. 

\ 

Department of Health and Human 
 Servces 

OFFICE OF


INSPECTOR GENERAL


SUCCESSFUL OMBUDSMAN PROGRAMS


Vl. 

Richard P. Kusserow 

INSPECfOR GENERA 11 

oIa JU 1991 
, - l' 

OFFICE OF INSPECTOR GENERAL


The mission of the Offce of Inspector Genera (OIG), as madated by Public Law 95-452, as amended, is to protect the integrty of the Depanent of Health and Human Services ' (HHS) progrs as well as the health and welfare of beneficiares served by those progrs. This 

statutory mission is cared out though a nationwide network of audits, investigations, and 

inspections conducted by thre OIG operating components: the Offce of Audit Services, the 

Office of Investigations, and the Offce of Evaluation and Inspections. The OIG also infonns the 

Secretar of HHS of progr, and maagement problems, and recommends courses to correct 

them. 

OFFICE OF AUDIT SERVICES 

The OIG' s Offce of Audit Services (OAS) provides all auditig services for HHS, either by conducting audits with its own audit resources or by overseeing audit work done by others. 

Audits examne the perfonnance of HHS program and/or its grantees and contractors in caring out their respective responsibilities and ar intended to provide independent assessments of HHS programs and operations in order to reduce waste, abuse, and mismanagement and to promote economy and effciency throughout the Depanment. 

OFFICE OF INVESTIGATIONS 

The OIG' s Office of Investigations (01) conducts crmial, civil, and admisttative 

investigations of allegations of wrongdoing in HHS programs or to HHS beneficiares and of 

unjust enrchment by providers. TIe investigative efforts of 01 lead to criminal convictions 

administrative sanctions, or civil money penalties. The 01 also oversees State Medicaid fraud 

control units which investigate and prosecute fraud and patient abuse in the Medicaid program. 

OFFICE OF EVALUATION AND INSPECTIONS 

The OIG' s Office of Evaluation and Inspections (OEI) conducts short-tenn management and 

program evaluations (called tnspections) that focus on issues of concern to the Depanmem, the Congress, and the public. The findings and recommendations contaned in these inspection 

repons generate rapid, accurate, and up-to-dte infonnation on the effciency, vulnerability, and effectiveness of depanmemal programs. This study was conducted in the New York Regional 

Offce under the diection of Thomas F. Tully, Regional Inspector General, Region II, Office of Evaluation and Inspections and Alan S. Meyer, Deputy Regional Inspector General. 

Panicipating in the project were the following people: 

Renee C. Schlesinger (Project Leader) Alan S. Levine,
 Headquarters Demetta Arpakos Thomas A. Purvis, San Francisco 

Nancy Harson 

Raul Manynek 
. , ..

Department of Health and Human Servces


OFFICE OF


INSPECTOR GENERAL


SUCCESSFUL OMBUDSMAN PROGRAMS


VlCI. 

Richard P. Kusserow 

INSPECfOR GENERAL I' 

~oIa OEI-02-90-02120 
EXECUTIVE SUMMARY


PURPOSE 

The purose of this inspection is to determne the charcteristics of successful State long term 

care ombudsman progrs. 

BACKGROUND 

The State Long Term Care Ombudsman progr was established in response to growing 

concern over the poor quality of care in nursing homes. The Act requires each State Unit on 

Aging to establish and operate, either diectly or under conttact, an Ombudsman program. In 

1981, the Ombudsman program was extended to board and car facilities. 

The ombudsman is to be an advocate of the institutionalized elderly to ensure that they have a 

vigorous voice in their own tteatment and care. Some activities include investigating and 

resolving complaints on behalf of elderly residents of long term care facilities, infonning 

residents of their legal rights and providing information on long term care issues to public 

agencies, legislatures and the community-at-large. Most of the State Ombudsman programs 

operate under the diect auspices of their State s Unit on Aging. 

In October 1988, the AoA funded the formation of the National Center for State Long Term Care 

Ombudsman Resources to provide training, technical assistance and information exchange on 

long term car and ombudsmen issues to ombudsmen. 

METHODOLOGY 

This inspection included the following activities: 52 telephone interviews with ombudsmen 

from all States, the Distrct of Columbia (DC) and Puerto Rico (PR); onsite visits with six State 

Ombudsman programs involving interviews with the ombudsman, sub-State program officials, 

- directors of the State Units on Aging, advocacy groups and/or other experts in the field (28). 

