantages.

a. State Ombudsmen whose programs are housed within nonprofit organizations reported 

high levels of autonomy. Similarly, local Ombudsmen whose local Ombudsman entities

are housed within legal services providers and social services nonprofit agencies 

reported higher autonomy than their counterparts whose programs have other 

organizational placements. Limited autonomy for State and local Ombudsmen whose 

programs are located in central State Offices within SUAs was particularly evident as it 

related to carrying out systems advocacy, speaking with the media, and having control 

over their program’s fiscal resources.

b. State Ombudsmen outside SUAs (65%) were more likely to report having control to 

determine the use of fiscal resources to operate their programs compared to those whose

programs are housed within SUAs (44%)

c. State and local Ombudsmen whose programs are housed within SUAs, AAAs, or other 

state or local government agencies reported benefiting from “built-in” resources, such as 

human resources, data systems, information technology (IT), and legal assistance. 
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d. Several State Ombudsmen whose programs are housed within SUAs reported having 

greater visibility for the Ombudsman program among relevant groups, a “seat at the 

table” in important discussions about long-term care, and the ability to engage in 

coordinated efforts with key organizations. Proximity to partner organizations that are colocated within the SUA was also described as facilitating greater opportunities for crosstrainings. 

e. State Ombudsmen whose programs are housed within SUAs reported greater risk for 

organizational conflicts of interest, and less independence to operate the program. For 

example, when legal counsel is shared among the Ombudsman program and the SUA or 

other agencies such as licensing and certification or APS, State Ombudsmen reported 

that it may be difficult to obtain legal advice that prioritizes the Ombudsman program and 

long-term care residents. 

Reauthorization of OAA and Implementation of the Final Rule 

1. Implementation of the Final Rule affected Ombudsman programs’ organizational placement at 

both the state and local levels.

a. A few State Ombudsmen reported moving or being in the process of identifying new

homes for their State Offices or local Ombudsman entities to comply with regulations that 

require avoidance of organizational conflicts of interest. 

2. Most State Ombudsmen reported that implementation of the reauthorized OAA and Final Rule will 

eventually strengthen the program’s independence and authority. At present, however, State 

Ombudsmen also reported challenges coming into compliance with the legislation and regulation. 

a. Although the Final Rule added few new requirements, some State Ombudsmen 

perceived the regulation as an unfunded mandate with a relatively short implementation 

timeline which, in turn, placed strain on some Ombudsman programs, particularly when 

programmatic resources were limited. Promulgation of the Final Rule, however, also 

revealed that some programs had not been meeting OAA’s existing requirements. For 

these programs, coming into compliance with the regulation required a relatively greater 

investment of time and effort. 

b. Requirements of the Final Rule that address organizational conflicts of interest can limit 

Ombudsman programs’ options for appropriate organizational placement. States are 

increasingly moving to redesign their long-term care systems and these redesigns often 

add, or consolidate responsibilities for home and community-based care. These changes 

present increased opportunities for perceived or actual conflicts of interest that may be 

incompatible with, or require remedy under the Final Rule and OAA. 

c. OAA reauthorization required that Ombudsman programs serve all residents of long-term 

care facilities, regardless of age. While some programs have always served residents of 

all ages, the new age requirement can strain the resources of other Ombudsman 

programs. 

3. Activities surrounding the reauthorization of the OAA and the publication of the Final Rule were 

reported to increase the visibility of Ombudsman programs among stakeholders at the national, 

state, and local levels. Further, the presence of a full-time Director of Long-Term Care 
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Ombudsman Programs was critical for both raising the profile of the Ombudsman program as well 

as for the development and implementation of the Final Rule.

a. At the national level, federal staff and national stakeholders reported that the 

Ombudsman program’s profile increased as a result of the Central Office’s engagement 

with other agencies and stakeholders in promulgating the Final Rule. 

b. Implementation of the Final Rule required Ombudsman programs at the state and local 

levels to educate partners and other entities about new and existing requirements that 

affect the Ombudsman program and entities with which it coordinates. 

Support from SUA Directors and ACL Central and Regional Offices

1. State Ombudsmen reported that having the support of their SUA Director is very important for 

enhancing their ability to carry out statewide program mandates. This was true regardless of their 

program’s structure or organizational placement, although SUA Director support was particularly 

valued by State Ombudsmen whose programs were housed within SUAs.

2. State Ombudsmen generally found ACL’s Central and Regional Office staff to be helpful and 

supportive. However, State Ombudsmen within SUAs reported more difficulties working with their 

Regional Offices than those whose programs were housed outside of SUAs. A few State 

Ombudsmen reported that their ACL Regional Administrator’s closer relationship with their SUA 

Director lowered the likelihood that they would bring sensitive matters to the Regional 

Administrator’s attention (particularly if they involved the SUA). State Ombudsmen reported that 

having joint meetings with the Regional Administrator and SUA Director can inhibit the State 

Ombudsman from speaking freely, particularly if their Office is located within the SUA. 

3. The level of communication between State Ombudsmen and their ACL Regional Offices varied by 

region, with some Regional Offices being more responsive than others.

1.3.2. Research Question 2: How do LTCOPs use existing resources to resolve problems of 

individual residents and to bring about changes at the facility and government (local, state, and 

federal) levels that will improve the quality of services available/provided? 

Program Resources

1. Ombudsman programs draw on multiple resources to carry out mandated functions. These 

resources include legislation, regulations, federal, state, and local funds, staff (paid and 

volunteer), legal counsel, partnerships, peer-to-peer support, training and technical assistance, 

administrative support, data systems, and IT.

2. Sources of financial support vary widely among state Ombudsman programs. 

a. In federal fiscal year (FFY) 2017, LTCOP expenditures totaled $106.7 million across all 

funding sources. Federal, state, and local funding accounted for 50%, 43%, and 7%, 

respectively, of national program expenditures. 

b. State funding for Ombudsman programs varied considerably, accounting for between 

zero percent and 83% of total expenditures of Ombudsman programs. 

3. Staff and volunteer resources vary widely among state Ombudsman programs.
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a. In FFY 2017, 1,319 paid full-time equivalent staff (FTEs) supported the program. 

Ombudsman programs operated with an average of 25 FTEs, ranging from two to 156. 

Across programs, the ratio of FTEs to facility beds was 1:2,355, ranging from the lowest 

ratio of 1:594 in Washington, DC to the highest ratio of 1:6,814 in Minnesota. 

i. During the Ombudsman program’s last evaluation in 1995, the Institute of 

Medicine (IOM) recommended a minimum staff to bed ratio of one FTE 

Ombudsman to 2,000 beds. It should be noted that the ratio reported here, 

however, is an overestimation because the National Ombudsman Reporting 

System (NORS) does not distinguish between Ombudsmen and other program 

staff. Even with the overestimation, however, the average FTE to bed ratio of one

to 2,355 still falls short of the IOM’s 1995 recommendation. 

b. In FFY 2017, 8,810 volunteers supported the program, 6,625 of whom were designated

volunteer Ombudsmen. The number of volunteers ranged from zero to 948 individuals 

across all programs, with an average of 147 among programs that use volunteers. Four

states reported no volunteers and seven states reported no designated volunteer 

Ombudsmen. 

4. Ombudsman programs draw on multiple sources of legal support to address program needs and 

representation. These include the Office of the Attorney General (AG), state agency attorneys, inhouse counsel/non-governmental host agency attorneys, private attorneys under contract, and 

pro bono attorneys. Sixty-four percent of State Ombudsmen reported accessing legal support 

from more than one source, and these sources addressed specific program needs as well as 

perceived or actual conflicts of interest. 

5. In addition to assigned legal counsel, State Ombudsmen reported coordinating efforts with their 

State legal assistance developers and legal assistance providers/legal aid.

Program Activities

1. Given the diversity of resources that characterize programs as well as widely varying state and 

local circumstances, there is considerable variation in the extent to which Ombudsman programs 

conduct individual advocacy, education/outreach, and systems advocacy. According to the 

National Ombudsman Reporting System data (NORS; the program’s administrative reporting 

tool): 

a. In FFY 2017, Ombudsman programs visited 68% of nursing homes and 30% of board 

and care homes on at least a quarterly basis. Across programs, quarterly visits to nursing 

homes ranged between 11% and 100%, while quarterly visits to board and care homes 

ranged between zero percent and 100%. These percentages reflect routine Ombudsman 

facility visits, not those that occur only in response to a complaint. 

b. In FFY 2017, Ombudsman programs handled 201,460 complaints, ranging from 214 to 

41,834 across programs. 

c. In FFY 2017, Ombudsman programs provided information on rights, care, and related 

services to individuals and long-term care facility staff on 529,098 occasions, ranging

from 413 to 85,352 occasions across programs. 

d. In FFY2017, Ombudsman programs conducted 10,170 community education sessions, 

ranging from two to 1,686 sessions across programs. 
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e. In FFY 2017, Ombudsman programs attended 22,999 resident and family council 

meetings, ranging from two to 3,447 meetings across programs. 

f. At the state/territory level, the estimated percentage of paid staff time spent on systems 

advocacy efforts such as monitoring/working on laws, regulations, government policies, 

and actions ranged between two percent and 65% (with an average of 27%). At the local 

level, the estimated percentage of paid staff time spent on these systems advocacy 

activities ranged between zero percent to 25% (with an average of seven percent). 

Individual Advocacy

1. At the individual level, Ombudsman programs are required to (1) identify, investigate, and resolve 

complaints on behalf of residents; (2) provide services to assist residents in protecting their 

health, safety, welfare, and rights; (3) inform residents about how to obtain facility or agency 

services; (4) ensure that residents have regular access to advocacy services; (5) assist in the 

development of resident and family councils; and (6) assist residents who are transitioning from a 

long-term care facility to a home care setting.

a. Ombudsman programs meet these requirements through services that are provided 

during visits to long-term care facilities, community presentations, and responses to 

questions over the phone. 

2. Although ACL does not specify a required frequency for Ombudsman visits to facilities, NORS 

defines “regular basis” to mean facility visits that occur no less than quarterly and that are not in 

response to a complaint. Among State Ombudsmen whose programs set visitation standards, 

most aim to visit nursing homes and board and care homes at least quarterly. 

a. More than three-quarters (79%) of State Ombudsmen reported that their program visited 

most nursing homes at least quarterly and 55% reported visiting most board and care 

homes at least quarterly. (Note that the study asked State Ombudsmen to report on all 

visits made to most facilities, including visits made in response to a complaint. Due to 

differences in question wording, these percentages are different from those reported in 

NORS.) 

3. Although State Ombudsmen conduct visits to long-term care facilities, these visits are primarily 

conducted by local and volunteer Ombudsmen. 

a. A higher percentage of Ombudsmen at all levels reported visiting nursing homes, 

compared to board and care homes. 

b. Among State Ombudsmen who reported visiting nursing homes, 45% do so on a routine 

basis, compared to 81% of local Ombudsmen, and 95% of volunteer Ombudsmen. 

c. Among State Ombudsmen who reported visiting board and care homes, 36% reported 

doing so on a routine basis, compared to 78% of local Ombudsmen and 93% of 

volunteers. 

4. Whereas most local Ombudsmen reported visiting each of the nursing homes and board and care 

homes assigned to them at least quarterly (72% and 66%, respectively), most volunteer 

Ombudsmen reported visiting these facilities on at least a monthly basis (79% and 62%, 

respectively). 

5. Sixty-five percent of local Ombudsmen and 56% of volunteer Ombudsmen reported spending an 

average of one to two hours visiting nursing homes during their routine visits, and 19% of local 

Ombudsmen and 28% of volunteer Ombudsmen reported spending between two to three hours 
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during these visits. Board and care homes generally have fewer beds than nursing homes, and 

local and volunteer Ombudsmen reported spending less time visiting these facilities. Forty-nine 

percent of local Ombudsmen and 46% of volunteer Ombudsmen reported spending one to two 

hours visiting board and care homes during routine visits, and 43% of local Ombudsmen and 41% 

of volunteer Ombudsmen reported spending less than an hour during routine visits to these 

facilities. 

6. The top three complaints handled in nursing homes concerned discharge/eviction, failure to 

respond to requests for assistance, and issues related to dignity/respect. The top three 

complaints handled in board and care homes concerned discharge/eviction, medications, and 

food service. 

7. According to historical NORS data, the types of complaints that the Ombudsman program 

handles have become more complex and challenging over time, moving away from requests for 

assistance with daily needs to more urgent concerns such as involuntary discharges and 

evictions. 

8. Complaints about resident-related issues are initiated by a variety of individuals. Residents were 

the complainant in 40% of cases (a case can contain multiple complaints). Other complainants 

included relatives/friends (18%) and non-relative guardians or legal representatives (one

percent). Almost one-fifth of complaints made on behalf of residents were initiated by facility staff 

(19%). As with other complainants, facility staff may reach out to Ombudsmen to assist with both 

resident concerns (e.g., family conflict) and facility issues (e.g., closures). Ombudsmen may also 

initiate complaints based on their observations during facility visits. These complaints accounted 

for 11% of cases. 

9. Two-thirds of local and three-quarters of volunteer Ombudsmen (66% and 78%, respectively) 

reported that a majority of their relationships in nursing homes are effective. Over half of local and 

three-quarters of volunteer Ombudsmen (59% and 78%, respectively), reported that a majority of 

their relationships in board and care homes are effective.

10. State, local, and volunteer Ombudsmen attributed the effectiveness of their relationships with 

facility staff to the ongoing presence they maintain in facilities and the positive working 

relationships they develop with facility staff who come to view them as a resource. Local 

Ombudsmen also reported that their knowledge, confidence, and experience level are important 

factors in determining the effectiveness of their relationships with facility staff. 

11. Some State Ombudsmen reported that the strength of their state’s regulations for board and care 

homes is a major factor in the effectiveness of their relationships with staff in this service setting. 

12. The extent of staff resources affects Ombudsman programs ability to visit facilities and identify 

and address resident complaints. Lower paid FTE staff to facility ratios are correlated with higher 

percentages of facilities visited at least quarterly.

13. State and local Ombudsmen reported several barriers that hinder their ability to engage in 

individual advocacy, including inadequate financial and staffing resources as well as lack of 

understanding among stakeholders about the Ombudsman program’s role. In addition,

Ombudsmen described limitations in their ability to fully resolve certain types of complaints, 

particularly when solutions are ultimately outside of the program’s control. Examples include 

cases involving lack of available nursing homes or board and care homes, low facility staffing 

rates, and the absence of needed services (e.g. mental health services). 
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Systems Advocacy

1. At the systems level, Ombudsman programs are required to (1) represent residents’ interests 

before governmental agencies and pursue administrative, legal, and other appropriate remedies; 

(2) analyze, comment on, and monitor the development and implementation of federal, state, and 

local laws, regulations, and other governmental policies and actions relating to the adequacy of 

long-term care facilities and services; (3) make recommendations regarding these laws,

regulations, policies, and actions; and (4) facilitate public comment on the laws, regulations, 

policies, and actions that pertain to residents’ health, safety, welfare, and rights. Ombudsman 

programs meet these requirements primarily through legislative advocacy, issues advocacy, and 

coalition building/partnerships. Supporting the development of resident and family councils may 

involve elements of systems advocacy if these efforts aim to assist multiple residents. 

2. State Ombudsmen have primary responsibility for systems advocacy efforts. All State 

Ombudsmen reported engaging in systems advocacy, compared to 57% of local Ombudsmen. Of 

local Ombudsmen who are responsible for systems advocacy, however, 30% reported being 

unable to perform this task due to lack of time, resources, or training. A smaller percentage of 

volunteers (13%) also reported responsibility for systems advocacy activities, including

monitoring/working on laws, regulations, government policies, and actions, and three percent 

reported working with the media on issues that impact residents. 

3. Seventeen percent of local Ombudsmen reported not knowing whether systems advocacy was 

one of their responsibilities. When asked about specific tasks that they carry out, however, these 

local Ombudsmen reported engaging in activities that are consistent with systems advocacy, 

including participation in committees/workgroups/task forces; advocacy for changes to laws, 

regulations, or policies; engagement in policy making; communication with the media about 

advocacy issues; and grassroots organizing. Differences between local Ombudsmen’s reported 

engagement in “systems advocacy” and their actual activities may reflect a lack of clarity in 

responsibilities or differences in terminology for common activities. 

4. Although 19% of State Ombudsmen reported no barriers to carrying out systems advocacy 

activities at the state or local levels, the remaining State Ombudsmen identified several 

challenges related to inadequate resources, organizational placement, politics, lack of expertise, 

and misunderstandings about the program’s autonomy.

5. The Final Rule clarified that when Ombudsmen provide legislators and government agencies with 

information and recommendations concerning laws, regulations and policies, these efforts are not 

considered lobbying. Because many states prohibit government employees from lobbying, the 

Final Rule’s clarification ensures that Ombudsmen who are state employees (those whose 

programs are located in state and local government agencies) can engage in this type of 

legislative advocacy in accordance with the OAA and Final Rule. Nonetheless, at the time of this 

study’s data collection, many State Ombudsmen whose programs are located in state and local 

government agencies reported that state laws continue to restrict programs from engaging in 

legislative advocacy. 

Adequacy of Resources

1. Insufficient resources were reported to be a major challenge for programs in meeting their federal 

mandates. 

a. Only 23% of State Ombudsmen and 26% of lead local Ombudsmen reported having 

sufficient financial resources to meet all of their programs’ federal mandates. 
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b. Similarly, 27% of State Ombudsmen and 37% of lead local Ombudsmen reported having 

sufficient paid staff to meet all of their programs’ federal mandates. 

c. Only 15% of State Ombudsmen and 21% of lead local Ombudsmen reported having 

enough volunteers to meet all of their programs’ federal mandates. 

d. Fifty-six percent of State Ombudsmen and 29% of lead local Ombudsmen reported 

having adequate legal counsel to meet all of their programs’ federal mandates.

2. State Ombudsmen reported that they are unable to fully carry out the following activities due to 

lack of resources:

a. Volunteer recruitment and retention (69%);

b. Regular board and care visits (67%);

c. Resident and family council development and support (60%);

d. Community education activities (56%);

e. Legal assistance for residents (52%);

f. Regular nursing home visits (50%);

g. Facilitating public comments on proposed legislation, laws, regulations, policies, and 

actions (48%);

h. Training for facility staff (44%);

i. Research and policy analysis to inform systems advocacy work (42%);

j. Analyzing and monitoring federal, state, and local laws, regulations, and other 

government policies and actions (38%);

k. Resident and family education at facilities (38%);

l. Complaint investigation and resolution activities (23%);

m. Consultations to facilities (15%);

n. Other activities (13%); and 

o. Information and consultations to individuals (six percent).

Strategies to Address Resource Constraints

1. When faced with resource constraints, Ombudsman programs limit, forgo, or prioritize program 

activities and rely heavily on volunteers and inter-organizational relationships to support program 

operations.

a. State Ombudsmen reported forgoing professional development activities such as 

trainings, conferences, and statewide annual volunteer recognition luncheons for 

themselves or their staff. Inadequate resources also prevent some programs from 

traveling to facilities for routine visits or hiring translators to assist with meeting the needs 

of diverse populations, such as American Indian tribes and predominately Spanishspeaking communities. 

b. State Ombudsmen reported prioritizing nursing home visits over board and care home 

visits; urgent complaints over less time-sensitive ones; visiting facilities in response to a 
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complaint over routine visits; visiting facilities within shorter traveling distances over ones 

located in remote areas, and engaging in individual advocacy over systems advocacy. 

c. For many Ombudsman programs, volunteers are essential for ensuring that residents 

have access to advocacy services. Without volunteers, some programs would struggle to 

maintain a routine presence in long-term care facilities. 

i. The same resource constraints that compel programs to use volunteers, 

however, also present challenges for recruiting and supporting volunteers and

optimizing their contributions. Nearly three-quarters (73%) of State Ombudsmen 

reported that recruiting and supporting volunteers is a challenge that their 

programs face, emphasizing the need for adequate resources to ensure that this 

segment of the program’s workforce is well-trained and effective. Without these 

resources, the cost of training and managing volunteers can outweigh their 

benefits, particularly if programs lack staff for volunteer supervision and/or 

administration.

d. State and local Ombudsmen cultivate relationships with a wide range of entities to 

support individual and systems advocacy activities, particularly when program resources 

are limited. These partnerships are valuable for addressing residents’ needs and 

providing the necessary “teeth” to address certain types of complaints. 

Factors that Facilitate Meeting Program Mandates

1. When programmatic resources are adequate, State Ombudsmen reported the ability to be

proactive rather than reactive in their advocacy efforts. 

a. At the individual level, for example, one State Ombudsman reported that the ability to 

maintain a routine presence in facilities enabled Ombudsmen to expedite residents’ 

relocation when a facility closed because they were already familiar with residents’ 

preferences. Other State Ombudsmen reported that regular Ombudsman visitation to 

facilities empowered residents to speak up on their own behalf as well as encouraged 

facility staff to reach out to Ombudsmen about resident concerns before issues rise to the 

level of a complaint. 

b. At the systems level, one State Ombudsman reported that time spent cultivating a broad 

base of stakeholder support facilitated the program’s ability to marshal partners for 

various proposed legislation. 

c. With respect to legal resources, one State Ombudsman reported having access to 

independent legal counsel supports their program’s ability to fulfill mandated functions.

2. State Ombudsmen reported that committed staff and volunteers are among the program’s most 

valuable resources. A majority of Ombudsmen join the program because of its mission (75% of 

State Ombudsmen, 63% of local Ombudsmen, and 55% of volunteers). Despite resource 

constraints and low salaries that are often inconsistent with Ombudsmen’s responsibilities, staff 

motivation and dedication are viewed as the driving force behind program operations. 

a. In FFY 2017, volunteer Ombudsmen contributed 591,363 hours of service to 

Ombudsman programs. The Independent Sector estimated the value of volunteer time for 

that year at $24.69/hour, suggesting that volunteers provide over $14.6 million in labor 

assets to Ombudsman programs.
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b. Former Ombudsmen who continue to work in the aging network and long-term care 

community are also critical supports to Ombudsman programs. State Ombudsmen 

reported that staff who take positions with organizations that interact with Ombudsman 

programs help facilitate understanding and communication with these entities. 

3. State Ombudsmen reported that the independence vested in the program is a key strength. 

However, several factors prevent some programs from exercising this authority. These reasons 

included issues concerning organizational placement (e.g., organizational conflicts of interest, 

ability to engage in systems advocacy) as well as misunderstandings related to the Ombudsman 

program’s autonomy. 

4. Stakeholders and State Ombudsmen reported that the program’s reputation for credible 

information about resident concerns and conditions in long-term care facilities supports the 

willingness of other entities to work with Ombudsmen. Because the Ombudsman program is the 

only program that has direct, unimpeded access to residents and has the authority to represent 

residents, other entities actively seek Ombudsmen’s perspectives and view them as an important 

independent resource. 

5. State, local, and volunteer Ombudsmen reported that ongoing relationships and regular 

communication with residents, facility staff, and coordinating entities are critical to the program’s 

success.

1.3.3. Research Question 3: With whom do LTCOPs partner, and how do LTCOPs work with 

partner programs?

Role of Partnerships at the Federal Level

1. At the federal level, ACL’s Central and Regional Offices play important roles in facilitating 

relationships with national stakeholders and other entities to advance the LTCOP’s mission, 

increase the program’s visibility, and identify areas where training and technical assistance are 

needed.

2. The goals of partnership at the national level are to increase awareness and understanding about 

the Ombudsman program among relevant entities, and to ensure that the concerns of long-term 

care residents are represented in the development of new policies and regulations.

Types of Partnerships and Interactions at the Federal, State, and Local Levels

1. The Ombudsman program partners with a broad range of federal and state agencies (some of 

which make up the aging network), associations, nonprofits, long-term care providers, work 

groups, coalitions, and other partners with missions that are relevant to populations that the 

Ombudsman program serves.

2. While all State Ombudsmen reported dedicating time to develop and maintain partnerships on 

behalf of their statewide programs, a smaller percentage (75%) of lead local Ombudsmen 

reported engaging in these efforts, and even fewer (35%) local Ombudsmen (without managerial 

responsibilities) reported allocating time to these activities.

3. Partnering with other entities supports the Ombudsman program’s mandate for individual and 

systems advocacy, as well as education and outreach. For all activities, State Ombudsmen often 

reported coordinating with Adult Protective Services (APS), facility and long-term care provider 

licensure and certification programs, Area Agencies on Aging (AAA), the State legal assistance 

developer, and legal assistance/legal aid programs. 
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Requirements for Coordination with Entities and Perceptions of Effectiveness

1. The Final Rule’s requirement for State Ombudsmen to provide evidence of coordination with 

entities, such as memoranda of understanding (MOUs), was generally perceived by State 

Ombudsmen as a positive development that has improved communication and provided much 

needed clarification about roles and responsibilities. However, a few State Ombudsmen 

described this requirement as unnecessary and sometimes disruptive to longstanding, informal 

relationships.

2. A majority of State Ombudsmen reported that for most entities with which they are required to 

coordinate, collaborative relationships enable their programs to meet the needs of long-term care 

residents. The frequency with which these relationships were reported as important was lower 

among local Ombudsmen.

3. National stakeholders reported that both the level of engagement and the effectiveness of 

relationships with the Ombudsman program are strong at the federal level (with ACL), but they 

vary across and within programs. 

4. State Ombudsmen and national stakeholders reported that relationships with other entities are 

most effective when there is ongoing communication and a clear understanding of roles and 

responsibilities. The inability to interact regularly, and lack of clarification of roles and 

responsibilities can prevent critical partnerships from being fully developed and utilized.

Benefits and Challenges of Partnerships 

1. Other entities benefit from the Ombudsman program’s unique perspective and knowledge about 

resident issues, given their intimate and frequent interaction with long-term care residents, and 

facility staff.

2. Partnerships with external entities are particularly important when Ombudsman programs are 

constrained by limited funds and staffing.

3. Developing and maintaining effective partnerships requires allocating resources on the part of 

both the Ombudsman program and the partnering agency or organization. Accordingly, a lack of 

resources on either or both sides can create barriers to fully leveraging these relationships to 

serve the interests of long-term care residents.

1.3.4. Research Question 4: How does the LTCOP provide feedback on successful practices and 

areas for improvement? 

Training and Technical Assistance

1. Nearly all (98%) Ombudsmen reported that they received orientation, training, or support when 

they first started in their role, and this training was generally regarded as helpful in establishing 

and providing feedback on their responsibilities. 

a. Volunteer Ombudsmen rated the effectiveness of their training most highly, followed by 

local Ombudsmen and State Ombudsmen. Ninety-five percent of volunteers reported that 

their orientation training was “very effective” or “somewhat effective,” compared to 83% of 

local Ombudsmen and 70% of State Ombudsmen.

2. Many Ombudsmen reported that additional training would have been helpful.

a. Half of State Ombudsmen (51%) reported that other training would have been helpful on 

topics such as data entry, service provision, and working with legislators.
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b. Thirty-nine percent of local Ombudsmen, and 26% of volunteer Ombudsmen indicated 

that additional training would have been helpful (e.g., mentoring/shadowing with 

experienced staff, more site visits, and additional hands-on, facility-based trainings). 

3. Nearly all local and volunteer Ombudsmen reported that they received ongoing training and 

feedback in their current roles. 

a. Local Ombudsmen reported that they receive ongoing training and support primarily via 

conference calls and online platforms such as webinars. 

b. Volunteer Ombudsmen most often receive this type of support via guidance from their 

supervisors and informal support from other Ombudsmen. 

4. Sources of training and ongoing support differed between State and local Ombudsmen.

a. State Ombudsmen rely heavily on training resources provided by the Resource Center, 

such as webinars, self-training materials, and NASOP’s mentorship program for State 

Ombudsmen, as well as other sources of training and technical assistance delivered by 

Consumer Voice.

b. Local and volunteer Ombudsmen were most often trained via in-person or in-service 

training. These sessions used materials and guidance from AAAs, local programs, and 

the Office of the SLTCO. 

5. Perceptions of resource effectiveness of training reflected differences in how frequently resources 

were used across respondent groups.

a. State Ombudsmen reported that the Resource Center’s materials were most helpful.

b. Local Ombudsmen reported that resources from the Office of the SLTCO were most 

helpful. Exposure to national resources was limited among local Ombudsmen without 

management responsibilities.

c. Volunteer Ombudsmen rated the helpfulness of resources from state or local entities (i.e., 

AAA, their local program, and Office of the SLTCO) higher than those from national 

entities. 

d. Perceived challenges to establishing effective training and support included funding 

limitations that affect both the scope and approach to providing training and support (e.g., 

webinars rather than face-to-face training); problems providing support in relatively 

remote areas, and potential challenges providing comparable certification training for 

designation of staff and volunteers, a requirement under the Final Rule. 

LTCOP Data Collection and Reporting

1. At both the state and local levels, NORS data are widely used to identify potential problems and 

areas for programmatic improvement, as well as targets for systems advocacy. 

2. Although all state Ombudsman programs are required to collect NORS data, some states collect 

additional data to support program management and improvement efforts. These additional data 

generally fall under five categories: program activities, outcome measures, facility data, resident 

data, and general long-term care data. 

3. State Ombudsmen appreciated the benefits that NORS data provide, but they also reported a 

number of limitations associated with these data. These limitations included underreporting of 

Ombudsman activities, burdensome coding requirements, incompatibility of software programs 
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with NORS requirements, and a lack of reporting flexibility. Some of these issues will be 

addressed when NORS is revised in October of 2019.

4. Ombudsmen reported challenges associated with state-level data systems, including data 

compatibility and integration problems for states with many reporting units; lack of information on 

outcomes and topics of local importance; burdensome data entry and documentation; and lack of 

time and resources for data entry, which can result in inaccurate or incomplete data.

5. In some cases, Ombudsmen reported that in-house data systems can supplement or replace 

commercial products, thereby mitigating some challenges that are linked to commercial products. 

1.4. Recommendations

1.4.1. Coordination within and Support for Ombudsman Programs: 

1. ACL should continue supporting State Ombudsmen’s efforts to comply with the Final Rule and 

assess the regulation’s effect on Ombudsmen’s ability to freely conduct systems advocacy. 

Based on those findings, ACL should consider whether additional steps need to be taken to 

enforce the independence of the Ombudsman program, particularly for State Ombudsman 

programs that are housed within SUAs. 

2. State Ombudsmen reported that coordination among stakeholders at the national and state 

levels helps to ensure that the Ombudsman program’s voice is being heard and that program 

needs are addressed. ACL’s Central and Regional Offices should continue their efforts to bring 

visibility to the program and to support State and local Ombudsmen in working with other 

entities.

3. To ensure open communications, ACL Regional Administrators should establish meetings with 

State Ombudsmen that are separate from those with the SUA.

4. While some State Ombudsmen acknowledged that understanding of the Ombudsman program 

is improving among ACL Regional Administrators, ACL’s Central Office staff should continue 

efforts to increase knowledge and ensure Regional Administrators are positioned to provide 

consistent support to state programs.

1.4.2. Management of State and Local Programs:

1. To prevent perceived program fragmentation, State Ombudsmen with decentralized program 

structures should develop coordinated approaches to ensure seamless monitoring of local 

Ombudsman staff.

2. SUA Directors should ensure that policies and procedures are in place that support the State 

Ombudsman’s ability to determine the use of the fiscal resources appropriated or otherwise 

available for the operation of the Office, as well as approval of allocations of federal and state 

funds provided to local Ombudsman entities, as appropriate. 

3. Given the importance of SUA Director support for the State Ombudsmen’s ability to fulfill their 

responsibilities, and the challenges identified by State Ombudsmen housed within SUAs in 

interacting effectively with their SUA, a concerted effort should be made by all parties (ACL staff, 

SUA Directors, and State Ombudsmen) to foster positive relationships, and to improve 
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understanding of the role of the Ombudsman program. These efforts should be focused on 

relationship-building that goes beyond the guidance set forth in the Final Rule.

1.4.3. General Resource Needs:

1. Given the limited resources of many Ombudsman programs, meeting federal requirements as 

described in the OAA and the Final Rule is challenging. Few Ombudsmen at either the state or 

local level reported that existing resources are adequate to meet federal mandates. 

Consideration of ways to address this mismatch between mandates and available funding is 

needed among stakeholders at all levels. There is a need for more guidance and support for 

State Ombudsman around identifying and advocating for potential funding. 

2. At the conclusion of the outcome evaluation, ACL should work with stakeholders to determine 

whether the IOM’s 1995 recommended minimum staffing ratio of one FTE Ombudsman per 

2,000 long-term care facility beds is adequate or needs revising. 

1.4.4. Fiscal Resources:

1. Some State Ombudsmen reported that their expertise in financial management was insufficient 

for them to handle all of their fiscal responsibilities under the Final Rule. Additional training 

opportunities may be needed from relevant host agencies to address this shortcoming. 

1.4.5. Staffing Resources and Training Needs:

1. Given the tremendous benefits that having a full-time dedicated Director of the Office of LongTerm Care Ombudsman Programs, ACL should ensure that the position is filled on a full-time 

basis to continue providing support and advocacy for the program.

2. Greater support for local Ombudsmen is needed and can be provided with greater coordination 

with the National Association of State Long-Term Care Ombudsman Programs (NASOP), 

National Association of Local Long-Term Care Ombudsmen (NALLTCO), National Association of 

States United on Aging and Disabilities (NASUAD), and the National Association of Area 

Agencies on Aging (n4a). 

3. States with volunteer Ombudsmen should ensure that their programs have staff with the time 

and expertise to provide volunteer management. To improve volunteer recruitment, training, and 

management, resources to support a dedicated volunteer coordinator at the state or local level 

should be considered. 

4. State Ombudsmen should actively support local and volunteer Ombudsmen’s use of the 

National Long-Term Care Ombudsman Resource Center’s training and technical materials. 

5. As part of building a statewide program, State Ombudsmen should provide additional training 

opportunities to local and volunteer Ombudsmen with respect to systems advocacy; data entry 

and data management; and various types of service settings (e.g., home-based, communitybased) as well as residents (e.g., supporting residents with behavioral health needs). 

a. Local and volunteer Ombudsmen should receive more hands-on training opportunities, 

such as job shadowing and formal mentorship from more experienced program staff. 
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6. The Resource Center and State Ombudsmen should facilitate more opportunities for peer-topeer learning, both online and in-person (e.g., facilitating group case-study sessions at 

conferences).

7. Interim State Ombudsmen should receive training, including mentorship from NASOP and the 

Resource Center. As NORS is revised, ACL and the Resource Center should continue to 

address the challenges of collecting and reporting these data. 

8. ACL’s Central Office and the Resource Center should help programs to develop and share 

solutions to problems that programs encounter in designing and using state data systems.

9. To address State Ombudsmen’s challenges with navigating the National Ombudsman Resource 

Center’s website, the Resource Center should explore ways to enhance this resource with a 

more user-friendly design to facilitate access to materials. 

1.4.6. Legal Resources: 

1. Further education and guidance is needed to address State Ombudsmen’s concerns related to 

assigned legal counsel and potential conflicts of interest. While most State Ombudsmen 

reported positive experiences with legal counsel, lack of familiarity with the program remains a 

concern for some. State Ombudsmen should encourage attorneys assigned to the program to

receive additional training, including completion of certification training. 

1.4.7. Coordination with Entities at the Federal/National, State, and Local Levels:

1. State and local Ombudsmen need more resources to improve relationships and create more 

effective partnerships with entities with which they have infrequent contact, such as the courts, 

law enforcement, and victim advocacy programs. 

a. Programs should identify key partners to help facilitate relationships with entities with 

which poor or no relationships exist.

b. Materials and training activities need to be developed to expand understanding of the 

Ombudsman program among entities with which partnerships have been historically 

underdeveloped. 

2. Further clarification of roles and responsibilities of the LTCOP and other coordinating entities is 

needed. Continued development of memoranda of understanding (MOUs) and policies and 

procedures can facilitate this clarification. While informal relationships may work well with 

established team members, staff turnover within the Ombudsman program or partnering 

agencies can introduce complications when educating new staff about accepted practices. 

Ombudsman programs should seek to formalize relationships wherever possible to avoid 

breakdowns in partnership or communication.

3. Misunderstandings between the Ombudsman program and potential partners with respect to the

program’s role and independence were reported to impede coordination with these partners. 

Ombudsman programs should continue to seek and take advantage of the opportunity to 

educate partners about the program, as well as opportunities to learn more about partner 

agencies. By leveraging positive national level relationships with federal level agencies and 

associations, ACL’s Central and Regional Offices may be able to facilitate these opportunities in 

states or regions where they are needed most. 
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4. State and local Ombudsmen should look for opportunities to engage in activities such as crosstraining events and work groups to improve communication and coordination with other entities 

that are involved in issues related to long-term care residents. 

5. Ombudsmen at all levels highlighted work groups as an efficient and effective way to partner 

with multiple agencies simultaneously to accomplish common goals. One way to address the 

challenge of partnering with specific agencies (whether it is due to a lack of resources, staff, 

time, etc.) is to ensure that there are work groups or coalitions that include as many relevant 

parties as possible. 

6. Given State Ombudsmen’s interest in cultivating or improving relationships with various entities, 

the Resource Center should systematically collect information on this topic. This information 

could then assist ACL’s Central Office staff in identifying opportunities to further promote these 

partnerships through national and regional networks. 
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Chapter 2. Introduction 

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

Care Ombudsman program (LTCOP or Ombudsman program) began in 1972 as a Public Health Service 

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

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

programs originated with former U.S. Commissioner on Aging, Dr. Arthur S. Fleming, as part of President 

Nixon’s initiative to address widely-reported problems involving abuse and poor quality of care in nursing 

homes. As federal law and regulations for standards of care were being enacted in the early 1970s, Dr. 

Fleming argued that to be effective, these legislative efforts needed to be supported with communitybased resident advocacy. As Fleming stated, “Our nation has been conducting investigations, passing 

new laws and issuing new regulations relative to nursing homes at a rapid rate during the past few years. 

All of this activity will be of little avail unless our communities are organized in such a manner that new 

laws and new regulations are utilized to deal with the individual complaints of older persons who are living 

in nursing homes. The individual in the nursing home is powerless. If the laws and regulations are not 

being applied to her or to him, they might just as well not have been passed or issued.” (AoA Technical 

Assistance Memo 76-24).

The Older Americans Act (OAA, or the Act) 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. The 

2006 OAA amendments expanded the definition of board and care to include assisted living facilities. 

Today the Ombudsman program is administered by the Administration on Aging (AoA), within the 

Administration for Community Living (ACL) of the United States Department of Health and Human 

Services (DHHS). Through grants to states and territories, Ombudsman programs operate in all 50 states, 

as well as the District of Columbia, Puerto Rico, and Guam. 

Since its inception, the Ombudsman program has played a unique role in protecting and promoting the 

health, safety, welfare, and rights of long-term care residents – its services are not duplicated by any 

other federal agency. To fully represent residents’ interests and improve their quality of life and quality of 

care, the OAA delineated responsibilities for the program at both the individual and systems level. At the 

individual level, Ombudsman programs assist residents by resolving complaints about the care they 

receive and help ensure that residents’ rights are protected. In addition to investigating and resolving 

problems that have already taken place, Ombudsmen and their designated representatives play a 

sentinel role through the facility and resident visits that they conduct. Serving as the “eyes and ears” of 

the program, Ombudsmen help address concerns before they rise to the level of complaints requiring 

outside intervention by preventing negative actions or inactions that affect residents’ care, rights, and 

quality of life from occurring. At the systems level, Ombudsmen advocate for improvements in the longterm care system that benefit residents at the local, state, and national levels. Such activities are not 

limited to legislative advocacy, but include coalition building, speaking to the media, and other strategies 

used to broadly advance the rights and well-being of residents. To help build capacity for both individual 

and systems advocacy, the program also carries out education and outreach activities. These activities

include providing information and consultation to facilities and residents and their families, collaborating 

with other agencies, supporting family and resident councils, developing citizen organizations, and 

empowering residents and their caregivers to effectively advocate on their own behalf. 

Over the years, various aspects of the LTCOP have been studied but the only national evaluation of the 

program was carried out by the Institute of Medicine (IOM) in 1995. More than two decades since the IOM 

evaluation, the Ombudsman program has come to operate under a very different long-term care 
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landscape. The rapid aging of the U.S. population, growing consumer preference for receipt of home and 

community-based services (HCBS) both in home and in other residential settings, the tremendous growth 

of residential options other than nursing homes, and changes in the delivery and financing of post-acute 

care and long-term services and supports (LTSS) are all factors that impact the program’s service 

delivery since the IOM study. These trends, moreover, pose challenges as well as opportunities for 

LTCOPs at a time when significant new regulatory actions have been introduced. With the 2016 

reauthorization of the OAA and implementation of the State Long-Term Care Ombudsman Programs 

Final Rule (effective July 1, 2016), states have been newly tasked with ensuring that the structure and 

implementation of their programs are consistent with these provisions. The Final Rule, in particular, has 

caused the greatest changes in program practices. For some programs, achieving compliance involved 

formalizing existing policies and procedures while for others, compliance may require changing the 

program’s organizational placement and/or updating state laws/statutes, regulations, policies, or practices 

that may take months to years to implement. 

Changes in both the landscape of long-term care service provision and the program itself present an 

opportune time to understand how the program is making progress toward achieving its goals. To assess 

as well as strengthen the program’s ability to meet its mandates, ACL contracted with NORC at the 

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

LTCOP. The NORC research team includes 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 Human Services Research Institute 

(HSRI). This report summarizes findings from the process evaluation and based on those analyses, offers 

recommendations for improving program practices. For the remainder of this chapter, we provide an 

overview of the OAA and Ombudsman programs, a summary of the evaluation’s research objectives, and 

a description of the organization of the report. 

2.1. Background 

2.1.1. Older Americans Act

In 1965, Congress passed the OAA to promote the health, independence, and safety of older adults 

through the provision of comprehensive home and community-based social services to individuals aged 

60 years and above. To accomplish this goal, the OAA developed and fostered the implementation of the 

aging services network, a nationwide system of federal, state, and local agencies dedicated to 

coordinating and providing a broad array of essential services to the U.S.’s aging population. At the 

federal level, the OAA established the AoA within the then Department of Health, Education and Welfare 

(now Department of Health and Human Services), to administer OAA grant programs and to serve as the 

chief federal agency advocate for older adults. At the state level, the OAA required each state to create a 

state or territorial unit on aging (SUA) to serve as the primary state agency responsible for developing 

and administering multi-year state plans for OAA programs and activities. In general, federal law allocates 

funding to each SUA based on the percentage of people age 60 or older residing in the state. The Act 

also authorizes grants to tribal organizations to provide services to older Native Americans. At the local 

level, the OAA established Area Agencies on Aging (AAA) in 1972 to plan and develop services based 

upon state-approved area plans on aging. Designated and managed by SUAs, AAAs oversee a 

coordinated system for delivering social services to older individuals within their local or regional 

jurisdictions or planning service areas (PSAs)4 through direct service provision or contracts with local 

 

4 States that have a single planning service area lack AAAs.
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service providers (LSPs). Today there are 56 SUAs, 618 AAAs, over 20,000 direct-service providers, 27 

Tribal and Native Hawaiian organizations and hundreds of thousands of volunteers.

5 

2.1.2. Long-Term Care Ombudsman Program 

Since enactment of the OAA, Congress has authorized targeted programs and services through 

successive amendments that respond to specific needs of older adults. Under the 1978 amendments, the 

OAA required states to establish Nursing Home Ombudsman Programs (previously a demonstration 

program that began in 1972) to address widely reported problems concerning poor quality of care in 

nursing homes. To ensure the protection of residents’ rights, the OAA set forth three primary legislative 

mandates for the program. First, the OAA charges the program with serving as an advocate for individual 

residents of nursing homes. Responsibility for advocacy in board and care homes and similar adult care 

facilities was added in the 1981 amendments. To reflect expanded Ombudsman coverage, the program’s 

name was also changed to the Long-Term Care Ombudsman program (LTCOP). In these residential 

settings, Ombudsmen identify, investigate and resolve complaints about the care residents receive with 

respect to their health, safety, welfare, and rights. Second, the LTCOP 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 residential long-term care facilities. Third, the program is tasked with providing 

outreach and education to residents/their representatives and facility staff, and collaborating with other 

agencies. 

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 STLCO) in coordination with the SUA in all 50 

states, the District of Columbia, Puerto Rico, and Guam. The State Ombudsman is responsible for 

statewide program administration and oversight of designated representatives of the Office who serve as 

local Ombudsman staff and volunteers to help resolve residents' complaints, address systemic issues, 

and provide information on long-term care services and supports to consumers. In federal fiscal year 

(FFY) 2017, 1,319 Ombudsmen FTEs and 6,625 designated volunteer Ombudsmen supported the 

program. 

As part of the 1992 amendments, the LTCOP was folded under the newly created Title VII “Vulnerable 

Elder Rights Activities” of the OAA (these provisions were previously included under Title III), and the 

National Long-Term Care Ombudsman Resource Center (Resource Center) was established to enhance 

the skills, knowledge, and management capacity of LTCOPs. Hosted since 1994 by The National 

Consumer Voice for Quality Long-Term Care (Consumer Voice), in cooperation with the National 

Association of States United for Aging and Disabilities (NASUAD), the National Ombudsman Resource 

Center (Resource Center) serves programs by providing training, technical assistance, and information 

dissemination. The LTCOP’s work is also enhanced by national membership organizations, including the 

National Association of State Long-Term Care Ombudsmen Programs (NASOP) at the state level, and 

the National Association of Local Long-Term Care Ombudsmen (NALLTCO) at the local level. These 

affiliations provide professional and educational opportunities, information sharing, and advocacy support 

to members.

With support from this infrastructure, the program was responsible for advocating on behalf of over 3.1 

million residents in 74,407 nursing homes and board and care homes nationwide in FFY 2017. According 

to the National Ombudsman Reporting System (NORS), the program’s administrative reporting system, 

 

5 https://acl.gov/about-acl/authorizing-statutes/older-americans-act
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Ombudsman programs completed resolution work on 201,460 complaints and provided information on 

rights, care and related services to individuals and long-term care facility managers and staff 529,098

times.

2.2. Overview of the Process Evaluation

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

assessing the LTCOP’s implementation at the federal, state, and local levels. To that end, this report 

examines the program’s structure and operations, use of resources to carry out legislative mandates, the 

nature of partnerships, and program quality assurance activities. 

2.2.1. Research Questions

The process evaluation includes four main research questions that are guided by a family of logic models 

previously developed for the Evaluation Study Design of the Long-Term Care Ombudsman Program. The 

logic models are intended to provide a common understanding of how the LTCOP operates and to clarify 

how program elements and their associated activities translate to desired short-, medium- and long-term 

outcomes. As part of the study design effort, the logic models were developed in close consultation with 

ACL and a Technical Advisory Group (TAG) composed of a broad range of knowledgeable stakeholders 

with specific expertise in Ombudsman programs, aging program evaluation, elder abuse, neglect and 

exploitation research, and long-term care systems. 