Additionally, the State ombudsman programs were rated on their responses to certain criteria for 

visibility and complaint resolution obtained from the telephone interviews. 

FINDINGS 

Twelve programs (CA, CO, DE, DC, KY, LA, MA, MI, NM, OH, OR and TX) were identified 

as the most successful based on the information obtained from telephone surveys, onsite visits 

and the use of scoring criteria. 
The Most Successful Programs Are Highly Visible 

Through the use of paid staf and volunteers, these programs visit facilities very frequently, 

typicaly weekly. These visits famliarze residents with the ombudsman personally and the 

progr in genera. In conttast, the remaining 39 programs are not nearly as likely to visit as 

often. 

While the successful programs increase their visibility with the assistance of volunteers, nine 

volunteers. Some less successful States have volunteers in some 

regions of the State, but not in others. The top States are effective in recruiting, ttaining and 

retaning volunteers. Paid staf playa major role in their efforts to recruit, ttain, supervise and 

maintan volunteers. 

other programs have no 

Successful progrs make themselves very visible in the aging community through the use of 

posters or brochures, publicized toll-fre numbers and community outreach efforts. 

Successful progrs respond onsite to potentially life-threatening complaints within 24 hours; 

all but three of the top programs actually respond to all complaints, both life-threatening and non 

life-theatening within 24 hours. In conttast, alost 20 percent of the ombudsmen from the 39 

remaining States require from three days to a week to respond to potentially life-threatening 

complaits. 

Successful Programs Obtain Adequate Funding And Support 

All States link adequate funding with having more professional staf, which allows them to visit 

facilities more frequently; to improve response time to complaints; to ttain and supervise staff 

and volunteers, and to become more involved in legislative planning and decision-makng. Most 

States would give priority to hirng more professional staff if additional funds were made 

available. 

Many successful State ombudsmen enhance their budgets through innovative fund-raising 

techniques. Some use traditional methods such as bake sales, auctions and $100-a-plate dinners, 

while others have developed more sophisticated approaches. 

Strong enabling legislation, legal support, independence and other intangible factors are 

considered important for success. 

Ombudsmen Want Additional Support 

Ombudsman generally feel the National Resource Center is helpful, but would like, the Center to 

get more involved in ttaining, as well as become more active in circulating information about 

best practices and other ombudsman issues. 

Ombudsmen would also like more direct involvement with AoA; including an AoA focal point. 
. ,

RECOMMENDATIONS 

The Admisttation on Agig should work with the States in addressing the concerns of the 

ombudsmen by: 

Developing model operational guidelines in aras such as frequency of visits; staff-to-bed 

ratios; volunteer-to-bed ratio; complait response time; complaint resolution percentages; 

recruitment, trning and retention of staff and volunteers; and program publicity. 

Providing technical assistace regarding the use of volunteers, fund-raising, obtaining 

legal support, confidentiality and other areas of concern. 

Assuring that information about successful program and effective techniques (including 

that obtained in this inspection) is dissemiated to States in a systematic and detailed way 

with recommendations for implementation. 

Responding to the concerns of ombudsmen about sttengthening the role of the Resource 

Center. 

COMMENTS 

Comments received from AoA were generally supportve of our findings and recommendations. 

However, AoA is concerned that we do not acknowledge the extent to which the National 

Resource Center is involved in supporting the Long Tenn Car Ombudsman Program. We 

should note that it was not within the scope of our study to evaluate the Center, itself, but rather 

to obtain the sentiments of the ombudsmen regarding the Center. We have added AoA' 

information about the Center to the background of the report. It may be helpful for AoA to 

communicate more fully with ombudsmen about the activities of the Resource Center. 

The comments of AoA essentially respond to the study recommendations. These comments are 

in Appendix A. 
, ...... .... .. .... .................. ...................... .. .......................... ...................... ................... .................. ............................................. ............................... .. .... ........ .... .. ...... ..

TABLE OF CONTENTS


EXECUTIV SUMMARY 

INTRODUCTION.......... ...... 

Purpose................................................................................. 


Background.................................................................................... ......................


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


FINDINGS................................................................................................................. 


The most successful programs are highly visible................................................. 

Successful progrs obtain adequate funding and support ................................ 

Ombudsmen want additional support.... 

RECO MMENDA TIO NS 

Comments.......................................................................................................... l 0


APPENDIX A: COMMENTS TO DRAFT REPORT 
 ....................................... A­

, ,

INTRODUCTION


PURPOSE 

The purpose of this inspection is to determne the charcteristics of successful State long term 

care ombudsman progrs. 

BACKGROUND 

History 

The State Long Term Care Ombudsman program was established under the Older American 

Act (OAA) in response to growing concern over the poor quality of car in nursing homes. The 

ombudsman was to be an advocate of the institutionalzed elderly to ensure that they have a 

vigorous voice in their own treatment and care. The Ombudsman program is modeled after a 

similar progr in Scandiavian countres. 

In 1972, the Admnistrtion on Aging (AoA) awarded seven States conttacts to car out long 

term care ombudsman demonstration projects. In 1975, amendments to the OAA authorized 

AoA to make grants for all States to have ombudsman projects. Further amendments in 1978 

required each State Unit on Aging to establish and operate, either directly or under contract, an 

Ombudsman program. In 1981 , the Ombudsman program was extended to board and care 

facilities. 

Prior to FY 1987 the OAA required States to spend at least one percent of their supportive 

services allotment under Title Ill-B of the OAA or $20,00, whichever was greater, to support 

statewide ombudsman activities. Based on amendments in 1987 States must in the future spend 

at least as much on the Ombudsman program as they did in FY 1987, as long as Federal 

allotments continue above 1987 levels. 

Role of ombudsman 

Ombudsmen conduct a varety of activities in the long-term care community. They investigate 

and resolve complaints on behalf of elderly residents of long term car facilities concerning 

matters that may adversely affect their health, safety, welfar or rights. They also inform 

residents of their legal rights and provide information on long term care issues to public 

agencies, legislatures and the community-at-large. They trn volunteers and promote the 

development of grass roots organizations to assist long term care residents. Additionally, they 

monitor the development and implementation of Federal, State and local laws relating to long 

term care. 

Most of the State Ombudsman programs operate under the diect auspices of their Stare s Unit on 

Aging, which assures that OAA requirements are met. Most States also have sub-State 
. ,

Ombudsman progrs. These are progrs in varous aras of the State that have ombudsman 

responsibilties. These ar either managed directly by the State or are sponsored by a varety of 

organizations, including Ara Agencies on Aging, other sub-State governmental units, citizen 

advocacy committees and private, non-profit organizations. 

National Center for State Long Term Care Ombudsman Resources 

In October 1988, the AoA funded the formation of the National Center for State Long Term Care 

Ombudsman Resoures (caled the Resource Center). The center is admnistered by cooperative 

agreement with the National Association of State Units on Aging (NASUA), which operates it 

cooperatively with the National Citizens Coalition for Nuring Home Reform. The Center 

provides ttning, technical assistance and information exchange on long term care and 

ombudsmen issues. 

The goal of the Center is to enhance the capacity of the nation s State Units on Aging in the 

design, development and admnistrtion of Statewide Ombudsman Programs. The Center priar focus is on building Statewide systems of ombudsman services to address the issues 

facing older residents in long term car facilties. 

Durg its fIrst two years, the center initiated a number of activities including: development of a 

State Ombudsman Resource Manual; multi-regional teleconferences for information sharng 

with and among States; a National Traning Conference for Ombudsman and State staff; training 

modules for States to use in ttaining local ombudsmen; simplified guides to OBRA legislation; a 

bi-monthly Center newsletter called the "Ombudsman Reporter ; and, the production of a video 

to inttoduce the Ombudsman Progrm to the genera public that wil also serve as viable 

recruitment tool. 

National Association of State Long Term Care Ombudsman Programs 

The National Association of State Long Term Care Ombudsman Programs, established to 

provide a common voice for all S tate Ombudsman programs, informs ombudsmen of 

opportnities available through Federal sources, panicularly the AoA. It also promotes the 

sharng of ideas and experiences among State ombudsman staf. 

Prior Studies 

The National Center for State Long Term Care Ombudsman Resources recently completed two 

studies on the Ombudsman program. The first surveyed all State ombudsmen regarding their use 

of volunteers and found the recruitment of volunteers to be the most difficult management task. 

The second study, which examined ombudsmen involvement in board and care found it 

insufficient. It reported that the degree to which ombudsmen work with board and care is 

dependent upon the number of total licensed facilities and the number of paid and volunteer staff 

in the State.