The process evaluation’s research questions are: 

1. How is the LTCOP structured and how does it operate at the local, state, and federal levels? 

2. How do LTCOPs use existing resources to resolve problems of individual residents and to bring 

about changes at the facility and governmental (local, state, and federal) levels that will improve 

the quality of services available/provided? 

3. With whom do LTCOPs partner, and how do LTCOPs work with partner programs?

4. How does the LTCOP provide feedback on successful practices and areas for improvement?

2.3. Organization of the Report

The remaining chapters of this report describe the process evaluation’s methodology and findings. 

Chapter 3 presents an overview of the study’s methodology, including the design, data sources, and 

analytic strategies. Chapters 4 through 7 summarizes findings and recommendations for each of the four 

main research questions.
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Chapter 3. Process Evaluation Data and Methodology

To address the process evaluation’s four main research questions, the NORC team collected and 

analyzed qualitative and quantitative data from primary and secondary data sources. For research 

questions that could not be addressed by existing data sources, we obtained information from program 

staff at the federal, state and local levels, as well as national stakeholders who are well-positioned to 

provide input on Long-Term Care Ombudsman program (LTCOP) activities and operations. In Exhibit 1, 

we present the four main research questions and the corresponding data sources that were used to 

answer them. Following, this chapter describes the sample selection, data collection procedures 

(including recruitment strategies and response rates), and analytic approach for the study. 

Exhibit 1: Research Questions and Data Sources

Research Question

NORS DataNational Ombudsman Resource Center 

Materials

Federal Staff InterviewsNational Stakeholder InterviewsState Ombudsman Interviews State Ombudsman SurveyLocal Ombudsman SurveyVolunteer Ombudsman Survey

Q1: How is the LTCOP structured and how does it 

operate at the local, state and federal levels? X X X X X X X X 

Q2: How do LTCOPs use existing resources to 

resolve problems of individual residents and to bring 

about changes at the facility and governmental (local, 

state and federal) levels that will improve the quality 

of services available/provided?

X X X X X X 

Q3: With whom do LTCOPs partner, and how do 

LTCOPs work with partner programs? X X X X X X X 

Q4: How does the LTCOP provide feedback on 

successful practices and areas for improvement? X X X X X X 

3.1. Secondary Data Sources

Based on an environmental scan and assessment of existing data sources, two data sources were 

identified that provide insight into the program’s resources and activities. Existing data sources that were 

used for the process evaluation are: 

National Ombudsman Reporting System (NORS) data. 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), and this information is then summarized in a variety of reports. NORS case and complaint 

data are reported by facility type (nursing homes or board and care homes which include assisted living 
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and other residential care communities), and programs may report optional data for those who provide 

Ombudsman services in non-facility settings. In addition to discrete data fields, NORS includes text-based 

narrative fields that report on systems advocacy activities, programs’ priorities in long-term care issues, 

and barriers and efforts that are encountered in resolving these issues. 

National Ombudsman Resource Center (Resource Center) materials. The National Long-Term Care 

Ombudsman Resource Center provides support, technical assistance, and training to Ombudsman

programs. The Center is a rich source of material on the LTCOP’s history, operations, program and 

volunteer management, best practices, accomplishments, advocacy efforts, training materials, customer 

satisfaction surveys, summaries of annual meetings, and general resources for Ombudsmen. Notably, the 

Resource Center prepares and maintains updated Program Management Data Chart which provides a 

snapshot of state-level LTCOP program elements such as program placement and structure, type of legal 

counsel, and participation in other federal initiatives such as Money Follows the Person and Senior 

Medicare Patrol (SMP) collaboration, unique areas of expertise, funding, and data management. On an 

ad hoc basis, the Resource Center also collects state-level information on a variety of topics related to 

program operations. 

3.2. Primary Data Sources

The process evaluation’s primary data collection included a mix of telephone interviews and surveys (both 

web- and paper-based). Exhibit 2 presents respondent classes that were targeted for primary data 

collection and the data collection method that was used for each class. 

Exhibit 2: Respondent Classes and Data Collection Method

Respondent Class

Data Collection

Interview Survey

Federal Staff X 

National Stakeholders X 

State Ombudsmen X X 

Local Ombudsmen X 

Volunteer Ombudsmen X 

3.2.1. Sample Selection 

Data collection was carried out in two phases. The first phase collected data from federal staff, national 

stakeholders, and State Ombudsmen. The second phase collected expanded data from State 

Ombudsmen as well as from local Ombudsmen and volunteers. Sampling methods for each respondent 

class are described below.

Federal Staff and National Stakeholders 

Based on input and priorities from ACL, NORC invited five ACL Central and Regional staff members, 

three representatives from other federal agencies, and 16 stakeholders to participate in the evaluation. 

These respondents were purposefully selected because each possessed a unique perspective on the 

LTCOP and provided important information concerning the intra- and inter-agency relationships that are 

of interest to the study. 
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Federal staff included individuals from: 

■ Administration for Community Living (ACL) 

■ Office of the Assistant Secretary for Planning and Evaluation (ASPE)

■ Centers for Medicare & Medicaid Services (CMS)

■ Department of Justice (DOJ)

National stakeholders included individuals from: 

■ American Health Care Association (AHCA)

■ Altarum Institute

■ Argentum

■ Center for Medicare Advocacy

■ Consumer Coalition for Quality Health Care

■ Justice in Aging

■ LeadingAge

■ National Association of Area Agencies on Aging (n4a)

■ National Association of State Long-Term Care Ombudsman Programs (NASOP)

■ National Association of Local Long-Term Care Ombudsmen (NALLTCO)

■ National Adult Protective Services Association (NAPSA)

■ National Association of States United on Aging and Disabilities (NASUAD)6

■ National Long-Term Care Ombudsman Resource Center (Resource Center) 

■ National Disability Rights Network (NDRN)

■ Pioneer Network

■ Institute for Health and Aging, at the University of California, San Francisco

■ The National Consumer Voice for Quality Long-Term Care (Consumer Voice)

State Ombudsmen

To ensure that the full spectrum of Ombudsman programs’ experiences were captured, all 53 State 

Ombudsmen were invited to participate in the study. This decision was driven by the considerable 

variability across programs in how the LTCOP is administered, and the need to understand the 

programmatic implications of this variability. 

Local Ombudsmen and Volunteers

For local data collection, a multistage stratified sampling approach was used. To ensure that every ACL 

region was represented, the sampling began with stratifying programs by the 10 ACL regions. We 

allocated the state sample to each region proportionally based on the number of facilities in each region, 

with at least two states allocated to each region. Within each region, states were selected randomly, with 

probability proportional to size. Size is defined as the number of facilities served by programs per state. 

To ensure that the diversity of both centralized state Ombudsman programs and those with local 

Ombudsman entities was captured, a sample of 27 states was identified, and in these states, all local 

 

6 In August of 2019, NASUAD changed its name to ADvancing States.
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Ombudsmen were invited to participate, as well as half of the volunteer Ombudsmen who were randomly 

sampled and invited to participate. Local Ombudsman entities with fewer than three volunteer 

Ombudsmen were oversampled to ensure representation. The sampling frame was defined using lists 

that were provided by participating programs. Among the 27 programs, 26 use volunteers (South Dakota 

reported no volunteers). 

Exhibit 3 lists the 27 states, organized by ACL region. 

Exhibit 3: States Participating in Local Data Collection

ACL Region States Participating in the Local Data Collection

Region 1 Maine, Rhode Island

Region 2 New Jersey, New York

Region 3 Delaware, Virginia

Region 4 Florida, Kentucky, Tennessee, South Carolina

Region 5 Illinois, Indiana, Ohio, Minnesota, Wisconsin 

Region 6 Louisiana, New Mexico

Region 7 Iowa, Nebraska

Region 8 North Dakota, South Dakota

Region 9 Arizona, California, Hawaii, Nevada

Region 10 Alaska, Washington

3.2.2. Data Collection Procedures and Response Rates

Data collection included telephone interviews and web- and paper-based surveys. Data collection 

procedures are described below for federal staff, national stakeholders, State Ombudsmen, local 

Ombudsmen, and volunteers by data collection phase or round.

Round 1 Data Collection 

Telephone interviews were conducted with 24 federal staff and national stakeholders and all 53 State 

Ombudsmen. ACL first contacted and notified federal staff, national stakeholders, and State Ombudsmen 

who were identified to participate in the process evaluation. These notifications took place in June of 

2017. The project team then contacted respondents by email or phone to schedule interviews which took 

place between June and August of 2017. 

State Ombudsmen were also asked to complete a web-based survey to obtain supplemental data that 

were not collected during the interviews. Respondents were contacted by email or phone in February of 

2018 with a request to provide this information. Between February and April of 2018, 52 State 

Ombudsmen (98%) completed the online survey. 

Round 2 Data Collection 

The second round of data collection involved administering surveys to local and volunteer Ombudsmen. 

To optimize response rates, the project team worked closely with State Ombudsmen to obtain staff and 

volunteer contact information for the sampling frame as well as assistance in encouraging participation. 

These interactions also provided an opportunity to ask about the best approaches to communicate with 

participants, issues that may impact data collection in different programs, and other considerations that 
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could impact response rates. For respondents who were not responsive to the web-based survey, such 

as those with limited access to the Internet, the project team offered a paper survey as an alternative. In 

states that agreed to the incentives approach, volunteers were compensated with a $25 Target or 

Walmart gift card for their participation. 

To familiarize local Ombudsmen and volunteers with the study and the survey administration, the project 

team held four webinars and staffed a dedicated helpdesk (both email and phone) to address questions 

throughout the data collection period. Email and postcard reminders were sent to both groups and the 

participant list was updated as the team learned of departures or changes in status (e.g., active or 

inactive). 

In each state, all local Ombudsmen were asked to participate in the study and at least one-half of 

volunteer Ombudsmen were randomly selected and invited to participate. In some local Ombudsman 

entities, volunteer Ombudsmen were oversampled to ensure representation. Of the 723 local 

Ombudsmen who were selected, 69% completed the survey between May and June of 2018. Of the 

1,419 volunteers who were selected, 50% completed the survey between June and July of 2018. 

Exhibit 4, shows response rates for each respondent class.

Exhibit 4: Survey Response Rates by Respondent Class

Respondent Class Total Sample (N) Survey Response Rate

State Ombudsmen 52 98%

Local Ombudsmen* 497 69%

Volunteer Ombudsmen 711 50%

* Of the 497 local Ombudsmen, 189 were lead local Ombudsmen. 

3.2.3. Interview and Survey Topic Areas

For each data collection instrument and protocol, items were tailored to the specific respondent class and 

organized into six sections: 

Section A – Background Information 

Section B – Structure and Resources 

Section C – State and Local Coordination 

Section D – Program Activities 

Section E – Program Quality Assurance

Section F – Demographic Information

Given the customization of the data collection instruments, not all sections were relevant to every

respondent category. For example, questions on program structure and state and local coordination are 

not applicable to volunteer Ombudsmen, and questions about program quality assurance do not apply to 

national stakeholders. Demographic information was only collected from state- and local-level program 

staff and volunteers to understand workforce characteristics. 

Interviews. Telephone interviews conducted with selected federal staff, national stakeholders, and State 

Ombudsmen were semi-structured to collect data on the same topics across programs. This approach 
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also allowed for exploration of unique programmatic elements and identification of common themes that 

could not have been anticipated when the instruments were developed. 

Surveys. A survey (web- or paper-based) was administered to State Ombudsmen and a sample of local 

Ombudsmen, and volunteers. The surveys primarily contained closed-ended questions but also included 

several open-ended items. 

It is important to note that due to both program structure and program-specific needs, there is great 

diversity in roles in the local Ombudsmen respondent group. Local Ombudsmen included in this category 

included Deputy State Ombudsmen, Regional Ombudsmen, and a host of other titles that reflected 

variability in responsibilities or specialties (e.g., Managed Care Ombudsman) or state- and local-specific 

terms (e.g., Advocate). 

Although the study could not tailor surveys to accommodate this heterogeneity, the project team 

developed two versions of the local Ombudsman survey to distinguish between “lead local Ombudsmen” 

and “local Ombudsmen”. This approach ensured data were captured about the local Ombudsman entity 

as a whole (where applicable) as well as each respondent’s individual experience. Both survey versions 

asked similar questions about local Ombudsmen’s experiences with the program, but a small number of 

questions were added for lead respondents who had program management responsibilities (“lead local 

Ombudsmen”). Lead local Ombudsmen were asked about their perspectives concerning the entities they 

oversaw. Additionally, local Ombudsmen were not always evenly distributed across states’ local 

Ombudsman entities and states could have as few as one local Ombudsman staffed at a specific local 

Ombudsman entity. In cases where there was only one local Ombudsman, participants responded to 

questions from the lead local Ombudsman survey. When reporting data on these items, we indicate 

whether the respondent group referred to lead local Ombudsmen or local Ombudsmen. In instances 

where both lead local and local Ombudsmen answered the same question, we simply refer to the 

respondent group as local Ombudsmen. In this study, there were 189 lead local Ombudsmen. 

3.2.4. Analytic Approach 

The process evaluation’s mixed-methods data collection strategy enabled the project team to triangulate 

information from multiple sources and develop a nuanced understanding of the program’s processes and 

implementation. Our examination of the four main research questions involves standard approaches for 

descriptive analysis as well as tailored analytic strategies that address the specific nuances of each 

question. These approaches draw on more than one data source because of the complexity of the 

Ombudsman program’s functions and the considerable heterogeneity that characterizes programs. 

Qualitative Data Analysis

A large body of contextual knowledge about the Ombudsman program was collected through telephone 

interviews with respondents at the national and state levels. Qualitative data derived from the transcribed 

interviews were analyzed using Dedoose, a software package that facilitates identification of themes from 

qualitative information. An initial coding plan was developed based on a priori knowledge of the program, 

and this plan was used to code and categorize qualitative data to allow for comparisons of concepts 

across programs. Interview data were aggregated and reported at the respondent class level to preserve 

confidentiality.

In addition to qualitative interview data, open-ended survey responses were coded and summarized. 

Selected quotes were drawn from free-text survey responses to highlight important themes. 
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Quantitative Data Analysis

Findings that draw on existing (NORS) as well as newly collected quantitative data are presented mainly 

as descriptive statistics. The team also conducted bivariate analyses to examine both sub- and betweengroup differences. 

Descriptive Statistics. We generated a standard set of descriptive statistics for categorical data and 

measures of central tendency (mean, median) for numeric data. 

Bivariate Analysis. For a select number of variables, we conducted bivariate analyses to gain a deeper 

understanding of program activities in the context of their organizational characteristics and staff roles. 

Subgroup analyses of key questions were performed using cross-tabulations that examined whether 

survey responses varied by subgroups (e.g., whether perceptions of effectiveness varied by program

structure) and between respondent groups (e.g., whether perceptions of program effectiveness varied 

between State and local Ombudsmen). With respect to the latter, we analyzed parallel questions across 

survey instruments to understand program implementation from various perspectives. For example, we 

asked all respondent classes to describe the frequency with which they visit nursing homes; this enabled 

us to compare responses of State Ombudsmen, local Ombudsmen, and volunteers on this important 

issue. 

The extent of comparisons across respondent groups is determined by the questions that are repeated 

across surveys. Whereas some questions are relevant to all state and local program staff (such as 

training), others may only pertain to two or three groups. For example, only paid staff may be familiar with 

issues related to local and state coordination. Our general approach to instrument development and 

analytical planning was to optimize our ability to make relevant comparisons across groups in a manner 

that addresses the project’s main research questions.
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Chapter 4. Research Question 1: How is the LTCOP 

structured and how does it operate at the local, state, and 

federal levels?

4.1. Key Findings

4.1.1. Program Structure and Operations

1. The Older Americans Act (OAA) and the Long-Term Care Ombudsman Programs Final Rule 

(Final Rule) provide legislative and regulatory guidance and requirements for the structure and 

operations of Long-Term Care Ombudsman programs (LTCOPs). 

2. Long-Term Care Ombudsman programs are administered by the Administration on Aging (AoA), 

within the Administration for Community Living (ACL) of the United States Department of Health 

and Human Services (DHHS). As the chief federal agency charged with helping to maximize the 

independence of older adults and individuals with disabilities, ACL issues OAA grants to State 

agencies or state or territorial units on aging (SUAs). These designated, state-level agencies are 

responsible for developing and administering multi-year state plans for OAA activities and 

programs, including the Long-Term Care Ombudsman program.

3. Within ACL, Central and Regional Offices7 provide critical support to state Long-Term Care 

Ombudsman programs.

a. The Office of Long-Term Care Ombudsman Programs (Central Office) includes the 

Director of the Long-Term Care Ombudsman Programs and the Ombudsman Program 

Specialist who, together, support States’ implementation of OAA grants for their LongTerm Care Ombudsman programs. In addition to administrative duties, the OAA requires 

that the Director of the Long-Term Care Ombudsman Program advocate on behalf of 

residents of long-term care facilities within DHHS and other departments, agencies, and 

instrumentalities of the federal government. This advocacy includes all federal policies 

affecting populations that are covered by the Ombudsman program. 

b. The Office of Regional Operations (Regional Office) serves as the focal point for the 

development, coordination, and administration of ACL programs across ACL’s 10 

regions. The Regional Office is also the local point of contact for SUAs. 

4. SUAs are responsible for establishing an Office of the State Long-Term Care Ombudsman (Office 

or Office of the SLTCO) that is distinct, and separately identifiable from the SUA. The OAA also 

requires that SUAs ensure that Ombudsman programs have sufficient resources and protections 

to carry out their legislatively mandated functions. This includes establishing or ensuring policies 

and procedures; monitoring local programs (where applicable); ensuring Ombudsmen have 

private and unimpeded access to residents; providing disclosure of information provisions; 

ensuring freedom from individual and organizational conflicts of interest; assigning adequate legal 

counsel, and managing personnel functions if programs are organizationally located within the 

SUA. 

5. The Office of the SLTCO is headed by a full-time State Ombudsman who is responsible for the 

leadership and management of the State Long-Term Care Ombudsman program in coordination 

 

7 As of June 2019, the Regional Office became the “Center for Regional Operations.”
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with the SUA, and where applicable, any other host agency that implements the Ombudsman 

program. Key duties of State Ombudsmen include statewide program administration and 

oversight of representatives of the Office at the state and local levels.

6. The OAA affords broad flexibility to State agencies in how they administer Ombudsman 

programs. This administration is defined by both the program’s structure and its organizational 

placement. 

a. A program’s structure can be described as either centralized or decentralized. In a 

centralized structure, all program staff are employees of the agency housing the Office of 

the SLTCO. In a decentralized structure, the Office of the SLTCO is housed in a state 

agency or contracted entity, but local Ombudsman staff are employed by another 

contracted entity designated by the State Ombudsman as a local Ombudsman entity. 

b. Organizational placement refers to the location of the program. At both the state and local 

levels, programs can be “hosted” by (or housed within) the SUA, or with another agency 

or entity that is under contract with the SUA to administer the Ombudsman program. 

These placements include other state or local government agencies, independent 

agencies within state government, or within nonprofit organizations, including freestanding Ombudsman programs. 

7. There are 21 state Ombudsman programs with a centralized program structure. Of these, eight

programs have Offices that are housed within SUAs, and the remaining 13 are housed outside of

SUAs. By definition, centralized programs do not have local Ombudsman entities. However, 

some centralized programs have offices located outside of the State Office that facilitate 

statewide access to the program. 

8. There are 32 state Ombudsman programs with a decentralized program structure. Of these, 25 

programs have Offices that are housed within SUAs, and the remaining seven are housed 

outside of SUAs. 

a. Decentralized state Ombudsman programs have local Ombudsman entities located 

within a number of different organizational placements, although most are housed within 

Area Agencies on Aging (AAAs) or nonprofit social service agencies. 

9. Ombudsman programs’ structure offer notable advantages and disadvantages.

a. State Ombudsmen whose programs are characterized by a centralized structure reported 

that they could ensure consistency in their program’s implementation across all program 

staff. This was partly attributed to having greater direct access to, and communication 

with staff that facilitates coordination of activities. At the same time, a few State 

Ombudsmen reported that increased oversight can be difficult to manage when staff are 

geographically dispersed throughout the state. 

b. State Ombudsmen with decentralized programs reported greater ability to carry out 

systems advocacy and higher levels of local program autonomy in setting priorities, 

compared to their counterparts who lead centralized programs. However, State 

Ombudsmen with decentralized programs were also more likely to report fragmentation in 

service delivery across local programs and conflicts with local host agencies concerning 

personnel management. They also described challenges managing fiscal resources due 

to lack of access to detailed budget information at the local level. 

10. Ombudsman programs’ organizational placement at the state and local levels offer notable 

advantages and disadvantages.
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a. State Ombudsmen whose programs are housed within nonprofit organizations reported 

high levels of autonomy. Similarly, local Ombudsmen whose local Ombudsman entities

are housed within legal services providers and social services nonprofit agencies, 

reported higher autonomy than their counterparts whose programs have other 

organizational placements. Limited autonomy for State and local Ombudsmen whose 

programs are located in central State Offices within SUAs was particularly evident as it 

related to carrying out systems advocacy, speaking with the media, and having control 

over their program’s fiscal resources.

b. State Ombudsmen outside SUAs (65%) were more likely to report the ability to determine 

the use of fiscal resources to operate their programs compared to those whose programs 

are housed within SUAs (44%). 

c. State and local Ombudsmen whose programs are housed within SUAs, AAAs, or other 

state or local government agencies reported benefiting from “built-in” resources, such as 

human resources, data systems, information technology (IT), and legal assistance. 

d. Several State Ombudsmen whose programs are housed within SUAs reported having 

greater visibility for the Ombudsman program among relevant groups, a “seat at the table” 

in important discussions about long-term care, and the ability to engage in coordinated 

efforts with key organizations. Proximity to partner organizations that are co-located within 

the SUA was also described as facilitating greater opportunities for cross-trainings. 

e. State Ombudsmen whose programs are housed within SUAs reported greater risk for 

organizational conflicts of interest, and less independence to operate the program. For 

example, when legal counsel is shared among the Ombudsman program and the SUA or 

other agencies such as licensing and certification or APS, State Ombudsmen reported 

that it may be difficult to obtain legal advice that prioritizes the Ombudsman program and 

long-term care residents. 

4.1.2. Reauthorization of OAA and Implementation of the Final Rule 

1. Implementation of the Final Rule affected Ombudsman programs’ organizational placement at 

both the state and local levels. 

a. A few State Ombudsmen reported moving or being in the process of identifying new 

homes for their State Offices or local Ombudsman entities to comply with regulations that 

require avoidance of organizational conflict of interest. 

2. Most State Ombudsmen reported that implementation of the reauthorized OAA and Final Rule will 

eventually strengthen the program’s independence and authority. At present, however, State 

Ombudsmen also reported challenges coming into compliance with the legislation and regulation. 

a. Although the Final Rule added few new requirements, some State Ombudsmen 

perceived the regulation as an unfunded mandate with a relatively short implementation 

timeline which, in turn, placed strain some Ombudsman programs, particularly when 

programmatic resources were limited. Promulgation of the Final Rule, however, also 

revealed that some programs had not been meeting OAA’s existing requirements. For 

these programs, coming into compliance with the regulation required a relatively greater 

investment of time and effort. 
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b. Requirements of the Final Rule that address organizational conflicts of interest can limit 

Ombudsman programs’ options for appropriate organizational placement. States are 

increasingly moving to redesign their long-term care systems and these redesigns often 

add, or consolidate responsibilities for home and community–based care. These changes 

present increased opportunities for perceived or actual conflicts of interest that may be 

incompatible with, or require remedy under the Final Rule and OAA. 

c. OAA reauthorization required that Ombudsman programs serve all residents of long-term 

care facilities, regardless of age. While some programs have always served residents of 

all ages, the new age requirement can strain the resources of other Ombudsman 

programs. 

3. Activities surrounding the reauthorization of the OAA and the publication of the Final Rule were 

reported to increase the visibility of Ombudsman programs among stakeholders at the national, 

state, and local levels. Further, the presence of a full-time Director of Long-Term Care 

Ombudsman Programs was critical for both raising the profile of the Ombudsman program as well 

as for the development and implementation of the Final Rule.

c. At the national level, federal staff and national stakeholders reported that the 

Ombudsman program’s profile increased as a result of the Central Office’s engagement 

with other agencies and stakeholders in promulgation of the Final Rule. 

d. Implementation of the Final Rule required Ombudsman programs at the state and local 

levels to educate partners and other entities about new and existing requirements that 

affect the Ombudsman program and entities with which it coordinates. 

4.1.3. Support from SUA Directors and ACL Central and Regional Offices

1. State Ombudsmen reported that having the support of their SUA Director is very important for 

enhancing their ability to carry out statewide program mandates. This was true regardless of their 

program’s structure or organizational placement, although SUA Director support was particularly 

valued by State Ombudsmen whose programs were housed within SUAs.

2. State Ombudsmen generally found ACL’s Central and Regional Office staff to be helpful and 

supportive. However, State Ombudsmen within SUAs reported more difficulties working with their 

Regional Offices than those whose programs were housed outside of SUAs. A few State 

Ombudsmen reported that their ACL Regional Administrator’s closer relationship with their SUA 

Director lowered the likelihood that they would bring sensitive matters to the Regional 

Administrator’s attention (particularly if they involved the SUA). State Ombudsmen reported that 

having joint meetings with the Regional Administrator and SUA Director can inhibit the State 

Ombudsman from speaking freely, particularly if their Office is located within the SUA. 

3. The level of communication between State Ombudsmen and their ACL Regional Offices varied by 

region, with some Regional Offices being more responsive than others.
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4.2. Introduction

The Older Americans Act (the Act, OAA) and Long-Term Care Ombudsman Programs Final Rule (Final 

Rule)8 provide legislative guidance and requirements for the structure and operations of State Long-Term 

Care Ombudsman programs (SLTCOPs). Given the significance of these provisions for Ombudsman 

programs’ organizational placement and operations, this chapter summarizes recent changes and 

clarifications introduced in the OAA reauthorization and Final Rule regarding the program’s scope and 

responsibilities, and describes initial responses to those changes from key stakeholders and program 

staff. It then describes how the program operates within the administrative hierarchy established by the 

OAA. Lastly, the chapter emphasizes the program’s structure and organizational placement at the state 

and local levels and their relationship to program operations, autonomy, resources, and the program’s 

effectiveness in carrying out mandated activities.

4.3. Findings

4.3.1. Federal Law, Regulations, and Ombudsman Program Oversight

2016 Reauthorization of the Older Americans Act

In 2016, the OAA reauthorized Ombudsman programs for federal fiscal years 2017 through 2019, making

several important changes and clarifications to the Ombudsman program. The OAA reauthorization9: 

■ Authorized Ombudsman programs to serve all long-term care facility residents, regardless of age. 

[Section 711(6)] 

■ Clarified that the State Ombudsman is responsible for the fiscal management of the Office of the 

State Long-Term Care Ombudsman. [Section 712(a)(2)] 

■ Clarified that 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 Ombudsmen to ensure that residents have private, unimpeded access to the 

program. [Section 712(a)(3)(D)] 

■ Required 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 Ombudsman programs to serve residents transitioning from a long-term care facility to 

a home-care setting, when feasible. [Section 712(a)(3)(I)] 

■ Clarified that the 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 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)] 

 

8 It should be noted that while each state’s Ombudsman program is also subject to state-specific laws that may dictate or affect 

program activities, federal law and regulations precede state law and regulations.

9 https://acl.gov/sites/default/files/about-acl/2017-04/OAA-Summary-Final.pdf 
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■ Provided examples of individual and organizational conflicts of interest requiring remediation or 

removal of such conflicts. [Section 712(f)] 

■ Required that each State Ombudsman or his/her designee participate in training provided by the 

National Long-Term Care 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)] 

Although the Ombudsman program had already been performing many of these functions, including 

serving all residents of long-term care facilities, the 2016 clarifications aimed to strengthen and bring 

consistency to program delivery. As described above, these clarifications touched on a number of 

program elements such as assisting with the development of resident and family councils, requiring 

Ombudsmen and representatives of the Office to receive training, and ensuring that residents have

private, unimpeded access to the program. The OAA reauthorization also clarified existing provisions by 

providing examples of individual and organizational conflicts of interest, describing the roles of State and 

local Ombudsmen and their host agencies, and detailing key areas to be addressed in the development 

of program policies and procedures. 

Long-Term Care Ombudsman Programs Final Rule 

As outlined in federal law, states are tasked with ensuring that programs meet specific requirements that 

flow down from the OAA, but programs can exercise considerable discretion in fulfilling program functions 

in a manner that best serves their older adult populations. States’ ability to expand program 

responsibilities (e.g., in-home services) and their broad flexibility in administering the program (e.g., 

organizational location at both the state and local levels, sources of funding), as well as differing 

interpretations of the Act in the absence of formal guidance, result in considerable variation in the 

structure, operation, and effectiveness of Ombudsman programs. 

To strengthen the effectiveness of Ombudsman programs and ensure consistency in consumer 

protections across programs, the Administration for Community Living (ACL) embarked on an historic 

undertaking in 2015 by promulgating regulations for the LTCOP. The culmination of several years of 

stakeholder collaboration and consensus-building around areas of needed guidance, the State LongTerm Care Ombudsman Programs Final Rule represents the first regulation focused specifically on 

Ombudsman program implementation. 

Promulgated under the authority of sections 201(e), 307(a), and 712-713 of the OAA (42 U.S.C. 3011(e), 

3027, and 3058g-3058h), respectively, the regulation was published on February 11, 2015, and became 

effective on July 1, 2016. Adding few new requirements, the Final Rule focused its regulatory guidance on 

areas of greatest inconsistency in program implementation. Key provisions of the Final Rule addressed:

10

■ 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] and

 

10 https://ltcombudsman.org/uploads/files/library/ltcop-regs-overview.pdf 
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■ Conflicts of Interest [45 CFR §1324.21]

The Final Rule, for example, clarified the criteria for establishing consistent, person-centered approaches 

for resolving complaints (including the appropriate role of Ombudsman programs in resolving abuse 

complaints), and processes to identify, remedy, and report conflicts of interest so that residents have 

access to effective, credible Ombudsman services (see Appendix B for more information on the Final 

Rule’s provisions). 

In addition to its goal of ensuring greater alignment and consistency across state programs, the Final 

Rule sought to clarify provisions of the Act – particularly those that are uniquely applied to the 

Ombudsman program – that have been sources of confusion for SUAs, Ombudsman programs, as well 

as entities that work with programs. The regulation operationalizes OAA provisions that are 

uncharacteristic of how SUAs and AAAs operate other OAA programs, including (1) State Ombudsman 

responsibility to designate representatives and local Ombudsman entities; (2) stringent disclosure 

provisions; (2) individual and organizational conflict of interest requirements, and (4) Ombudsman 

responsibility to perform system advocacy functions. 

National Stakeholder and State Ombudsmen Responses to Changes and Clarifications Introduced 

in the OAA Reauthorization and LTCOP Final Rule 

To help guide State agencies, Ombudsman programs, and other entities that work with Ombudsman 

programs to implement the Final Rule, ACL’s Central and Regional Offices and the National Long-Term 

Care Ombudsman Resource Center (Resource Center) provided training and technical assistance 

through conference sessions, webinars, and a list of frequently asked questions (FAQs). National 

membership organizations, including the National Association of States United for Aging and Disabilities

(NASUAD) and National Association of Area Agencies on Aging (n4a), also worked with their members to 

promote understanding of the implications of the Final Rule for SUA and AAA operations. 

Federal staff, national stakeholders, and State Ombudsmen reported 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 back-end.” ACL’s

Central and Regional Office staff spent considerable time working with State Ombudsman programs to 

examine program structure, organizational placement, and policies and procedures to help 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. 

During this study’s data collection period (2017-2018), programs were still actively working toward 

meeting Final Rule’s requirements. Given that the process evaluation occurred during this timeframe, 

findings about organizational structure and activities reflect ongoing program efforts to comply with the 

regulation. Key themes of the findings included: 

Strengthening and Clarifying the Ombudsman Program. Most federal staff, national stakeholders, and 

State Ombudsmen reported that implementation of the reauthorized OAA and Final Rule complemented 

one another and will eventually strengthen the program’s service delivery. For many, the Final Rule 

provides necessary clarifications relating to the independence and role of the Ombudsman program and 

its relationship with other entities that serve residents of long-term care facilities. 
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■ The Final Rule’s description of the Office of the State Long-Term Care Ombudsman 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. 

► State Ombudsmen reported that the uniqueness and independence of the Ombudsman 

program became clearer with the new regulations, and most agreed that the OAA 

reauthorization and the Final Rule were positive developments.

► Some State Ombudsmen viewed the Final Rule as a federal mandate for program 

independence and autonomy. 

► Many State Ombudsmen (especially those housed within SUAs) were optimistic that the Final 

Rule would strengthen their independence, and increase understanding of both the program 

and the role of Ombudsmen. However, a few also expressed concern that the Final Rule 

does not go far enough (e.g. it does not refer explicitly to the program’s independence), and 

that there is no mechanism to enforce the language outlining the Ombudsman program’s 

independence and authority. As a granting agency and not an enforcement agency, ACL can 

only compel compliance by withholding funds.

Misunderstandings About the Ombudsman Program. Although the Final Rule affirmed many 

longstanding provisions in the OAA, its publication also brought to light a number of misunderstandings 

about the Ombudsman program among parties that are directly or indirectly responsible for its 

implementation. These parties include Ombudsman program staff, SUA Directors, host agencies at the 

state and local levels, entities with which Ombudsmen coordinate, key decision-makers within State 

agencies, legislators, and stakeholders. Chief areas of confusion related to the independence of the 

program, individual and organizational conflicts of interest, disclosure of resident information, and 

programmatic oversight versus personnel management among programs with a decentralized structure. 

Misunderstandings about the Ombudsman program only underscored the need for the Final Rule. 

■ Stakeholders and State Ombudsmen reported that leadership at some SUAs and other state or 

local government host agencies struggled to understand the requirement or need for 

Ombudsman program independence. 

► Because the OAA authorizes Ombudsmen and representatives of the Office to represent the 

interests of the resident (and not the State or the aging network), Ombudsman program 

independence is vital to fulfilling this legislative mandate. Serving as the voice of residents, 

however, can create confusion and tension when Ombudsmen take public policy positions 

that do not align with SUAs, AAAs, or other state and local agencies that house the Office or 

local Ombudsman entities. For example, one State Ombudsman reported that advocating for 

independence can be challenging when the State agency is responsible for hiring, firing, and 

evaluating the State Ombudsman’s performance. 

► Unlike other aging services programs and activities that SUAs and AAAs deliver, the 

Ombudsman program is subject to individual and organizational conflicts of interest

provisions. These requirements ensure that Ombudsmen can act independently on behalf of 

residents, but they can also create misunderstandings because other aging services 

programs do not have the same requirements. 

► Given that State Ombudsmen frequently reported challenges with effectively communicating 

the role of the Ombudsman program and its need for independence to both state and local 

host agencies, many expressed appreciation for having this more clearly defined in the Final 

Rule.
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■ State Ombudsmen reported that the Ombudsman program’s disclosure provisions can create 

confusion for agencies that work with Ombudsmen. 

► The OAA outlines stringent disclosure provisions that prohibit Ombudsmen from sharing 

identifying information about residents to any individual or entity without the resident’s 

consent. These disclosure provisions must be followed for Ombudsmen to effectively support 

residents’ wishes concerning their personal information. However, because state and local 

agencies may routinely share information about beneficiaries they serve, this programmatic 

distinction can create expectations that the Ombudsman program should do the same. As a 

result, Ombudsmen must explain to other agencies that the program’s confidentiality 

provisions prevent disclosure of identifying information. 

■ Other misconceptions concern the extent to which Ombudsmen can access long-term care 

facilities. These included the mistaken belief that Ombudsmen can only enter facilities in 

response to a complaint and that resident access is limited to paid Ombudsmen staff. One State 

Ombudsman reported that a provider association prohibited volunteer Ombudsmen from visiting 

long-term care facilities until the Final Rule clarified that the duties of representatives of the Office

pertain to both paid and volunteer Ombudsmen. 

■ In terms of program structure and organizational placement, some State Ombudsmen and 

stakeholders reported that responsibility for overseeing program staff has been an area of 

longstanding confusion for both Ombudsmen and host agencies. This is particularly true for 

decentralized programs that house local Ombudsman entities in AAAs and other host agencies.

For example, when an Ombudsman program is contracted out to a host agency at the local level, 

the agency is responsible for personnel management, while the State Ombudsman is responsible 

for programmatic oversight. This division of responsibility can be a source of confusion for host 

agencies that are accustomed to having both programmatic and personnel responsibilities for 

programs they administer. 

■ Stakeholders reported that Ombudsman programs operate very differently across states and 

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

program staff about roles at the state and local levels. 

■ Long-held assumptions about the Ombudsman program’s implementation and responsibilities

have led some parties within the aging network to misperceive the Final Rule’s requirements as 

entirely new, rather than as clarifications of existing OAA provisions with a few new requirements. 

Activities Undertaken to Come into Compliance. Although the Final Rule went into effect on July 1, 

2016, not all states were in compliance by the time data were collected for this study. As of March, 2017, 

ACL had approved compliance plans and timelines submitted by a majority of states. Whereas some 

states were already in compliance and only needed to formalize current practices and policies, others 

anticipated needing to find new homes for their programs and/or revise existing state laws, regulations, 

policies and practices that were inconsistent with the Final Rule. Because programs are subject to the 

schedule of state legislative sessions, however, programs’ ability to make the required updates varied 

considerably – from months to years. 

■ Many State Ombudsmen discussed working with their SUAs and state legislatures to update 

state statutes to comply with the new regulations. However, changing state statutes also requires 

many levels of review and approval, and the schedule of a state’s legislative body can greatly 

affect the timeline for enacting these statutory changes.
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■ A few State Offices and local Ombudsman entities had to relocate to a different host agency to 

eliminate organizational conflicts of interest and comply with the Final Rule, while others 

implemented new policies or revised existing policies and procedures to identify and remedy 

individual and organizational conflicts of interest. 

■ As a result of the provisions and clarification regarding organizational conflicts of interest, State 

Ombudsmen and SUAs were, at minimum, compelled to consider whether their program’s 

placement was appropriate. 

■ To address potential conflicts of interest concerning legal counsel, Ombudsmen reported 

developing memoranda of understanding (MOUs) to clarify roles and responsibilities when 

assigned legal counsel for the Ombudsman program is shared with other agencies (e.g., Adult 

Protective Services (APS)) within the host agency. 

Challenges with Implementation. Stakeholders and State Ombudsmen reported challenges associated 

with implementing the Final Rule 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, Ombudsmen are often the primary intake point for allegations 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. 

■ Other stakeholders reported concern about privacy issues related to residents’ personal 

information. 

► In small towns, residents and their families may know the Ombudsman outside of their role in 

the program, and may not want their personal information to be shared with the Ombudsman. 

It is important to note that the Final Rule has clarified requirements regarding disclosure of 

resident information and requires policies to identify, remedy, and remove individual conflicts 

of interest because of concerns shared by the stakeholder. 

► On the other hand, provisions that restrict disclosure of confidential information to host 

agencies can lead to concerns about the availability of information that is needed to monitor 

Ombudsman activities. 

■ The Final Rule clarified that state policies and procedures exclude the State Ombudsman and 

representatives of the Office from any state lobbying prohibitions that are inconsistent with the 

OAA, such that Ombudsmen can engage in mandated systems advocacy. Despite the Final 

Rule’s clarification on this issue, State Ombudsmen reported that restrictions against lobbying still 

exist for Ombudsmen who are located in state or local government agencies because they are 

state employees. 

■ The OAA’s reauthorization required that Ombudsman programs serve all residents of long-term 

care facilities, regardless of age. While some programs have always served residents of all ages, 

the new age requirement may strain the resources of other Ombudsman programs. 

■ Requirements of the Final Rule that address organizational conflicts of interest can limit 

Ombudsman programs’ options for appropriate organizational placement. States are increasingly 

seeking to redesign their long-term care systems. These redesigns often add or consolidate 

responsibilities for home and community–based care, changes that present increased 
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FINAL REPORT | 42 

opportunities for perceived or actual conflicts of interest that are incompatible with new Final Rule 

requirements. 

■ Although the Final Rule added few new requirements, some State Ombudsmen perceived the 

regulation as an unfunded mandate with a relatively short implementation timeline. They reported 

that ACL’s Central Office staff may have unrealistic expectations of what programs are able to 

accomplish. One State Ombudsman explained that the period between publication of the Final 

Rule (February 2015) to the date of its implementation (July 2016) – including eliminating all 

conflicts of interest – was insufficient for programs to come into compliance, given the unique 

landscapes and circumstances of each state and territory. For these reasons, implementation of 

the regulation placed a strain on some programs, particularly when programmatic resources were 

limited. It should be noted that ACL worked with each state to develop a compliance plan with the 

state or territory determining the timeline for achieving compliance.

■ Promulgation of the Final Rule revealed that some programs had not been meeting the OAA’s 

existing requirements. For these programs, coming into compliance with the regulation required 

relatively greater investment of time and effort. 

■ Some State Ombudsmen reported that ACL’s Central Office could do more to enforce the 

requirement for independence of the Ombudsman program from the SUA and other state 

agencies.

Increasing the Visibility of the Ombudsman Program. Respondents reported that both the process of 

promulgating the Final Rule as well as support for its implementation raised the visibility of the 

Ombudsman program at the national, state, and local levels, as well as increased communication among 

the program’s staff and partners. 

■ Stakeholders and State Ombudsmen reported that both the OAA reauthorization and the Final 

Rule served as tools to educate stakeholders at the federal, state, and local levels about the 

program’s responsibilities and the role of Ombudsmen. A few stakeholders noted that federal 

policy makers may not be as aware of the Ombudsman program as they should be and that there 

is a need for ongoing education due to turnover. 

■ State Ombudsmen reported that implementation of the Final Rule resulted in greater 

communication between Regional Administrators, SUAs, AAAs, and entities with which the 

program coordinates.

4.3.2. Program Structure at the Federal, State, and Local Levels

The OAA established a multi-level administrative structure to operate OAA programs. Ombudsman 

programs are administered by the AoA, within ACL of DHHS. As the chief federal agency charged with 

maximizing the independence of older adults and individuals with disabilities, ACL issues OAA grants to 

SUAs. These designated, state-level agencies are responsible for developing and administering multiyear state plans for OAA activities and programs, including the Long-Term Care Ombudsman program.

This granting authority requires that States provide assurance of compliance with the OAA and related 

regulations. 

SUAs are responsible for establishing an Office of the State Long-Term Care Ombudsman (Office or 

Office of the SLTCO) that is distinct, and separately identifiable from the SUA. The SUA may carry out the 

Long-Term Care Ombudsman program in one of two ways. The Office may be a distinct entity, separately 

identifiable, and located within or connected to the SUA. Alternatively, the SUA may enter into a contract 

or other arrangement with any public agency or nonprofit organization which establishes the Office as a 

separately identifiable, distinct entity. 
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The Office of the SLTCO is headed by a full-time State Ombudsman who is responsible for the leadership 

and management of the State Long-Term Care Ombudsman program in coordination with the SUA and, 

where applicable, any other host agency that implements the Ombudsman program. Key duties of State 

Ombudsmen include statewide program administration and oversight as well as designation of 

representatives of the Office and local Ombudsman entities that carry out the program at the local level. 

4.3.3. Federal Level – ACL Central and Regional Offices

Within ACL, the Office of Long-Term Care Ombudsman Programs (which includes the Director of the 

Office of Long-Term Care Ombudsman Programs, and the Ombudsman Program Specialist), support 

States’ implementation of OAA grants for Ombudsman programs. ACL’s Office of Regional Operations 

(Regional Office) is the focal point for development, coordination, and administration of ACL programs 

across the 10 ACL regions as well as the local point of contact for SUAs. 

The OAA delineates that the Director of the Office of Long-Term Care Ombudsman Programs:

11

■ Serve as an advocate for individuals in long-term care facilities; 

■ Coordinate the activities of the Administration with the activities of other federal entities, state and 

local entities and non-governmental entities, relating to State Long-Term Care Ombudsman 

programs (SLTCOPs); 

■ Supervise the activities carried out under the authority of the Administration that relate to 

SLTCOPs;

■ Administer the National Long-Term Care Ombudsman Resource Center and make 

recommendations to the Assistant Secretary regarding its operation;

■ Advocate, monitor, and coordinate federal and state activities of Long-Term Care Ombudsmen 

under the OAA;

■ Submit an annual report on the effectiveness of services provided under section 307(a)(9) and 

section 712 to the Speaker of the House of Representatives and the President;

■ Have authority to investigate the operation or violation of any federal law administered by the 

Department of Health and Human Services that may adversely affect the health, safety, welfare, 

or rights of older individuals;

■ Establish training standards for representatives of the Office of the State Long-Term Care 

Ombudsman, including unpaid volunteers;

■ Collect and analyze best practices related to responding to elder abuse, neglect, and exploitation 

in long-term care facilities, and publishing a report of such findings; and

■ Review and make recommendations to the Assistant Secretary regarding multiple areas relating 

to SLTCOPs, such as:

► provisions in State plans relating to the SLTCOPs including the adequacy of budgets and 

policies relating to programs; 

► policies designed to assist SLTCOs and methods to monitor and evaluate the operations of 

SLTCOPs; 

 

11 Older Americans Act Reauthorization of 2016, §201(d)(3)
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► problems relating to SLTCOPs and solutions to those problems; 

► existing and proposed Federal legislation, regulations, and policies regarding the operation of 

SLTCOPs; and

► policies of the Administration relating to SLTCOPs. 

Although the 1992 OAA amendments established the Director of the Office of Long-Term Care 

Ombudsman Programs (initially called Associate Commissioner), the position was not filled on a full-time 

basis until 2010 when Kathy Greenlee (a former State Ombudsman) served as Assistant Secretary for 

Aging and ACL Administrator (2009-2016) and appointed an individual to serve in this position. Many 

stakeholders and State Ombudsmen viewed the full-time position, in tandem with Kathy Greenlee’s 

appointment, as a critical opportunity to advance the Ombudsman program’s work. Multiple respondents 

also noted that having former State Ombudsmen occupy key roles at ACL afforded the agency a deeper 

understanding of the Ombudsman program and enhanced their ability to be leaders at the national level. 

In addition to Kathy Greenlee, the Director and the Ombudsman Program Specialist were both former 

State Ombudsmen, as well at least two Regional Administrators. 

The Director of the Office of Long-Term Care Ombudsman Programs played a key role in developing and 

advancing the Final Rule, and this leadership was highly regarded by State Ombudsmen, federal staff, 

and stakeholders. Some credited the Director, in coordination with the Ombudsman Program Specialist,

with increasing programmatic consistency with the Final Rule, and raising the program’s visibility at the 

national and state levels. Although initial efforts to develop regulations for the Ombudsman program 

started in the 1990s, they were never successfully promulgated until the Director position was filled fulltime. Although it cannot be said whether the regulation would have come to fruition absent these events, 

the combination of filling the Director position full-time and Kathy Greenlee’s appointment are widely 

perceived as having facilitated the process. 