Three recent OIG studies have touched upon the activities of the Ombudsman program, one 

entitled "Board and Care Homes" (OEI-02- 89-0l860) and two others entitled "Resident Abuse 
in Nursing Homes" (OEI-06-88-00360 and OEI-06-88-O361). The fIrt found varability in the 

level of service delivery among Ombudsman progrs; the latter two identifed weakesses in 

State complaint-reportng systems and reponed that ombudsmen consider many areas of patient 

abuse and neglect to be serious problems in nursing homes. 

The Genera Accounting Offce (GAO) and the House Select Commttee on Agig have issued 

reports on board and car homes which address the role of the ombudsman in those facilities; 

both found that the ombudsman does not always get involved when abuse and neglect occur in 

board and car homes. 

The ombudsmen from Louisiana and Massachusetts presented a repon at a conference in June 

1990 to the Senate Special Commttee on Aging entitled "Capacities of the State Long Term 

Care Ombudsman Progrs." Their conclusions were that: (1) Federa funds are distrbuted to 

the States according to a formula that does not correspond to the number of clients ombudsmen 

serve; (2) stafng levels between State Ombudsman program var; and (3) Ombudsmen believe 

they are severely limited by fiscal and personal constraints. 

The Ohio State ombudsman presented a paper at the same conference identifying three barers 

to effective advocacy: (1) the unspecified role of Area Agencies on Aging in monitoring the 

Ombudsman progrm; (2) difficulty in maintaining confidentiality; and (3) the limited provision 

of legal representation to ombudsmen. 

METHODOLOGY 

This inspection was conducted in three phases. Firt, ombudsmen from all States, the Distrct of 

Columbia (DC) and Pueno Rico (PR) were interviewed by telephone and asked to identify some 

programs they felt were the most successful across the countr and best practices for certain 

ombudsman activities. They were also asked to suggest criteria for successful progrs; describe and assess the dissemination of such information; and to recommend the most effective 

way to use ombudsman funds. 

Second, based on the above discussions, on the results of a literature review and on the 

recommendations of expens in the field, six State Ombudsman progrs (CA, DC, MA, MI, NJ 

and OH) were selected for onsite visits. Four (CA, MA, MI, OH) received the most votes from 

other ombudsmen as representing a model program. The other two (DC, NJ), also well regarded. 

were selected primarly because of their unique featurs: the NJ progr is one of the few that is 

located in an independent State agency and has a sttong enforcement focus; DC conttacts out all 

its services to the American Association of Retied Persons (AARP). Discussions were held 

during onsite visits with the State Ombudsman, sub-State program offcials, directors of the State 

U nits on Aging, advocacy groups and/or other experts in the field. These discussions provided 

information on why these State programs are effective and how they overcame barers. In all 

28 interviews were conducted onsite. 

Additionally, 51 State ombudsman programs (one was not included due to lack of information) 

were rated on their responses to certain criteria for visibility and complaint resolution which 
were obtained from the telephone interviews. Visibility crteria included the frquency of visits 

to each facilty annually, the ratio of professional staf to the number of long term care facility 

beds, and the ratio of volunteers to beds. 

Based on the frequency distrbution of each, every State s perfonTance was scored from high to 

low. The same was done with complaint resolution criteria which dealt with response time to 

both life thatening and less serious complaints, and the percentage of complaints resolved. The 

number of votes each State program received from other ombudsmen as being a model State was 

incOIporated into the score. All the scores were then totalled to obtain a final score for each 

State. 
FINDINGS


Twelve programs (CA, CO, DE, DC, KY LA, MA, MI, NM, OH, OR and TX) were 

identifed as the most successful based on the informtion obtained from 

telephone surveys, onsite visits and on the use of scoring criteria. The 12 most

successful programs included the top four selected for onsite visitation. This is 

not to say that there are not some very goodfeatures in other programs. In fact 

25 scored as moderately successful, while 14 scored as least successful. In 

discussing the findings, however, the moderate and least successful are grouped 

together when contrasts are mae to the successful programs. Thefollowing 

findings characterize the key features of the 12 most successful programs.

Additionally, an indepth case study analysis of the onsite visits wil be reported in 

a subsequent inspection report. 

THE MOST SUCCESSFUL PROGRAMS ARE HIGHLY VISIBLE 

They visit facilties very frequently. 