It should further be noted that the position of Director was vacated in March of 2017, and the Deputy 

Assistant Secretary for Aging assumed the role. Many viewed this departure as a tremendous loss and 

expressed concern that the continued vacancy on a full-time basis may diminish the program’s impact

and reduce its visibility at the federal level. Given that the Deputy Assistant Secretary for Aging has 

considerable administrative responsibility, some perceived that the Ombudsman program would not 

receive the same attention that a dedicated, full-time staff person would offer. 

In terms of day-to-day operations, ACL’s Central Office provides guidance and technical support to 

Ombudsman programs in a number of ways. These include one-on-one assistance, trainings, conference

sessions, and standing conference calls, such as those organized by the National Association of State 

Ombudsman Programs (NASOP). State Ombudsmen reported seeking guidance, assistance, or 

information from ACL’s Central Office on many topics. These included requesting guidance on laws and 

regulations (such as the Final Rule), obtaining assistance resolving issues (e.g., conflicts of interest, 

disputes with host agencies, working through difficult cases), receiving training or technical assistance on 

various subjects (e.g. submitting data through NORS, and updating state policies and procedures), and 

exchanging updates about federal and state activities. 

About half of State Ombudsmen described ACL’s Central Office staff as “responsive,” “available,” 

“helpful,” and/or “supportive.” State Ombudsmen praised ACL’s Central Office for facilitating 

dissemination of important information through the Resource Center, conference presentations, webinars, 

and conference calls. Many valued the Central Office’s assistance to help programs come into 

compliance with the Final Rule and a few also expressed appreciation for the letter that ACL’s Central 

Office sends to SUAs communicating State Ombudsmen’s requirement to attend the annual training 
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conference. Some described the Central Office staff’s participation in the NASOP meetings as a sign that 

ACL is engaged with State Ombudsmen and supportive of their work. 

Although ACL provides guidance and support to Ombudsman programs, states and territories have 

discretion in how they implement their programs. About half of State Ombudsmen reported that ACL does 

not directly influence the goals they set for their programs, but many reported that ACL can influence 

prioritization of program goals and activities. For example, one State Ombudsman explained that any 

deadline communicated by ACL is prioritized over other program activities, and that federal mandates 

(reinforced by ACL’s Central Office) are used to assess the state’s existing goals and make changes as 

appropriate. About one-fourth of State Ombudsmen reported that ACL influences their program’s goals 

primarily through enforcement of the Final Rule, and by working with states and territories to come into 

compliance with its regulations. 

Of State Ombudsmen who reported that ACL does not influence their program’s goals, a few clarified that 

the OAA or the needs of state and local jurisdictions guide program goals and activities. One State 

Ombudsman expressed a desire for more input from ACL on goals and priorities, while others reported 

that their program’s goals were influenced to a greater degree by entities other than ACL. The latter

included NASOP, the Resource Center (an ACL grantee), other state agencies, and the advocacy 

community. 

With respect to Regional Offices, State Ombudsmen reported interacting with staff through quarterly or 

other standing conference calls with states in their region, as well as during annual monitoring visits. 

Similar to findings from ACL’s Central Office, State Ombudsmen reported discussing a variety of issues 

with ACL’s Regional Offices. These included interpretation and implementation of the Final Rule, 

resolving organizational conflicts of interest, and receiving training and other technical assistance. They 

also reported that the Regional Office facilitates constituent referrals as well as relationships between the 

Ombudsman program and other agencies. 

When asked about ACL Regional Office support for the Ombudsman program, about one-quarter of State 

Ombudsmen reported that Regional Office staff are “responsive,” “helpful,” and “available.” One State 

Ombudsman added that regional meetings are sometimes more useful than national meetings because 

they focus on region-specific characteristics or common issues. About one-quarter of State Ombudsmen 

reported that the Central Office is their primary ACL resource, with slightly fewer identifying the Regional 

Office as their primary resource. 

Exhibit 5 shows that most State Ombudsmen described their relationship with ACL’s Central Office and 

ACL’s Regional Office as “very effective” or “somewhat effective” (75% and 66%, respectively). Part of 

this difference may be due to the State Ombudsman’s organizational placement as well as differences in 

the Regional Administrator assigned to support Ombudsman programs. A few State Ombudsmen 

reported that their ACL Regional Administrator has a closer relationship and more communication with 

their SUA Director than with them. As a result, they reported that they were less likely to bring sensitive 

matters to the Regional Administrator’s attention, particularly if the issue involved the SUA. Additionally, 

nearly one-quarter of State Ombudsmen reported that relationships between State Ombudsmen and their 

ACL Regional Offices are inconsistent across regions, with some Regional Offices being more 

communicative than others.
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Exhibit 5: Effectiveness of Relationship with ACL Central and Regional Offices 

Effectiveness of Relationship with ACL Central and 

Regional Offices

State Ombudsmen

N=52

State Ombudsmen

N=52

ACL Central Office ACL Regional Office

Very effective 38% 37%

Somewhat effective 37% 29%

Neutral 17% 19%

Somewhat ineffective 0% 8%

Very ineffective 4% 2%

4.3.4. Program Structure and Organizational Placement at the State and Local Levels 

States are afforded broad flexibility in how to administer their Ombudsman programs. This program 

administration is defined by both the program’s structure and its organizational placement. A program’s 

structure can be described as either centralized or decentralized. In a centralized structure, all program 

staff are employees of the agency housing the Office of the SLTCO (Office or State Office) regardless of 

their physical location (e.g. State Office, or elsewhere in the state, such as the Regional Offices of the 

State Ombudsman Program). Staff in centralized program structures report directly to the State 

Ombudsman. In a decentralized structure, the Office of the SLTCO is housed in a state agency or 

contracted entity, but local Ombudsman staff are employed by another contracted entity designated by 

the State Ombudsman as a local Ombudsman entity. Local Ombudsman entities may be housed within 

Area Agencies on Aging (AAAs), within other entities such as nonprofit organizations or legal aid offices, 

or a mix of AAAs and these other entities. There are 21 State Ombudsman programs that have a 

centralized structure, and 32 that have a decentralized structure. 

Within these two types of program structures, Ombudsman programs may differ in their placement. 

Organizational placement refers to the location of the State Office and local Ombudsman entities. At both 

the state and local levels, programs can be free-standing, or they can be “hosted” by (or housed within) 

another agency or entity that is contracted by the SUA to administer the Ombudsman program. These 

include placement within other state or local government agencies, in independent agencies within state 

government, or within nonprofit organizations. 

The structure and organizational placement of Ombudsman programs and the interaction between the 

two have important implications for program operations and the implementation of program activities. 

Based on FFY 2017 NORS data, Exhibit 6 shows the number of SLTCOPs by their structure and 

placement. For simplicity, the exhibit presents two categories for organizational placement (within an SUA 

or outside an SUA), recognizing that other combinations exist (see Table A in Appendix D for state-level 

detail).

12 

■ Almost half of Ombudsman programs have a decentralized structure with Offices located within 

SUAs.

■ Most Ombudsman programs with a centralized structure have Offices located outside of SUAs. 

 

12 Note that all organizational placements outside of the SUA have been combined in many of the findings within this chapter. Where 

meaningful differences exist among this combined group, findings are presented on those separate placements. 
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Exhibit 6: Program Structure and State Office Organizational Placement

Program Structure

State Office Placement

Housed within SUA Housed outside of SUA

Centralized 8 13

Decentralized 25 7 

Based on FFY 2017 NORS data, Exhibit 7 presents the distribution of local Ombudsmen entities by their

organizational placement and Ombudsman program structure. Note that for Ombudsman programs that 

are characterized by a centralized structure, the concept of “local Ombudsman entity” does not technically 

apply, but we present them here for comparison purposes and to reflect NORS reporting. These 

programs may have staff working in the State Office or off-site throughout the state, in what is referred to 

as “Regional Offices of the State Ombudsman Program.” There are 74 of these regional offices. Within 

decentralized programs, a majority (73%) of local Ombudsman entities are housed within AAAs or social 

services nonprofit agencies (14%).

Exhibit 7: Local Ombudsman Entity Organizational Placement by Program Structure 

Local Ombudsman Entity Organizational Placement 

Centralized 

Program 

Structure 

N=74

Decentralized 

Program 

Structure 

N=449

Area Agency on Aging 0 329

Social Services Nonprofit Agency 0 65

Free-standing Ombudsman Program 0 27

Legal Services Provider 0 21 

Other Local Government Entity 0 4 

Other 0 3 

Regional Offices of the State Ombudsman Program 74 0 

Program Structure – Centralized vs. Decentralized

State and local Ombudsmen reported benefits and challenges to both centralized and decentralized

structures, particularly as they relate to management of program staff and activities. 

■ Centralized programs appeared to benefit from more consistent program implementation, a 

simpler management structure, greater interaction among staff, and less conflicting guidance 

between the Office and regional offices. 

■ State Ombudsmen in centralized programs reported more frequently than those in 

decentralized programs that they could ensure consistency across staff in program 

implementation. This enhanced coordination was partly attributed to greater access to and 

communication with staff.

■ State Ombudsmen in centralized programs described having a simpler management 

structure than decentralized programs because all program staff report to the State 

Ombudsman. 
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■ A smaller percentage of lead local Ombudsmen (15%) in centralized programs reported 

receiving conflicting guidance from the Office of the SLTCO and their local host agency, 

compared to lead local Ombudsmen in decentralized programs (26%). 

■ Seventy-eight percent of local Ombudsmen in centralized programs reported interacting with 

staff from the central State Office at least once a week, compared to just 40% of local 

Ombudsmen in decentralized programs. 

■ A few State Ombudsmen reported that increased oversight was difficult to manage in states 

where Ombudsman staff are geographically dispersed throughout the state.

■ Decentralized programs appeared to benefit from programmatic autonomy in setting local 

priorities and in their ability to carry out systems advocacy. However, the challenges of 

decentralized program structures included “fragmentation” in program staff management and 

operations and obtaining access to budget information to manage fiscal resources. 

■ Local Ombudsmen in decentralized programs were more likely to report autonomy in setting 

local priorities than their counterparts in centralized programs (see Exhibit 8).

■ Local Ombudsmen in decentralized programs were more likely than their counterparts in 

centralized programs to report that their program structure enables their local entity to carry 

out systems advocacy activities. They may perceive greater autonomy to carry out this work 

in part because of their organizational separation from the State Office.

■ Nearly one-third of State Ombudsmen in decentralized programs reported difficulties 

navigating lines of authority with local host agencies, particularly in distinguishing personnel 

management from program oversight. 

■ A few State Ombudsmen in decentralized programs noted that they lack the authority to hire 

or fire local program staff despite being responsible for designating them. This concern was 

more of a challenge for State Ombudsmen who described having less collaborative 

relationships with their local host agencies. Others disagreed with how some local host 

agencies were managing their local Ombudsman entities, particularly with respect to budget

decisions for Ombudsman activities. For example, one host agency restricted Ombudsman 

travel budgets due to financial concerns, thereby limiting the program’s ability to carry out 

visits beyond the quarterly goal.

■ State Ombudsmen with decentralized programs reported challenges managing fiscal 

resources due to a lack of access to detailed budget information at the local level. These 

challenges were reported to occur when AAAs are the host agency or subcontract to another 

entity.

■ Although there may be some challenges related to maintaining consistency of program 

services and management of staff within a decentralized structure, a few State Ombudsmen 

reported that this structure is necessary to ensure coverage across the state, particularly for 

programs serving large rural areas.
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Exhibit 8: Local Ombudsman Entity Autonomy by Program Structure 

To what extent does the Office of the SLTCO 

drive your local program’s priorities?

SLTCOP with Centralized 

Structures 

N=32a 

SLTCOP with Decentralized 

Structures 

N=145b 

High level of involvement (less local autonomy) 44% 29%

Medium level of involvement 34% 39%

Low level of involvement (more local autonomy) 22% 32%

a

 Not applicable=7 (I work in the State Office, so our priorities are the same.) 

b

 Not applicable=5 (I work in the State Office, so our priorities are the same.) 

Overall, most State Ombudsmen are satisfied with their current program structures, despite identifying 

certain challenges that affect program operations. 

■ A majority (94%) of local Ombudsmen in both centralized and decentralized programs reported 

that lines of authority and accountability are clearly defined for all Ombudsmen staff (paid and 

volunteer). 

Nearly all (94%) State Ombudsmen reported that their statewide program is “very effective” or “somewhat 

effective”. However, important differences emerge when program structure is considered. As shown in 

Exhibit 9, State Ombudsmen with centralized program structures were more likely to report that their 

statewide program is “very effective” (55%), compared to State Ombudsmen operating within

decentralized program structures (41%). 

Exhibit 9: State Ombudsman Perceptions of Statewide Program Effectiveness by Program Structure 

State Ombudsman Perceptions of Statewide 

Program Effectiveness 

SLTCOP with Centralized 

Structure 

N=20

SLTCOP with Decentralized 

Structure 

N=32

Very effective 55% 41%

Somewhat effective 40% 53%

Neutral 0% 0%

Somewhat ineffective 0% 0%

Very ineffective 0% 3%

Don’t know 5% 3%

Similarly, as shown in Exhibit 10, local Ombudsmen operating within centralized statewide programs were 

more likely to report that their statewide programs are “very effective” (60%), compared to local 

Ombudsmen whose statewide programs are characterized by decentralized structures (48%). 
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Exhibit 10: Local Ombudsman Perceptions of Statewide Program Effectiveness by Program Structure 

Local Ombudsman Perceptions of Statewide 

Program Effectiveness 

SLTCOP with Centralized 

Structure

N=129

SLTCOP with Decentralized 

Structure

N=367a 

Very effective 60% 48%

Somewhat effective 19% 27%

Neutral 12% 15%

Somewhat ineffective 5% 4%

Very ineffective 2% 3%

Don’t know 2% 4% a Missing=1

Local Ombudsmen’s perceptions of effectiveness appeared to be related to their relationship with staff in 

the State Office (Exhibit 11). Those whose programs are characterized by a centralized structure were 

more likely to report that their relationship with the State Office is “very effective” (60%), compared to local 

Ombudsmen whose programs are decentralized (50%). 

Exhibit 11: Local Ombudsman Perceptions of Effectiveness of Relationship between Central State Office 

and Local Ombudsman Entity by Program Structure 

Local Ombudsman Perceptions of Effectiveness of 

Relationship with State Office 

SLTCOP with 

Centralized Structure

N=106a 

SLTCOP with 

Decentralized Structure

N=363b 

Very effective 60% 50%

Somewhat effective 18% 26%

Neutral 11% 12%

Somewhat ineffective 4% 6%

Very ineffective 4% 3%

Don’t know 3% 4%

a Not applicable=23 (My program has a centralized structure and all staff are located in the central office.) 

b Missing=2, Not applicable=3 (My program has a centralized structure and all staff are located in the central office.) 

Office of the State Long-Term Care Ombudsman – Organizational Placement

As described earlier, State Offices and local Ombudsman entities have different organizational 

placements. As shown in Exhibit 12, most State Offices are housed within SUAs. State Offices may also 

be located within other state government agencies (e.g. Department of the Treasury), in independent 

agencies within state government, or within a nonprofit organization. 
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Exhibit 12: State Office Organizational Placement 

State Office Organizational Placement Number of State Programs

State Unit on Aging 33

Other State Government Agency 8 

Nonprofit Organization 8 

Independent State Agency 4 

State Office placement appears to impact how State Ombudsmen viewed their relationships with ACL’s 

Central and Regional Offices.

■ State Ombudsmen in Offices placed within SUAs were more likely to report effective relationships 

with ACL’s Central Office than with ACL’s Regional Office. Seventy-nine percent of State 

Ombudsmen with Offices located within SUAs reported that their relationship with ACL’s Central 

Office was “very effective” or “somewhat effective”. By contrast, 63% of this group reported that 

their relationship with ACL’s Regional Office was “very effective” or “somewhat effective” (data 

not reported in exhibits). 

■ A few State Ombudsmen reported that their ACL Regional Administrators’ closer relationship with 

their SUA Director reduced the likelihood that they would bring sensitive matters to the Regional 

Administrator’s attention, particularly if they involved the SUA. By contrast, holding meetings with 

the Regional Administrator, SUA Director, and the State Ombudsman inhibited the State 

Ombudsman from speaking freely, particularly if their Office is located within the SUA. 

■ State Ombudsmen in programs outside of SUAs reported that their relationships with ACL’s

Central and Regional Offices were equally effective, with 70% reporting that both relationships 

were “very effective” or “somewhat effective” (data not reported in exhibits). 

■ Nearly all State Ombudsmen (94%) reported that ACL’s Central Office was “very helpful” (32%) 

or “somewhat helpful” (62%), although slightly fewer overall (86%) found their ACL Regional 

Office to be “very helpful” (38%) or “somewhat helpful” (48%). These reports did not vary by state 

program organizational placement (data not reported in exhibits). 

State Ombudsmen described each type of State Office organizational placement as having a unique set 

of benefits and challenges that affect program operations. 

■ Organizational placement of State Offices within SUAs were reported to bring important benefits, 

including access to resources and greater visibility among agencies and stakeholders. 

Challenges included greater risk of organizational conflicts of interests, restrictions on legislative 

advocacy, and political pressure.

■ State Ombudsmen reported placement in SUAs provides access to “built-in” resources (e.g. 

human resources, data systems and technical support, IT, and legal assistance). 

■ Several State Ombudsmen reported having greater visibility for the Ombudsman program 

among relevant groups, a “seat at the table” in important discussions about long-term care, 

and the ability to engage in coordinated efforts with key organizations. Proximity to partner 

organizations that are co-located within the SUA was also described as facilitating greater 

opportunities for cross-trainings. 

■ State Ombudsmen reported higher risk for organizational conflicts of interest, and less 

independence in operating the program freely. For example, when legal counsel is shared 
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among the Ombudsman program and the SUA or other agencies such as licensing and 

certification or APS, it may be difficult to obtain legal advice that prioritizes the Ombudsman 

program and long-term care residents. 

■ State Ombudsmen reported feeling restricted (sometimes explicitly, but more often implicitly) 

in their ability to take a position or testify on an issue that their SUA may not agree with, 

thereby limiting their ability to fully engage in systems advocacy. One State Ombudsman 

described tension in publicly disagreeing with the SUA on certain issues because the SUA is 

also responsible for approving the Ombudsman program’s budget and staffing.

■ State Ombudsmen reported that the SUA’s political environment may affect program 

operations. For example, SUA Directors appointed by the governor may pressure State 

Ombudsmen not to challenge the governor’s positions on certain issues. It should be noted 

that in some states, State Ombudsmen are also appointed by the governor. 

■ Organizational placement of State Offices outside of SUAs were reported to bring important 

benefits, including greater autonomy to carry out systems advocacy work and fiscal control, as 

well as challenges, such as fewer resources and lower program visibility. 

■ State Ombudsmen reported having greater autonomy and freedom to operate their programs 

without political pressure, and fewer organizational conflicts of interest, as shown in Exhibit 

13. This was particularly evident for programs housed within an independent state agency or 

a nonprofit organization (data not shown in exhibits). 

■ Although all State Ombudsmen in programs outside of SUAs agreed that their statewide 

program has the autonomy to carry out systems advocacy work, 88% of State Ombudsmen 

whose Offices are located in nonprofits “strongly” agreed with this statement compared to 

50% of State Ombudsmen whose Offices are located within an independent state agency or 

state government other than the SUA (data not shown in exhibits).

■ State Ombudsmen’s sense of program autonomy also appears to be reflected at the local 

level. Eighty percent of lead local Ombudsmen whose State Offices are housed outside of 

SUAs agreed that their organizational placement enables their local entity to carry out 

systems advocacy activities, compared to 66% of those whose State Offices are housed 

within SUAs (data not shown in exhibits). 

■ State Ombudsmen located outside of SUAs (65%) were more likely to report having the 

ability to determine the use of fiscal resources to operate their state programs than those 

whose programs are housed within SUAs (44%) as shown in Exhibit 14. Nevertheless, most 

State Ombudsmen reported having at least partial ability to determine the use of fiscal 

resources, regardless of where their program is placed. 

■ State Ombudsmen in programs housed outside of SUAs reported more challenges taking 

advantage of certain resources or partnerships to which State Ombudsmen within SUAs 

seem to have greater access or stronger connections. A few also noted that their salaries are 

typically lower than their counterparts who are state employees. 

■ State Ombudsmen whose programs are located outside of SUAs reported lower program 

visibility among agencies or organizations that they might partner with to serve residents and 

carry out other program activities.
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Exhibit 13: Autonomy of Ombudsman Program by State Office Organizational Placement

Statements about Autonomy of Statewide 

Ombudsman Program

State Office in SUA

N=32 a

State Office Outside of SUA

N=20

My statewide program has been unable to fulfill some 

program duties due to legislative or regulatory 

restrictions. 23% 10%

My statewide program has the autonomy to carry out 

systems advocacy work. 84% 100%

My statewide program is free to speak to the media. 69% 100%

My statewide program is able to represent the 

interests of residents to state agencies involved in 

long-term care without political interference. 75% 95%

a Missing=1 (Missing data only applies to the first statement on autonomy.) 

Exhibit 14: Ability to Determine Use of Fiscal Resources to Operate LTCOP by State Office 

Organizational Placement

Are you able to determine the use of fiscal 

resources to operate the LTCOP at the state level?

State Office in SUA

N=32

State Office Outside of SUA

N=20

Yes 44% 65%

Partially 47% 30%

No 9% 5%

Exhibit 15 shows that a majority of State Ombudsmen reported that their statewide program is “very 

effective” or “somewhat effective” across all types of organizational placement. However, State 

Ombudsmen whose Offices are in nonprofits or independent state agencies were more likely to report 

that their statewide programs are “very effective” (88% and 75%, respectively) than those whose 

programs are located in SUAs or state government (41% and 13%, respectively). 

Exhibit 15: State Ombudsman Perceptions of Statewide Program Effectiveness by State Office 

Organizational Placement 

State Ombudsman Perceptions of 

Statewide Program Effectiveness 

State Office in 

SUA 

N=32

State Office in 

State 

Government

N=8

State 

Ombudsmen in 

Independent 

State Agency 

N=4

State Office in 

Nonprofit 

N=8

Very effective 41% 13% 75% 88%

Somewhat effective 53% 75% 25% 13%

Neutral 0% 0% 0% 0%

Somewhat ineffective 0% 0% 0% 0%

Very ineffective 0% 13% 0% 0%

Don’t know 6% 0% 0% 0%
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Local Ombudsman Entities – Organizational Placement

Organizational placement of local Ombudsman entities varies in much the same way as State Office 

placement. In a decentralized program, local Ombudsmen entities may be free-standing or they can be 

hosted by an agency or entity that is contracted to administer the Ombudsman program.

Based on NORS data, Exhibit 16 shows the distribution of local Ombudsman entities across each type of 

organizational placement in FFY 2017. Ombudsman programs that are characterized by a centralized 

structure (described earlier) are not reported here. 

Exhibit 16: Local Ombudsman Entity Organizational Placement 

Local Ombudsman Entity Organizational Placement 

Number of Local Ombudsman 

Entities 

Area Agency on Aging 329

Social Services Nonprofit Agency 65

Free-standing Ombudsman Program 27

Legal Services Provider 21 

Other Local Government Entity 4 

Other 3 

State Ombudsmen reported both benefits and challenges to having local Ombudsman entities located 

within various host agencies, particularly with respect to placements within or outside of AAAs. Paralleling 

findings at the state level with respect to SUA placement, local Ombudsman entities housed outside of 

AAAs may benefit from greater autonomy, but they may also face other challenges related to resources 

that AAAs provide. 

■ Local Ombudsman entity’s location within AAA brings important resource advantages. 

■ Many AAAs supplement the resources of local Ombudsman entities, including financial 

support and in-kind contributions (e.g., payroll, data systems, office space), allowing local 

Ombudsman entities to carry out more activities than would be possible without these 

contributions. One State Ombudsman noted that one of their AAAs was able to financially 

support the local Ombudsman entity while the State program’s budget review was in process, 

thereby providing a “safety net” while they awaited approval to release funds.

■ State Ombudsmen reported that proximity to other aging network partners (e.g., those 

providing benefits counseling, transportation services, etc.) that are co-located in AAAs 

facilitate the Ombudsman program’s ability to serve residents. 

■ AAAs’ familiarity with LTSS and OAA services was perceived to support the work of local 

Ombudsmen. Other agencies or organizations may not have the same familiarity with LTSS 

for older adults, and may therefore require more guidance from the State Ombudsman 

regarding the program’s role.

■ Organizational placement of local Ombudsman entities within AAAs also comes with challenges, 

including greater risk of conflicts of interest and less autonomy to engage in systems advocacy. 

■ Like SUAs, AAAs deliver direct services to long-term care residents, or they determine 

eligibility for services in settings that Ombudsman programs also serve. In addition, AAAs 

may host other agencies such as APS or licensing and certification entities. Although co-
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location may facilitate coordination with these entities, it can also present opportunities for 

conflicts of interest or affect the autonomy of Ombudsmen in carrying out their 

responsibilities.

■ Like State Ombudsmen, lead local Ombudsmen who work within AAAs reported having less 

autonomy to carry out systems advocacy than their peers located outside of AAAs, 

particularly as it related to legislative advocacy or providing testimony. Lead local 

Ombudsmen whose local entities are located within legal services provider agencies – 

particularly social services nonprofit agencies – reported a much higher sense of program 

independence and autonomy compared to their peers whose programs have other 

organizational placements.

Support of SUA Director 

Regardless of Ombudsman program structure and organizational placement, many State Ombudsmen 

underscored the importance of their SUA Director’s support for effective program implementation. Several 

State Ombudsmen reported that the most important way that their SUA supports their program was by 

allowing the State Ombudsman to operate without interference or restriction. Helping the program make 

changes to policies and state statutes to come into compliance with the Final Rule was reported as an 

important form of support. Additionally, SUA Directors who are communicative as well as knowledgeable 

and supportive of the Ombudsman program’s purpose and mission were also reported as major 

strengths. 

State Ombudsmen across program location categories reported relatively high support from their SUA 

Directors, with half or more reporting that their SUA Director is either “very supportive” or “fully supportive” 

(Exhibit 17). 

Exhibit 17: Support from SUA Director by State Office Organizational Placement

Overall, how would you describe 

the support your Office of the 

SLTCO receives from the SUA 

Director?

State Office in 

SUA 

N=32

State Office in 

State 

Government

N=8

State Office in 

Independent 

Agency

N=4

State Office in 

Nonprofit

N=8

Fully supportive 50% 38% 50% 75%

Very supportive 28% 50% 0% 13%

Somewhat supportive 16% 13% 25% 0%

Not supportive 0% 0% 0% 0%

Indifferent 6% 0% 25% 13%

State Ombudsmen within SUAs provided concrete examples of how the SUA Director supports them. 

These included sending letters to stakeholders emphasizing the independence of the LTCOP, attending 

presentations made by State Ombudsmen to stakeholders, referring complaints or issues to the 

Ombudsman program, establishing connections between the State Ombudsman and individuals or 

entities (e.g. governor, legislators, etc.), and administrative tasks such as making payments to 

contractors, and securing additional program staff. One State Ombudsman found it particularly helpful to 

have the SUA Director communicate the importance of the Ombudsman program’s independence to the 

AAAs operating their local programs.

Some State Ombudsmen housed within SUAs described having the freedom to conduct systems 

advocacy activities, while also noting that they provide advance notice to their SUA Director about any 
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public statements or testimony they provide, or advocacy activities they plan to carry out. Whereas some 

viewed this as an expectation, others viewed providing this advance notice as a courtesy. 

4.4. Recommendations

■ ACL should continue supporting State Ombudsmen’s efforts to comply with the Final Rule and 

assess the regulation’s effect on Ombudsmen’s ability to freely conduct systems advocacy. 

Based on those findings, ACL should consider whether additional steps need to be taken to 

enforce the independence of the Ombudsman program, particularly for State Ombudsman 

programs that are housed within SUAs. 

■ Given the tremendous benefits derived from having a full-time, dedicated Director of the Office of 

Long-Term Care Ombudsman Programs, ACL should ensure that the position is filled on a fulltime basis.

■ State Ombudsmen reported that coordination among stakeholders at the national and state levels 

helps ensure that the Ombudsman program’s voice is heard and that program needs are 

addressed. ACL’s Central and Regional Offices should continue their efforts to bring visibility to 

the program and to support State and local Ombudsmen in working with other entities.

■ To ensure open communications, ACL Regional Administrators should establish meetings with 

State Ombudsmen that are separate from those with SUA Directors. 

■ While some State Ombudsmen acknowledged that understanding of the Ombudsman program is 

improving among ACL Regional Administrators, ACL Central Office staff should continue efforts 

to increase knowledge and ensure Regional Administrators are better positioned to provide 

consistent support to programs.

■ To prevent perceived program fragmentation, State Ombudsmen in decentralized structures 

should develop coordinated approaches to ensure seamless monitoring of local Ombudsman 

staff.

■ SUA Directors should ensure that policies and procedures are in place that support the State 

Ombudsman’s ability to determine use of fiscal resources appropriated or otherwise available for 

the operation of the Office, as well as approval of allocations of federal and state funds provided 

for local Ombudsman entities, as appropriate. 

■ Given the importance of SUA Director support for State Ombudsmen’s ability to fulfill their 

responsibilities, and the challenges identified by State Ombudsmen housed within SUAs in 

interacting effectively with their SUA, a concerted effort should be made by all parties (ACL staff, 

SUA Directors, and State Ombudsmen) to foster positive relationships, and to improve 

understanding of the role of the Ombudsman program. These efforts should be focused on 

relationship-building that goes beyond the guidance set forth in the Final Rule.
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Chapter 5. Research Question 2: How do LTCOPs use 

existing resources to resolve problems of individual 

residents and to bring about changes at the facility and 

governmental (local, state and federal) levels that will 

improve the quality of services available/provided?

5.1. Key Findings

5.1.1. Program Resources

1. Ombudsman programs draw on multiple resources to carry out mandated functions. These 

resources include legislation, regulations, federal, state, and local funds, staff (paid and 

volunteer), legal counsel, partnerships, peer-to-peer support, training and technical assistance, 

administrative support, data systems, and information technology (IT). 

2. Sources of financial support vary widely among state Ombudsman programs. 

a. In federal fiscal year (FFY) 2017, Long-Term Care Ombudsman program (LTCOP) 

expenditures totaled $106.7 million across all funding sources. Federal, state, and local 

funding accounted for 50%, 43%, and 7%, respectively, of national program 

expenditures. 

b. State funding for Ombudsman programs varied considerably, accounting for between 

zero percent and 83% of total expenditures of Ombudsman programs. 

3. Staff and volunteer resources vary widely among state Ombudsman programs.

a. In FFY 2017, 1,319 paid full-time equivalent staff (FTEs) supported the program. 

Ombudsman programs operated with an average of 25 FTEs, ranging from two to 156. 

Across programs, the ratio of FTEs to facility beds was 1:2,355, ranging from the lowest 

ratio of 1:594 in Washington, DC to the highest ratio of 1:6,814 in Minnesota. 

i. During the Ombudsman program’s last evaluation in 1995, the Institute of 

Medicine (IOM) recommended a minimum staff to bed ratio of one FTE 

Ombudsman to 2,000 beds. It should be noted that the ratio reported here, 

however, is an overestimation because the National Ombudsman Reporting 

System (NORS; the program’s reporting system) does not distinguish between 

Ombudsmen and other program staff that support the program (i.e., volunteer 

managers, administrative staff, in-house counsel). Even with the overestimation, 

however, the average FTE to bed ratio of one to 2,355 still falls short of the IOM’s 

1995 recommendation. 

b. In FFY 2017, 8,810 volunteers supported the LTCOP, 6,625 of whom were designated

volunteer Ombudsmen. The number of volunteers ranged from zero to 948 across all 

programs, with an average of 147 among programs that use volunteers. Four states 

reported no volunteers and seven states reported no designated volunteer Ombudsmen. 

4. Ombudsman programs draw on multiple sources of legal support to address program needs and 

representation. These include the Office of the Attorney General (AG), state agency attorneys, inhouse counsel/non-governmental host agency attorneys, private attorneys under contract, and 
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pro bono attorneys. Sixty-four percent of State Ombudsmen reported accessing legal counsel

from more than one source, and these sources are used to address specific program needs as 

well as perceived or actual conflicts of interest. 

5. In addition to assigned legal counsel, State Ombudsmen reported coordinating efforts with their 

State legal assistance developers and legal assistance providers/legal aid.

5.1.2. Program Activities

1. Given the diversity of resources that characterize programs as well as widely varying state and 

local circumstances, there is considerable variation in the extent to which state Ombudsman 

programs conduct individual advocacy, education/outreach, and systems advocacy. According to 

NORS data: 

a. In FFY 2017, Ombudsman programs visited 68% of nursing homes and 30% of board 

and care homes on at least a quarterly basis. Across programs, quarterly visits to nursing 

homes ranged between 11% and 100%, while quarterly visits to board and care homes 

ranged between zero percent and 100%. These percentages reflect routine Ombudsman 

facility visits, not those that occur only in response to a complaint. 

b. In FFY 2017, Ombudsman programs handled 201,460 complaints, ranging from 214 to 

41,834 across programs. 

c. In FFY 2017, Ombudsman programs provided information on rights, care, and related 

services to individuals and long-term care facility staff on 529,098 occasions, ranging

from 413 to 85,352 occasions across programs. 

d. In FFY 2017, Ombudsman programs conducted 10,170 community education sessions, 

ranging from two to 1,686 sessions across programs. 

e. In FFY 2017, Ombudsman programs attended 22,999 resident and family council 

meetings, ranging from two to 3,447 meetings across programs. 

f. At the state/territory level, the estimated percentage of paid staff time spent on systems 

advocacy efforts such as monitoring/working on laws, regulations, government policies, 

and actions ranged between two percent and 65% (with an average of 27%). At the local 

level, the estimated percentage of paid staff time spent on these systems advocacy 

activities ranged between zero percent to 25% (with an average of seven percent). 

5.1.3. Individual Advocacy

1. At the individual level, Ombudsman programs are required to (1) identify, investigate, and resolve 

complaints on behalf of residents; (2) provide services to assist residents in protecting their 

health, safety, welfare, and rights; (3) inform residents about how to obtain facility or agency 

services; (4) ensure that residents have regular access to advocacy services; (5) assist in the 

development of resident and family councils; and (6) assist residents who are transitioning from a 

long-term care facility to a home care setting. Ombudsman programs meet these requirements 

through services that are provided during visits to long-term care facilities, community 

presentations, and responses to questions over the phone. 

2. Although the Administration for Community Living (ACL) does not specify a required frequency for 

Ombudsman visits to facilities, NORS defines “regular basis” to mean facility visits that occur no 

less than quarterly and that are not in response to a complaint. Among State Ombudsmen whose 
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programs set visitation standards, most aim to visit nursing homes and board and care homes at 

least quarterly. 

a. More than three-quarters (79%) of State Ombudsmen reported that their program visited 

most nursing homes at least quarterly and 55% reported visiting most board and care 

homes at least quarterly. (Note that the study asked State Ombudsmen to report on all 

visits made to most facilities, including visits made in response to a complaint. Due to 

differences in question wording, these percentages are different from those reported in 

NORS.)

3. Although State Ombudsmen conduct visits to long-term care facilities, these visits are primarily 

conducted by local and volunteer Ombudsmen. 

a. A higher percentage of Ombudsmen at all levels reported visiting nursing homes, 

compared to board and care homes. 

b. Among State Ombudsmen who reported visiting nursing homes, 45% do so on a routine 

basis, compared to 81% of local Ombudsmen, and 95% of volunteer Ombudsmen. 

c. Among State Ombudsmen who reported visiting board and care homes, 36% reported 

doing so on a routine basis, compared to 78% of local Ombudsmen and 93% of 

volunteers. 

4. Whereas most local Ombudsmen reported visiting each of the nursing homes and board and care 

homes assigned to them at least quarterly (72% and 66%, respectively), most volunteer 

Ombudsmen reported visiting these facilities on at least a monthly basis (79% and 62%, 

respectively). 

5. Sixty-five percent of local Ombudsmen and 56% of volunteer Ombudsmen reported spending an 

average of one to two hours visiting nursing homes during their routine visits, and 19% of local 

Ombudsmen and 28% of volunteer Ombudsmen reported spending between two to three hours 

during these visits. Board and care homes generally have fewer beds than nursing homes, and 

local and volunteer Ombudsmen reported spending less time visiting these facilities. Forty-nine 

percent of local Ombudsmen and 46% of volunteer Ombudsmen reported spending one to two 

hours visiting board and care homes during routine visits, and 43% of local Ombudsmen and 41% 

of volunteer Ombudsmen reported spending less than an hour during routine visits to these 

facilities. 

6. The top three complaints handled in nursing homes concerned discharge/eviction planning, 

failure to respond to requests for assistance, and issues related to dignity/respect. The top three 

complaints handled in board and care homes concerned discharge/eviction-planning, 

medications, and food service. 

7. According to historical NORS data, the types of complaints that the Ombudsman program 

handles have become more complex and challenging over time, moving away from requests for 

assistance with daily needs to more urgent concerns such as involuntary discharges and 

evictions. 

8. Complaints about resident-related issues are initiated by a variety of individuals. Residents were 

the complainant in 40% of cases (a case can contain multiple complaints). Other complainants 

included relatives/friends (18%) and non-relative guardians or legal representatives (one 

percent). Almost one-fifth of complaints made on behalf of residents was initiated by facility staff 

(19%). As with other complainants, facility staff may reach out to Ombudsmen to assist with both 

resident concerns (e.g., family conflict) and facility issues (e.g., closures). Ombudsmen may also 
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initiate complaints based on their observations during facility visits. These complaints accounted 

for 11% of cases. 

9. Two-thirds of local and three-quarters of volunteer Ombudsmen (66% and 78%, respectively) 

reported that a majority of their relationships in nursing homes are effective. Over half of local and 

three-quarters of volunteer Ombudsmen (59% and 78%, respectively) reported that a majority of 

their relationships in board and care homes are effective.

10. State, local, and volunteer Ombudsmen attributed the effectiveness of their relationships with 

facility staff to the ongoing presence they maintain in facilities and the positive working 

relationships they develop with facility staff who come to view them as a resource. Local 

Ombudsmen also reported that their knowledge, confidence, and experience level are important 

factors in determining the effectiveness of their relationships with facility staff. 

11. Some State Ombudsmen reported that the strength of their state’s regulations for board and care 

homes is a major factor in the effectiveness of their relationships with staff in this service setting. 

12. The extent of staff resources affects Ombudsman programs’ ability to visit facilities and identify 

and address resident complaints. Lower paid FTE staff to facility ratios are correlated with higher 

percentages of facilities visited at least quarterly.

13. State and local Ombudsmen reported several barriers that hinder their ability to engage in 

individual advocacy, including inadequate program funding and staffing as well as lack of 

understanding among stakeholders about the Ombudsman program’s role. In addition,

Ombudsmen described limitations in their ability to fully resolve certain types of complaints, 

particularly when solutions are ultimately outside of the program’s control. Examples include 

cases involving lack of available nursing homes or board and care homes, low facility staffing 

rates, and the absence of needed services (e.g. mental health services). 

5.1.4. Systems Advocacy

1. At the systems level, Ombudsman programs are required to (1) represent residents’ interests 

before governmental agencies and pursue administrative, legal, and other appropriate remedies; 

(2) analyze, comment on, and monitor the development and implementation of federal, state, and 

local laws, regulations, and other governmental policies and actions relating to the adequacy of 

long-term care facilities and services; (3) make recommendations regarding these laws, 

regulations, policies, and actions; and (4) facilitate public comment on the laws, regulations, 

policies, and actions that pertain to residents’ health, safety, welfare, and rights. 

a. Ombudsman programs meet these requirements primarily through legislative advocacy, 

issue advocacy, and coalition building/partnerships. Supporting the development of 

resident and family councils may involve elements of systems advocacy if these efforts 

aim to assist multiple residents. 

2. State Ombudsmen have primary responsibility for systems advocacy efforts. All State 

Ombudsmen reported engaging in systems advocacy, compared to 57% of local Ombudsmen. Of 

local Ombudsmen who are responsible for systems advocacy, however, 30% reported being 

unable to perform this task due to lack of time, resources, or training. A smaller percentage of 

volunteers (13%) also reported responsibility for systems advocacy activities, including 

monitoring/working on laws, regulations, government policies, and actions, and three percent 

reported working with the media on issues that impact residents. 
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3. Seventeen percent of local Ombudsmen reported not knowing whether systems advocacy was 

one of their responsibilities. When asked about specific tasks that they carry out, however, these 

local Ombudsmen reported engaging in activities that are consistent with systems advocacy, 

including participation in committees/workgroups/task forces; advocacy for changes to laws, 

regulations, or policies; engagement in policy making; communication with the media about 

advocacy issues; and grassroots organizing. Differences between local Ombudsmen’s reported 

engagement in “systems advocacy” and their actual activities may reflect a lack of clarity in 

responsibilities or differences in terminology for common activities. 

4. Although 19% of State Ombudsmen reported no barriers to carrying out systems advocacy 

activities at the state or local levels, the remaining State Ombudsmen identified several 

challenges related to inadequate resources, organizational placement, politics, lack of expertise, 

and misunderstandings about the program’s autonomy.

5. The Long-Term Care Ombudsman Programs Final Rule (Final Rule) clarified that when 

Ombudsmen provide legislators and government agencies with information and 

recommendations concerning laws, regulations and policies, these efforts are not considered 

lobbying. Because many states prohibit government employees from lobbying, the Final Rule’s 

clarification ensures that Ombudsmen who are state employees (i.e., those whose programs are 

located in state and local government agencies) can engage in this type of legislative advocacy in 

accordance with the Older Americans Act (OAA) and Final Rule. Nonetheless, at the time of this 

study’s data collection, many State Ombudsmen whose programs are located in state and local 

government agencies reported that state laws continue to restrict programs from engaging in 

legislative advocacy. 

5.1.5. Adequacy of Resources

1. Insufficient resources were reported to be a major challenge for programs in meeting their federal 

mandates. 

a. Only 23% of State Ombudsmen and 26% of lead local Ombudsmen reported having 

sufficient financial resources to meet all of their programs’ federal mandates. 

b. Similarly, 27% of State Ombudsmen and 37% of lead local Ombudsmen reported having 

sufficient paid staff to meet all of their programs’ federal mandates. 

c. Only 15% of State Ombudsmen and 21% of lead local Ombudsmen reported having 

enough volunteers to meet all of their programs’ federal mandates. 

d. Fifty-six percent of State Ombudsmen and 29% of lead local Ombudsmen reported 

having adequate legal counsel to meet all of their programs’ federal mandates.

2. State Ombudsmen reported that they are unable to fully carry out the following activities due to 

lack of resources:

a. Volunteer recruitment and retention (69%);

b. Regular board and care visits (67%);

c. Resident and family council development and support (60%);

d. Community education activities (56%);

e. Legal assistance for residents (52%);

f. Regular nursing home visits (50%);
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g. Facilitating public comments on proposed legislation, laws, regulations, policies, and 

actions (48%);

h. Training for facility staff (44%);

i. Research and policy analysis to inform systems advocacy work (42%);

j. Analyzing and monitoring federal, state, and local laws, regulations, and other 

government policies and actions (38%);

k. Resident and family education at facilities (38%);

l. Complaint investigation and resolution activities (23%);

m. Consultations to facilities (15%);

n. Other activities (13%); and 

o. Information and consultations to individuals (six percent). 

5.1.6. Strategies to Address Resource Constraints

1. When faced with resource constraints, Ombudsman programs limit, forgo, or prioritize program 

activities and rely heavily on volunteers and inter-organizational relationships to support program 

operations.

a. State Ombudsmen reported forgoing professional development activities such as 

trainings, conferences, and statewide annual volunteer recognition luncheons for 

themselves or their staff. Inadequate resources also prevent some programs from 

traveling to facilities for routine visits or hiring translators to assist with meeting the needs 

of diverse populations, such as American Indian tribes and predominately Spanishspeaking communities. 

b. State Ombudsmen reported prioritizing nursing home visits over board and care home 

visits; urgent complaints over less time-sensitive ones; visiting facilities in response to a 

complaint over routine visits; visiting facilities within shorter traveling distances over ones 

located in remote areas, and engaging in individual advocacy over systems advocacy. 

c. For many Ombudsman programs, volunteers are essential for ensuring that residents 

have access to advocacy services. Without volunteers, some programs would struggle to 

maintain a routine presence in long-term care facilities. 

i. The same resource constraints that compel programs to use volunteers, 

however, also present challenges for recruiting and supporting volunteers and

optimizing their contributions. Nearly three-quarters (73%) of State Ombudsmen 

reported that recruiting and supporting volunteers is a challenge that their 

programs face, emphasizing the need for adequate resources to ensure that this 

segment of the program’s workforce is well-trained and effective. Without these 

resources, the cost of training and managing volunteers can outweigh their 

benefits, particularly if programs lack staff for volunteer supervision and/or 

administration.

d. State and local Ombudsmen cultivate relationships with a wide range of entities to 

support individual and systems advocacy activities, particularly when program resources 

are limited. These partnerships are valuable for addressing residents’ needs and 

providing the necessary “teeth” to address certain types of complaints. 
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5.1.7. Factors that Facilitate Meeting Program Mandates

2. When programmatic resources are adequate, State Ombudsmen reported the ability to be 

proactive rather than reactive in their advocacy efforts. 

a. At the individual level, for example, one State Ombudsman reported that the ability to 

maintain a routine presence in facilities enabled Ombudsmen to expedite residents’ 

relocation when a facility closed because they were already familiar with residents’ 

preferences. Other State Ombudsmen reported that regular Ombudsman visitation to 

facilities empowered residents to speak up on their own behalf as well as encouraged 

facility staff to reach out to Ombudsmen about resident concerns before issues rise to the 

level of a complaint. 

b. At the systems level, one State Ombudsman reported that time spent cultivating a broad 

base of stakeholder support facilitated the program’s ability to marshal partners for 

various proposed legislation. 

c. With respect to legal resources, one State Ombudsmen reported having access to 

independent legal counsel supports their program’s ability to fulfill mandated functions.

3. State Ombudsmen reported that staff and volunteers are among the LTCOP’s most valuable 

resources. A majority of Ombudsmen join the program because of its mission (75% of State 

Ombudsmen, 63% of local Ombudsmen, and 55% of volunteers). Despite resource constraints 

and low salaries that are often inconsistent with Ombudsmen’s responsibilities, staff motivation 

and dedication are viewed as the driving force behind program operations. 

a. In FFY 2017, volunteer Ombudsmen contributed 591,363 hours of service to 

Ombudsman programs. The Independent Sector estimated the value of volunteer time for 

that year at $24.69/hour,13 suggesting that volunteers provide over $14.6 million in labor 

assets to Ombudsman programs.

b. Former Ombudsmen who continue to work in the aging network and long-term care 

community are also critical supports to Ombudsman programs. Staff who take positions 

with organizations that interact with Ombudsman programs help facilitate understanding 

and communication with these entities. 

4. State Ombudsmen reported that the independence vested in the program is a key strength. 

However, several factors prevent some programs from exercising this authority. Reasons 

included issues concerning organizational placement (e.g., organizational conflicts of interest, 

ability to engage in systems advocacy) as well as misunderstandings related to the Ombudsman 

program’s autonomy. 

5. Stakeholders and State Ombudsmen reported that the program’s reputation for providing credible 

information about resident concerns and conditions in long-term care facilities supports the 

willingness of other entities to work with Ombudsmen. Because the Ombudsman program is the 

only OAA program that has direct, unimpeded access to residents and has the authority to 

represent residents, other entities actively seek Ombudsmen’s perspectives and view them as an 

important independent resource. 

6. State, local, and volunteer Ombudsmen reported that ongoing relationships and regular 

communication with residents, facility staff, and coordinating entities are critical to the program’s 

success.

 

13 https://independentsector.org/news-post/value-of-volunteer-time-release/
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5.2. Introduction

The Older Americans Act (OAA) delineates several responsibilities for the Long-Term Care Ombudsman 

program (LTCOP, or Ombudsman program). State Ombudsmen or their designated representatives of the 

Office (i.e. local and volunteer Ombudsmen) are required to: 

■ Handle complaints: “Identify, investigate, and resolve complaints that are made by, or on behalf 

of, residents...” and that relate to action, inaction, or decisions of providers or public agencies, 

that may “adversely affect the health, safety, welfare, or rights of the residents.” [Section

712(a)(3)(A)]

■ Protect resident health, safety, welfare, and rights: “Provide services to assist the residents in 

protecting the health, safety, welfare, and rights of the residents.” [Section 712(a)(3)(B)]

■ Provide information about long-term services and supports (LTSS): “Inform the residents 

about means of obtaining services” provided by LTSS providers, public agencies, or health and 

social service agencies.” [Section 712(3)(C)]

■ Ensure access to the LTCOP: “Ensure that the residents have regular, timely, private, and 

unimpeded access to the services provided through the Office and that the residents and 

complainants receive timely responses from representatives of the Office to complaints.” [Section

712(a)(3)(D)]

■ Advocate for residents: “Represent the interests of the residents before governmental 

agencies, and seek administrative, legal, and other remedies to protect the health, safety, 

welfare, and rights of the residents.” [Section 712(a)(3)(E)]

■ Monitor and advocate for changes to laws, regulations, and policies: “Analyze, comment on, 

and monitor the development and implementation of Federal, State, and local laws, regulations, 

and other governmental policies and actions, that pertain to the health, safety, welfare, and rights 

of the residents, with respect to the adequacy of long-term care facilities and services in the 

State; recommend any changes in such laws, regulations, policies and actions as the [State] 

Office determines to be appropriate; and facilitate public comment on the laws, regulations, 

policies, and actions.” [Section 712(a)(3)(G)]

■ Support citizen organizations: “Promote the development of citizen organizations, to participate 

in the program.” [Section 712(3)(H)(ii]

■ Support resident and family councils: “Provide technical support for, actively encourage, and 

assist in the development of resident and family councils to protect the well-being and rights of 

residents.” [Section 712(3)(H)(iii)]

The 2016 OAA reauthorization outlined several important changes to the Ombudsman program, 

including: 

■ Authorizing the program to expand service to younger residents of long-term care facilities and 

residents who are transitioning to in-home settings; 

■ Strengthening the ability of Ombudsman program staff to access residents and their health 

information; 

■ Clarifying the State Ombudsman’s responsibility for leadership and management of the Office, 

including fiscal management; 
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■ Introducing additional steps to report and limit both individual and organizational conflicts of 

interest; 

■ Enhancing Ombudsman program activities such as handling complaints on behalf of individuals 

who are unable to communicate their wishes and assisting in the development of resident and 

family councils, and 

■ Requiring certain types of training for all State Ombudsmen. 

The Long-Term Care Ombudsman Programs Final Rule (Final Rule) clarified several OAA provisions

regarding Ombudsman program functions. These included guidance on fiscal management, systems 

advocacy policies and procedures, systems advocacy leadership and coordination, the provision of 

information about Ombudsman services, raising awareness about resident concerns, and complaint 

handling and processing (for additional detail, see Appendix B).

To carry out these programmatic mandates, the Ombudsman program draws on a variety of resources, 

including legislation, regulations, funding, staffing (paid and volunteer), legal counsel, partnerships, peerto-peer support, training and technical assistance, data systems, and information technology (IT). 

This chapter focuses on how Ombudsman programs use fiscal, staffing, and legal resources to fulfill 

responsibilities described in the OAA and Final Rule. A discussion of other resources can be found 

elsewhere in this report. Chapter 6 describes findings on partnerships or entities with which the program 

coordinates. Chapter 7 presents findings related to training and technical assistance (at the state and 

local level), peer-to-peer support, data systems, and IT. 

This chapter begins with a description of the Ombudsman program’s fiscal, staffing, and legal resources, 

and the adequacy of those resources. It then explores the program’s main activities, strategies to address 

resource constraints, and the strengths of Ombudsman programs. 

5.3. Findings

5.3.1. Program Resources

Fiscal Resources 

Ombudsman programs are funded by multiple sources at the federal, state, and local levels. These 

include: 

■ Federal OAA Title III, Grants for State and Community Programs on Aging – States receive 

funding based on their older adult (60 years of age or older) population [Section 304(a)(1)]. 

■ Federal OAA Title VII funds, Allotments for Vulnerable Elder Rights Protection Activities – 

The Ombudsman program is authorized under Chapter 2 of Title VII, and each state receives an 

annual allocation based on its population of older individuals as a proportion of older individuals in 

all states [Section 703(a)(1)]. The OAA requires that funds allocated to each state Ombudsman 

Program cannot be less than the amount allotted under Title III to each state in FY 2000 [Section

703(a)(2)(C)]. 

■ State funds – State funds allocated to the Ombudsman program vary by state government.

■ Local funds – Local funds allocated to the Ombudsman program vary by local government.
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According to NORS data, Ombudsman program expenditures from all sources totaled $106.7 million in 

FFY 2017. As shown in Exhibit 18, federal, state, and local funding accounted for 50%, 43%, and seven 

percent, respectively, of program expenditures. 

Exhibit 18: Statewide Program Funds Expended ($ in millions)

Source: NORS, FFY 2017 

Exhibit 19 presents data on program expenditures per state in FFY 2017. Given states’ discretion in 

funding their Ombudsman programs, state contributions vary considerably, ranging from zero percent to

83% of total program expenditures (see Table B in Appendix E for state-level data). State Ombudsman 

programs may also receive additional sources of funding that are not reflected in NORS data. These

sources include state and local funds for activities other than those authorized under the OAA, such as 

work related to in-home care.14

Half of all programs expended less than $647,000 in federal funding, less than $607,000 in state funding, 

and less than $33,000 in local funding. Total expenditures per state ranged from $11 per long-term care 

facility bed to $188 per long-term care facility bed. Federal expenditures also varied considerably across 

states, from $6 to $92 per long-term care facility bed. 

Exhibit 19: Minimum, Maximum, and Average Program Expenditures per State*

Funding

Source

Range

($ in 

thousands)

Median

($ in 

thousands)

Mean

($ in 

thousands)

Range of funds 

per LTC facility 

bed

Average funds 

per LTC facility 

bed

Federal funds $134 - $6,042 $647 $1,034 $6 - $92 $23

State funds $0 - $5,992 $607 $878 $0.50 - $120 $20

State funds as 

% of total funds 0 - 83% 44% 40% 0 - 83% 40%

Local funds $0 - $2,261 $33 $139 $0 - $18 $2

Total funds $177 - $12,790 $1,332 $2,052 $11 - $188 $46

* This table on state level expenditures includes 50 states, DC, and Puerto Rico; **older adult defined as 60 years of age or older 

Source: NORS, 2017; American Community Survey, 2017 

 

14 Instructions for Completing the State Long Term Care Ombudsman Program Reporting Form for the National Ombudsman 

Reporting System (NORS). OMB NO: 0985-0005. Expiration date: 01/31/2019. 

Source

2017

$ in millions

2017

% of total

Federal Funds $53.8 50%

Title VII, OAA $17.1 16%

Title III, OAA $30.9 29% 

Other Federal Funds $5.8 5% 

State Funds $45.7 43%

Local Funds $7.2 7%

Total $106.7 100%
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As shown in Exhibit 20, 36% of State Ombudsmen and 47% of lead local Ombudsmen reported that their 

Office of the State Long-Term Care Ombudsman (Office of the SLTCO) or local Ombudsman entity 

secures additional financial resources beyond federal and state allocations. Outside of grants, much of 

the state, local and other support comes from Ombudsmen’s host agencies. These funding sources and 

in-kind contributions included: 

■ Grants from government agencies, foundations, nonprofits, or private entities, including funds 

from civil monetary penalties (CMP), Victims of Crime Act (VOCA), Violence Against Women 

Program, Medicaid administrative claims, community development block grants, and Money 

Follows the Person (MFP); 

■ Provider fees such as nursing home quality of care fees (often called a “bed tax”); 

■ County or city funding; 

■ Donations, including those received from the establishment of 501(c)(3) nonprofit organizations;

■ Monetary support from state and local host agencies, including fundraising events held by host 

agencies; 

■ In-kind contributions from state and local host agencies, including staffing (such as administrative 

support), volunteer hours, IT, fiscal accounting, human resources, pro bono legal assistance, 

supplies, and office space. 

State and lead local Ombudsmen reported that these supplemental funds support general program 

operations or they are earmarked for specific staff roles (e.g., local Ombudsman positions) or activities

(e.g., volunteer and educational programs or the development of resident and family councils). 

Exhibit 20: State Offices and Local Ombudsman Entities that Secure Additional Financial Resources

Secure Additional Financial Resources Beyond Federal and 

State Funds Allocated

State 

Ombudsmen

N=44a 

Lead Local

Ombudsmen

N=158b 

Yes 36% 47% 

No 64% 53% 

a Missing=1, Not applicable=7 (The Office or local program does not have the ability to secure additional financial resources or inkind contributions.) 

b Missing=3, Not applicable=28 (The Office or local program does not have the ability to secure additional financial resources or inkind contributions.) 

Overall, funding sources vary widely across Ombudsman programs. Whereas state funds account for at 

least half of total program expenditures for 16 Ombudsman programs, five programs relied almost entirely 

on federal funds to support program operations (these programs reported that state funds represented 

less than 10% of total funds). Finally, 23 programs reported securing no local funds. 

Program Staff and Volunteers

Ombudsman programs are supported by a variety of staff, including the SUA Director, State Ombudsmen,

representatives of the Office (local and volunteer Ombudsmen), legal counsel, administrative staff, and IT 

personnel, among others. This study focuses on the experiences of State Ombudsmen and their 

designated representatives of the Office. Designated representatives of the Office refer to staff that 

perform the duties of the Office. Although the OAA and Final Rule only refer to the State Ombudsman as 
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the “Ombudsman,” many program staff and volunteers use the term Ombudsman in practice (rather than 

“representatives of the Office”). For this reason, in this report we refer to both the State Ombudsman and 

representatives of the Offices as Ombudsmen in this study, the latter distinguished by whether they are 

local Ombudsmen or volunteer Ombudsmen. 

Within the Ombudsman role, there is considerable variation within and across states and territories in 

position titles and responsibilities. For example, some programs have Deputy State Ombudsmen or 

Regional Ombudsmen who perform functions that are similar to the State Ombudsman, such as oversight 

of local staff and systems advocacy. Other programs have volunteer coordinators at the state and/or local 

levels who focus on volunteer administration and management, including volunteer recruitment, training, 

and supervision. Volunteer coordinators may also be responsible for visits to long-term care facilities. 

Ombudsmen may specialize in a specific functional area or type of complaint, such as relocation, 

managed care, discharge/transfer, assisted living facilities, home care, or residents who are veterans. In 

this study, any staff person with Ombudsman responsibilities was eligible for data collection. Although the 

study could not tailor surveys that captured the full heterogeneity of the Ombudsman role, a key 

distinction was made among Ombudsmen – those with managerial responsibilities (“lead local 

Ombudsmen”) and those without managerial responsibilities (“local Ombudsmen”). For a small subset of 

questions, lead local Ombudsmen were asked several questions about the local Ombudsman entity they 

oversaw, while local Ombudsmen were asked about their experiences with specific activities. All other 

questions were identical for both groups of local Ombudsmen. 

Staff terminology is also related to programs’ organizational structure. As described in Chapter 4, 

Ombudsman programs are characterized by a centralized or decentralized structure. In a centralized 

structure, all program staff and volunteers are “state-level staff” because they are employees of the

agency housing the Office of the SLTCO, even if they are assigned to a regional office. In a decentralized 

structure, the Office of the SLTCO is housed in a state agency or contracted entity, but local Ombudsmen 

are employed by another organization that is contracted by the State Ombudsman and designated as a 

local Ombudsman entity. In decentralized programs, staff located in the State Office are considered 

“state-level” while staff located in local Ombudsman entities are considered “local-level.” In this study, we 

refer to all “state-level staff” other than the State Ombudsman as local or volunteer Ombudsmen.

According to NORS data, staff and volunteer resources varied widely across state Ombudsman programs

in FFY 2017 (Exhibit 21; see also Table C in Appendix E for state-level data). 

■ In FFY 2017, the average number of paid staff FTEs in each state LTCOP was 25, with a range 

of two to 156. Twelve states had only one paid staff FTE in the State Office (i.e. the State 

Ombudsman). 

■ Across programs, the ratio of FTEs to facility beds covered by the program was 1:2,355, ranging 

from the lowest ratio of 1:594 in Washington, DC to the highest ratio of 1:6,814 in Minnesota. 

■ During the Ombudsman program’s last evaluation in 1995, the IOM recommended a 

minimum FTE Ombudsman to bed ratio of 1:2,000 beds. Although this ratio has not been 

updated to reflect growth in board and care homes, the increasing complexity of complaints, 

or the geographic distance between facilities, this ratio remains an important benchmark for 

assessing Ombudsman program capacity. It is important to emphasize that the ratio reported 

here is an overestimation because NORS does not distinguish between Ombudsmen and 

other program staff. Even with this overestimation, however, the average paid staff FTE to 

bed ratio of 1:2,355 still falls short of the IOM’s 1995 recommendation.
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■ Our analysis of NORS FFY 2017 data found that lower paid FTE staff to facility ratios are 

correlated with higher percentages of facilities being visited at least quarterly (r=-.49, p<.001). 

■ In FFY 2017, the number of volunteers ranged from zero to 948 across all programs, with an 

average of 147 among programs that use volunteers (the average is 127 across all programs). 

Seven states/territories reported no certified15 volunteer Ombudsmen (Alabama, Mississippi, 

Montana, Puerto Rico, South Dakota, West Virginia, and Wyoming).16 

■ Although the program has large numbers of volunteers, paid staff contribute more time to the 

program. In FFY 2017, there were 1,319 paid full-time equivalents (FTEs), and these FTEs 

translated to 2.7 million staff hours throughout the year. This is more than four times the number

of hours donated by volunteer Ombudsmen.

Exhibit 21: FFY 2017 Ombudsman Staff and Volunteersa

Staff Levels

Paid Staff 

FTEs

Full 

Time 

Staff #

Paid Staff 

Hoursb

Paid 

Clerical 

Staff 

FTEs

Certified 

Volunteer 

Ombudsmen 

# of people

Certified 

Volunteer 

Ombudsman 

hours

State level staff 206 192 427,461 28 519 55,062

Regional/ Local 

level staff 1,114 857 2,316,517 40 6,106 536,301

Total – All staff 1,319 1,049 2,743,978 68 6,625 591,363

Average Per State 

(mean) 25 20 52,769 1 127c 11,372

State Minimum 2 1 10,400 0 0 0 

State Maximum 156 102 324,480 16 948 98,518

a This includes all 50 states, D.C., and Puerto Rico. 

b Calculated assuming 2,080 hours annually per FTE 

c Among programs that use volunteers, the average number is 147. 

Note: Staff and volunteer data are provided as a snapshot of actual staffing at the end of the federal fiscal year. Staff and volunteer 

hours are estimated for the entire federal fiscal year. 

Source: NORS, 2017 

Motivations for Joining the Ombudsman Program

As shown in Exhibit 22, most Ombudsmen join the program because of its mission (75% of State 

Ombudsmen, 63% of local Ombudsmen, and 55% of volunteers). Personal fulfillment was reported as

another key reason for serving the program. 

 

15 With respect to volunteer Ombudsmen, NORS uses the term “certified” rather than “designated”. 

16 Montana, Alabama, and Puerto Rico reporting having “other volunteers.” 
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Exhibit 22: Motivation to Work for the LTCOP

Motivation to Work for LTCOP 

State 

Ombudsmen

N=52

Local 

Ombudsmen

N=492a

Volunteer

Ombudsmen

N=703b 

Personal fulfillment (e.g. enjoyment in helping others) 65% 65% 68%

Interest in the program's mission 75% 63% 55%

Career development 48% 40% 6%

Family/friends received long-term services and supports 15% 15% 27%

Personal experience with the program 23% 15% 8%

Other 21% 11% 16%

a

 Missing=5; b Missing=8 

As advocates for long-term care facility residents, the skills, knowledge, and commitment that are 

required of Ombudsmen can be very demanding. Ombudsmen and representatives of the Office must be 

familiar not only with resident rights and available resources on topics as diverse as eligibility for services 

and power of attorney, but they must also have a working knowledge of a broad range of state and 

federal regulations that govern long-term care settings. In addition, to fully represent resident interests, 

Ombudsmen must be able to problem-solve, and navigate delicate or challenging relationships with 

facility staff, other agencies that may be involved in a complaint, as well as family members. Facility visits 

also expose Ombudsmen to a wide range of difficult experiences, such as cases of abuse and neglect. 

State Ombudsmen reported that the challenges of the Ombudsman role, as well as resource constraints 

and low salaries that are often inconsistent with Ombudsmen’s responsibilities, often lead to staff 

turnover. Stakeholders and State Ombudsmen reported that committed staff and volunteers who remain 

with the program despite these challenges are among the program’s most valuable resources. As shown 

in Exhibit 23, Ombudsmen’s average tenure with the program is about six years. However, tenure varied 

widely, with some respondents being recent hires while others served the program for over 27 years.

Exhibit 23: Staff Tenure with Ombudsman Program

Length of Time Working for 

LTCOP

State Ombudsmen

N=52

Local Ombudsmen

N=495a 

Volunteer

Ombudsmen

N=701b 

Mean number of years 6.6 5.9 5.9

Range <1 year – 27 years <1 year – 34 years <1 year – 32 years a Missing=2; b Missing=10

Prior to assuming their current roles, almost one-fifth of local Ombudsmen previously held a position with 

the Ombudsman program (Exhibit 24). Notably, former Ombudsmen who move on to roles in the aging 

network and long-term care community also continue to support Ombudsman programs. State 

Ombudsmen reported that staff who take positions with organizations that interact with Ombudsman 

programs help facilitate understanding and communication with these entities. 
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Exhibit 24: Held Previous Positions in the LTCOP

Held previous position(s) in LTCOP

Local Ombudsmen

N = 494a

Yes 18%

No 82%

a Missing=3

State Ombudsmen

Each LTCOP has a State Ombudsman who heads the Office and is responsible to personally, or through 

representatives of the Office, fulfill the functions, responsibilities and duties of the OAA and the Final 

Rule. 

■ The OAA states, “The Office shall be headed by an individual, to be known as the State LongTerm Care Ombudsman, who shall be selected from among individuals with expertise and 

experience in the fields of long-term care and advocacy.” [Section 712(a)(2)] 

■ The Final Rule adds: “The Ombudsman, as head of the Office, shall have responsibility for the 

leadership and management of the Office in coordination with the State agency, and, where 

applicable, any other agency carrying out the Ombudsman program...” [45 CFR § 1324.13]

According to the OAA and Final Rule, State Ombudsmen have the following key functions and 

responsibilities: 

■ Serve on a full-time basis and personally or through representatives of the Office conduct 

required LTCOP functions such as investigating complaints, and carrying out systems advocacy 

[Section 712(a)]

■ Be the head of a unified statewide program and establish or recommend policies, procedures, 

and standards for administration of the LTCOP; and require local Ombudsmen to fulfill the duties 

described in the Final Rule [45 CFR § 1324.13(b)]

■ Designate and de-designate local Ombudsman entities and local Ombudsmen, and monitor their 

performance [45 CFR § 1324.13(c)]

■ Establish training requirements [45 CFR § 1324.13(c)(2)]

■ Perform fiscal management [45 CFR § 1324.13(f)]

■ Lead state-level coordination, and support appropriate local Ombudsman entity coordination 

between the Ombudsman program and other relevant entities [45 CFR § 1324.13(h)]

Staff Management

As outlined in the OAA and the Final Rule, State Ombudsmen designate and provide programmatic 

oversight for all local Ombudsmen and volunteers. However, there are important distinctions in 

management responsibilities that relate to Ombudsman programs’ structure. For Ombudsman programs 

that are characterized by a centralized structure, the State Ombudsman directly manages program staff, 

regardless of the staff’s physical location (e.g., the central State Office, or elsewhere in the state). In a 

decentralized structure, the State Ombudsman has programmatic responsibilities for local Ombudsmen 

while the local Ombudsman entity has responsibility for personnel management. 
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Fiscal Management

According to the Final Rule, State Ombudsmen are required to manage state-level resources and 

approve allocations to local Ombudsman entities. The regulation states:

Fiscal management. “The Ombudsman shall determine the use of the fiscal resources 

appropriated or otherwise available for the operation of the Office. Where local 

Ombudsman entities are designated, the Ombudsman shall approve the allocations of 

Federal and State funds provided to such entities, subject to applicable Federal and State 

laws and policies. The Ombudsman shall determine that program budgets and 

expenditures of the Office and local Ombudsman entities are consistent with laws, 

policies and procedures governing the Ombudsman program.” [45 CFR § 1324.13 (f)]

Despite this guidance, State Ombudsman reported barriers to fulfilling these fiscal responsibilities: 

■ A little over half (52%) of State Ombudsmen reported that they are able to determine the use of 

fiscal resources to operate the Ombudsman program at the state level. Forty percent reported 

that they are only partially able to fulfill this task, and eight percent reported not having the ability 

to fulfill this task (Exhibit 25). 

■ Forty-five percent of State Ombudsmen who oversee local Ombudsman entities reported that

they do not approve allocations of federal and state funds to their local Ombudsman entities

(Exhibit 26). 

Exhibit 25: State Ombudsman Ability to Determine use of Resources to Operate the Ombudsman 

Program at the State Level

State Ombudsman able to Determine use of Resources to 

Operate LTCOP at the State Level (N=52)
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Exhibit 26: Ability of State Ombudsmen with Decentralized Programs to Approve Allocation of Federal 

and State Funds to Local Programs

 **Missing=1, Not applicable=20 

Some State Ombudsmen reported difficulty managing their fiscal responsibilities due to lack of expertise, 

experience, and access to budget information. For one State Ombudsman, taking on this responsibility 

has been like “walking into a foreign country” due to lack of accounting expertise and the complexity of 

the program’s funding sources. Another State Ombudsman’s lack of historical involvement in fiscal 

management as well as confusion over the Final Rule’s requirement made it difficult to understand the 

state LTCOP budget and whether local Ombudsman entity budgets housed in AAAs required State 

Ombudsman approval. A State Ombudsman whose program is decentralized reported challenges in 

having responsibility for fiscal management when detailed final operational budgets for local Ombudsman 

entities are not provided by AAAs or their subcontracted entities. The State Ombudsman added that 

budget monitoring will also be difficult because of time constraints. 

Local Ombudsmen Staff

Across all Ombudsman programs, there are 1,319 FTEs, 1,114 of whom are considered “regional/local 

level staff” (Exhibit 21). Some of the 206 “state-level” staff are employees of the agency housing the 

Office of the SLTCO and are assigned to a region of the state. These staff were considered “local 

Ombudsmen” in our data collection protocol. 

As shown in Exhibit 27, 80% of local Ombudsmen worked full-time for the Ombudsman program. In 

addition, 11% of Ombudsmen reported sharing their time with another program or entity. Among 

respondents in the latter group, local Ombudsmen dedicated an average of 74% of their time to the 

Ombudsman program. 

State Ombudsman Approves Allocation on

Federal and State Funds to Local Program (N=31*)
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Exhibit 27: Time Dedicated to the LTCOP 

Time Dedicated to the LTCOP Local Ombudsmen

Work full-time or part-time for the LTCOP N = 488a

Full-time 80%

Part-time 20%

Share time with another program or entity N = 494b

Yes 11%

a Missing=9; b Missing=3

Exhibit 28 shows management functions performed by local Ombudsmen. The most commonly reported

functions were data collection (92%), data management (73%), staff training (72%), and developing 

partnerships (57%). 

Exhibit 28: Management Functions Performed by Local Ombudsmen

Management Functions

Local Ombudsmen

N=444a 

Data collection, including documenting activities and cases/complaints. 92% 

Data management, including entry, quality control, reporting, etc. 73% 

Providing staff training 72% 

Developing partnerships 57% 

Analysis of trends and sharing findings, such as with the Office of the State 

LTCO or sharing of facility information with surveyors prior to survey, etc. 55% 

Program administration 46% 

Other (please specify) 16% 

a Missing=10, Not applicable=43 (I do not have any management responsibilities.) 

Exhibit 29 shows that most local Ombudsmen visit nursing homes (89%), investigate complaints (88%), 

and visit board and care homes (76%). In addition, 40% of local Ombudsmen perform systems advocacy 

work.

Exhibit 29: Activities Performed by Local Ombudsmen 

Program Activity 

Local 

Ombudsmen N

Personally visit nursing homes 89% 497

Investigate or assist with complaints 88% 493a

Personally visit board and care homes 76% 497

Perform systems advocacy work 40% 488 b

a Missing=4; b Missing=9
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Volunteers 

Ombudsman programs’ use of volunteers differs by state law and policy, as well as programmatic need or 

the program’s ability to recruit volunteers.17 States also differ in the number of volunteers that support 

their programs. According to NORS data, 49 of the 53 programs reported using volunteers in FFY 2017.

18

The number of volunteers ranged from zero to 948 across all programs, with an average of 147 among 

programs that use volunteers. It should be noted that within a state or territory, volunteers are not 

necessarily evenly distributed, with the presence and number of volunteers varying considerably across 

and within Ombudsman programs, some of which may have no volunteers. 

Volunteer Roles. Volunteers are primarily responsible for making visits to long-term care facilities. A 

notable exception is volunteers who perform clerical tasks. Among volunteers who visit facilities, there are 

important differences with respect to complaint handling. Some volunteers may only make “friendly” visits 

to residents and refer complaints brought to their attention to paid Ombudsmen staff. Other volunteers 

may be trained and designated to serve as Ombudsmen, a role that involves complaint handling. The 

latter group can be divided into volunteer Ombudsmen who handle only certain types of complaints and 

those who are trained to handle all types of complaints. Programs may use their volunteers in any 

combination of these capacities. Of the 8,810 volunteers who supported the program in FFY 2017, 6,625 

(75%) were designated volunteer Ombudsmen.19 Importantly, the Final Rule clarifies that the State

Ombudsman must prohibit any representative of the Office from carrying out the duties of the Office 

unless they have been trained and approved by the Ombudsman as qualified to carry out the activity on 

behalf of the Office. At the time this report was prepared, State Ombudsmen with programs that use 

volunteers who are not designated (sometimes referred to as “friendly visitors”) reported being in the 

process of transitioning these volunteers into designated representatives of the Office with the 

expectation of fulfilling those duties. 

Although volunteers’ main focus is individual advocacy and education/outreach, Exhibit 30 highlights the 

range of activities that they perform. Nearly all volunteers (97%) in our sample conducted routine facility 

visits, and 86% investigated and resolved complaints raised by, or on behalf of, residents. More than twothirds also carry out education and outreach activities such as distributing program brochures, providing 

information and consultation to consumers, and distributing information, resources, and support to 

resident councils. In addition, smaller numbers of volunteers reported performing systems advocacy work 

such as monitoring laws, regulations, and policies (13%), and working with the media (3%).

 

17 At the time of this survey, some state regulations prohibited volunteers from conducting complaint investigations. ACL addressed 

this issue as part of the implementation of the Final Rule.

18 The Mississippi, South Dakota, West Virginia, and Wyoming programs reported no volunteers. 19 Seven states (Alabama, Mississippi, Montana, Puerto Rico, South Dakota, West Virginia, and Wyoming) reported having no 

designated volunteer Ombudsmen. The Alabama, Montana, and Puerto Rico programs reported having “other volunteers.”
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Exhibit 30: Activities Performed By Volunteer Ombudsmen

Activities Performed by Volunteer Ombudsmen N=711

Make visits (not in response to a complaint) to residents of long-term care facilities 97% 

Investigate and resolve complaints raised by, or on behalf of, residents 86% 

Distribute program brochures, letters to introduce myself, ensure that program contact 

information is prominently posted 69%

Provide information, resources, and support to resident councils 68%

Provide information and consultation to consumers (residents, families, the general 

public) 65%

Collect, manage, and/or report data about my case work and/or activities 57%

Provide consultations to facility staff 39%

Participate as a resident advocate in facility licensure surveys 32%

Provide information, resources, and support to family councils 28%

Provide training to other volunteers 24%

Provide community education 22%

Monitor/work on laws, regulations, government policies and actions 13%

Provide training to facility staff 12%

Work with media on issues impacting residents of long-term care facilities 3%

Other (please specify) 8%

Challenges in Management and Recruitment. State Ombudsmen have long recognized the value of 

volunteer contributions, but they also emphasize the need for adequate resources to ensure that they are

well-trained and effective. Nearly three-quarters (73%) of State Ombudsmen reported that recruiting and 

supporting volunteers is a challenge that their programs face. Without adequate resources to ensure that 

this segment of the program’s workforce is well-trained and effective, however, the cost of training and 

managing volunteers can outweigh their benefits, particularly when programs lack staff for volunteer 

supervision or if they have insufficient funds for volunteer administration. In 2017, only 16 State 

Ombudsmen reported having a full- or part-time volunteer coordinator at the state or local level.20 More 

than two-thirds of programs lacked dedicated staff to recruit, oversee, and provide training and support to 

volunteers. State Ombudsmen frequently expressed an urgent need for a coordinator to not only help 

grow their volunteer programs, but also to free up staff time to conduct facility visits. Absent staff 

dedicated to volunteer management, programs must rely on paid Ombudsman staff to recruit and 

supervise volunteers, tasks that are added to their other responsibilities. Given competing priorities as 

well as time and resource constraints, State Ombudsmen reported that some programs often struggle to 

identify and retain volunteers who are a good fit for the Ombudsman role. 

Insufficient funds also prevent State Ombudsmen from developing their volunteer programs. For example, 

lack of financial resources limits programs’ ability to advertise volunteer opportunities. One State 

Ombudsman reported that volunteers do not have access to the program’s complaint management 

 

20 LTCOP Management Highlights 2017
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system. This operational challenge was linked to the cost of data licenses, ultimately requiring paid staff 

to enter reporting data for volunteers, at the expense of not visiting long-term care facilities. 

Resource constraints may also render programs unable to provide travel reimbursement to volunteers, 

even though visits to some facilities involve long travel times, especially in states with large rural areas. 

Given that many volunteers are older and retired, the need to cover their own travel expenses can be 

financially burdensome, and it may contribute to volunteer attrition. Lack of funds has also resulted in

some programs being forced to reduce or forgo volunteer training or recognition events. State 

Ombudsmen reported paying for volunteer recognition events out of pocket, although program funds were

used in the past. Some Ombudsmen also reported that the cost of volunteer luncheons or other tokens of 

appreciation may also be paid out of pocket. 

Difficulties recruiting volunteers are especially challenging among programs that cover rural regions. Not 

only do these areas have smaller pools of potential volunteers, but even when volunteers express 

interest, it can be challenging to incentivize them to travel long distances to remote areas of the state. 

One State Ombudsman noted the difficulty in recruiting volunteers if program staff do not reside in the 

community and are viewed as outsiders, particularly in smaller communities. Onboarding volunteers can 

also be time consuming and inefficient for all programs. These challenges, however, are especially 

pronounced if only one volunteer is joining the program at a given time, requiring both staff and the 

prospective volunteer to travel long distances for training. Moreover, in small communities, many 

residents know one another. Under these circumstances, identifying volunteers who are free of conflicts 

of interest that would arise through personal relationships with family members or friends who reside or 

work at facilities to which the volunteer are assigned can be especially challenging. 

Legal Counsel

Amendments to the OAA as well as publication of the Final Rule outlined requirements concerning the 

Ombudsman program’s provision of legal counsel and representation. Section 712(g) of the OAA requires 

that the state or territorial unit on aging (SUA) ensure that adequate legal counsel is available and able, 

without conflict of interest (COI), to provide advice and consultation that is needed to protect the health, 

safety, welfare, and rights of residents and assist the Ombudsman program in performing its official 

duties. The SUA must also ensure that legal representation is provided to the Office if a suit or other legal 

action is brought or threatened to be brought in connection with the Ombudsman’s performance of their

official duties.

The Final Rule clarified requirements concerning the scope and characteristics of legal counsel, stating

that the SUA must ensure that provision of legal counsel to the Ombudsman program is “adequate, 

available, has competencies relevant to the legal needs of the program and of residents, and is without 

conflict of interest” [45 CFR § 1324.15(j)(1)(i)]. In the event of COI, the Final Rule specifies that “legal 

counsel may be provided by one or more entities, depending on the nature of the competencies and 

services needed and as necessary to avoid conflicts of interest. However, at a minimum, the Office shall 

have access to an attorney knowledgeable about the Federal and State laws protecting the rights of 

residents and governing long term care facilities” [45 CFR § 1324.15(j)(2)]. 

Ombudsman Program Legal Counsel

As shown in Exhibit 31, Ombudsman programs draw on multiple sources of legal support to address 

program needs and representation. Sixty-four percent of State Ombudsmen reported accessing legal 

counsel from more than one entity.
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More than half of State Ombudsmen reported that their State’s Office of the Attorney General (AG) is 

among the legal resources that is available to them. Twenty-three Ombudsman programs that are housed 

in state agencies are assigned attorneys within the state agency. These programs frequently also have 

access to the Office of the AG. One fifth of Ombudsman programs have in-house counsel or legal support 

that is provided by a nonprofit host agency. A small number of programs reported access to legal counsel 

through private attorneys that work under contract or who provide pro bono services.

Among State Ombudsmen who reported other sources of legal support, these sources included attorneys

that serve on the program’s board of directors, public interest organizations (such as disability law centers 

and the Elder Law Project), the Bar Association, and coalitions and task forces that focus on law and 

elder rights. 

Exhibit 31: Sources of Legal Counsel

Legal Counsel SLTCOPs 

Office of the Attorney General 30

State Agency Attorney 23

In-house/Host Agency Attorney (non-government) 11

Private Attorney under Contract 5 

Pro Bono Attorney 5 

Other 15

State Ombudsmen reported working with between one and four legal entities at the state level to address 

diverse programmatic needs and potential COI. A small number of programs reported setting aside funds 

to secure an attorney outside of their main sources of legal counsel should these needs arise. In other 

programs, legal supports are directed at specific functional areas. For example, an Ombudsman program 

may only access legal counsel provided by state agencies for representation in litigation or for 

development of contracts and MOUs, but seek external counsel experienced in long-term care for 

programmatic issues related to individual and systems advocacy. The latter may be private attorneys 

under contract or pro bono attorneys if the program has insufficient resources. A program may also retain 

independent counsel when a COI arises that cannot be addressed with a program’s existing legal 

counsel. 

Similar to findings at the state level, legal support for local Ombudsman entities is also varied, and local 

supports may be the same or different from those that are available at the state level. State Ombudsmen 

reported that local program staff typically seek support from legal aid, legal service providers, private 

attorneys under contract or working pro bono, public interest organizations, advocacy groups, and county 

attorneys. Although the Office of the AG is available to some local Ombudsman entities (in coordination 

with the State Ombudsman), compared to the state level, there is less reliance on the Office of the AG at 

the local level. 

Sources of legal support can also vary across local Ombudsman entities within a state, often depending 

on the host agency that houses the local Ombudsman entity. For example, legal services agencies that 

house local Ombudsman entities typically provide legal support to Ombudsmen. Local Ombudsman 

entities that are hosted by other types of agencies, such as Area Agencies on Aging (AAAs), may also 

secure legal assistance by contracting out the service. 
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In addition to their primary sources of legal support, State Ombudsmen reported coordinating with their 

State legal assistance developers and legal assistance providers/legal aid. These sources of legal 

assistance are described in Chapter 6, along with other entities with which programs coordinate.

Scope of Legal Assistance

Ombudsman programs use legal support to address the program’s individual and systems advocacy 

activities as well as broader programmatic needs (Exhibit 32). A majority of State Ombudsmen reported 

that the scope of their legal assistance includes responding to requests for information, such as in 

response to a subpoena or FOIA request (79%), providing representation in the event of a lawsuit (73%), 

providing consultation on complaints against State or local Ombudsmen (71%), and legal issues related 

to resident complaints (69%). In addition, a little over half of State Ombudsmen (54%) reported that legal 

assistance is available to consult on whatever issue arises. Although making improvements to the longterm care system is a key responsibility of the Ombudsman program, less than half (40%) of State 

Ombudsmen reported that legislative and regulatory advocacy is within the scope of their legal 

assistance. 

In addition to the legal activities shown in Exhibit 32, 17% of State Ombudsmen described “other” support 

provided by legal counsel. These activities included assistance with meeting regulatory requirements 

(such as the Final Rule), ensuring consistency among administrative rules, and participating in elder 

coalitions. 

Exhibit 32: Scope of Legal Assistance Available to the Office of the SLTCO

Scope of Legal Assistance Available to the Office of the SLTCO

State Ombudsmen 

N=52 

Requests for information (e.g. response to a subpoena, FOIA request) 79%

Representation in the event of a lawsuit 73%

Consultation on complaints against State/local Ombudsmen 71%

Consultation on legal issues related to complaints (e.g. public benefits, 

guardianships) 69%

Whatever issue I need to consult about 54%

Administrative appeals 42%

Legislative or regulatory advocacy 40%

Represent individual residents in legal matters 25%

Civil remedies (e.g. injunctions) 23%

Other 17%

Don’t know 2%

Required Characteristics of Legal Counsel 

The Final Rule specifies that legal counsel made available to the Ombudsman program should be 

“adequate, available, has competencies relevant to the legal needs of the program and of residents, and 

is without conflict of interest” [45 CFR § 1324.15(j)(1)(i)]. The extent to which the Ombudsman program’s 

legal counsel meets these requirements is described below.

Knowledge of Legal Counsel. Although most State Ombudsmen who use their Office’s assigned legal 

counsel reported that they are knowledgeable about the Ombudsman program’s issues and/or long-term 
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care (LTC) issues, 14% of State Ombudsmen reported not having legal counsel that is familiar with either 

topic (Exhibit 33). State Ombudsmen reported that the areas of expertise of their assigned counsel may 

be less relevant to program needs, such as consumer protection. In addition, lack of familiarity with elder 

rights may result in legal counsel that is unable to adequately protect and promote resident rights. When 

a program’s assigned legal counsel is not familiar with long-term care issues or the OAA, the program 

may need to identify other sources of legal support. 

Notably, almost one-fifth of State Ombudsmen reported not using or rarely using the legal counsel 

assigned to them. Reasons reported for not coordinating with assigned legal counsel included lack of 

expertise, non-responsiveness, and the costs associated with these professional services. For some 

programs, assigned legal counsel charges a fee for services, requiring State Ombudsmen to be judicious 

about use of these funds, given Ombudsman program’s limited resources. Under these arrangements, 

the cost of services may deter State Ombudsmen from seeking legal advice on a routine basis, even 

when counsel is present. Instead, some Ombudsman programs prioritize needs for which legal counsel is 

sought or identify other, more affordable sources of support. This may involve identifying a pro bono

attorney or forgoing legal assistance altogether. For example, one State Ombudsman reported assisting 

residents at discharge hearings when legal counsel could not be obtained or when it was too costly. 

Exhibit 33: Legal Counsel Knowledge 

Legal Counsel Knowledge about LTCOP and LTC Issues

State Ombudsmen

N=42a

Legal Counsel is knowledgeable in Ombudsman programmatic issues and/or longterm care issues 86% 

Legal Counsel is not knowledgeable in either Ombudsman programmatic issues or 

long-term care issues 14% 

a Missing=1, Not applicable=9 (I have not used, or rarely use the legal counsel assigned.) 

Timeliness of Legal Assistance. Nearly three-quarters (74%) of State Ombudsmen reported they were 

able to obtain timely legal assistance. The inability to access timely legal assistance was often reported to 

be due to lack of resources and competing priorities. For example, an AG’s office or other legal entity may 

have limited availability of legal support due to a backlog of cases, forcing the AG to prioritize certain 

agency cases over others. 

Conflict-Free Legal Counsel. The OAA and Final Rule require that legal counsel is without COI, as 

defined by the State ethical standards governing the legal profession. In the event of COI, the Final Rule 

specifies that “legal counsel may be provided by one or more entities, depending on the nature of the 

competencies and services needed and as necessary to avoid conflicts of interest [45 CFR §

1324.15(j)(2)]. To ensure that legal counsel is free from COI, State Ombudsmen reported establishing 

both formal and informal conflict avoidance procedures. For example, should a potential COI arise with 

the general counsel assigned to the program, other legal supports such as the AG or external counsel

may intervene and provide assistance. Some State Ombudsmen reported having funds set aside to hire 

private attorneys should potential COI situations arise. 

Although COI can arise for any Ombudsman program, the potential for COI is greater for programs that 

are housed in state agencies that also host other units, departments, or agencies that provide services to 

long-term care residents, or entities that play a regulatory role in long-term care facilities. Under this type 

of organizational placement, the state agency may assign the Office of the AG as the primary legal 

counsel to all agencies it houses. In this setting, COI may occur in a dispute if the AG represents both the 
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Ombudsman program and another agency that is housed within the state agency (e.g., APS, licensing 

and certification). Given the different organizational allegiances, a conflict results when legal counsel is 

constrained from fully representing the Ombudsman program because of dual responsibilities or interests 

to the State or other agencies. However, the OAA is clear on this matter, requiring that adequate legal 

counsel “provide advice and consultation needed to protect the health, safety, welfare, and rights of 

residents and to assist the Ombudsman and representatives of the Office in the performance of the 

official duties of the Ombudsman and representatives” [Section 712(g)(1)(A)(i)(ii)].

Many State Ombudsmen described that they are able to obtain other sources of legal support to resolve 

COI, but addressing these conflicts is especially challenging when the Office of the AG is the only source 

of legal support that programs can access. Absent adequate resources, State Ombudsmen reported 

remedying COI by seeking assistance from pro bono attorneys or legal services programs if no other 

legal support options were available or provided by the state agency. 

Effectiveness of Legal Assistance

Although the OAA and Final Rule set forth requirements to ensure that Ombudsman programs have 

adequate legal counsel, it was notable that only 56% of State Ombudsmen reported that their legal 

counsel was sufficient to enable their programs to meet federal mandates. Further, as shown in Exhibit 

34, nearly half of State Ombudsmen (49%) reported that the legal assistance that they received was “very 

effective.” Notably, ten percent reported that their legal assistance was “somewhat ineffective” or “very 

ineffective” and six percent reported not knowing how effective these services were. 

Exhibit 34: Effectiveness of Legal Assistance

Effectiveness of Legal Assistance Received by Program

State Ombudsmen 

N=49a

Very effective 49%

Somewhat effective 18%

Neutral 16%

Somewhat ineffective 4%

Very ineffective 6%

Don't know 6%

a Missing=3 

While a majority of State Ombudsmen reported effective, knowledgeable, and timely legal assistance, 

they also reported important challenges to obtaining adequate legal support. These challenges involved 

interrelationships among the OAA’s and Final Rule’s requirements with respect to legal counsel’s 

availability, competence, and freedom from COI. When legal counsel does not meet all these 

requirements, the support provided to Ombudsman programs can be inadequate. For example, some 

State Ombudsmen reported that their legal counsel was accessible but lacked the necessary expertise to 

appropriately advise the program. Others described having knowledgeable legal counsel that may not be 

conflict-free. State Ombudsmen also reported experiences where legal counsel was free of COI but was 

unresponsive to or unhelpful in providing assistance.
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Adequacy of Resources

When asked about program challenges, 75% of State Ombudsmen and 70% of lead local Ombudsmen

reported insufficient funding as a challenge (data not shown in exhibits). Many State Ombudsmen 

identified insufficient resources—primarily funding and staff—as the program’s most significant 

challenges.

As shown in Exhibit 35, most State Ombudsmen and lead local Ombudsman did not consider fiscal 

resources and paid staff and volunteers to be sufficient to meet federal mandates. Only 23% of State 

Ombudsmen and 26% of lead local Ombudsmen reported that their program’s fiscal resources were 

sufficient to meet federal mandates. One State Ombudsman who reported having sufficient resources to 

fulfill federal mandates noted that Ombudsman program funding is in the state budget every year and 

requires a minimum number of Ombudsmen based on population.

Twenty-seven percent of State Ombudsmen and 37% of lead local Ombudsmen reported that their 

program has sufficient paid staff to meet federal mandates. State Ombudsmen who reported sufficient 

staffing had lower numbers of facilities per staff on average, compared to their counterparts who did not 

report sufficient staff (41 vs. 64 facilities per staff21). Fifteen percent of State Ombudsmen and 21% of 

lead local Ombudsmen reported having sufficient volunteers to meet federal mandates. 

Exhibit 35: Resources Sufficient to Enable the Program to Meet Federal Mandates

Resources that are Sufficient

State Ombudsmen 

N=52

Lead Local 

Ombudsmen N=189

Fiscal resources 23% 26% 

Legal counsel 56% 29% 

# of paid staff 27% 37% 

# of volunteers 15% 21% 

# of volunteer hours 13% 20% 

Data/information systems 63% 58% 

Administrative support 46% 37% 

Communication methods to share information with consumers 

and stakeholders 48% 35% 

Training and technical assistance 52% 47% 

Other 15% 14% 

Exhibit 36 shows the impact of insufficient LTCOP resources on program activities by reporting activities 

that were not fully carried out due to lack of resources: 

■ State Ombudsmen most frequently identified volunteer recruitment and retention (69%), regular 

board and care home visits (67%), and resident and family council development and support 

(60%) as activities that were not fully carried out due to lack of resources. 

■ Lead local Ombudsmen most frequently identified volunteer recruitment and retention (60%) 

regular nursing home visits (45%), and regular board and care home visits (44%) as activities that 

were not fully carried out due to lack of resources. 

 

21 NORS data on LTCOP staff and long-term care facilities, 2017
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State Ombudsmen and lead local Ombudsmen differed markedly in their perceptions of the adequacy of 

the following activities: (1) regular board and care home visits, (2) information and consultations to 

individuals, and (3) resident and family council development and support. These findings may be due to 

differing priorities between the two groups or to different perspectives on how much these activities are 

carried out at the local level.

Exhibit 36: Ombudsman Program Activities Not Carried Out Fully Due to Lack of Resources

Program Activity 

State Ombudsmen

N=52

Lead Local 

Ombudsmen

N=189

Complaint investigation and resolution activities 23% 32% 

Regular nursing home visits, not in response to a complaint 50% 45% 

Regular board and care home visits, not in response to a 

complaint 67% 44% 

Training for facility staff 44% 40% 

Consultations to facilities 15% 19% 

Information and consultations to individuals 6% 20% 

Resident and family education at facilities 38% 37% 

Resident and family council development and support 60% 41% 

Community education activities 56% 43% 

Legal assistance for residents 52% 42% 

Analyzing and monitoring federal, state, and local law, 

regulations, and other government policies and actions 38% 36% 

Research and policy analysis to inform systems advocacy work 42% 43% 

Facilitating public comments on proposed legislation, laws, 

regulations, policies, and actions 48% 43% 

Volunteer recruitment and retention 69% 60% 

Other 13% 10% 

Given limitations in program capacity, State Ombudsmen reported limiting, forgoing, or prioritizing

program activities and relying heavily on volunteers and inter-organizational relationships to support 

program operations. State Ombudsmen reported forgoing professional development activities such as 

trainings, conferences, and statewide annual volunteer recognition luncheons, for themselves or their 

staff. Inadequate resources also prevent some programs from traveling to facilities for routine visits or 

hiring translators to assist with meeting the needs of diverse populations, such as American Indian tribes 

and predominately Spanish-speaking communities. 

Additionally, State Ombudsmen may prioritize activities through formal strategic planning processes or 

other, informal approaches. Some State Ombudsmen reported prioritizing facility visits and individual 

case work over systems advocacy. Others described triaging methods to prioritize daily work, such as 

responding to cases where a resident’s health or safety is at risk. Other strategies included conducting 

nursing home visits over board and care home visits; visiting facilities in response to a complaint over 

routine visits; and visiting facilities within shorter traveling distances over ones located in remote areas. 

For Ombudsman programs with insufficient funds or staffing, volunteers may be relied upon to ensure 

advocacy services are accessible to residents. As described earlier, without them, many State 
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Ombudsmen reported that programs would struggle to maintain an ongoing presence in long-term care 

facilities. 

Although State Ombudsmen reported lack of time to build new and/or improve existing relationships with 

coordinating entities, they also reported that their programs develop relationships and coordinate with 

other entities to supplement functional areas they are unable to address due to limited capacity. 

(Additional findings about program partnerships can be found in Chapter 6.)

5.3.2. Ombudsman Program Activities

This section describes Ombudsman program activities that are set forth in the OAA. For the purposes of 

this report, activities are grouped into three main categories: individual advocacy, systems advocacy, and 

education/outreach.

22 It should be noted, however, that overlap exists across these categories, 

depending on context. For example, we consider regular facility visits to be part of individual advocacy, 

but Ombudsmen also conduct education and outreach activities during these visits. Ombudsmen trainings 

for facility staff and administrators about long-term care issues, such as person-centered care, constitutes 

education but this activity is also a vehicle to encourage improvement in facility practices.

Individual Advocacy 

At the individual level, Ombudsman programs are required to: 

■ Identify, investigate, and resolve complaints on behalf of residents; 

■ Provide services to assist residents in protecting their health, safety, welfare, and rights; 

■ Inform residents about how to obtain facility or agency services; 

■ Ensure that residents have regular access to advocacy services; 

■ Assist in the development of resident and family councils; and 

■ Assist residents who are transitioning from a long-term care facility to a home care setting. 

Ombudsman programs largely meet these requirements through services that are provided during visits 

to long-term care facilities, community presentations, and a dedicated phone line for residents or others to 

ask questions or report a complaint. Facility visits, along with complaint handling, are typically the primary 

activities carried out by Ombudsman programs.

Facility visits are generally unannounced and varied in their scheduling. During facility visits, Ombudsmen 

interact with and listen to residents; observe the general conditions and daily activities of the facility and 

residents; share information about Ombudsman program services to residents, family and staff; support 

resident and family councils, provide information about long-term care options; identify and address 

complaints; and empower residents to speak up on their own behalf or voice concerns for those who are 

unable to do so. Other individual advocacy activities may include participating in nursing facility surveys 

with licensure and certification staff, or representing consumers in administrative hearings or appeals 

processes. Ombudsmen provide these advocacy services at no cost to residents or other complainants. 

Standards for Frequency of Facility Visits

Although ACL does not specify a frequency for Ombudsman facility visits, NORS defines “regular basis” 

to mean facility visits that occur no less than quarterly and that are not in response to a complaint. 

Because of these reporting requirements, quarterly visits are the only standard on which programs 

 

22 Additional state mandates for which programs are responsible (such as in-home advocacy) are outside the scope of this study.
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currently report data. Beginning in October 2019, new reporting requirements will require programs to 

report data on facility visits regardless of whether they are complaint-driven. 

Given the diversity of resources that are available to programs as well as widely varying state and local 

circumstances (e.g., rurality), there is considerable variation in the extent to which state Ombudsman 

programs are able to conduct quarterly facility visits. According to NORS in FFY 2017, Ombudsman 

programs visited 68% of nursing homes and 30% of board and care homes on at least a quarterly basis. 

Within states and territories, quarterly visits to nursing homes ranged between 11% and 100%, while 

quarterly visits to board and care homes ranged between zero percent and 100% (see Table C in 

Appendix E for state-level data). 

Visitation Goals. At the state level, most Ombudsman programs set visitation goals for nursing homes 

(88%) and board and care homes (83%), with a majority aiming to visit nursing homes and board and 

care homes at least quarterly (Exhibit 37). While the visitation goals between the two settings are similar, 

programs aim to visit nursing homes more frequently than board and care homes. Consistent visitation to 

facilities offers the opportunity for Ombudsmen to build relationships with residents, understand their 

preferences, and raise residents’ comfort level in expressing concerns. 

Exhibit 37: Statewide Program Goals for Visiting Facilities

Visitation Goals

Nursing Homes

N=52

Board and Care Homes

N=51a

At least weekly 4% 2%

At least monthly 15% 6%

At least quarterly 60% 53%

At least twice a year 2% 4%

At least annually 6% 10%

Other 2% 8%

None 12% 18% a Missing=1 

Frequency of Facility Visits. As shown in Exhibit 38, Ombudsman programs indicate being able to meet 

their quarterly visit goals to varying degrees. More than three-quarters (79%) of State Ombudsmen

reported that their statewide program visits most or all nursing homes on at least a quarterly basis, 

regardless of whether the visit is complaint-driven. Compared to nursing homes, board and care homes 

are visited less frequently. Just over half (55%) of State Ombudsmen reported that their statewide 

program visits board and care homes at least quarterly. One-fourth of State Ombudsmen reported a 

range of "other" frequencies of visits to most, or all board and care homes. The frequency of these visits 

is driven by multiple factors, including the distance from the program office, the type and size of the 

facility, and staff availability.
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Exhibit 38: Statewide Average Frequency of LTCOP Visits to Most or All Facilities 

Frequency of Visits

Nursing Homes

N=52

Board and Care Homes

N=52

Weekly 8% 0%

Monthly 33% 17%

Quarterly 38% 38%

Twice a year 6% 8%

Annually 2% 12%

Other 13% 25%

A majority of local and volunteer Ombudsmen reported visiting nursing homes and board and care homes 

on at least a quarterly basis (Exhibit 39). Volunteer Ombudsmen, however, reported more frequent visits 

to both types of facilities, compared to local Ombudsmen. Over half (53%) of volunteers reported that 

they visit nursing homes on a weekly basis and 62% reported visiting board and care homes on at least a 

weekly (22%) or monthly basis (40%).

Exhibit 39: Frequency of Local and Volunteer Ombudsman Visits to Long-Term Care Facilities

Frequency of Visits

Local 

Ombudsmen

Nursing Homes

N=442a

Volunteer

Ombudsmen

Nursing Homes

N = 555b

Local 

Ombudsmen

Board and Care

N=373c

Volunteer

Ombudsmen 

Board and Care

N=350d

Weekly 11% 53% 2% 22%

Less than weekly but at least 

once a month 28% 26% 16% 40%

Less than monthly but at least 

once a quarter 33% 14% 48% 31%

Twice a year 4% 1% 7% 2%

Once a year 1% 0% 7% 1%

As needed 14% 3% 13% 3%

Other (please specify) 9% 3% 7% 1%

a

 Missing=2, Not applicable=53; b Missing=11, Not applicable=145; c Missing=6, Not applicable=118; d Missing=15, Not 

applicable=346 

Note: Ombudsmen who do not visit that facility type are considered N/A. 

Assignments for Facility Visits

Exhibit 40 shows how local programs make decisions about facility visits. Most lead local Ombudsman 

reported that Ombudsmen are assigned to a specific facility or group of facilities based on geographic 

region (93%) or in response to information concerning facility problems or to follow-up on resident 

complaints (71%). Smaller percentages of lead local Ombudsmen reported that Ombudsmen are 

assigned to facilities based on facility characteristics (27%), Ombudsman expertise (20%), or they 

prioritize facilities that have not recently received complaint-related visits (17%).
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Exhibit 40: Decisions Made About Facility Visits 

How Decisions are Made about Facility Visits

Lead Local Ombudsmen

N=189

Ombudsmen are assigned to a specific facility or group of facilities to visit, based on 

geographic region. 93%

Ombudsman visit facilities in response to information about facility problems and 

resident complaints. 71%

Ombudsmen are assigned to a specific facility or group of facilities to visit, based on 

facility characteristics (for example, size, and ownership, level of services provided). 27%

Ombudsmen are assigned to cases (regardless of facility) based on their expertise 

in the type of complaint that has been reported (for example, complaints related to 

involuntary discharges or transfers).

20%

Ombudsmen prioritize facilities that have not recently received complaint-related 

visits. 17%

Ombudsmen are not assigned to specific facilities or groups of facilities. 4% 

Other 13%

Time Spent During Visit. Exhibit 41 shows the average amount of time local Ombudsmen reported 

spending in nursing homes and board and care homes during routine visits. Ombudsmen generally spent 

less than two hours per visit in both settings, respectively (with one to two hours being the most common 

visit duration). Ninety-two percent of local Ombudsmen and 87% of volunteers spent two hours or less for 

each board and care home visit, while 78% of local Ombudsmen and 65% of volunteers reported

spending two hours or less for each nursing home visit. 

According to NORS data, nursing homes had an average of 104 beds per facility compared to an average 

of 24 beds in board and care homes in FFY 2017. Likely due to the larger number of beds in nursing 

homes, local and volunteer Ombudsmen reported spending more time visiting nursing homes than board 

and care homes. A larger percentage of local and volunteer Ombudsmen reported spending over two 

hours in nursing homes compared to board and care homes. By contrast, a larger percentage of local and 

volunteer Ombudsmen reported spending less than an hour in board and care homes compared to 

nursing homes. 

Exhibit 41: Average Amount of Time Local and Volunteer Ombudsmen Spent in Facility for Each Routine 

Visit 

Amount of Time

Local 

Ombudsmen

Nursing Homes

N=405a

Volunteer

Ombudsmen

Nursing Homes

N=554b

Local 

Ombudsmen

Board and Care

N=348c

Volunteer 

Ombudsmen

Board and Care

N=342d

Less than an hour 13% 9% 43% 41%

Between 1 to 2 hours 65% 56% 49% 46%

Between 2 to 3 hours 19% 28% 7% 10%

More than 3 hours 3% 7% 1% 3%

a Missing=5, Not applicable=87; b

 Missing=9, Not applicable=148; c Missing=6, Not applicable=143; d Missing=23, Not 

applicable=346 

Note: Ombudsmen who do not visit that facility type or who do not conduct routine visits are considered N/A. 
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Staffing of Facility Visits

Exhibit 42 shows that Ombudsmen at all levels conduct visits to long-term care facilities. State 

Ombudsmen, however, are less likely to visit nursing homes and board and care homes (81%), compared 

to local and volunteer Ombudsmen (91% and 97%, respectively). 

Exhibit 42: Visits to Nursing Homes or Board and Care Homes

Visits Nursing Homes or Board and Care Homes

State 

Ombudsman

N=52

Local 

Ombudsmen

N=497

Volunteer 

Ombudsmen

N=705a

Visits nursing homes and/or board and care homes 81% 91% 97%

Does not visit any type of facility 19% 9% 3%

a Missing=7

Exhibit 43 shows the percent of Ombudsman staff that conducts each type of facility visit, the types of 

visits they conduct, and the number of facilities they are assigned. 

■ Among State Ombudsmen who reported visiting nursing homes, 45% do so on a routine basis, 

compared to 81% of local Ombudsmen, and 95% of volunteer Ombudsmen. 

■ Among State Ombudsmen who reported visiting board and care homes, 36% reported doing so 

on a routine basis, compared to 78% of local Ombudsmen and 93% of volunteers. 

Results also show differences between local and volunteer Ombudsmen in terms of the type of visit and 

the number of assigned facilities:

■ A larger percentage of local Ombudsmen visit board and care homes (76%) compared to 

volunteer Ombudsmen (51%). 

■ Local Ombudsmen are assigned to more facilities compared to volunteer Ombudsmen. Local 

Ombudsmen are assigned to a median of 30 facilities, with a range from zero to 1,700 facilities, 

while volunteers are assigned to a median of two facilities, with a range of zero to 60 facilities. A 

very small number of Ombudsmen are not assigned to specific facilities, but still may conduct 

visits to nursing homes or board and care homes based on program needs (such as in response 

to a complaint).

■ Whereas volunteers primarily visit facilities on a routine basis (95%), local Ombudsmen are more 

likely to visit nursing homes in response to facility problems and resident complaints (87%), 

compared to volunteers (59%). 
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Exhibit 43: Ombudsman Visits to Long-Term Care Facilities – Type of Visit and Facilities Assigned

Facility Type

State 

Ombudsmen

Local 

Ombudsmen

Volunteer 

Ombudsmen

Nursing Homes N=52 N=497 N=711

Visits nursing homes 81% 89% 80%

Type of visit conducted: N=42a N=443b N=562c

Visit on a routine basis (not complaint driven) 45% 81% 95%

Visit in response to facility problems and 

resident complaints 71% 87% 59%

Other 43% 16% 8%

# of facilities assigned: - N=385d N=546e

Mean - # of facilities assigned - 20 2 

Range - # of facilities assigned - 0-300 0-30

Board and Care Homes N=52 N=497 N=704f

Visits board and care homes 69% 76% 51%

Type of visit conducted: N=36g N=375h N=350i

Visit on a routine basis (not complaint driven) 36% 78% 93%

Visit in response to facility problems and 

resident complaints 64% 79% 52%

Other 31% 10% 4%

# of facilities assigned: - N=344j N=339k

Mean - # of facilities assigned - 45 5 

Range - # of facilities assigned - 0-1652 0-40

All Facilities N=52 N=419l N=664m 

Mean - # of facilities assigned - 58 4 

Range - # of facilities assigned - 0-1700 0-60

Median - # of facilities assigned - 30 2 

a Not applicable=10; b

 Missing=1, Not applicable=53; c Missing=4, Not applicable=145; d Missing=59, Not applicable=53; e

Missing=20, Not applicable=145; f Missing=7; g

 Not applicable=16; h Missing=4, Not applicable=118; i Missing=15, Not 

applicable=346; j Missing=35, Not applicable=118; k

 Missing=26, Not applicable=346; l Missing=50; m Missing=23, Not applicable=24 

Ease of Access to Residents. The OAA requires that Ombudsmen have private and unimpeded access 

to residents. A majority of local and volunteer Ombudsmen reported that they rarely or never experienced 

problems in accessing residents in long-term care facilities (Exhibit 44). 

■ Compared to local Ombudsmen, volunteers reported less frequent problems accessing residents 

in facilities. Ninety percent of volunteer Ombudsmen reported that they “rarely” or “never” 

experienced problems accessing residents in nursing homes and board and care facilities. 

■ Almost one-third (32%) of local Ombudsmen reported that they “often” or “sometimes” had 

problems accessing residents in nursing homes. One quarter of local Ombudsmen also reported 

that they “often” or “sometimes” had encountered problems accessing residents in board and 

care homes. 
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Exhibit 44: Frequency of Problems Accessing Residents in Long-Term Care Facilities

Facility Type Local Ombudsmen Volunteer Ombudsmen

Nursing Homes N=268a N=559b

Often 13% 1%

Sometimes 19% 9%

Rarely 47% 33%

Never 22% 57%

Board and Care Homes N=231c N=349d

Often 4% 1%

Sometimes 21% 9%

Rarely 48% 32%

Never 27% 58%

a

 Missing=4, Not applicable=36; b Missing=7, Not applicable=145; c Missing=5, Not applicable=72; d Missing=16, Not applicable=346 

Complaint Handling 

State Ombudsmen reported that complaint 

handling is among their highest priority 

activities. In FFY 2017, Ombudsman 

programs handled 201,460 complaints, with 

a range from 214 to 41,834 across states

(see Table C in Appendix E for state-level 

data). Of these complaints, 71% were addressed in nursing homes, 27% in board and care homes, and 

2% in other settings. Fewer complaints arising from board and care homes compared to nursing homes 

may be due in part to their less frequent visitation by Ombudsmen.

NORS classifies complaints that Ombudsmen handle into five main categories: (1) resident rights; (2) 

resident care; (3) quality of life; (4) facility administration (e.g., inappropriate level of care provided, staff 

shortages); and (5) issues with agencies and individuals that are external to the facility (e.g., access to 

information from licensing agency, conflicts with family members). These categories are further organized 

into 16 broad complaint categories23 within which Ombudsman programs assign a code (out of 133

possible detailed codes) for each complaint that is reported. Exhibit 45 shows the top 10 most frequent 

types of complaints that Ombudsmen addressed in FFY2017, with the most frequent complaint among 

residents of both nursing homes and board and care homes relating to discharge/eviction. 

State Ombudsmen reported that the types of complaints that the program currently handles are more 

complex and challenging than in the past. Complaints have moved away from requests for assistance 

with daily needs to more urgent concerns such as involuntary discharges and evictions. 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. By contrast, for the last seven years, discharge/ eviction have 

 

23 The 16 broad complaint categories are as follows: (1) abuse, gross neglect, exploitation; (2) access to information by resident or 

resident’s representative; (3) admission, transfer, discharge, eviction; (4) autonomy, choice, preference, exercise of rights, privacy; 

(5) financial, property; (6) care; (7) rehabilitation or maintenance of function; (8) restraints – chemical and physical; (9) activities and 

social services; (10) dietary; (11 environment; (12) policies, procedures, attitudes, resources; (13) staffing; (14) certification/licensing 

agency; (15) State Medicaid agency; (16) system/others.

One State Ombudsman noted, “I think that every Ombudsman 

has one case, or one situation that they can point to that they 

really made a significant impact in a resident’s life—it might be 

around life in the facility, it might be about a community 

discharge that everybody was opposed to—that ultimately 

ended up working for that individual. I think our success is 

oftentimes at the individual level.”
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topped the list of the most frequently reported complaints handled by the program. 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. Similarly, in board and care homes, the most 

common complaints addressed by Ombudsmen in recent years (2017, 2016, and 2014) were for

discharge/eviction. Prior to that, the most frequent complaints concerned medications or food service 

(1996-2013, 2015). 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.

Exhibit 45: Top Ten Most Frequent Complaint Types (FFY 2017) 

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

According to FFY 2017 NORS data, complaints about resident-related issues are initiated by a variety of 

individuals. Exhibit 46 shows the number and percent of cases that were reported by type of complainant. 

Of the 128,091 cases closed by the program, residents were the most frequent complainants (40%). In 

18% of cases, relatives or friends of residents reported problems to Ombudsmen. Almost one-fifth of 

complaints made on behalf of residents were initiated by facility staff (19%). As with other complainants, 

facility staff may reach out to Ombudsmen to assist with both resident concerns (e.g., family conflict) and 

facility issues (e.g., closures). One State Ombudsman described a common scenario that their program 

has experienced with facility staff. When facility staff are unable to resolve difficult behavioral interactions 

with residents or their family members, they will contact the Ombudsman to help informally mediate, 

prevent escalation, and diffuse conflict. Ombudsmen may also initiate complaints based on their 

observations during facility visits, with such complaints accounting for 11% of cases. 
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Exhibit 46: Type of Complainant and Number and Percentage of Cases Closed (FFY 2017)

Type of Complainant Number of Cases Percent of Cases

Resident 51,350 40%

Facility Administration, Staff 24,008 19%

Relative/Friend 23,409 18%

Ombudsman, Volunteer Ombudsman 13,332 11% 

Other Agency Representative 5,808 4% 

Other Medical - Physician/Staff 3,539 3%

Unknown/Anonymous 3,337 3%

Other 2,014 2%

Non-Relative, Guardian, Legal Representative 1,294 1%

Exhibit 47 shows data on how Ombudsman programs handle complaints. Most local and volunteer 

Ombudsmen reported investigating complaints (88% and 87%, respectively). In this group, local and 

volunteer Ombudsmen reported handling all types of complaints (93% and 80%, respectively). 

■ Among local Ombudsmen who reported only handling certain types of complaints, some 

described addressing cases that were more complex, difficult, or “delicate.” These included cases 

of abuse, involuntary discharge, or problems requiring legal expertise. Others described 

addressing complaints related to residents’ rights, resident care, quality of life, and facility 

administration concerns. A few Ombudsmen reported working on insurance-related complaints, 

such as issues with Medicare. 

■ Of the 20% of volunteers who reported only handling certain types of complaints, the most 

common complaints concerned basic needs issues such as food and the quality of services and 

staff (83%). Others reported specifically focusing on financial and medical issues (17%).

Most program staff and volunteers investigate complaints on their own, seek support from other staff or 

volunteers, and refer complaints to other entities.

■ Compared to volunteers, local Ombudsmen were more likely to report supporting other program 

staff/volunteers as they handle complaints (76% vs. 32%). 

■ Compared to local Ombudsman, a lower percentage of volunteers handle complaints on their 

own (71% vs. 83%). 

■ Of the 29% of volunteers who did not report handling complaints on their own, many reported 

consulting with other program staff or volunteers as needed, and referring the complaint to an 

appropriate entity.
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Exhibit 47: Complaints Handled by Local Ombudsmen and Volunteer Ombudsmen

Complaint Handling

Local 

Ombudsmen

N=493a

Volunteer

Ombudsmen

N=710b

Investigates or assists other ombudsmen with complaints 88% 87%

Of those who handle complaints... N=435c N=609d

I handle all types of complaints 93% 80%

I handle only some types of complaints 7% 20%

How complaints are handled: N=436e N=615f

I handle complaints on my own 83% 71%

I support other program staff/volunteers as they handle complaints 76% 32%

I consult with other program staff or volunteers, as needed 79% 77%

I refer the complaint to other program staff or volunteers N/A 32%

I refer the complaint to the appropriate entity when I have resident 

consent 76% 72%

Other 4% 6%

a Missing=4; b

 Missing=1; c Missing=3, Not applicable=59; d Missing=8, Not applicable=94; e Missing=2, Not applicable=59; f Missing=2, Not applicable=94 

Note: Not applicable in this table refers to Ombudsmen who reported that they do not handle complaints 

State, lead local, local, and volunteer Ombudsmen reported important differences in their ability to 

engender effective relationships with nursing homes and with board and care homes, as shown in 

Exhibits 48 through 51. While local and volunteer Ombudsmen tended to report higher levels of effective 

relationships with both types of providers than State Ombudsmen, State Ombudsmen were asked to 

report on their statewide program and lead local Ombudsmen were asked to report on their local 

programs. Comparisons between respondent groups, then, should be interpreted with caution because of

these differences in the reference group. 

State, lead local, local, and volunteer Ombudsmen were more likely to report effective relationships with 

nursing homes than with board and care homes. This finding corresponds with the greater number and 

frequency of Ombudsmen visits that are dedicated to nursing homes than board and care homes. 
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Exhibit 48: Effectiveness of 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=51a

Board and Care 

Homes 

N=51b

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%

a

 Missing=1; b Missing=1 

Exhibit 49: 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 50: Effectiveness of 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 

Exhibit 51: Effectiveness of Relationship with Nursing Homes and Board and Care Homes (Volunteer 

Ombudsmen)

Overall, how would you rate the effectiveness of your 

relationship with the following types of facilities and 

providers?

Nursing Homes 

N=513a

Board and Care 

Homes 

N=357b

A majority of the relationships are effective 78% 78% 

Some of the relationships are effective 18% 17% 

A few of the relationships are effective 3% 4% 

None of the relationships are effective <1% 0% 

a

 Missing=55; Not applicable=143; b Missing= 28, Not applicable=326 
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In open-ended follow-up questions, Ombudsmen were asked to describe factors that informed their 

assessments of effectiveness. Although all levels of Ombudsmen reported a regular presence in facilities 

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

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 focusing on maintaining a 

regular presence. Much larger percentages of lead and local Ombudsmen (32% and 47%, respectively) 

reported that establishing positive working relationships with facility staff are major contributing factors to 

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

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

reporting issues before they become complaints, seeking training, or connecting residents to available 

resources. Another 19% of local Ombudsmen reported that the knowledge, confidence, and experience 

level of the Ombudsman is an important factor in the effectiveness of their relationships with facilities. 

Volunteers focused on the importance of having effective communication and responsive facility staff 

(40%). Thirteen percent of volunteers reported that the facility's level of trust in the Ombudsman program 

and program volunteers (i.e. their intentions and their work) determined the effectiveness of the 

relationship. Other factors that contribute to the effectiveness of relationships included working with the 

facility staff as a team (10%), low staff turnover (six percent), and experience with the facility (five 

percent). 

Other contributors to effectiveness were reported to depend on provider setting. Indeed, a key difference 

between nursing homes and board and care homes that affects resident advocacy is the source and 

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

relatively 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 80.24 

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

perceptions of how well their state regulations facilitated efforts to advocate for board and care home 

residents. Exhibit 52 shows that 43% of State Ombudsmen reported that regulations for board and care 

homes in their state are 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. 

 

24 Office of the Assistant Secretary for Planning and Evaluation. 2015. “Compendium of Residential Care and Assisted Living 

Regulations and Policy: 2015 Edition.”
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Exhibit 52: Sufficiency of State Board and Care Home Regulations to Enable State Ombudsman 

Programs to Adequately Serve Residents 

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=51a

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%

a 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. 

State Ombudsmen noted that whereas nursing home federal regulations enable programs to refer facility 

staff to requirements they must follow, state regulations with respect to assisted-living are much 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 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. 

Compared to nursing homes, State Ombudsmen reported other unique challenges to effective advocacy 

in board and care homes, including fewer beds per facility and greater numbers of facilities to visit, lower 

awareness of the Ombudsman program (due in part to some types of residences not being required to 

publicize the LTCOP’s services), fewer facility staff, and greater difficulty in maintaining confidentiality due 

to lack of privacy in smaller settings. 

State and local Ombudsmen reported several barriers that affect their ability to engage in individual 

advocacy more broadly, including the programs’ inadequate financial and staffing resources as well as 

lack of understanding among stakeholders about the Ombudsman program’s role.

Systems Advocacy

Building on individual advocacy activities, systems advocacy addresses the underlying systems and 

processes that affect residents’ rights, quality of care and quality of life. At the systems level, Ombudsman 

programs are required to: 

■ Represent residents’ interests before governmental agencies and pursue administrative, legal, 

and other appropriate remedies; 

■ Analyze, comment on, and monitor the development and implementation of federal, state, and 

local laws, regulations, and other governmental policies and actions relating to the adequacy of 

long-term care facilities and services; 
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■ Make recommendations regarding these laws, regulations, policies, and actions; and 

■ Facilitate public comment on the laws, regulations, policies, and actions that pertain to residents’ 

health, safety, welfare, and rights.

Ombudsman programs meet these requirements primarily through legislative advocacy, issue advocacy, 

and coalition building/partnerships. Supporting the development and maintenance of resident and family 

councils may involve elements of systems advocacy if these efforts target multiple residents. 

Improvements to the long-term care system can take many forms and can be implemented at the facility, 

local, state, and national levels. Listed below are examples of how programs engage in systems 

advocacy activities at each level: 

■ Provider/Facility Level. State Ombudsmen described advocating for changes to provider 

practices, such as promoting facility staff’s adoption of resident-centered care, enabling residents 

to have greater choice and control over personal schedules, food, roommates, telephone access, 

and other activities or care provision. Other examples included working with facility staff on 

emergency preparedness and response procedures and ensuring appropriate facility placement 

for residents with special care needs. 

■ Local and State/Territory Level. State Ombudsmen described monitoring, analyzing, and 

commenting on state laws and regulations that affect residents of long-term care facilities. At the 

state level, State Ombudsmen reported advocating for increases in residents’ personal needs 

allowances (PNAs) and facility staffing ratios. Specific activities included providing testimony to a 

legislative body, mobilizing community support or building coalitions, or drafting legislation. A few 

State Ombudsmen reported working with legislators or other entities to develop or advocate for 

specific policies that are relevant to the program’s work. Another Ombudsman collaborated with 

legislators on a bill to strengthen enforcement actions in assisted living facilities. Several State 

Ombudsmen are also involved on committees or task forces that typically aim to improve the 

quality of long-term care services and supports. These include efforts related to dementia, The 

Green House Project,25 culture change, financial exploitation, and geriatric mental health. 

■ National Level. State Ombudsmen described monitoring, analyzing, and commenting on federal 

laws and regulations that affect residents of long-term care facilities. These included regulations 

that directly impact the Ombudsman program, such as the reauthorization of the OAA and 

LTCOP Final Rule, as well as other regulations that impact Ombudsman program service 

delivery, such as the Nursing Home Regulations, HCBS Settings Final Rule, and Medicaid 

Managed Care Final Rule.

Responsibility for Systems Advocacy Activities 

State Ombudsmen have primary responsibility for systems advocacy efforts. Although all State 

Ombudsmen reported engaging in some type of systems advocacy activity, there was variation in their

ability to address systems-level changes. Whereas some reported being deeply involved in systems 

advocacy efforts, others reported this work reflected only a small share of their overall responsibilities. 

According to FFY 2017 NORS data, at the state/territory level, the estimated percentage of paid staff time 

spent on systems advocacy efforts such as monitoring/working on laws, regulations, government policies, 

and actions ranged between two percent and 65% (with an average of 27%). At the local level, the 

estimated percentage of paid staff time spent on these systems advocacy activities ranged between zero 

percent to 25% (with an average of seven percent). 

 

25 The Greenhouse Project is a long-term care housing model: https://www.thegreenhouseproject.org/ 
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The Final Rule requires the Office of the SLTCO to provide leadership to statewide systems advocacy 

efforts and coordinate activities carried out by local Ombudsman staff and volunteers. Seventy-four 

percent of State Ombudsmen reported providing systems advocacy technical assistance or training to 

local programs during the last year. When asked about areas of expertise, 41% of lead local Ombudsmen 

reported that their program has expertise in systems advocacy, while only 23% of local Ombudsmen that 

they personally have expertise in systems advocacy. 

Although a few State Ombudsmen reported developing a formal systems advocacy agenda, many 

described processes to establish advocacy priorities, while others reported they had no specific advocacy 

agenda. Some State Ombudsmen reported coordination with local Ombudsman entities on their systems 

advocacy agenda or on ongoing systems advocacy activities.

State Ombudsmen reported that systems advocacy activities are often driven by statewide trends in 

concerns and complaints. A few programs analyze complaint data, and one State Ombudsman described 

gathering information during an annual conference from local Ombudsman program coordinators on the 

complaints that their programs receive and systemic issues that they observe. 

As shown in Exhibit 53, 57% of local Ombudsmen are responsible for systems advocacy work. However, 

17% reported being unable to perform this task due to lack of time, resources, or training. This represents 

30% of local Ombudsmen who reported that systems advocacy is part of their responsibilities. Of local 

Ombudsmen who are responsible for conducting systems advocacy, 92% of lead local Ombudsmen 

reported that their State Ombudsman encourages their local program to carry out systems advocacy 

activities, and 73% reported that their State Ombudsman coordinates with the local program to carry out 

this work. 

Notably, 17% of local Ombudsmen reported not knowing whether systems advocacy was one of their 

responsibilities. When asked about specific tasks that they carry out, however, these local Ombudsmen 

reported engaging in activities that are consistent with systems advocacy, including work in 

committees/workgroups/task forces; advocacy for changes to laws, regulations, or policies; engagement 

in policy making; communication with the media about advocacy issues; and grassroots organizing

(Exhibit 54). Differences between local Ombudsmen’s reported engagement in “systems advocacy” and 

their actual activities may reflect a lack of clarity in responsibilities or differences in terminology for 

common activities. 

Exhibit 53: Responsibility for Systems Advocacy Work 

As part of your responsibilities, do you perform any systems advocacy work? 

Local Ombudsmen

N=488a

Yes 40% 

Yes, Although systems advocacy is included in my responsibilities, I am unable to 

perform this task (for example, due to a lack of time, resources, or training) 17% 

No, systems advocacy is not part of my responsibilities 26%

Don't know 17%

a Missing=9
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Exhibit 54: Systems Advocacy Activities Performed by Local Ombudsmen 

Which of the following 

activities do you perform?

Systems 

advocacy is 

part of my

responsibilities

N=277a 

Systems 

advocacy is 

not part of my

responsibilities

N=121b 

Don’t know 

whether systems 

advocacy is part of 

my responsibilities

N=80c 

All Local 

Ombudsmen

N=478d 

Advocacy for changes to laws, 

regulations, or policies 45% 7% 10% 31% 

Engagement in policymaking 20% 5% 2% 13%

Grassroots organizing 12% 5% 1% 8%

Communication with the media 18% 2% 6% 13% 

Involvement in committees such 

as work groups or task forces 55% 18% 30% 41% 

a Missing=2; b

 Missing=4; c Missing=4; d Missing=10 

Note that 488 Ombudsman responded to the question about whether or not systems advocacy is part of their responsibilities. Of this 

number, 10 did not respond the question on activities that they perform. 

The most common systems advocacy activities that local Ombudsmen reported performing included 

involvement in committees (41%) and advocacy for changes to laws, regulations, or policies (30%). Only 

13% of local staff reported engaging in policymaking and 13% reported communicating with the media 

about policy issues.

A small percentage of volunteers (13%) also reported engaging in systems advocacy activities such as 

monitoring/working on laws, regulations, government policies, and actions and three percent reported 

working with the media on issues that impact residents (Exhibit 30). 

Lead local Ombudsmen reported several types of systems advocacy activities that have not been carried 

out as fully as they would have liked due to a lack of LTCOP resources. These activities included 

facilitating public comment on proposed legislation, laws, regulations, and other governmental policies 

and actions (43%); analyzing and monitoring federal, state, and local law, regulations, and other 

governmental policies and actions (36%), and research and policy analysis to inform systems advocacy 

work (43%) (Exhibit 36). 

Barriers to Systems Advocacy 

When asked which advocacy activities are not carried out as fully as Ombudsmen would like due to lack 

of resources, about 48% of State Ombudsman and 43% of lead local Ombudsmen responded “facilitating 

public comments on proposed legislation, laws, regulations, policies, and actions”; and over a third

responded “analyzing and monitoring laws, regulations, and other government policies and actions”

(Exhibit 36)

Although 19% of State Ombudsmen reported no barriers to carrying out systems advocacy at the state or 

local levels, the remaining State Ombudsmen identified several challenges including inadequate 

resources, organizational placement, politics, lack of expertise, and misunderstandings surrounding the 

Ombudsman program’s independence. Although systems advocacy constitutes a broad range of 

activities, the ability to conduct legislative advocacy appeared to be main type of systems advocacy 

activity where the program experienced barriers.
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Inadequate Resources. For many State Ombudsmen, the lack of fiscal and staff resources as well as 

time constraints and travel expenses prevented them or their staff from engaging in systems advocacy 

efforts. When resources are limited, State Ombudsmen reported directing staff to prioritize individual 

advocacy over initiatives to advance systemic change. 

Organizational Placement. Ombudsman programs’ organizational placement may impede 

Ombudsmen’s ability to engage in systems advocacy in a number of ways. First, Ombudsman programs 

are subject to the laws or rules of their host agency. For example, Ombudsmen whose Offices or local 

Ombudsman entities are located in state and local government agencies are government employees. 

State laws often prohibit government employees from lobbying, unless they are registered lobbyists. 

There may also be policies that prevent employees from registering as a lobbyist, thereby limiting ability 

to conduct systems advocacy. The Final Rule clarified that the Ombudsman and representatives of the 

Office are to be excluded from any State lobbying prohibitions, to the extent that such requirements are 

inconsistent with section 712 of the Act. However, State Ombudsmen reported that prohibitions remain in 

place. In some instances, the State Ombudsman is a registered lobbyist which allows him or her to 

engage in legislative advocacy, but this issue is unresolved for local Ombudsmen. For example, if a 

legislator contacts a local Ombudsman about a concern that requires advocacy on an issue, the local 

Ombudsman must then forward those concerns to the State Ombudsman to handle. In other instances, a 

State Ombudsman may be restricted from engaging in systems advocacy because of the Office’s 

placement in a state agency. The State Ombudsman may turn to local Ombudsmen whose local 

Ombudsman entities are located in nonprofit agencies to carry out systems advocacy. 

In addition to legislative advocacy, State Ombudsmen whose statewide program is located within state 

and local government agencies reported other systems advocacy restrictions, such as speaking with the 

media. Others with Offices that are located in state agencies noted that while they are able to advocate, 

they need to seek prior approval or provide advance notice of their positions before providing testimony 

on proposed bills or making recommendations to legislation. 

Another type of organizational placement that can impede systems advocacy activities – particularly at 

the local level – occurs when local Ombudsman entities are located in legal services agencies. Local 

Ombudsman entities that are hosted by legal services agencies that receive funding from Legal Services 

Corporation (LSC)26 are prohibited from lobbying or engaging in grassroots organizing. 

Third, organizational placement may inhibit systems advocacy activities when Ombudsman programs are 

housed in agencies whose primary mission is the provision of LTSS. Tensions may arise if Ombudsmen 

take advocacy positions that bring attention to the inadequacy of services provided by their host agency. 

Political Interests. State Ombudsmen reported that political interests can also hinder systems advocacy, 

regardless of organizational placement. For example, programs face political pressure from provider 

associations that are reluctant to support regulations to increase minimum staffing ratios.

Lack of Experience. At the local level, State Ombudsmen reported that some staff are inexperienced 

with, or apprehensive about engaging in systems advocacy. Although local Ombudsmen may be 

comfortable with individual advocacy or participating in work groups, they can be intimidated by activities 

that involve speaking with legislators or the media. One State Ombudsman reported strategies to support 

 

26 Established by Congress in 1974, Legal Services Corporation (LSC) is an independent nonprofit that provides financial support 

for civil legal aid to low-income Americans. LSC awards grants to legal aid organizations, some of which host the Ombudsman 

program.
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local Ombudsmen in their systems advocacy efforts, including providing trainings on how to engage with 

legislators and legislative staff and to equip them with information to educate others about the 

Ombudsman program. Various advocates were invited to speak with staff, providing tips to use in their 

advocacy efforts as well as tools to build skills and increase their confidence in carrying out systems 

advocacy work. 

Misunderstandings About Program Autonomy. Lastly, misunderstandings about the Ombudsman 

program’s independence were also reported to impede systems advocacy work. State Ombudsmen 

reported the need to educate state directors, legislators, and other stakeholders on the program’s 

autonomy and its need for independence to be an effective advocate for residents. Tensions may arise 

when the program advocates on behalf of residents who are adversely affected by the policies and 

actions of the agencies that SUAs and AAAs represent. However, by advocating for the development and 

implementation of laws, regulations, and administrative action that affect residents – even when they 

differ from the policies and positions of the agency where the program is located – the LTCOP is fulfilling 

its mandated function. This inherent tension can create misunderstanding among agencies, state and 

local government, and the Ombudsman program unless there is a clear understanding and acceptance 

by all parties of the program’s mandate to serve as the independent voice of long-term care residents. 

Education and Outreach

LTCOP education and outreach activities can be grouped into two categories:

1) Efforts to promote and educate people about the Ombudsman program (e.g., its role and 

services) to spread awareness about, and increase access to the program.

2) Efforts to educate people about LTSS to improve the quality of these services and resident 

access (e.g., explaining LTSS options and residents’ rights to residents or explaining provider 

requirements to facility staff and administrators).

According to FFY 2017 NORS data, Ombudsman programs carried out the following education activities:

■ Ombudsman programs provided information on rights, care, and related services to individuals 

and long-term care facility staff on 529,098 occasions, ranging from 413 to 85,352 occasions 

across programs. 

■ Ombudsman programs conducted 10,170 community education sessions, ranging from two to 

1,686 sessions across programs. 

■ Ombudsman programs attended 22,999 resident and family council meetings, ranging from two

to 3,447 meetings across programs. 

Promoting the LTCOP

State Ombudsmen reported multiple strategies to promote awareness of the Ombudsman program 

among long-term care facility residents and family members, the general public, facility staff, and 

coordinating entities: 

■ Posters. Federal regulations require that nursing homes post contact information about the 

Ombudsman program in their facilities. Most Ombudsmen noted that they supplement with 

program posters to include more information about the LTCOP such as its mission statement, the 
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name of the State Ombudsman, the name of the local program, contact information, and photos 

of Ombudsmen assigned to the facility. 

■ Brochures and pamphlets. Programs also have informational brochures and pamphlets that 

describe the program and provide contact information. In some cases, brochures also contain 

information about residents’ rights. Ombudsmen distribute these materials during facility visits or 

ask facilities to provide them on a table in the facility or as part of admission packets. 

Ombudsmen also share these materials when they attend outreach events, such as conferences

or in community locations such as libraries and doctor’s offices.

■ Social media. A few Ombudsmen described efforts to have a social media presence (e.g., 

Facebook).

■ Regular visits with residents. State Ombudsmen reported regular facility visits as an important 

means to disseminate information about the Ombudsman program and ensure access to 

Ombudsman advocacy services. A few State Ombudsmen reported targeting outreach efforts at 

residents who are new, appear to be alone, or are not particularly vocal. Ombudsmen may also 

wear lanyards or ID badges to identify themselves during facility visits.

■ Resident and family councils. Programs participate in resident and family councils by attending 

meetings and delivering presentations about the Ombudsman program. 

■ Presentations at facilities. Ombudsmen give presentations to residents and facility staff to 

explain the role of the LTCOP. A few State Ombudsmen reported speaking at orientations for 

new residents. 

■ Community and governmental organization meetings. A few State Ombudsmen described 

speaking at community meetings such as those held by civic groups, caregiver groups, and 

Rotary Clubs. 

■ Community education. Several State Ombudsmen reported attending a variety of community 

events and staffing booths with information about the LTCOP. These activities included health 

fairs, senior center fairs, state fairs, housing fairs, and conferences. 

■ Media. Some State Ombudsmen reported promoting the program on radio shows, or in 

newspaper ads.

Two State Ombudsmen recommended launching a national campaign to spread awareness of the 

Ombudsman program; one explained that national advertising would be more effective than state and 

local efforts to raise awareness.

To educate the state legislature, host agencies, and entities with which the Ombudsman program 

coordinates, the following efforts were used:

■ One program educates the legislature about the LTCOP and the need for a regular presence in 

facilities in order to identify complaints. Another Ombudsman discussed the importance of 

educating state directors, legislators, and others to understand the need for LTCOP 

independence. This Ombudsman noted that the Final Rule has strengthened the program and 

helped support them to justify their need for independence. 

■ One State Ombudsman reported building relationships with industry provider groups and 

lobbyists to raise awareness about the Ombudsman program, in the hopes that the information 

would be shared with their providers. 
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■ One state educated its host agency on the LTCOP’s work because the agency did not fully 

understand the program.

■ One State Ombudsman reported educating coordinating entities about their program because 

they can work together more productively when those entities understand their work and their 

confidentiality requirements.

■ A few programs cross-train with other state agencies, such as the Medicaid Division or the Office 

of Ombudsman for Managed Care. LTCOPs also provide information to legislatures about longterm care issues, and they offer trainings and speak at conferences for non-state entities, such as 

provider associations, AARP, or disability rights groups. 

Providing Education on Long-Term Services and Supports 

State Ombudsmen described their programs’ efforts to educate residents, family members, facility staff 

and administrators, and coordinating entities about a range of LTSS issues. 

Education for Residents and Family Members. State Ombudsmen described hosting one-on-one 

education and group sessions at resident council meetings. The goal of these interactions was to 

empower residents by teaching them about their rights, how to address concerns, and the resources

available to them. Ombudsmen also advise residents on what they should expect from facilities and the 

care they receive. They also advise family members on how to advocate for residents and understand the 

long-term care system. One State Ombudsman explained, “I truly believe in empowerment, that if you 

help people understand, you provide them with some education about their rights...you give them 

support, you're empowering them to then address issues themselves and to resolve problems and to 

generally make their life better." 

A few State Ombudsmen reported that residents and family members may not know what they can 

expect from facilities (i.e., what is typical, and what should be addressed). One State Ombudsman 

informed residents and families where to find additional services outside of the Ombudsman program

such as Crime Victim Services. Another Ombudsman described advising families on how to solicit 

accurate information from the resident about the care they are receiving. This involved advising families 

to take the resident out of the facility to a relaxing place such as a mall or church and then ask them 

about the care they receive. The State Ombudsman added that because residents may be at risk for 

psychological abuse, they may not feel comfortable sharing concerns while they are in the facility. 

Additionally, a few State Ombudsmen indicated educating potential consumers by hosting resident rights 

training in facilities. Another State Ombudsman described an annual statewide event focused on 

educating residents on their rights.

To address residents’ needs and advocate effectively on their behalf, the Ombudsman program is 

expected to form relationships with individual residents as well as groups by developing resident councils. 

Work with resident councils is specified in the Final Rule under 45 CFR §1324.19(6), which mandates 

that the Ombudsman program “promote, provide technical support for the development of, and provide 

ongoing support as requested by resident and family councils.” Resident councils can help Ombudsman 

programs develop advocacy agendas (e.g., person-centered care), and provide a platform for training 

residents on matters that directly affect them. One State Ombudsman reported developing a coalition of 

families and nursing home providers to educate staff on reducing inappropriate use of anti-psychotic 

drugs in nursing homes and other facilities. 
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Resident and family councils also play a role in the training of local Ombudsmen. In fact, 45% of local 

Ombudsmen and 12% of State Ombudsmen reported attending resident council meetings as part of their 

initial training (Exhibit 67). These trainings help increase awareness of the Ombudsman program among 

residents and in some cases, even among facility staff that may not be aware of the program’s work. The 

Ombudsman program also coordinates with resident and family councils by obtaining feedback on how to 

improve Ombudsman program service delivery. 

A few State Ombudsmen coordinate with other entities to provide resident services, either by working 

together, or referring residents to other entities. For example, one LTCOP works with members of a task 

force against elder abuse to provide information to the public about abuse, neglect and exploitation. 

Another program helps connect the state’s Options counselor with residents who need information of

community-based LTSS options.

Community Education. Ombudsmen engage in community-facing education events whose goal is to 

engage consumers with the Ombudsman program before they need LTSS. State Ombudsmen described 

conducting community education efforts via media outlets and at community events. Additionally, a few 

State Ombudsmen indicated they educate consumers by attending health fairs. One program works with 

the media to educate the public about financial exploitation and residents’ rights. A few State 

Ombudsmen reported that, due to time constraints, they are unable to make community education a top 

priority, despite wanting to engage more in these efforts. One State Ombudsman noted that community 

education about long-term care is important because many people mistakenly believe that Medicare 

covers these services or they confuse the Ombudsman program with other types of ombudsmen 

providers in their state.

Education for Providers. Several State Ombudsmen described providing education or training to longterm care facility administrators or staff on topics such as residents’ rights, provider requirements, persondirected care, quality of life, and financial exploitation. 

■ Forty-five percent of local Ombudsmen reported providing information to a public or private 

agency as well as providing or coordinating training for facilities, respectively (Exhibit 55).

■ A few State Ombudsmen described determining the type of provider training based on problems 

identified in multiple facilities. For example, one state uses NORS data to determine the most 

common complaint types and then establishes trainings for providers in those problem areas. 

Another state program discusses common issues Ombudsman staff observe in facilities during 

their staff meetings and they use that opportunity to identify training needs of providers. 

■ Ombudsmen have educated facility staff and provider associations about which discharge notices 

to send to the Ombudsman program, a requirement of the revised nursing home regulations. 

■ State Ombudsmen reported providing training to facility staff on topics such as dementia, 

behavioral health, and mental health conditions. One state Ombudsman program coordinated a 

statewide training on appropriate care for residents with dementia, and another program is 

involved in a dementia care workgroup that focuses on reducing inappropriate use of antipsychotic medications. 
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Exhibit 55: Education/Outreach Activities Performed by Local Ombudsmen 

Education/Outreach Activities

Local Ombudsmen

N=485a

Providing information to a public or private agency 45% 

Providing or coordinating training for facilities or providing 

information to facility corporate leadership 45% 

a Missing=12 

Perceptions of Awareness of Ombudsman Program among National Stakeholders

Stakeholders reported that while there may be a high level of awareness and understanding of the 

Ombudsman program among entities within the aging network, they also reported that awareness of the 

Ombudsman program among consumers is likely much lower and insufficient. 

■ Some stakeholders noted that residents’ familiarity with the program varies based on the 

regularity of Ombudsmen’s visits. They noted that it is challenging to have a presence in every 

facility given the program’s limited resources. One stakeholder noted that publicizing the program 

beyond the current level could create more demand than the program is able to meet. 

■ A few stakeholders framed the lack of knowledge of the Ombudsman program in the context of a 

broader lack of public understanding of long-term care issues. 

■ One stakeholder wondered whether consumers mistakenly think Ombudsmen are employed by 

the facility where they reside. 

■ A few stakeholders reported that LTCOP posters that are placed in facilities help increase

awareness about the program once residents move in. 

5.4. Recommendations

■ Given the limited resources of many Ombudsman programs, meeting federal requirements as 

described in the OAA and the Final Rule is challenging. Few Ombudsmen at either the state or 

local level reported that their existing resources are adequate to meet federal mandates. 

Consideration of ways to address this mismatch between mandates and available funding is 

needed among stakeholders at all levels. There is a need for more guidance and support for 

State Ombudsmen around identifying and advocating for potential funding. 

■ At the conclusion of the outcome evaluation, ACL should work with stakeholders to determine 

whether the IOM’s 1995 recommended minimum staffing ratio of one FTE Ombudsman per 2,000 

long-term care facility beds is adequate or needs revising. 

■ SUA Directors should ensure that policies and procedures are in place that support the State 

Ombudsman’s ability to determine the use of the fiscal resources appropriated or otherwise 

available for the operation of the Office, as well as approval of allocations of federal and state 

funds provided to local Ombudsman entities, as appropriate. 

■ Some State Ombudsmen reported that their expertise in financial management was insufficient 

for them to handle all of their fiscal responsibilities under the Final Rule. Additional training 

opportunities may be needed from relevant host agencies to address this shortcoming. 
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■ States with volunteer Ombudsmen should ensure that they have staff with the time and expertise 

to provide adequate volunteer management. To improve volunteer recruitment, training, and 

management, resources to support for a dedicated volunteer coordinator at the state or local level 

should be considered. 

■ State Ombudsmen should provide or arrange additional training on systems advocacy to local 

Ombudsmen. 

■ Further education and guidance is needed to address State Ombudsmen’s concerns related to 

assigned legal counsel and potential conflicts of interest. While most State Ombudsmen reported

positive experiences with legal counsel, lack of familiarity with the program remains a concern for 

some. State Ombudsmen should encourage attorneys assigned to the program to receive 

additional training, including completion of certification training. 
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Chapter 6. Research Question 3: With whom do LTCOPs 

partner, and how do LTCOPs work with partner programs?

6.1. Key Findings

6.1.1. Role of Partnerships at the Federal Level

1. At the federal level, the Administration for Community Living’s (ACL) Central and Regional Offices 

play important roles in facilitating relationships with national stakeholders and other entities to 

advance the Long-Term Care Ombudsman program’s (LTCOP, or Ombudsman Program)

mission, increase the program’s visibility, and identify areas where training and technical 

assistance are needed.

2. The goals of partnership at the national level are to increase awareness and understanding about 

the Ombudsman program among relevant entities, and to ensure that the concerns of long-term 

care residents are represented in the development of new policies and regulations.

6.1.2. Types of Partnerships and Interactions at the Federal, State, and Local Levels

1. The Ombudsman program partners with a broad range of federal and state agencies (some of 

which make up the aging network), associations, nonprofits, long-term care providers, work 

groups, coalitions, and other partners with missions that are relevant to populations that the 

Ombudsman program serves. 

2. While all State Ombudsmen reported dedicating time to develop and maintain partnerships on 

behalf of their statewide programs, a smaller percentage (75%) of lead local Ombudsmen 

reported engaging in these efforts, and even fewer (35%) local Ombudsmen (without managerial 

responsibilities) reported allocating time to these activities.

3. Partnering with other entities supports the Ombudsman program’s mandate for individual and 

systems advocacy, as well as education and outreach. For all activities, State Ombudsmen often 

reported coordinating with Adult Protective Services (APS), facility and long-term care provider 

licensure and certification programs, Area Agencies on Aging (AAA), the State legal assistance 

developer, and legal assistance/legal aid programs. 

6.1.3. Requirements for Coordination with Entities and Perceptions of Effectiveness

1. The Final Rule’s requirement for the State Ombudsman to provide evidence of coordination with 

entities, such as memoranda of understanding (MOUs), was generally perceived by State 

Ombudsmen as a positive development that has improved communication and provided much 

needed clarification about roles and responsibilities. However, a few State Ombudsmen 

described this requirement as unnecessary and sometimes disruptive to longstanding, informal 

relationships.

2. A majority of State Ombudsmen reported that, for most entities with which they are required to 

coordinate, collaborative relationships enable their programs to meet the needs of long-term care 

residents. The frequency with which these relationships were reported as important was lower 

among local Ombudsmen.
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3. National stakeholders reported that both the level of engagement and the effectiveness of 

relationships with the Ombudsman program are strong at the federal level (with ACL), but they 

vary across and within programs.

4. State Ombudsmen and national stakeholders reported that relationships with other entities are 

most effective when there is ongoing communication and a clear understanding of roles and 

responsibilities. The inability to interact regularly, and lack of clarification of roles and 

responsibilities can prevent critical partnerships from being fully developed and utilized.

6.1.4. Benefits and Challenges of Partnerships

1. Other entities benefit from the Ombudsman program’s unique perspective and knowledge about 

resident issues, given their intimate and frequent interaction with long-term care residents, and 

facility staff.

2. Partnerships with external entities are particularly important when Ombudsman programs are 

constrained by limited funds and staffing.

3. Developing and maintaining effective partnerships requires allocating resources on the part of 

both the Ombudsman program and the partnering agency or organization. Accordingly, a lack of 

resources on either or both sides can create barriers to fully leveraging these relationships to 

serve the interests of long-term care residents.

6.2. Introduction

The Older American’s Act (OAA) requires that the Office of the State Long-Term Care Ombudsman 

(Office or Office of the SLTCO) coordinate Ombudsman services with specific entities to enhance the 

program’s capacity to engage in individual advocacy, systems advocacy, and education/outreach. These 

services include protection and advocacy systems (P&As) for individuals with developmental disabilities 

and mental illnesses, legal assistance, state and local law enforcement agencies, and courts of 

competent jurisdiction [Section 712(h)(7)]. The Long-Term Care Ombudsman Programs Final Rule (Final 

Rule) further underscored the importance of these coordinated efforts, requiring that State Ombudsmen 

“shall lead state-level coordination, and support appropriate local Ombudsman entity coordination, 

between the Ombudsman program and other entities with responsibilities relevant to the health, safety, 

well-being or rights of residents of long-term care facilities” [45 CFR § 1324.13(h)(10)]. Among the other 

entities enumerated in the Final Rule are Area Agencies on Aging (AAAs), Aging and Disability Resource 

Centers (ADRCs), Adult Protective Services (APS), facility and long-term care provider licensure and 

certification programs, the State Medicaid fraud control unit, and victim assistance programs.

This chapter describes Ombudsman program partnerships at the federal, state, and local levels, with 

special focus on the ten entities with which the OAA and Final Rule require the LTCOP to coordinate. 

Next, it describes the purpose of these partnerships, and factors that facilitate or hinder their development 

and optimization. 

It should be noted that not all Ombudsman relationships with entities are partnerships in the traditional 

sense of collaborators working toward shared goals. Because Ombudsmen and representatives of the 

Office represent the interest of residents – and not the host agency or other entity – at times they may be 

at cross-purposes with organizations with which they coordinate. Representing residents’ interests may 

also create tension resulting from adherence to different philosophical approaches (with Ombudsmen 

following a resident-centered approach), even if the goal of the partnership is the same. For simplicity, 
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this chapter uses the terms “partners” and “coordinating entities” interchangeably, although these 

relationships may involve different motives and processes.

6.3. Findings

6.3.1. LTCOP Partnerships at the Federal Level

Given the Ombudsman program’s wide-ranging responsibilities, staff at the federal, state, and local levels 

coordinate with a large network of entities that also play important roles in residents’ health, safety, 

welfare, and rights. At the national level, ACL’s Central and Regional Offices build relationships with 

federal agencies, national stakeholders, and other entities to advance the program’s mission and educate 

stakeholders about Ombudsmen’s advocacy on behalf of long-term care residents and to ensure that the

concerns of long-term care residents are adequately represented in the development of new policies and 

regulations that impact this population. These efforts are further supported by the National Long-Term 

Care Ombudsman Resource Center (Resource Center, an ACL funded training and technical assistance 

provider), Consumer Voice, and national membership organizations that represent the Ombudsman 

program’s staff or host agencies, including the National Association of States United for Aging and 

Disabilities (NASUAD), National Association of State Ombudsman Programs (NASOP), and National 

Association of Local Long-Term Care Ombudsmen (NALLTCO). 

ACL’s Central Office staff reported working with a broad range of federal agencies, including divisions 

within the Department of Health and Human Services (DHHS), such as the Centers for Medicare & 

Medicaid Services (CMS), the Substance Abuse and Mental Health Services Administration (SAMHSA), 

and the Office of the Assistant Secretary for Planning and Evaluation (ASPE). For example, ACL Central 

Office staff met with CMS on an ongoing basis as new regulations for home and community-based

services (HCBS) were being developed. These meetings ensured that development of the new 

regulations considered the interests of long-term care residents. Other agencies that ACL works with 

include the Department of Justice (DOJ), the Federal Trade Commission (FTC), and the Social Security 

Administration (SSA). 

In addition to federal agencies, ACL’s Central Office staff interacts with national member associations that 

often coordinate with Ombudsman programs. These include NASUAD, the National Association for Area 

Agencies on Aging (n4a), National Adult Protective Services Association (NAPSA), and National Disability 

Rights Network (NDRN).Other national-level partners and stakeholders include healthcare provider 

associations such as the American Health Care Association (AHCA), Argentum, and LeadingAge, as well 

as a wide array of organizations that focus on diverse issues that are relevant to long-term care residents. 

These organizations include Altarum Institute, the Consumer Coalition for Quality Health Care, Justice in 

Aging, Center for Medicare Advocacy, and the Pioneer Network, among others.

Many federal staff and stakeholders reported that ACL’s Director of the Office of Long-Term Care 

Ombudsman Programs and the Ombudsman Program Specialist play significant roles in forging 

relationships at the national level. They reported having regular communication and meetings that help 

maintain key relationships and they expressed appreciation for the opportunity to receive updates on 

program activities and relevant policies in other parts of the country. Most stakeholders also reported that 

the mission of the program and authority to represent residents are major strengths in motivating these

partnerships, and that the Ombudsman program is invaluable for ensuring that long-term care residents

have an advocate. 
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ACL’s coordination efforts at the federal level are intended to flow down and support coordination 

between state Ombudsmen programs and national, state, and local entities. For example, ACL 

coordinated with NDRN to facilitate Ombudsman programs work with protection and advocacy systems at 

the state level. ACL also facilitates communication between the Resource Center and other national-level 

resources that focus on populations that are relevant to the Ombudsman program. Examples include the 

National Limb Loss Resource Center, the Traumatic Brain Injury Resource Center, and the Independent 

Living Resource Center. Additionally, ACL coordinates with NASOP and NALLTCO to provide 

Ombudsmen with relevant, federal-level information that may impact the program’s work at the state or 

local levels. ACL’s Regional Office staff may coordinate meetings between State Ombudsmen in their 

regions and representatives from APS, CMS, or legal services developers. These meetings provide 

opportunities to identify shared goals and strategies for collaborative problem-solving.

6.3.2. OAA and Final Rule Requirements for Coordination 

As described earlier, the OAA and Final Rule require that the Office of the SLTCO coordinate 

Ombudsman services with specific entities that have responsibilities for the health, safety, well-being or 

rights of residents of long-term care facilities. Under the Final Rule, furthermore, State Ombudsmen are 

required to demonstrate evidence of coordination with each of these entities. This requirement can be 

met with memoranda of understanding (MOUs), policies and procedures outlining coordination 

requirements, joint participation in working groups or standing meetings, cross-training opportunities, and 

referral protocols. State Ombudsmen are also required to establish and provide ongoing support to 

promote coordination with relevant entities at the local levels in a manner that supports their program’s 

activities.

While all State Ombudsmen reported dedicating time to develop and maintain partnerships on behalf of 

their programs, a smaller percentage (75%) of lead local Ombudsmen reported engaging in these efforts, 

and even fewer (35%) lead local Ombudsmen (without managerial responsibilities) reported allocating 

time to these activities.

Exhibit 56 presents the 10 entities with which Ombudsman programs are required to coordinate and the 

extent to which State and lead local Ombudsmen reported having regular interactions with these entities.
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Exhibit 56: Regular Interaction with Entities Enumerated in the OAA and LTCOP Final Rule

Regular Interaction with Entities 

Enumerated in the OAA and 

Final Rule

State 

Ombudsmen

% 

State 

Ombudsmen 

N 

Lead Local 

Ombudsmen

% 

Lead Local 

Ombudsmen

N 

Area Agency on Aging 81% 52 87% 187

Aging and Disability Resource 

Center 69% 52 59% 183

Adult Protective Services 87% 52 87% 188

Protection and Advocacy Systems 71% 52 57% 175

Facility and long-term care 

provider licensure and certification 

program 94% 52 78% 187

State Medicaid fraud control 61% 51 44% 178

Victim assistance programs 24% 52 34% 175

State and local law enforcement 

agencies 51% 52 60% 179

Courts 39% 52 23% 172

State legal assistance developer 

and legal assistance/legal aid 

programs 80% 52 58% 180

A high percentage of both State and lead local Ombudsmen reported that their programs coordinate with 

licensing and certification programs, APS, and AAAs. The program’s collaboration with monitoring and 

enforcement agencies warrants special attention. The Ombudsman program’s approach is distinct from, 

and designed to complement long-term care provider licensure and certification agencies and programs. 

In contrast to the work of federal and state surveyors, the Ombudsman program does not have 

enforcement or regulatory oversight authority, nor does it sanction facilities for poor performance. Rather, 

the Ombudsman program supports surveyors and licensing agencies in addressing quality of care and 

protection of rights by providing complaint resolution services at the facility level, with limited outside 

intervention, and by maintaining a regular presence in these settings. This resident-directed complaint 

resolution process provides an option to address concerns for residents who might be hesitant to use 

formal mechanisms, such as the state survey agency for fear of reprisals or other reasons. In this way, 

the Ombudsman program offers an alternative dispute resolution method that supplements formal 

channels that are already in place. 

Compared to lead local Ombudsmen, State Ombudsmen were more likely to report coordinating with the 

state legal assistance developer and legal assistance/legal aid programs, ADRCs, and P&As than lead 

local Ombudsmen. In contrast, lead local Ombudsmen reported coordinating with state and local law 

enforcement agencies and victim assistance programs more often than State Ombudsmen. 

Other Partners 

Ombudsman programs interact with a wide range of entities beyond those required by law and regulation.

Among the additional entities about which State and lead local Ombudsmen were asked, State 

Ombudsmen most frequently reported coordinating with provider associations, quality improvement 

organizations (QIOs), veterans administration, disability groups, behavioral or mental health departments, 

and emergency preparedness teams. In general, coordination with these entities is carried out more often 

by State Ombudsmen than lead local Ombudsmen (Exhibit 57). 
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Exhibit 57: Other Entities with whom the State and Local Ombudsmen Programs Coordinate

Other Entities with whom the LTCOP Coordinates

State Ombudsmen

N=52

Lead Local 

Ombudsmen

N=189

Managed Care Organizations (MCOs) 37% 38%

Quality Improvement Organizations (QIOs) 71% 25%

Centers for Independent Living 44% 33%

Senior Medicare Patrol (SMP) 46% 30%

Provider Associations 81% 23%

Consumer Advocacy Groups 50% 37%

Physician Groups 13% 6%

Hospitals and Hospital Associations 37% 34%

Behavioral or Mental Health Departments 54% 50%

Disability Groups 56% 30%

Veterans Administration – State 58% 47%

Veterans Administration – Federal 17% 19%

Emergency Preparedness Teams 54% 33%

Other 15% 6%

State Ombudsmen reported working with a number of other partners including AARP, the Alzheimer’s 

Association, the National Association for Social Workers, long-term care worker unions, state legislatures, 

consumer protection agencies, the Better Business Bureau, Money Follows the Person programs, 

universities, and independent researchers. Local Ombudsmen also reported partnering with diverse 

organizations, including the Retired Senior Volunteer Program (RSVP), the coroner’s office, fire 

departments, faith-based organizations, the SSA’s Office of the Inspector General, elected 

representatives, career centers, and domestic violence and sexual assault programs. 

Beyond building and maintaining relationships with relevant partners, the Ombudsman program also 

actively participates in work groups and coalitions that address issues affecting long-term care residents 

and other stakeholders. Some coalitions focus on specific issues such as behavioral health, 

guardianships, nursing home culture change, and elder abuse, while others maintain a broad focus on a 

wide range of issues affecting older adults. State Ombudsmen also contribute to coalitions by holding 

regular meetings, organizing conferences and presentations on relevant topics, and developing and 

providing cross-training opportunities for partners and Ombudsmen. At the local level, lead local 

Ombudsmen reported engaging in state and local work groups such as elder abuse task forces (Exhibit 

58). 
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Exhibit 58: State and Local Level Work Groups

State and Local Level Work Groups

Lead Local Ombudsmen

N=189

Elder abuse task forces 52%

Culture change coalitions 26%

WINGS (guardianship groups) 10%

Ethics committees 10%

LANEs (Advancing Excellence for Nursing Homes) 4%

Other 14%

State, local, and volunteer Ombudsmen reported that they also view long-term care providers, staff, and 

administrators as partners in serving long-term care residents. Staff and administrators can help 

Ombudsmen identify issues before they rise to the level of a formal complaint, and in some cases, they 

collaborate with Ombudsmen to address these concerns. 

6.3.3. Activities Supported by Partnering with Other Entities 

State Ombudsmen reported leverage partnerships to support the program’s mandate to engage in 

individual advocacy, systems advocacy, and education/outreach. Certain relationships, such as those 

with licensing and certification programs, provide the “teeth” that compel facilities to improve care. In 

cases where the program’s resources are limited, these partnerships often “fill the gap” in service 

delivery. It is important to stress that programmatic resources refer to tangible assets such as funding and 

staffing, as well as less tangible ones such as specialized expertise, access to information, as well as 

connections to influential people in aging services, the legislature, or other entities that impact activities 

that fall under the program’s legislative mandate. 

Individual Advocacy

The Ombudsman program’s mandate to engage in individual advocacy includes an array of activities to 

protect and promote the health, safety, welfare, and rights of individual residents of long-term care 

facilities. These efforts include, but are not limited to, routine Ombudsman visits to long-term care

facilities, complaint investigation and resolution, information provisions about LTSS services, assistance 

with transitioning a resident from a long-term care facility to a home setting, consultation with residents or 

their family members, and obtaining legal assistance for resident representation. 

Among the entities with which Ombudsman programs are required to coordinate, APS and facility and 

long-term care provider licensure and certification programs were reported by State and lead local 

Ombudsmen as being the most common partners for addressing individual advocacy. A high percentage 

of State Ombudsmen also reported often working with the State legal assistance developer and legal 

assistance/legal aid programs to address individual resident issues (Exhibit 59). 
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Exhibit 59: Organizations with whom Ombudsmen Partner to Advance Individual Advocacy Goals

Purpose of Interaction is Individual 

Advocacy

State 

Ombudsmen

% 

State 

Ombudsmen

N 

Lead Local 

Ombudsmen

% 

Lead Local 

Ombudsmen

N 

Area Agency on Aging 54% 52 62% 178

Aging and Disability Resource Center 61% 51 55% 174

Adult Protective Services 90% 52 82% 186

Protection and Advocacy Systems 63% 51 53% 172

Facility and long-term care provider 

licensure and certification program 87% 52 75% 182

State Medicaid fraud control 55% 51 42% 175

Victim assistance programs 29% 51 33% 171

State and local law enforcement agencies 51% 51 61% 174

Courts 43% 51 33% 169

State legal assistance developer and legal 

assistance/legal aid programs 80% 51 56% 172

In resolving resident complaints, forging relationships with relevant entities is important not only for 

obtaining important information to address specific concerns, but also for setting up referral mechanisms

that benefit residents. Ombudsmen, for example, coordinate with APS on complaints related to abuse, 

neglect, or exploitation. For facility-related concerns – such as a nursing home closure – Ombudsmen 

may coordinate with licensing and certification programs to monitor the facility closure process. Issues 

related to guardianship and power of attorney may lead Ombudsmen to connect residents to legal 

assistance providers. Alternatively, other agencies, such as protection and advocacy programs, may refer 

resident issues they observe during a facility visit to the Ombudsman program. 

Individual advocacy can be, and often is, carried out through coordination with multiple partners. For 

example, to address a facility closure and ensure all residents are safely transitioned to a new care 

setting, the Ombudsman program may coordinate with a team of partners including licensing and

certification, the Department of Health, managed care plans, and housing providers.

In addition to the entities listed in Exhibit 59, Ombudsmen also work with facility staff and administrators 

to address resident concerns and complaints. Some State Ombudsmen noted that although they focus on 

residents’ needs, they also try to develop productive relationships with facility staff because these 

relationships can facilitate problem solving. They noted that these collaborations do not mean that 

relationships with facility staff are without conflict, but having credible and productive relationships with 

facility staff can often lead to greater cooperation, which ultimately benefits residents. One State 

Ombudsman noted that when Ombudsmen are not viewed as antagonistic, facility staff are more likely to 

be receptive to discussing how to resolve problems and share information that helps resolve problems 

quickly. Another noted that when facility staff view the Ombudsman program as a resource and trust 

Ombudsmen, issues can be addressed effectively through informal channels before they rise to the level 

where a formal complaint is needed. 
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One State Ombudsman attributed the large number of complaints that the program receives from facility 

staff to their comfort involving Ombudsmen in resident concerns. The State Ombudsman explained that 

facility staff may report a complaint to the Ombudsman when their efforts have fallen short and when they 

believe an Ombudsman can help diffuse conflict with a resident or a resident’s family member. In other 

cases, facility staff may submit a complaint about facility practices that may undermine resident interests. 

Systems Advocacy

Systems advocacy encompasses a range of activities aimed at improving the long-term care system, 

including analyzing and monitoring federal, state, and local law, regulations, and other government 

policies and actions; facilitating public comments on proposed legislation, laws, regulations, policies, and 

actions; and research and policy analysis to understand the impact of trends and policy changes on the 

quality of care received by long-term care facility residents.

Exhibit 60 shows that the most common partnerships for systems advocacy among both State and lead 

local Ombudsmen were facility and long-term care provider licensure and certification programs, AAAs, 

APS, and the State legal assistance developer and legal assistance/legal aid programs. While both State 

and lead local Ombudsmen reported coordinating with other entities to carry out systems advocacy, State 

Ombudsmen reported greater involvement in these efforts. 

Exhibit 60: Organizations with whom Ombudsmen Partner to Advance Systems Advocacy Goals

Purpose of Interaction is Systems 

Advocacy

State 

Ombudsmen

% 

State 

Ombudsmen

N 

Lead Local 

Ombudsmen

% 

Lead Local 

Ombudsmen

N 

Area Agency on Aging 65% 51 60% 181

Aging and Disability Resource Center 31% 51 36% 168

Adult Protective Services 63% 51 44% 174

Protection and Advocacy Systems 52% 50 39% 171

Facility and long-term care provider licensure 

and certification program 80% 51 51% 176

State Medicaid fraud control 43% 51 25% 171

Victim assistance programs 25% 51 21% 167

State and local law enforcement agencies 35% 51 28% 172

Courts 20% 50 16% 165

State legal assistance developer and legal 

assistance/legal aid programs 63% 51 27% 172

State Ombudsmen described a number of ways in which they coordinated with other entities to support 

legislative advocacy. Some reported working with the legal assistance developer and legal 

assistance/legal aid programs, as well as their assigned legal counsel to review proposed legislation or 

regulations, drafting comments, and preparing testimony. In addition, Ombudsmen may seek input or 

comments on proposed legislation from other agencies that may interact directly with residents – such as 

APS – to ensure they have a thorough understanding of all sides of key issues. Ombudsmen also 

reported enlisting other agencies to testify in support of legislation that the program promotes. 
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State Ombudsmen reported working with licensing and certification programs on improving training for 

facility staff to address broader concerns about quality of care within a particular facility or group of 

facilities. Additionally, P&As may bring forth lawsuits against individual facilities or corporations for 

providing poor care, and Ombudsmen may refer residents to join those suits as complainants. 

In addition to the entities listed in Exhibit 60, Ombudsmen also work with provider associations on

improving long-term care by sharing NORS data, survey data, and other information to help identify 

problems and their solutions. State Ombudsmen also reported partnering in systems advocacy work with 

AARP, the Alzheimer’s Association, Pioneer Network, the Better Business Bureau, consumer protection

agencies, and the Department of Veterans Affairs. Many of these organizations participate with the 

Ombudsman program in work groups, task forces, or coalitions. These collective efforts are particularly 

useful for leveraging networks and resources to focus attention on specific issues such as elder abuse, 

disability rights, mental and behavioral health, LGBT rights, and financial exploitation.

In other instances, Ombudsman programs work with less traditional partners. One State Ombudsman 

reported that their state passed legislation requiring utility companies to designate their survey agency as 

their third party contact. This authorizes the survey agency to receive and forward the duplicate 

notification of any service termination (e.g., gas, water, or electricity) to the State Ombudsman. Such 

advance notice allows the program to work with facilities to address the issue and represent residents’ 

interests, thereby avoiding lapses in service that could endanger residents’ health, safety, or welfare. 

Coordination with entities may also satisfy multiple programmatic functions. One State Ombudsman 

reported that their partnership with a nonprofit organization on systems advocacy work resulted in 

recruiting volunteers for the program. 

Education/Outreach 

Ombudsman programs are required to educate the public and stakeholders about the program’s services 

as well as options for obtaining LTSS. Ombudsmen provide this information through multiple channels, 

including regular meetings, conferences, presentations, publications (e.g. newsletters, brochures, etc.), 

and other media (e.g. television or radio). As part of these efforts, Ombudsmen may coordinate with other 

entities to reach a broader audience of consumers and potential agency partners about its advocacy 

services. State Ombudsmen most frequently reported coordinating with facility and long-term care 

provider licensure and certification programs (76%), AAAs (71%), and APS (69%) to conduct education 

and outreach activities. Lead local Ombudsmen also reported partnering most often with AAAs (76%), 

and APS (60%) for this work (Exhibit 61). 
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Exhibit 61: Organizations with whom Ombudsmen Partner to Advance Education/Outreach Goals

Purpose of Interaction is 

Education/Outreach

State 

Ombudsmen

% 

State 

Ombudsmen

N 

Lead Local 

Ombudsmen

% 

Lead Local 

Ombudsmen

N 

Area Agency on Aging 71% 51 76% 181

Aging and Disability Resource 

Center 58% 50 52% 169

Adult Protective Services 69% 51 60% 179

Protection and Advocacy Systems 43% 51 43% 173

Facility and long-term care provider 

licensure and certification program 76% 51 49% 174

State Medicaid fraud control 35% 51 31% 172

Victim assistance programs 26% 50 34% 167

State and local law enforcement 

agencies 31% 51 45% 170

Courts 16% 50 17% 159

State legal assistance developer 

and legal assistance/legal aid 

programs 45% 51 40% 170

Ombudsman programs also partner with organizations to provide trainings to LTSS providers on a variety 

of issues affecting residents. These include trauma informed care, culture change, reducing inappropriate 

prescribing of antipsychotic drugs, and other topics. Partners such as the Pioneer Network provide the 

Ombudsman program with materials and resources related to culture change that the program uses in 

training providers and facility staff to implement person-centered care. Provider associations are also an 

important partner in helping the Ombudsman program offer education and training to facility staff because 

they coordinate with their state and local-level affiliates to create these training opportunities. 

In addition to training delivery, State Ombudsmen and stakeholders reported that cross-training was 

useful to promote understanding of each entity’s respective roles and learn about the issues affecting 

long-term care residents. These trainings also provide opportunities for partners to identify shared goals 

and strategize on addressing common issues. 

6.3.5. Sufficiency and Effectiveness of Partnerships

The adequacy and level of engagement of partnerships that support Ombudsman program activities vary 

by partnering agency. Exhibit 62 shows that a majority of State Ombudsmen reported that their 

relationships with most entities enable their statewide programs to meet the needs of long-term care 

facility residents. However, it is noteworthy that for the program’s major partners (e.g., AAAs, APS, facility 

and long-term care provider licensure and certification programs, and the State legal assistance 

developers, and legal assistance/legal aid programs), somewhere between one quarter and one third of 

State Ombudsmen did not report that these relationships enabled their statewide programs to meet 

residents’ needs. Among lead local Ombudsmen, the percentage reporting that these relationships 

enable their programs to meet residents’ needs was even lower. 
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Exhibit 62: Relationship with Entities Enables Ombudsman Program to Meet Residents’ Needs

Relationship with Entities Enables 

Ombudsman Program to Meet 

Residents’ Needs

State 

Ombudsmen

% 

State 

Ombudsmen

N 

Lead Local 

Ombudsmen

% 

Lead Local 

Ombudsmen

N 

Area Agency on Aging 76% 52 73% 183

Aging and Disability Resource 

Center 60% 51 57% 173

Adult Protective Services 67% 52 64% 185

Protection and Advocacy Systems 55% 51 47% 169

Facility and long-term care provider 

licensure and certification program 73% 52 57% 178

State Medicaid fraud control 57% 50 38% 169

Victim assistance programs 40% 50 39% 163

State and local law enforcement 

agencies 51% 50 50% 175

Courts 44% 50 31% 166

State legal assistance developer and 

legal assistance/legal aid programs 67% 51 49% 171

As noted earlier, Ombudsmen may also view facility administrators and staff as partners in serving longterm care residents. Exhibit 63 shows the percentage of State and lead local Ombudsmen who reported

that their relationships with nursing homes are effective. Almost all State (98%) and lead local 

Ombudsmen (97%) feel that at least some of their relationships with nursing home providers are effective. 

Lead local Ombudsmen appear to be more positive about these relationships, perhaps in part because, 

compared to State Ombudsmen, they interact more frequently with facility staff through visits and 

complaint handling.

Exhibit 63: Effectiveness of Relationship with Facilities and Providers – Nursing Homes

Effectiveness of Relationships with Facilities and Providers

State Ombudsmen

N=51a 

Lead Local 

Ombudsmen

N=188b 

A majority of the relationships are effective 51% 68%

Some of the relationships are effective 47% 29%

A few of the relationships are effective 2% 3%

None of the relationships are effective 0% 0%

a Missing=1; b

 Missing=1 

Exhibit 64 shows the percentage of State and lead local Ombudsmen who reported that their 

relationships with board and care homes are effective. A majority of State (88%) and lead local 

Ombudsmen (90%) reported that at least some of their relationships with board and care providers are 

effective. 
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Exhibit 64: Effectiveness of Relationship with Facilities and Providers – Board and Care Homes

Effectiveness of Relationships with Facilities and Providers

State Ombudsmen

N=51a 

Lead Local 

Ombudsmen

N=173b 

A majority of the relationships are effective 39% 53%

Some of the relationships are effective 49% 37%

A few of the relationships are effective 12% 9%

None of the relationships are effective 0% 1%

a Missing=1; b

 Missing=7, Not applicable=9 

Partnership Facilitators

State Ombudsmen highlighted several factors that support partnership development. These include the 

Ombudsman program’s access and authority to represent residents, the Final Rule, a regular presence in 

facilities, strong nursing home and board and care home regulations, and working with entities whose 

staff are familiar with the Ombudsman program. 

Access and Authority to Represent Residents. Stakeholders and State Ombudsmen reported that the 

program’s reputation for credible information about resident concerns and conditions in long-term care 

facilities promotes willingness to work with the program. Because the Ombudsman program is the only 

program that has direct, unimpeded access to residents as well as the authority to represent residents,

entities seek Ombudsmen’s perspectives and view them as an important resource. Maintaining 

relationships with the program allows partner agencies that may not otherwise have regular interaction 

with consumers or providers to obtain real-time feedback on the conditions in long-term care facilities, 

and the experiences of residents to help inform their work. These relationships also help both parties 

identify common areas of concern and strategize on how to address them.

Final Rule. State Ombudsmen reported that the Final Rule helped strengthen key relationships by 

providing much needed clarity around roles and expectations, and requiring more formal partnership 

agreements. Ombudsmen further reported that clearly defining responsibilities in a formal agreement 

helped expedite the resolution of resident complaints. In addition, the regulation’s clarification on 

Ombudsmen’s role in handling abuse and neglect complaints helped to better define protocols between 

the Ombudsman program and APS, particularly with respect to sharing information, maintaining 

confidentiality, and delineating responsibilities for responding to, and investigating complaints. Others 

reported that the Final Rule’s requirement to establish MOUs with certain agencies motivated 

conversations about processes for working with other entities, and how to formalize those relationships. 

In addition, stakeholders reported that the Final Rule helped elevate the overall visibility and level of 

understanding of the Ombudsman in the public policy arena, a result that could promote or facilitate future 

partnerships.

Regular Communication. State and local Ombudsmen reported that an important aspect of effective 

relationships with entities is regular communication. Many Ombudsmen described being able to draw on 

the assistance of entities to support program activities, if needed, because of their frequent contact. With 

respect to facility staff, frequent interaction from regular facility visits enable Ombudsmen to build 

productive relationships and to become viewed as a resource to help address resident concerns. Both 

State and local Ombudsmen reported that relationships are more effective when the Ombudsmen and the 

facility staff work together to resolve issues. 
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Regular Presence in Facilities. State and lead local Ombudsmen emphasized that maintaining a regular 

presence in facilities has a considerable impact on the program’s ability to foster effective relationships 

with facility staff. As shown in Exhibits 65 and 66, local Ombudsmen who visited nursing homes or board 

and care homes frequently were more likely to report that a majority of their relationships with facility staff 

are effective. 

Exhibit 65: Visit Frequency and Effectiveness of Facility Relationships – Nursing Homes (Lead Local 

Ombudsmen) 

Effectiveness and 

Frequency of Nursing 

Homes Visits

Weekly 

N=13

Less than weekly 

but at least once 

a month

N=45

Less than monthly 

but at least once 

every quarter

N=59

Once or 

twice a year

N=9

As needed 

N=28

A majority of the 

relationships are effective 77% 73% 68% 44% 68%

Some of the relationships 

are effective 23% 24% 27% 56% 32%

A few of the relationships 

are effective 0% 2% 5% 0% 0%

None of the relationships 

are effective 0% 0% 0% 0% 0%

Missing=2, Not applicable=33 

Exhibit 66: Visit Frequency and Effectiveness of Facility Relationships – Board and Care (Lead Local 

Ombudsmen) 

Effectiveness and 

Frequency of Board and 

Care Visits

Weekly 

N=5

Less than weekly 

but at least once 

a month

N=21

Less than monthly 

but at least once 

every quarter

N=69

Once or 

twice a year

N=14

As needed 

N=21

A majority of the 

relationships are effective 80% 50% 53% 50% 67%

Some of the relationships 

are effective 20% 50% 40% 29% 33%

A few of the relationships 

are effective 0% 0% 7% 21% 0%

None of the relationships 

are effective 0% 0% 0% 0% 0%

Missing=4, Not applicable=55 

Strength of Nursing Home and Board and Care Regulations. State Ombudsmen reported that the 

strength of regulations for nursing homes and board and care homes is an important factor in the 

effectiveness of their relationships with facility staff in both settings. In general, regulations governing 

nursing homes were seen as comprehensive and sufficient, allowing Ombudsmen to appropriately 

advocate for residents in that setting. However, because regulations governing board and care homes 

vary by state, State Ombudsmen were more likely to report more effective relationships with board and 

care homes if they felt that their state’s board and care home regulations were sufficient to enable 

advocacy for those residents. 
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Familiarity with Ombudsman Program. State Ombudsmen and stakeholders both reported that an 

entity’s familiarity with the Ombudsman program facilitates partnerships. For example, individuals who 

previously worked for the Ombudsman program or for an SUA or AAA are likely to have a better 

understanding of the program and its role than staff without that experience. 

Barriers to Partnership

Ombudsman programs face meaningful challenges that impede them from establishing or optimizing

partnerships. These challenges were reported by federal staff and stakeholders, as well as State and 

local Ombudsmen, including insufficient resources (such as funding and staffing), misunderstandings 

about roles and responsibilities, and differing perspectives or priorities. Importantly, the Final Rule 

required some programs to assess whether existing relationships required the establishment of formal 

partnership agreements.

Insufficient Resources. A majority of State and local Ombudsmen (75% and 77%, respectively) reported 

insufficient funding as a challenge that programs face in carrying out their responsibilities. However, the 

same resource challenges that compel Ombudsman programs to cultivate partnerships also prevent 

programs from fully optimizing those partnerships. Staff turnover in the Ombudsman program as well as 

partner agencies means that each must be continually educated about each entity’s role. To improve 

relationships with entities with which Ombudsman programs coordinate, State and local Ombudsmen 

reported that additional funding and staffing are needed not only for the Ombudsman program itself, but 

also for entities with which they coordinate. For example, State Ombudsmen reported concerns about 

adequacy of resources with respect to State legal assistance developers and legal assistance programs. 

Ombudsmen reported that decreased funding for legal services at the local level makes addressing 

resident legal needs increasingly challenging, compelling them to be selective when choosing the cases 

they support. In the view of Ombudsmen, furthermore, because the legal assistance developers’ mandate 

to coordinate legal services is unfunded, resource constraints and heavy workloads limit their assistance. 

A few Ombudsmen indicated that if sufficient funding were made available to legal aid and other legal 

resources, relationships with those entities would be improved. Adequate resources would enable both 

parties to dedicate time and staff to build and maintain relationships, such as holding regular meetings 

and cross-trainings that optimize mutual understanding of missions and roles. More resources would 

enable the Ombudsman program to make regular visits and maintain steady contact with facility staff, 

ultimately improving relationships, which can facilitate successful complaint resolution. 

Misconceptions of Roles. State and local Ombudsmen reported that a greater understanding among all 

parties, but particularly a greater understanding of the Ombudsman program on the part of other 

agencies, would make relationships more effective. Some stakeholders echoed this opinion, noting that 

relationships would be improved if the Ombudsman program had a better understanding of their partners

as well. 

Several State Ombudsmen reported confusion about which types of cases fall under APS authority, as 

opposed to that of the Ombudsman program. For one program, this confusion results from conflicting 

state law that prohibits APS from investigating cases of abuse, neglect or exploitation for individuals who 

are residents of long-term care facilities. This leads to gaps in service when the Ombudsman program is 

unable to make a referral to an appropriate entity. However, the State Ombudsman noted that they work 

with APS as much as possible to ensure that an appropriate agency investigates while they 

simultaneously work with the state to change the statutes.
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Ombudsmen may also perceive other agencies or organizations as having different priorities, or as 

advocating on behalf of providers, rather than long-term care residents. These perceptions may impede 

efforts to collaborate. Some stakeholders who represent long-term care providers reported feeling 

“demonized” by some Ombudsman programs despite sharing the goal of improving the quality of longterm care. Similarly, State and local Ombudsmen described being seen by facility staff as adversaries, 

rather than resources. This mutual misunderstanding can make it difficult to identify common goals and 

foster productive working relationships. Both Ombudsmen and stakeholders reported that the most 

effective relationships are those where each party views the other as a partner, not an adversary. This 

may highlight both needs and opportunities for more education and cross-training in states or localities 

where these relationships are not fully optimized. 

Final Rule. Although the Final Rule helped some Ombudsman programs develop and formalize 

partnerships, others reported challenges in leveraging these partnerships because of the regulation. For 

example, one State Ombudsman reported that the requirements for resolving conflict of interests (COI) 

between the Ombudsman program and agencies (such as APS) complicated the program’s ability to 

partner on important activities. In small states or those with limited resources, programs may rely on their

ability to work freely with other agencies. At minimum, the new guidelines require programs to pause and 

examine their relationships for potential COI. Others who reported having good working relationships with 

partners viewed the establishment of MOUs as an interruption, a restriction, or an unnecessary 

formalization of relationships that did not need additional documentation.

The Final Rule also created a challenge related to responsibility for local program oversight. According to 

the Final Rule, the local Ombudsman entity’s host agency is responsible for personnel management but 

not the programmatic oversight of representatives, including employee and volunteer representatives of 

the Office. Ombudsmen are under strict guidance about information that can be shared outside the 

program. This can complicate working relationships between the State Ombudsman and AAAs, 

particularly when local Ombudsmen entities are subcontracted out to other host agencies. In these 

instances, oversight responsibility can become even more unclear. In some states, navigating the division 

of these roles can be tense, sometimes making partnerships between the Ombudsman program and the 

AAA a challenge.

Data Sharing. A few State Ombudsmen reported that a key barrier to coordination relates to sharing data 

and information with other entities, particularly APS. While both APS and the Ombudsman program are 

under strict requirements about the types of data they can share with outside agencies, these 

requirements are not always clearly communicated. This ambiguity can cause frustration when the 

Ombudsman program attempts to coordinate with other entities on individual cases as well as systemlevel issues. 

Partnerships in Need of Further Development

In addition to ongoing development of their relationships, State and local Ombudsmen cultivate new 

relationships to support the interests of long-term care residents. Given recent long-term care utilization 

trends and the expansion of LTSS to special populations, State Ombudsmen reported interest in 

establishing and improving relationships with entities that serve individuals with mental and behavioral 

health challenges, intellectual and developmental disabilities, and those with more acute medical 

conditions. Often, this included a desire to improve coordination with hospitals and other organizations 

that focus on individuals with disabilities or mental and behavioral health issues. 
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State Ombudsmen reported the need to work with and educate hospital discharge planners about how 

the Ombudsman program can assist with transitioning patients from hospitals to long-term care settings. 

These relationships would facilitate Ombudsmen’s ability to investigate complaints involving facilities’ 

refusal to accept residents after discharging them to hospitals. These cases often involve residents for 

whom a facility contests readmission, indicating they cannot provide appropriate care. This includes 

individuals with mental or behavioral health conditions, or intellectual or developmental disabilities. In 

these situations, the Ombudsmen can work with hospitals to identify appropriate placements or assist the 

resident’s return to the facility. One State Ombudsman noted that the high turnover among hospital 

discharge planners in their state has impeded the development of a stable working relationship. 

6.4. Recommendations

■ State Ombudsmen reported that coordination among stakeholders at the national and state levels 

helps to ensure that the Ombudsman program’s voice is being heard and that program needs are 

addressed. ACL’s Central and Regional Offices should continue their efforts to bring visibility to 

the program and to support State and local Ombudsmen in working with other entities.

■ State and local Ombudsmen need more resources to improve relationships and create more 

effective partnerships with entities with which they have infrequent contact, such as the courts, 

law enforcement, and victim advocacy programs. 

► Programs should identify key partners to help facilitate relationships with entities with which 

weak or no relationships exist.

► Materials and training activities need to be developed to expand understanding of the LTCOP 

among entities with which partnerships have been historically underdeveloped. 

■ Further clarification of roles and responsibilities of the Ombudsman program and other 

coordinating entities is needed. Continued development of MOUs and policies and procedures 

can facilitate this clarification. While informal relationships may work well with established team 

members, staff turnover within the Ombudsman program or partnering agencies can introduce 

complications when educating new staff about accepted practices. Ombudsman programs 

should seek to formalize relationships wherever possible to avoid breakdowns in partnership or 

communication.

■ Misunderstandings between the Ombudsman program and potential partners with respect to the

program’s role and independence were reported to impede its coordination with these partners. 

Ombudsman programs should continue to seek and take advantage of the opportunity to 

educate partners about the program, as well as opportunities to learn more about partner 

agencies. By leveraging positive national level relationships with federal level agencies and 

associations, ACL’s Central and Regional Offices may be able to facilitate these opportunities in 

the states or regions where they are needed most. 

■ State and local Ombudsmen should look for opportunities to engage in activities such as crosstraining events and work groups to improve communication and coordination with other entities 

that are involved in issues related to older adults. 
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■ Ombudsmen at all levels highlighted work groups as an efficient and effective way to partner 

with multiple agencies simultaneously to accomplish common goals. One way to address the 

challenge of partnering with specific agencies (whether it is due to a lack of resources, staff, 

time, etc.) is to ensure that there are work groups or coalitions that include as many relevant 

parties as possible. 

■ Given State Ombudsmen’s interest in cultivating or improving relationships with various entities, 

the Resource Center should systematically collect information on this topic. The information

could then assist ACL’s Central Office staff in identifying opportunities to further promote these 

partnerships through national and regional networks. 
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Chapter 7. Research Question 4: How does the LTCOP 

provide feedback on successful practices and areas for 

improvement? 

7.1. Key Findings

7.1.1. Training and Technical Assistance

1. Nearly all (98%) Ombudsmen reported that they received orientation, training, or support when 

they first started in their role, and this training was generally regarded as helpful in establishing 

and providing feedback on their responsibilities. 

a. Volunteer Ombudsmen rated the effectiveness of their training most highly, followed by 

local Ombudsmen and State Ombudsmen. Ninety-five percent of volunteers reported that 

their orientation training was “very effective” or “somewhat effective,” compared to 83% of 

local Ombudsmen and 70% of State Ombudsmen.

2. Many Ombudsmen reported that additional training would have been helpful.

a. Half of State Ombudsmen (51%) reported that other training would have been helpful. 

Topics for which State Ombudsmen indicated additional training would have been helpful 

included data entry, service provision, and working with legislators.

b. Thirty-nine percent of local Ombudsmen and 26% of volunteer Ombudsmen indicated 

that additional training would have been helpful (e.g., mentoring/shadowing with 

experienced staff, more site visits, and additional hands-on, facility-based trainings). 

3. Nearly all local and volunteer Ombudsmen reported that they received ongoing training and 

feedback in their current roles. 

a. Local Ombudsmen reported that they receive ongoing training and support primarily via 

conference calls and online platforms such as webinars. 

b. Volunteer Ombudsmen most often receive this type of support via guidance from their 

supervisors and informal support from other Ombudsmen. 

4. Sources of training and ongoing support differed between State and local Ombudsmen.

a. State Ombudsmen rely heavily on training resources provided by the National Long-Term 

Care Ombudsman Resource Center, such as webinars, self-training materials, and 

National Association of State Ombudsman Program’s (NASOP) mentorship program for 

State Ombudsmen, as well as other sources of training and technical assistance 

delivered by Consumer Voice.

b. Local and volunteer Ombudsmen were most often trained via in-person or in-service 

training. These sessions used materials and guidance from Area Agencies on Aging

(AAAs), local programs, and the Office of the State Long-Term Care Ombudsman (Office 

of the SLTCO). 

5. Perceptions of resource effectiveness of training reflected differences in how frequently resources 

were used across respondent groups.

a. State Ombudsmen reported that the Resource Center’s materials were most helpful.
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b. Local Ombudsmen reported that resources from the Office of the SLTCO were most 

helpful. Exposure to national resources was limited among local Ombudsmen without 

management responsibilities.

c. Volunteer Ombudsmen rated the helpfulness of resources from state or local entities (i.e., 

AAA, their local program, and Office of the SLTCO) higher than those from national 

entities. 

d. Perceived challenges to establishing effective training and support included funding 

limitations that affect both the scope and approach to providing training and support (e.g., 

webinars rather than face-to-face training); problems providing support in relatively 

remote areas, and potential challenges providing comparable certification training for 

designation of staff and volunteers, a requirement under the Long-Term Care 

Ombudsman Programs Final Rule (Final Rule). 

7.1.2. LTCOP Data Collection and Reporting

1. At both the state and local levels, National Ombudsman Reporting System (NORS; the program’s 

reporting system) data are widely used to identify potential problems and areas for programmatic 

improvement, as well as targets for systems advocacy. 

2. Although all state Ombudsman programs are required to collect NORS data, some states collect 

additional data to support program management and improvement efforts. These additional data 

generally fall under five categories: program activities, outcome measures, facility data, resident 

data, and general long-term care data. 

3. State Ombudsmen appreciated the benefits that NORS data provide, but they also reported a 

number of limitations associated with these data. These limitations included underreporting of 

Ombudsman activities, burdensome coding requirements, incompatibility of software programs

with NORS requirements, and a lack of reporting flexibility. Some of these issues will be 

addressed when NORS is revised in October of 2019.

4. Ombudsmen reported challenges associated with state-level data systems, including data 

compatibility and integration problems for states with many reporting units; a lack of information 

on outcomes and topics of local importance; burdensome data entry and documentation; and lack 

of time and resources for data entry, which can result in inaccurate or incomplete data.

5. In some cases, Ombudsmen reported that in-house data systems can supplement or replace 

commercial products, thereby mitigating some challenges that are linked to commercial products. 

7.2. Introduction

This chapter describes national, state, and local resources and trainings that support Ombudsman 

program service delivery and are used to provide feedback and identify areas for program improvement. 

In addition to resources that Ombudsmen receive from program staff, other supports include the National 

Long-Term Care Ombudsman Resource Center (Resource Center), The National Consumer Voice for 

Quality Long-Term Care (Consumer Voice), National Association of States United for Aging and 

Disabilities (NASUAD), National Association of State Ombudsman Programs (NASOP), and National 

Association of Local Long-Term Care Ombudsmen (NALLTCO). 
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7.3. Findings

7.3.1. Training and Technical Assistance for Ombudsmen

Initial Training and Support 

State, local, and volunteer Ombudsmen were asked about the orientation, training, and support they 

received when they first started their positions. As shown in Exhibit 67, the Resource Center is one of the 

main training resources for State Ombudsmen. These supports are delivered though self-study using online training or materials (75%), in-person trainings (67%), as well as webinars (56%) for new State 

Ombudsmen. Another common training resource for State Ombudsmen is outreach by State Ombudsmen 

from NASOP (60%). In contrast, the most common types of initial training and support for local and 

volunteer Ombudsmen are in-person training/in-services (90% and 96%, respectively) and 

mentoring/shadowing with experienced staff (82% and 74%, respectively). Notably, a very small 

proportion of Ombudsmen (2% of State, 1% of local, and <1% of volunteers) reported receiving no 

orientation, training, or support when first hired. Because respondents were asked to reflect on their initial 

experiences (which may have occurred up to 32 years ago), this small number of Ombudsmen likely 

joined the program before trainings were standardized. 

Exhibit 67: Orientation, Training, and Support Provided for Ombudsmen 

Type of Orientation, Training, or Support Received when 

First Began in Role

State 

Ombudsmen

N=52

Local 

Ombudsmen

N=496a

Volunteer 

Ombudsmen

N=706b

Self-study (on-line training or reviewing materials provided 

by state program) 40% 59% 29%

Self-study (on-line training or reviewing materials provided 

by the Resource Center) 75% 39% 15%

In-person training/In-services 21% 90% 96%

Resource Center in-person training for new SLTCO 67% N/A N/A

Resource Center webinar for new SLTCO 56% N/A N/A

Mentoring/shadowing with State Ombudsman 44% N/A N/A

Mentoring/shadowing with experienced staff 40% 82% 74%

A more experienced staff member or volunteer observed me N/A N/A 36%

Training in a nursing home setting or board and care home 

setting 15% N/A N/A

Training in a long-term care facility N/A 45% 21%

Attending a resident or family council meeting 12% 45% 32%

Introduction to key stakeholders in my state 38% 17% 5%

Outreach by Central or Regional ACL staff 42% 5% N/A

Outreach by State Ombudsmen from NASOP 60% N/A N/A

Outreach by individuals from NALLTCO N/A 10% N/A

Training by legal counsel 12% 11% 10%

Other 25% 3% 7%

None 2% 1% <1%

a Missing=1; b Missing=5
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Types of Ongoing Training and Support 

Ongoing training and support for Ombudsmen is offered in multiple formats. Exhibit 68 shows that online 

training is the primary type of ongoing training and support for local Ombudsmen. Online training includes 

webinars or conference calls on special topics (82%), followed by guidance from staff in the Office of the 

SLTCO (66%), training provided by the Office of the SLTCO (65%), and informal support from other 

Ombudsman staff in their office (64%). Volunteer Ombudsmen most often reported receiving ongoing 

training and support via guidance from their supervisor in the local office (61%) and informal support from 

other Ombudsman staff (60%). The Resource Center is more often a source of ongoing training and 

support for local Ombudsmen than volunteer Ombudsmen (50% vs. eight percent, respectively). Only one 

percent of both local and volunteer Ombudsmen reported that they did not receive any ongoing training 

and support.

Exhibit 68: Ongoing Training and Support for Ombudsmen 

Type of Ongoing Training and Support

Local 

Ombudsmen

N=496a

Volunteer 

Ombudsmen 

N=707b

Formal mentoring with experienced staff 33% 35%

Informal support from other Ombudsman staff in your office 64% 60%

Guidance from other local or regional Ombudsman offices 45% N/A

Guidance from staff in the Office of the SLTCO 66% 27%

Guidance from volunteer coordinator in the local office N/A 47%

Guidance from supervisor in the local office N/A 61%

Online training such as webinars or conference calls on special topics 82% 42%

Office of the SLTCO provides training (via conferences, web-based 

training, etc.) 65% 31%

Office of the SLTCO provides relevant information and support 56% 26%

Support from the Resource Center 50% 8%

Support from NALLTCO 16% 3%

Support from other state or local agencies 29% 13%

Conferences (e.g., Consumer Voice Conference) 48% 17%

Other 4% 17%

None 1% 1%

a Missing=1; b Missing=4

Case documentation is a key Ombudsman program activity. Exhibit 69 shows that a majority of local 

Ombudsmen and volunteer Ombudsmen reported that their local Ombudsman entity provides training 

and assistance on documenting cases, complaints, and other Ombudsman program activities (88% and 

86%, respectively). 
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Exhibit 69: Training and Assistance on Documentation of Ombudsman Program Activities

Training and Assistance Provided 

Local 

Ombudsmen

N=488a

Volunteer 

Ombudsmen

N=695b

Yes 88% 86%

No 9% 5%

Don’t know 3% 8%

a Missing=9; b

 Missing=16 

Performance reviews are a potentially important source of professional feedback for Ombudsmen. As 

shown in Exhibit 70, when asked how often they receive a performance review, a majority of local 

Ombudsmen (74%) reported that their performance reviews occur annually, and an additional 11% 

reported that their reviews occur on a more frequent basis (i.e., semi-annually or more frequently). A 

small percentage of local Ombudsmen (5%) indicated never receiving a performance review; however, 

15% of these Ombudsmen were relatively new, having only been in their position for less than a year. 

Exhibit 70: Frequency of Local Ombudsmen’s Performance Reviews

Frequency

Local Ombudsmen

N=474a

Quarterly or more 3%

Semi-annually 8%

Annually 74%

Less than annually 1%

Other 9%

Never 5%

a Missing=23 

Only nine percent of volunteer Ombudsmen reported that they receive a formal review; most reported that 

they receive informal feedback (37%) or none at all (54%). Among the latter, 31% had been in their role 

for less than a year (Exhibit 71). 

Exhibit 71: Volunteer Ombudsman Receipt of Performance Reviews

Performance Reviews

Volunteer Ombudsmen

N=680a

Yes, formal reviews 9%

Yes, ongoing informal feedback 37%

No 54%

a Missing=31 
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Ombudsmen’s Perceptions of Resource Center Materials

State Ombudsmen and lead local Ombudsmen were asked whether Resource Center resources are 

sufficient to support their program in carrying out their responsibilities. Exhibit 72 shows that a majority of 

State Ombudsmen (76%) and lead local Ombudsmen (71%) found that these resources are sufficient. In 

addition, all State Ombudsmen (except one respondent who reported never needing to use the Resource 

Center) agreed that the Resource Center has been available when needed.

Exhibit 72: Sufficiency of Resources Provided by the Resource Center for Carrying Out Program

Responsibilities 

Resources are Sufficient

State Ombudsmen

N=51a

Lead Local Ombudsmen

N=185b

Yes 76% 71%

Somewhat 20% N/A

No 0% 15%

Don't know 4% 14%

a Missing=1; b Missing=4

Local and volunteer Ombudsmen were asked a similar question about whether the Resource Center’s 

resources were sufficient, but this question focused on whether the resources were sufficient for carrying 

out their individual work responsibilities. While 59% of local Ombudsmen reported that these resources 

were sufficient for carrying out their work, only 34% of volunteer Ombudsmen reported this was the case, 

with a majority of volunteer Ombudsmen (61%) reporting they did not know if these resources were 

sufficient for carrying out their work (Exhibit 73). 

Exhibit 73: Sufficiency of Resources Provided by the Resource Center for Carrying Out Individual 

Ombudsman Work 

Resources are Sufficient

Local Ombudsmen 

N=295a

Volunteer Ombudsmen

N=676b

Yes 59% 34%

No 7% 4%

Don’t know 34% 61%

a Missing=13; b Missing=35 

While a majority of Ombudsmen found the Resource Center to be a useful source of information, State 

Ombudsmen reported difficulties navigating through the Resource Center’s website and obtaining specific 

information. Some respondents noted instances where information provided by the Resource Center 

lacked specificity because these materials typically target the full range of Ombudsman programs. This 

issue may limit the applicability of resources for some states.

Ombudsmen’s Ratings of Resources from National, State, and Local Entities

In addition to the Resource Center, several entities provide resources to enhance the skills, knowledge, 

and management capacity of Ombudsman program staff. Ombudsmen were asked to rate how helpful 

selected national, state, and local entities have been in this regard. State and local Ombudsmen reported 

that resources from most of these entities were either very helpful or somewhat helpful to them (Exhibit 74 
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and 75, respectively). State Ombudsmen most often rated resources from the Resource Center, 

Consumer Voice, and NASOP as “very helpful.” Local Ombudsmen most often found resources from the 

Office of the SLTCO to be very helpful. A relatively high percentage of local Ombudsmen reported that 

they were unfamiliar with resources from their state or territorial unit on aging (SUA) and NALLTCO or 

that resources from these entities were not applicable to their positions. 

Volunteer Ombudsmen reported that resources from state or local entities were more helpful than those 

from national entities (Exhibit 76). Volunteer Ombudsmen found resources from their local Ombudsman 

entity, Office of the SLTCO, and AAAs to be most helpful to their positions. Notably, a high percentage of 

volunteer Ombudsmen reported that they were unfamiliar with resources from NALLTCO and the 

Resource Center or that resources from these entities were not applicable to their roles. 

Exhibit 74: Perceived Helpfulness of National, State, and Local Resources (State Ombudsmen)

Entities Very helpful

Somewhat 

helpful Not helpful N 

Not 

applicable

SUA 37% 49% 14% 51 1 

NASOP 73% 27% 0% 52 0 

Resource Center 87% 13% 0% 52 0 

Consumer Voice 82% 18% 0% 50 0 

NASUAD 10% 63% 27% 49 2 

ACL – Central Office 32% 62% 6% 50 1 

ACL – Regional Office 38% 48% 14% 50 1 

Justice in Aging 52% 41% 7% 44 7 

Support from other state 

agencies 35% 52% 13% 46 4 

Exhibit 75: Perceived Helpfulness of National, State, and Local Resources (Local Ombudsmen)

Entities Very helpful

Somewhat 

helpful Not helpful

Not familiar with 

resource/Not 

applicable N 

AAA 34% 35% 13% 18% 459

SUA 10% 22% 16% 52% 422

Office of the SLTCO 58% 31% 6% 4% 469

NALLTCO 18% 29% 10% 42% 433

Resource Center 46% 38% 4% 13% 457

Resource Center website 

(ltcombudsman.org) 45% 36% 4% 15% 447
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Exhibit 76: Perceived Helpfulness of National, State, and Local Resources (Volunteer Ombudsmen)

Entities Very helpful

Somewhat 

helpful Not helpful

Not familiar with 

resource/Not 

applicable N 

AAA 28% 20% 4% 47% 597

Local Ombudsman entity 61% 20% 1% 17% 610

Office of the SLTCO 32% 35% 6% 27% 591

NALLTCO 8% 14% 5% 72% 542

Resource Center 12% 18% 5% 65% 555

Resource Center website 

(ltcombudsman.org) 11% 18% 6% 66% 536

State Ombudsmen’s Reports of Helpful Training and Technical Assistance Content 

State Ombudsmen provided numerous examples of helpful training and technical assistance topics that 

have been made available through the Resource Center and ACL, or ones that have been developed by 

Ombudsman programs themselves. These examples often related to three topics: LTCOP requirements 

and regulations, systems advocacy, and resident care. Helpful information on LTCOP requirements and 

regulations included understanding requirements under the Final Rule and changes to the OAA and 

nursing home regulations; complying with the OAA’s disclosure requirements; HIPAA; and changes in 

state regulations. Helpful topics related to systems advocacy included understanding the legislative 

process and working with legislators on bills that are relevant to long-term care; developing emergency 

preparedness plans; and fostering culture change and patient-centered care in facilities. Helpful resident 

care topics included techniques for interviewing and assisting individuals with developmental and other 

disabilities, working with suicidal residents, and issues related to abuse and neglect.

State Ombudsmen’s Reports of Helpful Training and Technical Assistance Delivery Mechanisms 

State Ombudsmen reported a number of helpful training and technical assistance delivery mechanisms. 

Many cited materials on the Resource Center’s website, including webinars, technical assistance sheets, 

issue briefs, training modules that can be incorporated into state manuals, as well as information on an 

array of topics (e.g., evidence-based practices). State Ombudsmen also noted the value of the Annual 

SLTCO Training Conferences and Consumer Voice Conferences, as well as individualized technical 

assistance provided by Resource Center staff. ACL delivery mechanisms were also considered helpful, 

including one-on-one consultation and technical assistance, conference presentations, website materials, 

and webinars. 

State Ombudsmen described peer learning as another important way that Ombudsmen access training 

and technical assistance. One example of a helpful form of peer learning was the Resource Center’s

practice of querying all State Ombudsmen to respond to state-specific requests. State Ombudsmen 

described ways that their Ombudsman programs develop peer learning opportunities, including having 

experienced Ombudsmen mentor new staff and volunteers, using group case-study sessions for staff to 

work through difficult issues, and posting training resources on YouTube to make them available to peers. 

State Ombudsmen highlighted different strategies that other entities used to develop and deliver their 

training and technical assistance resources to Ombudsmen. They reported that LTCOPs use trainings 

developed by other state or local agencies, including APS, the State Division of Aging, the Aging and 

Disability Resource Center, the state Health Care Association, and the State Department of Public 
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Health. Some State Ombudsmen described providing training to partnering agencies such as the 

Forensic Special Initiatives Unit, state or local committees or task forces, and medical professionals (e.g., 

nurses, psychiatrists, pharmacists, etc.). State Ombudsmen also reported that some programs have 

worked with other organizations to develop joint trainings to support their staff. One example involved a 

joint training between the LTCOP and APS about abuse and neglect. Other State Ombudsmen reported 

working with partners to arrange trips to relevant state and local agencies or advocacy organizations. 

Ombudsmen’s Perceptions of their LTCOP Training and Support 

Exhibit 77 shows that, among Ombudsmen who received orientation, training, or support when first hired, 

a majority of Ombudsmen at all levels indicated their orientation training was either “very effective” or 

“somewhat effective”. Reports of effective training were highest among volunteer Ombudsmen and lowest 

among State Ombudsmen – 69% of volunteer Ombudsmen rated their training as very effective 

compared to 46% of local and 20% of State Ombudsmen. Additionally, 88% of volunteer Ombudsmen 

agreed that their training, ongoing support, and professional interactions fully prepared them to carry out 

their role. It should be noted, however, that State Ombudsmen’s responsibilities are more expansive than 

those of local and volunteer Ombudsmen (some of whom only focus on facility visits). For this reason, 

training needs are also likely to be greater.

Exhibit 77: Ombudsmen’s Perceived Effectiveness of their Orientation Training 

Effectiveness of Orientation Training

State Ombudsmen

N=50a

Local 

Ombudsmen

N=492b

Volunteer 

Ombudsmen

N=698c

Very effective 20% 46% 69%

Somewhat effective 50% 37% 26%

Neutral 16% 11% 3%

Somewhat ineffective 6% 5% 1%

Very ineffective 6% 2% 1%

Don’t know 2% <1% <1%

a Not applicable=2; b

 Not applicable=5; c Missing=11, Not applicable=2 

When asked to identify aspects of their training that have been most relevant to their job, local 

Ombudsmen most frequently reported mentoring or shadowing with experienced program staff and onsite or field training at facilities. Some local Ombudsmen also identified classroom training and self-study 

as helpful, including online training from the Resource Center. Topic areas that Ombudsmen reported to 

be particularly relevant to their role included training on laws and regulations for long-term care facilities 

and resident rights, program policies and guidelines, as well as complaint resolution and advocacy. 

Ombudsmen were asked whether more training would have been helpful during orientation. As shown in 

Exhibit 78, a higher percentage of State Ombudsmen compared to local and volunteer Ombudsmen 

reported that it would have been helpful to have additional training at the time of orientation (51% vs 39% 

and 26%, respectively). 
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Exhibit 78: Ombudsmen’s Perceptions of Whether Other Training Would Have Been Helpful during 

Orientation Period

Would other training have been helpful?

State 

Ombudsmen

N=45a

Local 

Ombudsmen

N=441b

Volunteer 

Ombudsmen

N=672c

Yes 51% 39% 26%

No 49% 61% 74%

a Missing=7; b Missing=56; c Missing=39 

Ombudsmen’s Interest in Additional Training and Support 

Ombudsmen who reported that additional training would have been helpful during their orientation period 

were asked to describe the types of additional training that would have been helpful to them. Ombudsmen 

at all levels most often reported that they would have liked more hands-on training such as mentorship or 

shadowing opportunities with more experienced program staff, site visits, internships, and hands-on 

facility-based case management training. 

State, local, and volunteer Ombudsmen reported specific subject areas in which training at the time of 

orientation would have been helpful. These included: data and reporting practices and systems, finance 

and budgeting, regulations and laws, and specific issues related to long-term care, such as the 

differences between nursing homes and assisted living facilities, financial abuse, involuntary discharges, 

handling residents with behavioral or mental health conditions, assessing strengths and weaknesses of 

facilities, and policies related to Medicare, Medicaid and other insurance providers. Several local 

Ombudsmen reported that they would have liked more training on communication skills such as writing

memos, speaking with residents, family members and/or guardians effectively and/or while handling 

complex cases, and conflict resolution and complaint handling skills. Another Ombudsman expressed an 

interest in learning about best practices from other Ombudsmen. 

In interviews, State Ombudsmen also described several areas in which additional training and support 

would have been helpful. They expressed interest in receiving more training on NORS data entry, use of 

“home-grown” data entry systems, providing services for residents in home and community-based 

services (HCBS) settings and residents with behavioral health conditions, and working with legislators. 

State Ombudsmen also underscored the need for mentoring staff who serve as State Ombudsmen in an 

interim role. Peer-to-peer mentoring typically offered by NASOP is not provided to this group, yet interim 

State Ombudsmen may serve in this capacity for long periods of time. 

Some lead local Ombudsmen highlighted the need for more training for Regional Ombudsmen, including 

program management and coordination (such as budgeting), and staff management and supervision. A 

number of these Ombudsmen said they received no additional training when they moved from being a 

local Ombudsmen to a supervisory position such as Regional or District Ombudsman.

The types of additional support that local and volunteer Ombudsmen would like from the Office of the 

SLTCO or from state or local program staff are shown in Exhibit 79. Local Ombudsmen most often 

reported wanting to have more professional development opportunities (44%). Similar percentages of 

local and volunteer Ombudsmen reported an interest in having more opportunities to discuss challenges 

with other Ombudsmen (36% and 32%, respectively). Twenty percent of local Ombudsmen and 18% of 

volunteer Ombudsmen indicated wanting more feedback on their performance and effectiveness. Those 

who reported an interest in more feedback tended to have had less frequent performance reviews, often 
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less than annually or not at all. Notably, 29% of local Ombudsmen and 37% of volunteer Ombudsmen did 

not indicate an interest in any of the training and support resources. 

Exhibit 79: Ombudsmen’s Interest in Additional Types of Training and Support 

Type of Training and Support

Local 

Ombudsmen

N=497

Volunteer 

Ombudsmen

N=711

More information from State Ombudsman/program staff 17% 14%

More opportunities to discuss challenges with supervisor 21% 19%

More opportunities to discuss challenges with other Ombudsmen 36% 32%

More professional development opportunities 44% N/A

More formal training N/A 18%

More feedback on my performance and effectiveness 20% 18%

Did not select any of the above 29% 37%

Challenges to Providing Training and Support 

State Ombudsmen commented on several challenges in providing training and technical assistance for 

staff. Some noted that funding limitations frequently impact their ability to provide the level of training they 

believe is needed for local and volunteer Ombudsmen. A related issue was the sense that limited funding 

results in over-reliance on webinars as opposed to face-to-face training, the latter being viewed a 

necessary aspect of a complete training curriculum. Geographic distance was another challenge. State 

Ombudsmen noted difficulties in providing training to local programs in rural areas due to the high cost of 

traveling long distances. The complexity associated with developing separate training curricula for staff 

working in different types of facilities (e.g. nursing homes vs. home and community-based service 

locations) was also noted as a practical challenge. 

7.3.2. Data Collection and Reporting

Data Collection for National Reporting 

The National Ombudsman Reporting System (NORS) is the administrative data collection system 

Ombudsman programs use to fulfill their annual Administration for Community Living’s (ACL) reporting 

requirements. NORS data collection began in federal fiscal year (FFY) 1996, and it has supported LTCOP 

management at the local, state, and federal levels since that time. NORS data includes national and 

state-specific information on routine facility visits, complaint investigations, consultations, number of 

program full-time equivalent staff (FTEs), attendance at resident and family councils, community 

education, and systems advocacy. States are required to report aggregated data annually to the 

Administration on Aging (AoA) within ACL, and other stakeholders. 

State-Specific Data Collection

In addition to NORS data, some states collect data to manage and improve their programs. These data 

largely fall under four major categories: program activities, outcome measures (e.g. resident satisfaction 

surveys), facility data, and resident data (e.g. payment source, data on veterans). Program activity data 

often include facility visits (including non-complaint visits), visits conducted by volunteers, volunteer work 

with resident and family councils, travel time of local staff and volunteers, volunteer recruitment, the 

number of facilities without an Ombudsman presence, managed care work, care plan attendance, 
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disaster response activities, and local partner engagement. Facility data often include discharge/transfer 

notices by facility and type, closures, survey citations, use of arbitration agreements, staffing, and 

facilities identified in need of "special focus" for reasons such as a negative Centers for Medicare & 

Medicaid Services (CMS) rating, or having no assigned volunteer. 

State Ombudsmen highlighted other types of data that would be useful to them. These include

information on specific program activities, staff time according to complaint type, and incoming 

discharge/transfer notices. Some Ombudsmen also reported an interest in data on trends in long-term 

care in their state, such as the needs of HCBS and long-term services and supports (LTSS) consumers, 

resident-on-resident abuse, and the high cost of low quality care (which could be used to quantify the cost 

savings generated by an Ombudsman intervention). 

Data Reporting 

ACL’s annual reporting requirements draw on data from each statewide program’s data collection system. 

State Ombudsmen were asked whether their statewide program’s data system is adequate to meet ACL’s 

annual reporting requirements. Seventy-five percent of State Ombudsmen reported that the system is 

adequate for this purpose (Exhibit 80). 

Exhibit 80: Adequacy of Statewide Program’s Data Collection System for Annual Reporting

Statewide Program’s Data Collection System is Adequate

State Ombudsmen

N=52

Yes 75%

Somewhat 17%

No 6%

Don't know 2%

Exhibit 81 shows the frequency with which local and volunteer Ombudsmen submit reports. While local 

Ombudsmen most often submit reports on a monthly basis (44%), this percentage is considerably lower

than the 74% of volunteer Ombudsmen who reported submitting monthly reports. Additionally, a greater 

percentage of local versus volunteer Ombudsmen reported not being required to submit formal reports 

(26% of local vs. four percent of volunteer Ombudsmen). These findings should be interpreted with 

caution. Because respondents were not asked about submission of specific types of reports, local and 

volunteer Ombudsmen may have interpreted this question differently. Whereas volunteers may interpret 

reports to be the case notes from a facility visit, local Ombudsmen may be referring to reports to the 

Office of the SLTCO.
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Exhibit 81: Frequency of Report Submission

Frequency

Local Ombudsmen

N=493a

Volunteer Ombudsmen

N=700b

Weekly 13% 9%

Monthly 44% 74%

Quarterly 10% 6%

Whenever an activity is carried out/completed 4% 6%

As needed/requested 1% <1%

Other 3% 2%

Not required to submit formal reports 26% 4%

a Missing=4; b Missing=11 

With respect to the level of ease involved in collecting data and submitting reports, Exhibit 82 

demonstrates that volunteer Ombudsmen were more likely to rate these activities as easy compared to 

local Ombudsmen (39% vs. 24%, respectively). 

Exhibit 82: Ease of Collecting Data and Submitting Reports

Level of Ease

Local Ombudsmen

N=366a

Volunteer Ombudsmen

N=672b

Easy 24% 39%

Somewhat easy 46% 42%

Somewhat difficult 23% 15%

Difficult 6% 4%

a Missing=4, Not applicable=127; b

 Missing=12, Not applicable=27 

Program Use of Data 

State and local Ombudsmen reported on the ways in which they use NORS data. Exhibit 83 shows that 

State Ombudsman reported that NORS data are most often used to identify issues of concern (77%), 

determining where to focus systems advocacy efforts (75%), and program improvement (67%). 
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Exhibit 83: Use of NORS Data 

Use of NORS Data

State Ombudsmen

N=52

Local Ombudsmen

N=497

Program planning 56% 27%

Program improvement 67% 36%

Examining trends for determining systems advocacy 

issues to focus on 75% 36%

Identifying issues of concern 77% 42%

Identifying promising practices 17% 19%

Comparing program’s performance to programs in other 

states 25% 20%

Advocacy purposes 63% 32%

Other N/A 4%

Don’t know N/A 34%

State Ombudsmen reported that they regularly analyze NORS data to identify complaint patterns, gaps 

and problems in the service system, and to plan advocacy initiatives such as proposing legislation. Some 

reported sharing data with other entities, although these were generally limited to agencies that were part 

of the state’s Department of Social Services. Several State Ombudsmen also reported conducting regular 

data reviews to identify differences in trends among regions, and others reported reviewing complaint 

data to identify trends and to establish goals based on these findings. 

Challenges to Collecting Program Data

Despite the reported benefits of NORS, State Ombudsmen also identified challenges with this system. 

Several State Ombudsmen cited issues with how Ombudsman activities are reported, particularly the 

underreporting of facility visits. Because NORS only includes non-complaint driven visits that are made on 

a quarterly basis, facility visits that occur fewer than four times a year or in response to a complaint are 

not captured. Other shortcomings of the NORS system included lack of a consumer satisfaction measure, 

unnecessarily lengthy and burdensome codes, and incompatibility for documenting Ombudsmen activities 

in HCBS waiver programs. Some State Ombudsmen reported that these challenges, in addition to reports 

of inadequate NORS training, lead to inefficiencies and limited use of these data. 

NORS has been modified several times since it was developed, and ACL recently proposed substantial 

changes to the system as part of an initiative to revise data collection in all OAA programs. The proposed 

changes to NORS were finalized and approved by the Office of Management and Budget (OMB) in April, 

2018, and they will be implemented in October of 2019 (FFY 2020). ACL requested the NORS revision to 

enhance ACL’s ability to understand and report on LTCOP operations, the implementation of regulatory 

requirements, and the experience of long-term care facility residents (Federal Register, Vol. 81, No. 152, 

p. 52438). The changes are intended to streamline reporting by states, increase the reliability and 

accuracy of the data, implement regulatory requirements, and increase ACL’s ability to analyze state-level 

data. The changes to the NORS system will include key improvements to data reporting that address 

challenges reported by Ombudsmen. For example, in the new data collection, Ombudsman programs will 

report data on all facility visits, regardless of purpose or frequency. The revised NORS system will also 

have fewer data elements (e.g., complaint codes were reduced from 133 to 59 codes) and should 

therefore reduce the coding challenges that were described earlier in this report. 
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In addition to challenges with NORS, some Ombudsmen reported difficulties with their state data software 

systems. They indicated that the burden of data entry, coupled with insufficient time for detailed 

documentation, results in underreporting and data entry errors, especially among volunteers. These 

issues were described as an ongoing problem despite extensive training, and one that ultimately limits the 

ability to use the data for their intended purpose – program management and monitoring. 

To supplement, or as an alternative to customized commercial data products, some programs have 

developed their own in-house data systems. Ombudsmen from these states reported that their in-house 

systems are more user-friendly, capture information that is of local importance, provide better information 

about complaint outcomes, and reduce costs.

7.4. Recommendations

■ Greater support for local Ombudsmen is needed and can be provided with greater coordination 

with NASOP, NALLTCO, NASUAD, and n4a. 

■ States with volunteer Ombudsmen should ensure that their programs have staff with the time and 

expertise to provide volunteer management. To improve volunteer recruitment, training, and 

management, resources to support a dedicated volunteer coordinator at the state or local level 

should be considered.

■ State Ombudsmen should actively support local and volunteer Ombudsmen’s use of the 

Resource Center’s training and technical materials. 

■ As part of building a statewide program, State Ombudsmen should provide additional training 

opportunities to local and volunteer Ombudsmen with respect to systems advocacy; data entry 

and data management; and various types of service settings (e.g., home-based, communitybased) as well as residents (e.g., supporting residents with behavioral health needs). 

■ Local and volunteer Ombudsmen should receive more hands-on training opportunities, 

such as job shadowing and formal mentorship from more experienced program staff. 

■ The Resource Center and State Ombudsmen should facilitate more opportunities for peer-to-peer

learning, both online and in-person (e.g., facilitating group case study sessions at conferences).

■ Interim State Ombudsmen should receive training, including mentorship from NASOP

and the Resource Center. As NORS is revised, ACL and the Resource Center should 

continue to address the challenges of collecting and reporting this data.

■ ACL’s Central Office and the Resource Center should help programs to develop and share 

solutions to problems that programs encountered in designing and using state data systems.

■ To address State Ombudsmen’s reported challenge of navigating the Resource Center’s website, 

the Resource Center should explore ways to enhance this resource with a more user-friendly 

design to facilitate access to materials.
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Appendix A: Acronyms

AAA Area Agency on Aging 

ACL Administration for Community Living 

ADRC Aging and Disability Resource Center

AG Office of the Attorney General

AHCA American Health Care Association 

AoA Administration on Aging 

APS Adult Protective Services

ASPE Office of the Assistant Secretary for Planning and Evaluation 

Central Office ACL’s Office of Long-Term Care Ombudsman Programs

CMS Centers for Medicare & Medicaid Services

COI Conflict of interest

Consumer Voice The National Consumer Voice for Quality Long-Term Care 

DHHS United States Department of Health and Human Services

DOJ Department of Justice 

Final Rule State Long-Term Care Ombudsman Programs Final Rule 

FTC Federal Trade Commission 

FTE Full-time equivalent staff

FFY Federal fiscal year

HCBS Home and community-based services

IOM Institute of Medicine 

LSC Legal Services Corporation 

LSP Local Service Provider

LTC Long-term care

LTCOP Long-Term Care Ombudsman program

LTSS Long-term service and supports

MFP Money Follows the Person 

MOU Memorandum of Understanding 

n4a National Association of Area Agencies on Aging 

NALLTCO National Association of Local Long-Term Care Ombudsmen 

NDRN National Disability Rights Network

NAPSA National Adult Protective Services Association 

NASOP National Association of State Long-Term Care Ombudsmen Programs

NASUAD National Association of States United for Aging and Disabilities

NORS National Ombudsman Reporting System

OAA or the Act Older Americans Act

Office or Office of the SLTCO Office of the State Long-Term Care Ombudsman 

P&A Protection and advocacy systems

PSA Planning service area 

Regional Office Office of Regional Operations

Resource Center National Long-Term Care Ombudsman Resource Center

SAMHSA Substance Abuse and Mental Health Services Administration 

SLTCO State Long-Term Care Ombudsman 

SLTCOP State Long-Term Care Ombudsman Program

SMP Senior Medicare Patrol

SUA State or territorial unit on aging 

TAG Technical advisory group 
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Appendix B: Glossary of Terms

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 AoA and includes 56 SUAs, 622 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 – Board and care homes and similar facilities include residential care facilities, 

adult congregate living facilities, assisted living facilities, foster care homes, and other adult care homes 

which provide room, board, and personal care services to a primarily older residential population.

Coordinating entities – Coordinating entities refer to agencies and organizations with which the LTCOP 

works to support their activities. The Final Rule requires that State Ombudsmen “shall lead state-level 

coordination, and support appropriate local Ombudsman entity coordination, between the Ombudsman 

program and other entities with responsibilities relevant to the health, safety, well-being or rights of 

residents of long-term care facilities” [45 CFR § 1324.13(h)(10)]. 

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).

Lead local Ombudsmen – This term was developed for the purposes of data collection to distinguish 

local Ombudsmen who have program management responsibilities. 

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 due to 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 Local Long-Term Care Ombudsmen (NALLTCO) – NALLTCO serves as an 

organization for local Ombudsmen to organize and provide a common voice to advocate and protect the 

rights of residents living in long-term care settings (NALLTCO, 2019). 

National Association of State Long-Term Care Ombudsmen Programs (NASOP) – Formed in 1985, 

NASOP is a nonprofit organization that is composed of State Long-Term Care Ombudsmen representing 

their state programs. The organization serves to strengthen the Ombudsman program and enhance its 
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effectiveness to serve consumer and their families. This is accomplished by developing and implementing 

training programs for Ombudsmen, facilitating the sharing of information and best practices, and 

collaborating with consumer and advocacy organizations, as well as governmental bodies and health care 

providers (NASOP, 2019).

National Association of States United for Aging and Disabilities (NASUAD) – Founded in 1964, 

NASUAD is a nonprofit association representing the nation’s 56 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 more than 500 local Ombudsman entities. Funded by ACL, the 

Center is operated by Consumer Voice, in cooperation with NASUAD. The Center’s objectives are to 

enhance the skills, knowledge, and management capacity of programs to enable them to handle 

residents’ complaints and represent resident interests in both individual and systems advocacy (Resource

Center, 2019).

National Ombudsman Reporting System (NORS) – NORS is a set of data requirements that 

Ombudsman programs are required to collect and report annually to ACL. NORS is comprised of data on 

resident complaints and outcomes on complaints, Ombudsman program activities, and narrative data. 

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.).

Ombudsman – In the OAA and Final Rule, “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.

Residential care communities/facilities – Similar to board and care homes, a residential care facility is 

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 healthrelated 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 or territorial units 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).
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Systems advocacy –The OAA describes systems advocacy as involving the following: representing 

interests of residents; seeking administrative, legal, or other remedies; analyzing, commenting on, and 

recommending changes to a system to benefit long-term care residents; and facilitating public comment 

on laws, regulations, policies, and actions (AoA, 2015).

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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Appendix C: Long-Term Care Ombudsman Programs Final Rule

The Long-Term Care Ombudsman Programs Final Rule included provisions regarding:

27

■ Definitions (45 CFR §1324.1) 

■ The Office of the State LTC Ombudsman (45 CFR §1324.11)

■ SLTCOP Policies and Procedures (45 CFR §1324.11(e)) 

■ Functions and Responsibilities of the SLTCO (45 CFR §1324.13)

■ State Agency Responsibilities Related to the SLTCOP (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)

Each of these provisions is described below.

Definitions 

The following definitions apply:

Immediate family: household member or a relative with whom there is a close personal or significant 

financial relationship (pertaining to conflicts of interest as used in Section 712 of the Act).

Office of the State Long-Term Care Ombudsman: the organizational unit in a State or territory which is 

headed by a State Long-Term Care Ombudsman. 

Representatives of the Office of the State Long-Term Care Ombudsman: the employees or volunteers 

designated by the Ombudsman to fulfill the duties set forth in in § 1324.19(a), whether personnel 

supervision is provided by the Ombudsman or his or her designees or by an agency hosting a local 

Ombudsman entity designated by the Ombudsman pursuant to section 712(a)(5) of the Act. 

Resident representative means any of the following:

■ An individual chosen by the resident to act on behalf of the resident in order to support the 

resident in decision-making; access medical, social or other personal information of the resident; 

manage financial matters; or receive notifications;

■ A person authorized by State or Federal law (including but not limited to agents under power of 

attorney, representative payees, and other fiduciaries) to act on behalf of the resident in order to

support the resident in decision-making; access medical, social or other personal information of 

the resident; manage financial matters; or receive notifications;

■ Legal representative, as used in section 712 of the Act; or

■ The court-appointed guardian or conservator of a resident.

 

27 https://ltcombudsman.org/uploads/files/library/ltcop-regs-overview.pdf 
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■ Nothing in this rule is intended to expand the scope of authority of any resident representative 

beyond that authority specifically authorized by the resident, State or Federal law, or a court of 

competent jurisdiction.

State Long-Term Care Ombudsman, or Ombudsman: the individual who heads the Office and is 

responsible to personally, or through representatives of the Office, fulfill the functions, responsibilities and 

duties set forth in §1324.13 and 1324.19.

State Long-Term Care Ombudsman program, Ombudsman program, or program: the program through 

which the functions and duties of the Office are carried out, consisting of the Ombudsman, the Office 

headed by the Ombudsman, and the representatives of the Office. 

Willful interference: the actions or inactions taken by an individual in an attempt to intentionally prevent, 

interfere with, or attempt to impede the Ombudsman from performing any of the functions or 

responsibilities set forth in §1324.13, or the Ombudsman or a representative of the Office from performing 

any of the duties set forth in §1324.19.

The Office of the State Long-Term Care Ombudsman 

The Final Rule, in accordance with the OAA requires the State agency to establish the Office, which is 

headed by a State Long-Term Care Ombudsman, and is a “distinct entity” that is “separately identifiable” 

in order to provide ease of access for residents and complainants and to effectively meet other statutory 

requirements of the Office. The State agency shall establish and operate the Office, and carry out the 

program, directly, or by contract or other arrangement with any public agency or nonprofit private 

organization. The Ombudsman is to serve on a full-time basis and shall meet minimum qualifications as 

described in the federal rule. The Final Rule does not limit the authority of the Ombudsman program to 

provide Ombudsman services to populations other than residents of long-term care facilities so long as 

the appropriations under the Act are utilized to serve residents of long-term care facilities, as authorized 

by the Act.

SLTCOP Policies and Procedures

The Ombudsman program regulations stipulate that the Ombudsman establish or recommend LTCOP 

policies and procedures. The development of policies and procedures must include consultation with the 

agencies hosting local Ombudsman entities and with representatives of the Office. Policies and 

procedures specify how the Ombudsman program is carried out in accordance with the Act and must 

address specific areas, including program administration; access to facilities, residents, and records; 

disclosure of files, records, and other information; conflicts of interest; systems advocacy; the designation 

process; a grievance process; and determinations of the Office. Significant requirements of policies and 

procedures28 ensure: 

■ monitoring of local Ombudsman entities by the Ombudsman;

 

28 Where the Ombudsman has the legal authority to do so, he or she shall establish policies and procedures, in consultation with the 

State agency, to carry out the Ombudsman program in accordance with the Act. Where State law does not provide the Ombudsman 

with legal authority to establish policies and procedures, the Ombudsman shall recommend policies and procedures to the State 

agency or other agency in which the Office is organizationally located, and such agency shall establish Ombudsman program 

policies and procedures.
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■ a description of the process by which the agencies hosting local Ombudsman entities will 

coordinate with the Ombudsman in the employment or appointment of representatives of the 

Office; 

■ standards of promptness for complaint responses;

■ must clarify that the files, records, and information maintained by the Ombudsman program may 

be disclosed only at the discretion of the Ombudsman;

■ must exclude the Ombudsman and representatives of the Office from abuse reporting 

requirements, including when such reporting would disclose identifying information of a 

complainant or resident without appropriate consent or court order;

■ that the Office is required (and has sufficient authority) to carry out its statutory responsibilities, as 

the Office determines is appropriate, and regardless of State lobbying laws. 

Policies and Procedures that Support the Independence of the Program 

To support the independence of the Ombudsman program, the Final Rule set forth requirements with 

respect to policies and procedures related to systems advocacy activities. Policies and procedures must 

assure that the Office of the SLTCO is required, and has sufficient authority to analyze, comment on, and 

monitor the development and implementation of laws, regulations, policies, and actions pertaining to 

residents; and recommend any changes as the Office determines to be appropriate. The State 

Ombudsman and representatives of the Office must be excluded from state lobbying prohibitions that 

conflict with OAA provisions. Program policies and procedures can encourage and promote consultation 

with the State agency or other host agency in which the Office is organizationally located regarding 

positions or determinations of the Office of the SLTCO, but they must not require a right for the host 

agency to review or pre-approve positions or communications of the Office. The State Ombudsman must 

have the ability to make independent determinations and establish positions of the Office, without 

representing the positions of the State agency or other entity housing the Office. This independence 

relates to multiple areas, including the disclosure of information maintained by the Ombudsman program; 

recommendations to changes in laws, regulations, policies, and actions; and provision of information to 

public and private agencies, legislators, the media, and others as it relates to the problems and concerns 

of residents. 

Functions and Responsibilities of the State Ombudsman 

The State Ombudsman has responsibility for the leadership and management of the Office in 

coordination with the State agency and, where applicable, any other agency carrying out the Ombudsman 

program. The State Ombudsman is the head of a unified, statewide program, and is to establish or 

recommend policies, procedures, and standards for administration of the program, and require 

representatives of the Office to fulfill the duties of the program in accordance with LTCOP policies and 

procedures. The State Ombudsman is responsible for a wide range of activities associated with program 

management and operations, including:

■ designation of local Ombudsman entities, and representatives of the Office; 

■ investigation of allegations of misconduct of representatives of the Office; 

■ training for certification and continuing education of the representatives of the Office; 

■ management of files, records, and other information; 
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■ making determinations concerning disclosure of files, records, and other information maintained 

by the SLTCOP; 

■ determining the use of appropriated or other fiscal resources available for the operation of the 

Office, and approving allocations of Federal and State funds provided to local Ombudsman 

entities; 

■ independently developing and providing final approval of an annual report; and 

■ State-level coordination and support of local Ombudsman entity coordination with entities with 

responsibilities relevant to the health, safety, well-being, and rights of residents (e.g. AAAs, 

ADRCs, etc.).

State Agency Responsibilities Related to the SLTCOP 

As a condition of receiving OAA funds, the SUA (“State agency”) must fulfill certain responsibilities to the 

Ombudsman program, including ensuring the SLTCOP has sufficient authority and access to facilities, 

residents, and information needed; providing opportunities for training for the SLTCO and representatives 

of the Office; providing personnel supervision and management for the SLTCO and representatives of the 

Office who are employees of the SUA; monitoring (including fiscal) when the Office and/or local 

Ombudsman entity is located within another agency; integrating SLTCOP goals and objectives into the 

State plan; providing elder rights leadership; and requiring the coordination of SLTCOP services with 

activities of other Title VII programs and entities with responsibilities relevant to the health, safety, wellbeing, or rights of older adults.

The State Agency must ensure that mechanisms exist to prohibit and investigate allegations of 

interference, retaliation, and reprisals with respect to any resident, employee, or complainant, as well as 

against the SLTCO or representatives of the Office for performance of duties, and provide for appropriate 

sanctions. The State agency must ensure that legal counsel for the SLTCOP is adequate, available, and 

has competencies relevant to the legal needs of the program and of residents, and is without conflict of 

interest (as defined by the State ethical standards governing the legal profession) to provide consultation 

and representation for the SLTCO and representatives of the Office. Both the State agency and the 

SLTCO are responsible for identifying actual and potential conflicts and removing or remedying the 

conflicts identified. 

Responsibilities of Agencies Hosting Local Ombudsman Entities

States with local Ombudsman entities may divide some responsibilities between the host agency and the 

Ombudsman. For example, the host agency may retain the authority over the personnel functions of the 

agency, such as hiring and firing. However, the Ombudsman must have responsibility for the 

programmatic functions of the Ombudsman program, including designation and de-designation of 

representatives of the Office.29 The host agency shall not have personnel policies or practices that 

prohibit the representatives of the Office from performing the duties, or from adhering to the access, 

confidentiality and disclosure requirements of section 712 of the Act, as implemented through this rule 

and the policies and procedures of the Office. 

 

29 ACL Frequently Asked Questions (FAQ) https://www.acl.gov/node/762 
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Duties of the Representatives of the Office

In carrying out the duties of the Office, the Ombudsman may designate an employee or volunteer of the 

local Ombudsman entity as a representative of the Office. Representatives of the Office may also be 

designated employees or volunteers within the Office.

Representatives of the Office are required to investigate and resolve complaints; ensure regular and 

timely access to LTCOP services and response to complaints and requests for information; represent 

residents interests before governmental agencies; assure residents access to administrative, legal, and 

other remedies; analyze, comment on, and monitor the development of laws, regulations, policies, and 

actions, and recommend changes as appropriate; coordinate with and promote the development of citizen 

organizations; and promote and support resident and family councils.

Duties of representatives of the Office also have significant requirements with respect to complaint 

processing. Regardless of the complaint’s source, the SLTCO and representatives of the Office serve the 

resident. Complaint investigations are intended to be resolved to residents’ satisfaction and to promote 

their health, welfare, safety, and rights. The Final Rule further clarifies the need to obtain consent to take 

action on a complaint and outlines steps to take action when a resident cannot give consent. Information 

regarding a complaint may be shared with other agencies in order to substantiate facts for regulatory, 

protective services, law enforcement, or other purposes, insofar as the SLTCO or representatives 

adheres to disclosure rules. The SLTCO or representatives also shall not report cases of suspected 

abuse, neglect, or exploitation without the informed consent of the resident or the resident’s 

representative. 

Conflicts of Interest

The Final Rule stipulates that the State agency and the Ombudsman shall consider organizational and 

individual conflicts of interest that may impact the effectiveness and credibility of the work of the Office. 

Both parties are responsible for identifying actual and potential conflicts, and removing or remedying 

them. 

Organizational conflicts of interest may include, but are not limited to, placement of the Office, or requiring 

that an Ombudsman or representative of the Office perform conflicting activities, in an organization that is 

responsible for other activities related to long-term care facilities such as licensing, surveying, or certifying 

long-term care facilities; setting reimbursement rates for long-term care facilities; or making decisions 

regarding admission or discharge of individuals to or from long-term care facilities; among others. 

Additionally, the State agency must ensure that individuals involved in the designating, appointing, 

selecting or terminating of the Ombudsman are free from conflict. If conflicts are identified, the 

Ombudsman must describe the steps taken to remove or remedy the conflicts within the annual report 

submitted to the Assistant Secretary through NORS. Whether the Ombudsman program is 

organizationally placed within the State agency or carried out by contract with a public agency or nonprofit 

private organization, the State agency is required to establish a process for periodic review for conflicts, 

and criteria for approval of steps taken to remedy or remove conflicts. If a conflict cannot be remedied, 

the program must be moved and operated by another agency or organization without conflicts. The State 

Ombudsman holds the same responsibilities as it relates to the operation of local Ombudsman entities.

Individual conflicts of interest may exist if an Ombudsman, representatives of the Office, or members of 

their immediate family have direct involvement in the licensing or certification of a long-term care facility; 

have ownership, operational, or investment interest in an existing or proposed long-term care facility; are 
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or have been employed by, or participated in the management of a long-term care facility in the service 

area, or by the owner or operator of any long-term care facility in the service area; serves residents of a 

facility in which an immediate family member resides; or receives gifts, gratuities, or remuneration from a 

long-term care facility, its management, or the owner or operator. 

The State agency or Ombudsman must establish and implement policies and procedures to ensure that 

no Ombudsman or representatives of the Office are required or permitted to hold positions or perform 

duties that would constitute a conflict of interest. Policies should include establishing a process for 

periodic review and identification of conflicts, and efforts to avoid appointing or designating individuals 

with conflicts, or otherwise removing or remedying conflicts. 
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Appendix D: Program Structure and Organizational 

Placement

Table A: Program Structure and Organizational Placement

States/ 

Territories State Office Placement State Structure Local Ombudsman Entity Placement

Alabama SUA Decentralized AAAs 

Alaska Independent state agency Centralized Central State Office

Arizona SUA Decentralized AAAs and Inter-Tribal Council

Arkansas SUA Decentralized AAAs 

California SUA Decentralized Mix of AAAs and independent agencies

Colorado Nonprofit Decentralized AAAs 

Connecticut State government agency Centralized Central State Office

Delaware State government agency Centralized Central State Office

District of 

Columbia Nonprofit Centralized Central State Office

Florida SUA Centralized

Central State Office (oversees regions and 

districts) 

Georgia SUA Decentralized Mix of AAAs and other entities

Hawaii SUA Centralized Central State Office

Idaho SUA Decentralized AAAs 

Illinois SUA Decentralized Mix of AAAs and nonprofit entities

Indiana State government agency Decentralized Mix of AAAs and other entities

Iowa SUA Centralized Central State Office

Kansas Independent State Agency Centralized Central State Office and other offices

Kentucky Nonprofit Decentralized AAAs and Independent Living Centers

Louisiana SUA Decentralized Mix of AAAs and independent agencies

Maine Nonprofit Centralized Central State Office

Maryland SUA Decentralized AAAs 

Massachusetts SUA Decentralized Mix of AAAs and independent agencies

Michigan Nonprofit Decentralized Mix of AAAs and independent agencies

Minnesota State government agency Centralized

Central State Office, regional offices, home 

offices

Mississippi SUA Decentralized Mix of AAAs and other entities

Missouri SUA Decentralized Mix of AAAs and independent agencies

Montana SUA Decentralized AAAs and Council of Governments

Nebraska State government agency Decentralized AAAs 

Nevada SUA Centralized

Central State Office (housed at regional/local 

level)

New 

Hampshire State government agency Centralized Central State Office

New Jersey State government agency Centralized Central State Office

New Mexico SUA Centralized Central State Office and regional offices

New York SUA Decentralized Mix of AAAs and independent agencies

North Carolina SUA Decentralized AAAs 

North Dakota SUA Centralized Central State Office

Ohio SUA Decentralized Mix of AAAs and independent agencies
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States/ 

Territories State Office Placement State Structure Local Ombudsman Entity Placement

Oklahoma SUA Decentralized AAAs and Council of Governments

Oregon Independent state agency Centralized

Central State Office and offices across the 

state

Pennsylvania SUA Decentralized Mix of AAAs and independent agencies

Rhode Island Nonprofit Centralized Central State Office

South Carolina SUA Decentralized Mix of AAAs and independent agencies

South Dakota SUA Centralized Division field offices under Office of SLTCO

Tennessee SUA Decentralized Mix of AAAs and independent agencies

Texas SUA Decentralized Mix of AAAs and other entities

Utah SUA Decentralized Mix of AAAs and other entities

Vermont Nonprofit Centralized

Central State Office (Legal Aid across the 

state) 

Virginia SUA Decentralized Mix of AAAs and independent agencies

Washington Nonprofit Decentralized Mix of AAAs and independent agencies

West Virginia SUA Decentralized Local offices under Legal Aid

Wisconsin Independent state agency Centralized Central State Office

Wyoming State government agency Decentralized Local offices under Wyoming Citizens, Inc.

Puerto Rico SUA Decentralized Other

Guam SUA Centralized Central State Office
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Appendix E: Program Expenditures Data

Table B: Program Expenditures by Source – Federal, State, Local and Total Funds (FFY 2017)

State

Federal 

Funds

Federal

Funds as 

% of total

State 

Funds

State 

Funds as 

% of total

Local 

Funds

Local 

Funds as 

% of total Total Funds

50 States + 

DC & PR $53,768,649 50.4% $45,664,788 42.8% $7,247,830 6.8% $106,681,267

AK $311,266 36.0% $554,295 64.0% - - $865,561

AL $655,817 37.5% $1,011,325 57.8% $83,608 4.8% $1,750,750

AR $615,218 65.5% $193,858 20.6% $130,434 13.9% $939,510

AZ $676,021 46.6% $773,766 53.4% - 0.0% $1,449,787

CA $4,536,982 35.5% $5,991,780 46.8% $2,261,387 17.7% $12,790,149

CO $1,505,363 45.4% $1,435,248 43.2% $378,055 11.4% $3,318,666

CT $327,427 16.9% $1,613,051 83.1% - - $1,940,478

DC $179,350 28.9% $440,683 71.1% - - $620,033

DE* $303,158 62.1% $185,340 37.9% - - $488,498

FL $1,585,688 55.2% $1,284,788 44.8% - - $2,870,476

GA $1,347,333 50.2% $1,257,134 46.9% $78,269 2.9% $2,682,736

HI* $153,074 86.6% $23,776 13.4% - - $176,850

IA $318,791 24.3% $994,344 75.7% - - $1,313,135

ID $365,820 57.7% $267,854 42.3% - - $633,674

IL $2,354,076 43.8% $2,787,341 51.9% $230,551 4.3% $5,371,968

IN $581,867 67.7% $227,530 26.5% $49,895 5.8% $859,292

KS $550,230 80.0% $137,240 20.0% - - $687,470

KY $698,480 38.7% $1,089,462 60.4% $17,069 0.9% $1,805,011

LA $849,300 73.6% $282,248 24.5% $22,354 1.9% $1,153,902

MA $2,252,077 81.8% $426,696 15.5% $72,993 2.7% $2,751,766

MD $650,038 22.1% $1,401,056 47.7% $885,476 30.2% $2,936,570

ME $481,913 40.0% $723,188 60.0% - - $1,205,101

MI $850,675 47.6% $822,358 46.0% $113,094 6.3% $1,786,127

MN $1,299,900 67.3% $632,533 32.7% - - $1,932,433

MO $942,766 82.1% $125,617 10.9% $80,051 7.0% $1,148,434

MS $963,833 80.0% $113,439 9.4% $127,310 10.6% $1,204,582

MT $555,648 46.7% $581,630 48.9% $52,584 4.4% $1,189,862

NC $1,973,027 48.1% $1,793,407 43.7% $339,305 8.3% $4,105,739

ND $302,167 65.9% $156,448 34.1% - - $458,615

NE $289,314 90.0% $15,000 4.7% $17,129 5.3% $321,443

NH $277,644 54.9% $228,113 45.1% - - $505,757

NJ $1,118,309 40.9% $1,615,083 59.1% - - $2,733,392

NM $444,411 77.5% $129,328 22.5% - - $573,739

NV $643,861 47.7% $706,132 52.3% - - $1,349,993

NY $2,639,092 67.7% $1,190,000 30.5% $68,553 1.8% $3,897,645

OH $6,042,439 72.3% $1,955,826 23.4% $363,615 4.3% $8,361,880

OK $836,306 52.0% $701,761 43.6% $69,854 4.3% $1,607,921

OR $264,954 19.5% $1,095,198 80.5% - - $1,360,152

PA $1,808,630 33.8% $3,448,243 64.4% $98,130 1.8% $5,355,003

PR $336,501 100.0% 0.0% - - $336,501
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State

Federal 

Funds

Federal

Funds as 

% of total

State 

Funds

State 

Funds as 

% of total

Local 

Funds

Local 

Funds as 

% of total Total Funds

RI $339,408 46.8% $339,400 46.8% $46,119 6.4% $724,927

SC $1,582,294 67.0% $680,888 28.8% $97,329 4.1% $2,360,511

SD $565,672 92.8% $44,146 7.2% - - $609,818

TN $709,926 77.4% $76,356 8.3% $131,215 14.3% $917,497

TX $3,944,367 62.8% $2,229,652 35.5% $111,182 1.8% $6,285,201

UT $169,169 28.1% $263,101 43.6% $170,515 28.3% $602,785

VA $981,155 43.2% $392,184 17.3% $896,082 39.5% $2,269,421

VT $599,497 87.4% $86,218 12.6% - - $685,715

WA $510,383 24.9% $1,324,201 64.7% $212,649 10.4% $2,047,233

WI $862,245 38.6% $1,369,890 61.4% - - $2,232,135

WV $481,866 57.9% $307,426 37.0% $42,667 5.1% $831,959

WY $133,901 49.0% $139,207 50.9% $356 0.1% $273,464

*2016 data
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Table C: Program Data – Totals and by State/Territory

States/ 

Territories

# Paid 

Program 

Staff 

(FTE) 

Total # of 

All 

Volunteers

# of 

Certified 

Volunteers

# of Other 

Volunteers

% of 

Nursing 

Homes 

visited 

quarterlyb 

% of 

Board 

and Care 

Homes 

visited 

quarterlyb 

# 

Nursing 

Home 

Total

# Board 

and 

Care 

Total

Total # 

Facilities

Total # of 

Complaints

# of 

Complaints 

per LTC 

Facility Bed

Ratio FTE 

to LTC 

Facility 

Beds

50 States + 

DC & PR 1,319.22 8,810 6,625 2,185 68.4% 30.2% 16,376 58,031 74,407 201,460 0.06 1:2,355

AK 5.0 39 39 0 27.8% 9.1% 18 638 656 508 0.11 1:921

AL 21.5 38 0 38 99.6% 86.5% 235 349 584 1,238 0.03 1:1,781

AR 15.0 235 231 4 83.0% 98.4% 229 186 415 1,437 0.04 1:2,261

AZ 19.8 61 61 0 99.3% 27.8% 147 2,105 2,252 3,930 0.07 1:2,751

CA 156.3 738 730 8 75.9% 42.7% 1,244 7,406 8,650 41,834 0.14 1:1,949

CO 39.5 22 22 0 100.0% 100.0% 234 674 908 4,368 0.10 1:1,113

CT 9.0 29 16 13 15.8% 0.4% 221 231 452 3,090 0.09 1:4,035

DC 7.0 60 60 0 94.4% 14.0% 18 121 139 529 0.13 1:594

DEa 5.0 20 20 0 100.0% 62.8% 48 78 126 604 0.08 1:1,471

FL 42.0 353 292 61 39.3% 22.0% 682 3,448 4,130 5,395 0.03 1:4,395

GA 43.3 52 13 39 84.4% 49.2% 371 2,533 2,904 4,511 0.06 1:1,851

HI* 2.0 10 10 0 30.6% 2.1% 49 1,687 1,736 215 0.02 1:6,494

IA 10.0 71 64 7 11.3% 0.2% 442 405 847 1,333 0.02 1:5,461

ID 10.0 49 49 0 100.0% 100.0% 79 276 355 1,001 0.06 1:1,550

IL 77.7 78 78 0 86.7% 90.9% 968 623 1,591 8,009 0.06 1:1,821

IN 15.5 26 13 13 55.1% 29.5% 554 319 873 1,253 0.02 1:5,065

KS 8.0 89 89 0 71.5% 6.0% 347 467 814 1,490 0.04 1:4,447

KY 32.6 286 65 221 93.7% 85.1% 316 194 510 6,662 0.19 1:1,052

LA 17.6 11 2 9 100.0% 89.8% 278 118 396 1,393 0.03 1:2,371

MA 30.3 291 291 0 99.3% 98.5% 413 68 481 4,707 0.09 1:1,651

MD 36.5 168 101 67 97.3% 51.4% 226 1,509 1,735 4,238 0.09 1:1,356 

ME 13.7 41 41 0 100.0% 93.6% 100 251 351 1,824 0.13 1:1,064

MI 19.5 33 32 1 34.3% 0.0% 460 4,472 4,932 3,327 0.03 1:5,166

MN 17.0 57 57 0 66.0% 2.1% 371 6,336 6,707 2,402 0.02 1:6,814

MO 18.0 215 203 12 48.3% 41.9% 530 652 1,182 6,763 0.08 1:4,571

MS 17.0 0 0 0 99.1% 88.2% 211 195 406 1,807 0.07 1:1,566

MT 19.7 10 0 10 69.4% 67.7% 124 217 341 1,318 0.10 1:682

NC 38.5 948 948 0 87.1% 78.6% 420 1,250 1,670 4,350 0.05 1:2,318
NORC | Process Evaluation of the Long-Term Care Ombudsman Program (LTCOP)

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States/ 

Territories

# Paid 

Program 

Staff 

(FTE) 

Total # of 

All 

Volunteers

# of 

Certified 

Volunteers

# of Other 

Volunteers

% of 

Nursing 

Homes 

visited 

quarterlyb 

% of 

Board 

and Care 

Homes 

visited 

quarterlyb 

# 

Nursing 

Home 

Total

# Board 

and 

Care 

Total

Total # 

Facilities

Total # of 

Complaints

# of 

Complaints 

per LTC 

Facility Bed

Ratio FTE 

to LTC 

Facility 

Beds

ND 6.5 20 20 0 83.3% 78.9% 114 142 256 514 0.04 1:1,823

NE 7.5 49 49 0 46.5% 30.2% 226 288 514 890 0.03 1:3,906

NH 5.0 20 18 2 17.1% 2.0% 82 150 232 252 0.02 1:2,656

NJ 24.0 239 239 0 77.9% 384 521 905 5,631 0.07 1:3,236

NM 7.0 49 46 3 77.0% 25.1% 74 259 333 2,960 0.24 1:1,763

NV 12.5 13 8 5 95.0% 86.9% 60 505 565 2,807 0.18 1:1,229

NY 45.2 571 569 2 58.1% 30.6% 627 876 1,503 1,636 0.01 1:3,582

OH 88.5 235 235 0 45.0% 24.1% 983 1,652 2,635 9,470 0.06 1:1,750

OK 25.1 109 105 4 42.8% 20.0% 400 230 630 3,243 0.07 1:1,854

OR 10.5 176 160 16 54.4% 12.1% 136 2,005 2,141 4,429 0.10 1:4,312

PA 84.3 1,891 415 1,476 90.8% 61.2% 703 1,718 2,421 2,524 0.02 1:1,876

PR 11.0 3 0 3 100.0% 25.5% 9 825 834 2,755 0.16 1:1,542

RI 6.2 15 14 1 84.3% 78.5% 89 65 154 503 0.04 1:2,250

SC 26.1 78 78 0 79.1% 84.6% 268 479 747 7,367 0.17 1:1,615

SD 7.0 0 0 0 93.5% 38.9% 108 216 324 545 0.04 1:1,793

TN 13.5 234 200 34 85.2% 81.7% 324 371 695 2,617 0.05 1:4,243

TX 85.0 451 451 0 94.6% 93.8% 1,221 1,885 3,106 18,480 0.09 1:2,464

UT 9.2 18 10 8 61.0% 48.5% 105 229 334 1,795 0.10 1:2,007

VA 27.9 76 61 15 24.8% 23.0% 307 566 873 3,222 0.05 1:2,464

VT 6.6 10 8 2 97.4% 95.3% 39 129 168 500 0.08 1:992

WA 17.6 425 321 104 29.4% 14.0% 228 3,349 3,577 4,960 0.07 1:4,003

WI 31.0 98 91 7 17.3% 0.0% 393 4,402 4,795 3,681 0.04 1:3,075

WV 11.3 0 0 0 93.6% 4.4% 125 321 446 929 0.06 1:1,303

WY 4.0 0 0 0 97.2% 100.0% 36 40 76 214 0.04 1:1,190 a

 2016 data 

b Percentages are based on the local numbers reported and may slightly underrepresent the actual number of facilities visited for some states. 
NORC | Process Evaluation of the Long-Term Care Ombudsman Program (LTCOP)

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Table D: Program Data, Continued – Totals and by State/Territory

States/ 

Territories

# of 

Consultations 

to Facilities

# of 

Consultations 

to Individuals

# of Cases 

Closed/ 

Complainants

# of 

Community 

Education 

Sessions

# of 

Resident 

Council 

Meetings 

Attended

# of Family 

Council 

Meetings 

Attended

State - Estimated % of 

Total Paid Staff Time 

Spent on Laws, 

Regulations, 

Government Policies 

and Actions

Local - Estimated % of 

Total Paid Staff Time 

Spent on Laws, 

Regulations, 

Government Policies 

and Actions

50 States + 

DC & PR 127,068 402,030 128,091 10,170 21,211 1,788 N/A N/A

AK 215 448 296 39 2 0 10.0% 0.0%

AL 1,207 2,232 738 286 120 40 35.0% 21.0%

AR 451 9,142 847 221 166 56 15.0% 10.0%

AZ 4,429 7,879 1,789 126 453 25 35.0% 10.0%

CA 16,404 68,948 33,559 617 3,233 214 20.0% 15.0%

CO 6,117 8,904 2,293 588 1,292 32 40.0% 15.0%

CT 231 400 1,756 48 184 3 50.0% 20.0%

DC 149 1,215 344 94 123 27 30.0% 0.0%

DE* 315 98 553 7 10 0 15.0% 0.0%

FL 4,284 11,188 2,455 153 358 43 27.0% 18.0%

GA 4,141 9,741 2,471 193 215 24 15.0% 13.0%

HI* 1,501 1,534 71 30 4 1 25.0% 0.0%

IA 1,314 2,003 783 50 136 4 20.0% 2.0%

ID 736 1,539 569 72 94 7 35.0% 5.0%

IL 3,162 22,952 5,286 439 1,237 32 18.0% 2.0%

IN 1,911 5,746 823 43 62 15 30.0% 10.0%

KS 876 1,216 1,233 37 136 2 30.0% 10.0%

KY 4,090 13,805 3,582 1,686 1,026 111 25.0% 6.0%

LA 500 584 929 143 332 150 25.0% 10.0%

MA 1,254 2,232 3,207 157 188 25 40.0% 25.0%

MD 3,742 8,270 1,889 290 639 78 40.0% 7.0%

ME 576 754 1,227 66 26 1 35.0% 0.0%

MI 1,619 4,268 1,537 233 319 78 25.0% 15.0%

MN 2,129 5,436 970 63 309 74 46.0% 20.0%

MO 1,010 3,999 4,843 50 142 12 10.0% 10.0%

MS 1,749 1,883 1,151 70 307 19 40.0% 20.0%

MT 2,114 2,350 735 110 565 9 13.0% 5.0%

NC 2,747 5,785 2,031 575 109 18 13.0% 1.0%
NORC | Process Evaluation of the Long-Term Care Ombudsman Program (LTCOP)

FINAL REPORT | 157 

States/ 

Territories

# of 

Consultations 

to Facilities

# of 

Consultations 

to Individuals

# of Cases 

Closed/ 

Complainants

# of 

Community 

Education 

Sessions

# of 

Resident 

Council 

Meetings 

Attended

# of Family 

Council 

Meetings 

Attended

State - Estimated % of 

Total Paid Staff Time 

Spent on Laws, 

Regulations, 

Government Policies 

and Actions

Local - Estimated % of 

Total Paid Staff Time 

Spent on Laws, 

Regulations, 

Government Policies 

and Actions

ND 729 405 345 20 32 0 17.0% 3.0%

NE 642 1,495 683 15 69 5 30.0% 0.0%

NH 475 680 151 10 39 3 15.0% 0.0%

NJ 4,346 6,407 2,795 115 660 10 20.0% 0.0%

NM 720 894 1,906 10 11 4 15.0% 5.0%

NV 5,806 19,700 1,354 24 205 56 7.0% 0.0%

NY 2,993 43,768 885 240 2,541 274 15.0% 10.0%

OH 1,834 6,801 5,795 378 406 10 18.0% 2.0%

OK 678 1,998 1,957 170 39 6 40.0% 10.0%

OR 179 1,796 2,925 488 583 19 10.0% 0.0%

PA 3,821 14,307 1,401 947 1,516 31 30.0% 15.0%

PR 2,875 1,837 1,000 2 12 0 2.0% 0.0%

RI 3,594 783 339 31 4 4 27.0% 0.0%

SC 2,241 1,713 3,592 173 17 6 25.0% 5.0%

SD 551 233 376 20 79 1 40.0% 0.0%

TN 1,889 1,294 1,669 128 92 21 25.0% 10.0%

TX 5,029 21,789 14,535 201 1,015 107 35.0% 2.0%

UT 1,071 1,465 1,183 30 52 2 45.0% 5.0%

VA 1,636 11,417 2,106 196 471 64 65.0% 7.0%

VT 231 553 338 13 23 1 25.0% 5.0%

WA 11,390 47,063 2,865 153 662 42 55.0% 10.0%

WI 4,111 9,525 1,183 238 400 11 20.0% 15.0%

WV 1,010 1,251 546 34 457 11 5.0% 1.0%

WY 244 305 195 48 39 0 35.0% 0.0%

*2016 data 

** The counts in the first six columns combines the state and local counts of each activity. These counts were combined to capture all activity, regardless of level, that occurred within each state. 
NORC | Final Report 

FINAL REPORT | 158 

Appendix F: Complaint Dispositions

Table E: Complaint Dispositions – All Facilities (Nursing Homes and Board and Care Homes) 

States/ Territories

Requires 

government policy or 

regulatory change or 

legislative action to 

resolve

Withdrawn by 

resident or 

complainant

Referred to 

other agency 

for 

resolution30

No action 

needed or 

appropriate

Resolved to 

satisfaction of 

resident or 

complainant

Partially 

resolved but 

some 

problem 

remained

Resolved

/Partially 

resolved to 

satisfaction of 

resident or 

complainant

Not resolved 

to the 

satisfaction of 

resident or 

complainant

50 States + DC & 

PR 0.2% 4.8% 3.9% 12.8% 58.0% 15.3% 73.3% 5.0% 

AK 0.0% 1.2% 0.0% 0.0% 66.3% 31.5% 97.8% 1.0%

AL 4.7% 4.4% 9.1% 7.7% 57.6% 9.8% 67.4% 6.8%

AR 0.2% 0.9% 0.8% 9.5% 46.3% 19.7% 66.0% 22.5%

AZ 0.9% 1.4% 4.8% 7.2% 62.2% 17.7% 79.9% 5.8%

CA 0.1% 3.1% 1.9% 24.5% 51.4% 15.2% 66.6% 3.9%

CO 0.0% 9.4% 4.5% 4.9% 48.1% 25.7% 73.8% 7.3%

CT 0.0% 2.8% 11.1% 20.6% 37.7% 20.1% 57.9% 7.6%

DC 0.2% 2.3% 0.0% 0.2% 69.6% 25.0% 94.6% 2.6%

DE* 0.0% 0.3% 5.9% 7.1% 66.3% 18.3% 84.5% 2.2%

FL 0.1% 16.7% 2.1% 34.1% 38.4% 6.8% 45.2% 1.8%

GA 0.0% 8.4% 6.5% 15.0% 54.5% 12.0% 66.5% 3.6%

HI* 0.0% 8.8% 3.3% 19.1% 22.3% 35.8% 58.1% 10.7%

IA 0.0% 10.0% 2.8% 8.8% 43.8% 24.8% 68.7% 9.8%

ID 0.0% 6.5% 6.1% 16.0% 49.5% 17.1% 66.6% 4.8%

IL 0.2% 8.7% 5.3% 21.1% 48.3% 11.6% 59.9% 4.7%

IN 0.3% 5.8% 6.9% 25.0% 31.2% 24.3% 55.6% 6.5%

KS 0.0% 1.1% 2.6% 1.5% 65.5% 26.4% 91.9% 3.0%

KY 0.6% 1.4% 4.4% 2.7% 85.8% 3.8% 89.6% 1.4%

LA 0.0% 2.3% 11.1% 4.5% 78.6% 1.7% 80.3% 1.7%

MA 0.0% 6.8% 0.4% 19.1% 61.2% 8.4% 69.6% 4.0%

MD 0.0% 8.0% 4.7% 7.9% 42.8% 25.8% 68.6% 10.7%

ME 0.0% 3.1% 0.5% 0.0% 90.7% 4.5% 95.2% 1.2%

MI 0.1% 3.5% 10.2% 4.6% 56.3% 18.3% 74.6% 7.0%

 

30 Note that the “Referred to other agency for resolution” variable combines three fields: Report of final disposition not obtained (3.9%); Other agency failed to act on complaint (0.2%); and 

Agency did not substantiate complaint (0.8%).
NORC | Final Report 

FINAL REPORT | 159 

States/ Territories

Requires 

government policy or 

regulatory change or 

legislative action to 

resolve

Withdrawn by 

resident or 

complainant

Referred to 

other agency 

for 

resolution30

No action 

needed or 

appropriate

Resolved to 

satisfaction of 

resident or 

complainant

Partially 

resolved but 

some 

problem 

remained

Resolved

/Partially 

resolved to 

satisfaction of 

resident or 

complainant

Not resolved 

to the 

satisfaction of 

resident or 

complainant

MN 0.5% 4.6% 5.8% 7.0% 44.3% 26.6% 70.9% 11.3%

MO 0.1% 4.6% 2.0% 13.2% 37.7% 36.8% 74.5% 5.6%

MS 0.1% 1.8% 5.9% 4.1% 75.6% 8.6% 84.3% 3.9%

MT 0.0% 3.8% 6.2% 8.6% 51.3% 16.5% 67.8% 13.6%

NC 0.1% 11.0% 8.0% 16.6% 55.8% 5.4% 61.2% 3.1%

ND 1.8% 7.7% 7.5% 4.3% 37.5% 24.9% 62.3% 16.4%

NE 0.3% 2.1% 0.7% 3.0% 51.0% 28.3% 79.3% 14.5%

NH 0.0% 3.6% 4.4% 4.0% 77.0% 10.3% 87.3% 0.8%

NJ 0.0% 2.1% 0.7% 0.7% 86.6% 8.7% 95.3% 1.2%

NM 0.0% 2.9% 5.0% 3.3% 44.1% 30.4% 74.5% 14.2%

NV 0.0% 0.3% 3.7% 15.4% 74.3% 4.3% 78.6% 2.0%

NY 0.1% 2.1% 1.7% 10.0% 58.9% 17.6% 76.5% 9.7%

OH 0.2% 10.6% 1.0% 11.2% 65.5% 9.9% 75.5% 1.5%

OK 0.0% 14.1% 0.3% 0.4% 52.0% 22.8% 74.9% 10.3%

OR 0.9% 8.5% 6.2% 18.3% 45.9% 13.3% 59.2% 6.9%

PA 0.0% 4.5% 4.1% 11.6% 57.3% 17.5% 74.9% 5.0%

PR 0.0% 0.8% 0.2% 5.8% 80.4% 0.4% 80.8% 12.5%

RI 0.0% 4.9% 16.4% 19.4% 40.3% 10.5% 50.8% 8.5%

SC 1.1% 3.2% 12.8% 2.5% 79.3% 0.6% 80.0% 0.5%

SD 0.0% 8.1% 6.2% 9.7% 47.2% 17.2% 64.4% 11.6%

TN 0.0% 1.9% 4.8% 9.3% 64.7% 17.1% 81.8% 2.2%

TX 0.0% 1.3% 1.0% 3.4% 75.7% 15.4% 91.1% 3.3%

UT 0.0% 3.5% 8.4% 13.0% 61.4% 11.0% 72.3% 2.7%

VA 0.0% 2.6% 2.6% 5.3% 54.7% 23.6% 78.3% 11.2%

VT 0.0% 7.1% 2.1% 0.9% 73.8% 13.4% 87.3% 2.6%

WA 0.1% 4.7% 7.6% 10.1% 55.0% 16.6% 71.6% 5.8%

WI 0.1% 3.0% 8.5% 10.9% 24.6% 41.4% 66.0% 11.4%

WV 0.3% 5.4% 2.7% 12.9% 58.0% 14.4% 72.5% 6.2%

WY 0.0% 6.6% 11.5% 4.4% 55.7% 17.5% 73.2% 4.4%

*2016 data 
NORC | Final Report 

FINAL REPORT | 160 

Table F: Complaint Dispositions – Nursing Homes

States/ 

Territories

Requires government 

policy or regulatory 

change or legislative 

action to resolve

Withdrawn by 

resident or 

complainant

Referred to 

other agency 

for 

resolution31

No action 

needed or 

appropriate

Resolved to 

satisfaction 

of resident or 

complainant

Partially 

resolved 

but some 

problem 

remained

Resolved/

Partially resolved 

to satisfaction of 

resident or 

complainant

Not resolved 

to the 

satisfaction 

of resident or 

complainant

50 States + 

DC & PR 0.1% 4.8% 3.4% 12.5% 58.7% 15.7% 74.4% 4.7%

AK 0.0% 3.1% 0.0% 0.0% 74.2% 21.5% 95.7% 1.2%

AL 4.3% 4.6% 8.3% 7.9% 57.9% 9.7% 67.6% 7.3%

AR 0.2% 0.9% 0.8% 9.2% 45.3% 19.7% 65.1% 23.8%

AZ 0.3% 1.4% 3.7% 6.3% 64.0% 19.3% 83.4% 4.8%

CA 0.1% 3.0% 1.5% 26.3% 51.9% 13.9% 65.8% 3.4%

CO 0.0% 11.3% 4.4% 5.1% 45.3% 27.2% 72.5% 6.6%

CT 0.0% 2.7% 11.1% 20.4% 37.9% 20.1% 58.1% 7.7%

DC 0.0% 3.7% 0.0% 0.4% 64.8% 28.5% 93.3% 2.6%

DE* 0.0% 0.0% 6.1% 7.3% 67.8% 16.5% 84.3% 2.3%

FL 0.0% 17.6% 1.4% 31.4% 39.6% 8.4% 48.0% 1.7%

GA 0.0% 8.5% 4.7% 13.4% 57.3% 12.4% 69.7% 3.6%

HI* 0.0% 11.6% 3.6% 18.8% 25.0% 33.0% 58.0% 8.0%

IA 0.0% 10.7% 2.5% 8.8% 45.0% 24.0% 69.0% 9.0%

ID 0.0% 5.3% 8.0% 16.5% 45.7% 19.5% 65.2% 5.0%

IL 0.2% 8.6% 5.3% 21.0% 48.9% 11.5% 60.3% 4.5%

IN 0.1% 5.2% 6.6% 27.8% 29.7% 24.3% 54.0% 6.3%

KS 0.0% 1.3% 2.5% 1.5% 65.7% 26.2% 91.9% 2.8%

KY 0.6% 1.3% 4.0% 2.2% 86.5% 3.9% 90.5% 1.4%

LA 0.0% 2.4% 11.1% 4.2% 78.8% 1.7% 80.5% 1.8%

MA 0.0% 6.7% 0.5% 19.0% 61.4% 8.4% 69.9% 4.0%

MD 0.0% 7.5% 3.2% 6.9% 44.4% 27.1% 71.6% 10.9%

ME 0.0% 3.0% 0.4% 0.0% 90.8% 4.8% 95.6% 1.1%

MI 0.1% 3.4% 9.3% 4.5% 58.1% 17.9% 76.0% 6.7%

MN 0.5% 4.5% 5.6% 7.0% 44.5% 26.1% 70.6% 11.9%

MO 0.1% 4.4% 1.9% 13.6% 38.0% 36.9% 74.9% 5.0%

MS 0.1% 1.9% 6.0% 3.8% 75.9% 8.4% 84.3% 3.9%

 

31 Note that the “Referred to other agency for resolution” variable combines three fields: Report of final disposition not obtained (2.8%); Other agency failed to act on complaint (0.1%); and 

Agency did not substantiate complaint (0.6%).
NORC | Final Report 

FINAL REPORT | 161 

States/ 

Territories

Requires government 

policy or regulatory 

change or legislative 

action to resolve

Withdrawn by 

resident or 

complainant

Referred to 

other agency 

for 

resolution31

No action 

needed or 

appropriate

Resolved to 

satisfaction 

of resident or 

complainant

Partially 

resolved 

but some 

problem 

remained

Resolved/

Partially resolved 

to satisfaction of 

resident or 

complainant

Not resolved 

to the 

satisfaction 

of resident or 

complainant

MT 0.0% 3.3% 5.0% 8.1% 50.7% 16.0% 66.7% 17.0%

NC 0.0% 10.2% 7.3% 14.4% 59.1% 5.9% 65.0% 3.2%

ND 0.0% 7.1% 6.9% 4.0% 42.3% 24.0% 66.3% 15.7%

NE 0.5% 1.7% 0.6% 3.2% 51.3% 28.7% 80.0% 13.9%

NH 0.0% 4.5% 5.1% 1.7% 78.5% 9.6% 88.1% 0.6%

NJ 0.0% 1.9% 0.7% 0.8% 87.2% 8.1% 95.3% 1.3%

NM 0.0% 3.1% 5.6% 3.2% 42.6% 30.7% 73.3% 14.8% 

NV 0.0% 0.4% 0.7% 15.6% 75.9% 5.3% 81.3% 2.0%

NY 0.1% 2.1% 1.4% 10.8% 58.9% 17.2% 76.1% 9.6%

OH 0.1% 10.8% 0.9% 11.2% 65.7% 9.8% 75.5% 1.5%

OK 0.0% 14.6% 0.3% 0.4% 51.3% 23.3% 74.6% 10.0%

OR 0.4% 9.8% 6.8% 16.5% 47.7% 13.0% 60.7% 5.9%

PA 0.0% 5.3% 3.1% 12.0% 55.0% 19.7% 74.7% 4.9%

PR 0.0% 0.0% 0.0% 0.0% 100.0% 0.0% 100.0% 0.0%

RI 0.0% 5.3% 15.1% 20.7% 39.9% 10.6% 50.5% 8.4%

SC 0.4% 4.0% 11.7% 2.8% 80.1% 0.5% 80.6% 0.5%

SD 0.0% 6.0% 7.5% 10.7% 47.6% 17.0% 64.6% 11.2%

TN 0.0% 1.6% 4.1% 8.9% 66.0% 17.5% 83.5% 1.9%

TX 0.0% 1.1% 0.9% 3.3% 75.2% 16.3% 91.5% 3.3%

UT 0.0% 4.3% 8.6% 12.7% 61.0% 11.0% 72.0% 2.3%

VA 0.0% 2.2% 2.6% 4.8% 56.1% 23.6% 79.7% 10.6%

VT 0.0% 4.9% 1.9% 1.0% 74.7% 14.3% 89.0% 3.2%

WA 0.0% 4.2% 6.1% 8.4% 58.6% 17.2% 75.8% 5.5%

WI 0.1% 2.8% 6.5% 11.2% 24.2% 45.3% 69.5% 9.8%

WV 0.1% 5.7% 2.1% 11.3% 59.9% 15.0% 74.9% 5.8%

WY 0.0% 6.7% 10.7% 4.0% 56.0% 18.0% 74.0% 4.7%

*2016 data 
NORC | Final Report 

FINAL REPORT | 162 

Table G: Complaint Dispositions – Board and Care Homes

States/ Territories

Requires 

government policy 

or regulatory 

change or 

legislative action to 

resolve

Withdrawn by 

resident or 

complainant

Referred to 

other agency 

for 

resolution32

No action 

needed or 

appropriate

Resolved to 

satisfaction 

of resident or 

complainant

Partially 

resolved 

but some 

problem 

remained

Resolved/

Partially 

resolved to 

satisfaction of 

resident or 

complainant

Not resolved 

to the 

satisfaction of 

resident or 

complainant

50 States + DC & 

PR 0.4% 4.9% 5.1% 13.7% 55.9% 14.4% 70.3% 5.7%

AK 0.0% 0.3% 0.0% 0.0% 62.3% 36.5% 98.8% 0.9%

AL 7.4% 2.7% 15.5% 6.1% 55.4% 10.1% 65.5% 2.7%

AR 0.0% 1.3% 1.3% 12.1% 54.4% 19.5% 73.8% 11.4%

AZ 1.5% 1.4% 5.9% 8.2% 60.2% 16.0% 76.3% 6.7%

CA 0.1% 3.3% 2.7% 20.8% 50.4% 17.9% 68.2% 4.9%

CO 0.0% 5.8% 4.7% 4.3% 53.6% 22.8% 76.4% 8.8%

CT 0.0% 3.7% 14.8% 35.2% 25.9% 20.4% 46.3% 0.0%

DC 0.6% 0.0% 0.0% 0.0% 77.6% 19.3% 96.9% 2.5%

DE* 0.0% 1.6% 4.8% 6.5% 59.7% 25.8% 85.5% 1.6%

FL 0.3% 15.9% 2.8% 36.7% 37.2% 5.2% 42.4% 1.9%

GA 0.0% 8.2% 11.5% 19.3% 46.8% 10.8% 57.6% 3.4%

HI* 0.0% 5.8% 2.9% 19.4% 19.4% 38.8% 58.3% 13.6%

IA 0.0% 6.6% 4.1% 8.7% 38.8% 28.5% 67.4% 13.2%

ID 0.0% 7.2% 5.2% 15.6% 51.5% 15.8% 67.3% 4.7%

IL 0.1% 9.4% 5.5% 21.7% 45.5% 12.0% 57.5% 5.9%

IN 1.8% 9.2% 8.6% 6.1% 41.7% 24.5% 66.3% 8.0%

KS 0.0% 0.0% 2.6% 1.5% 64.5% 27.2% 91.7% 4.2%

KY 0.6% 1.8% 6.9% 5.4% 80.8% 3.2% 84.0% 1.3%

LA 0.0% 0.0% 11.1% 13.3% 73.3% 2.2% 75.6% 0.0%

MA 0.7% 11.6% 0.0% 23.9% 52.9% 8.0% 60.9% 2.9%

MD 0.1% 10.1% 10.7% 11.8% 36.5% 21.0% 57.5% 9.9%

ME 0.0% 3.3% 0.6% 0.0% 90.6% 3.9% 94.5% 1.7%

MI 0.4% 4.3% 19.6% 5.3% 37.0% 22.8% 59.8% 10.7%

MN 0.6% 4.9% 6.3% 7.0% 43.9% 27.7% 71.6% 9.6%

MO 0.2% 7.1% 4.0% 7.5% 33.8% 34.4% 68.3% 12.9%

 

32 Note that the “Referred to other agency for resolution” variable combines three fields: Report of final disposition not obtained (4.0%); Other agency failed to act on 

complaint (0.3%); and Agency did not substantiate complaint (0.8%).
NORC | Final Report 

FINAL REPORT | 163 

States/ Territories

Requires 

government policy 

or regulatory 

change or 

legislative action to 

resolve

Withdrawn by 

resident or 

complainant

Referred to 

other agency 

for 

resolution32

No action 

needed or 

appropriate

Resolved to 

satisfaction 

of resident or 

complainant

Partially 

resolved 

but some 

problem 

remained

Resolved/

Partially 

resolved to 

satisfaction of 

resident or 

complainant

Not resolved 

to the 

satisfaction of 

resident or 

complainant

MS 0.0% 1.3% 4.5% 7.1% 72.7% 11.0% 83.8% 3.2%

MT 0.0% 4.6% 8.2% 9.5% 52.3% 17.3% 69.6% 8.0%

NC 0.3% 12.1% 9.1% 19.6% 51.2% 4.7% 56.0% 2.9%

ND 5.7% 8.9% 8.9% 5.1% 26.8% 26.8% 53.5% 17.8%

NE 0.0% 3.1% 0.8% 2.7% 50.2% 27.4% 77.6% 15.8%

NH 0.0% 1.3% 2.7% 9.3% 73.3% 12.0% 85.3% 1.3%

NJ 0.0% 2.8% 0.6% 0.5% 83.9% 11.4% 95.3% 0.9%

NM 0.0% 2.5% 3.9% 3.5% 47.3% 29.8% 77.0% 13.1%

NV 0.0% 0.2% 7.6% 15.1% 72.2% 3.0% 75.2% 2.0%

NY 0.0% 2.1% 3.7% 3.7% 59.2% 20.9% 80.1% 10.5%

OH 0.3% 9.9% 1.8% 11.2% 64.9% 10.3% 75.2% 1.7%

OK 0.0% 10.0% 0.6% 0.0% 58.2% 18.9% 77.1% 12.3%

OR 1.2% 7.7% 5.9% 19.4% 44.9% 13.5% 58.4% 7.5%

PA 0.0% 2.7% 6.5% 10.5% 62.7% 12.5% 75.2% 5.1%

PR 0.0% 0.8% 0.2% 5.8% 80.2% 0.4% 80.7% 12.5%

RI 0.0% 2.6% 23.1% 12.8% 42.3% 10.3% 52.6% 9.0%

SC 2.4% 1.7% 14.8% 1.9% 77.8% 0.9% 78.7% 0.5%

SD 0.0% 13.9% 2.8% 6.9% 45.8% 18.1% 63.9% 12.5%

TN 0.0% 2.9% 7.4% 10.8% 59.9% 15.6% 75.5% 3.4%

TX 0.0% 2.0% 1.4% 3.9% 78.0% 11.5% 89.4% 3.4%

UT 0.0% 2.2% 8.2% 13.6% 61.8% 10.9% 72.8% 3.3%

VA 0.0% 3.6% 2.7% 6.6% 50.8% 23.7% 74.4% 12.7%

VT 0.0% 12.9% 2.6% 0.9% 71.6% 11.2% 82.8% 0.9%

WA 0.1% 5.3% 9.5% 12.3% 50.7% 15.9% 66.6% 6.3%

WI 0.1% 3.3% 11.5% 10.6% 25.2% 35.6% 60.9% 13.7%

WV 1.6% 3.9% 6.2% 22.5% 46.5% 10.9% 57.4% 8.5%

WY 0.0% 6.1% 15.2% 6.1% 54.5% 15.2% 69.7% 3.0%

*2016 data