Through the use of both paid staff and an extensive volunteer program, these programs typically 

make weekly visits to all nursing homes in their States. These visits ar proactive in nature and 

are intended priarly to familarze residents with the ombudsman personally and the program 

in general. During these visits the ombudsmen speak to residents and staff and identify 

complaits. The hope is that their presence may prevent futu problem situations. As one 

ombudsman said, "the ombudsman concept is to be omnipresent in facilties." An ombudsman 

from New England stated, "Our regular presence has had enonnous impact on the qualty of care 

in facilities. We effect change, accomplish systematic change which reflects a good program. 

One local program assigns a volunteer to each facilty in its region to provide this regular 

presence. 

In contrst, the remaining 39 programs ar not nearly as likely to visit as often. Nineteen (49 

percent) visit nursing homes only four times a year or less, while six programs (15 percent) 

respond to complaints only, bUt do not make routine visits. In those States there are many 

residents who never see an ombudsman. A total of nine (23 percent) of the less successful States 

make monthly visits and five (13 percent) report visitig al nursing homes weekly. As an 

ombudsman from a small rural State said, "When we get to homes we do really good work, but 

we are not in homes as much as I want to be." 

While the successful programs are able to increase their visibilty with the assistan e of 

volunteers, nine other progrms have no volunteers. One ombudsman from the Midwest

reported, "Our Legislature has mandated we not use volunteers." States without volunteers 

appear to be more limited in their ability to make routine visits. Five visit one to four times a 

year, three only respond to complaints and the last makes monthly visits. Some less successful 

States have volunteers in some regions of the State, but not in others. An ombudsman from the 
, 

Southwest said, "In the facilties where we have volunteers we ar making a dent, there s a lot 

out there we ar not addrssing. 

Top States are effective in recruiting, training and retaining volunteers. 

In these States good recruitment involves targeting the right audience at both the State and local 

levels, with an excellent source being the elder network. These programs often tap the services 

of the AARP, which helps State ombudsmen by mailing volunteer information to its members 

and asking people to join the ombudsman effort. Another effective source is the word-of-mouth 

recruitment efforts of their curnt volunteers who ar able to communicate to others the realities 

of the job. When successful ombudsmen recruit volunteers, they are honest about the demands 

of the work from the beginning. One successful State program is able to recruit lawyers who 

donate their services. 

These top States consider extensive ttning and staf support vital in order for volunteers to be 

effective. Several have detailed volunteer training manuals. One State has incorporated its 

volunteer training guidelines in legislation. It also employs a tiered approach with increased 

ttning hours linked to increased responsibilty levels, a way to build a career ladder. 

Paid staf playa major role in the volunteer effort. One ombudsman said If you don t have 

paid sta, you don t have a volunteer program. " Many ombudsmen feel that volunteers need as 

much, if not more, supervision and backup as other staff members. Some ombudsmen express 

the need for additional staff in order to recruit, ttn, supervise and maintain volunteers. One 

reflected the feelings of others when she said, " We rely heavily on volunteers but we need good 

staf to supervise them.


Good volunteer progrs retain workers by recognizing their worth. They treat the volunteers 

the same as the paid staff, have the same expectations of them and honor them with special 

awards and ceremonies. 

The best programs are highly publicized. 

Successful programs make themselves very visible in the aging community through the use of 

posters or brochures, publicized toll-free numbers and community outreach efforts. Other 

techniques include informing all residents about the ombudsman program upon admission 

media exposure, such as radio or television spots, and in-service trining for staf of the facilities 

on the ombudsman program. 

In contrast, only approximately half of the remaining 39 progrms make themselves available in 

a similar fashion to the successful ones. 

Successful programs handle complaints expeditiously. 

All but one of the top States respond onsite to potentially life-threatening complaints within 24 

hours. These complaints involve abuse or neglect which may seriously jeopardize a person 
well-being. Moreover, al but the of the top progrs actually respond to all complaints, both 

life-theatening and non life-theatening within 24 hour. 

In contrst, almost 20 percent of the ombudsmen frm the 39 remaining States require from 

thee days to a week to respond to potentially life-theatening complaints; 46 percent take four 

days or more to respond to non life-threatening complaits. One State taes months before 

being able to respond to some complaints; others report not being able to respond for several 

weeks. 

Almost all successful State ombudsmen report at least three-quarers of their complaints being 

resolved to the point of closur within 12 months, although they, and other ombudsmen, report 

some inconsistencies in how they define complaints resolved. 

Approximately half (56 percent) of the remaining 39 States similarly report coming to closure on 

75 percent or more of their complaints in a 12-month period; 21 percent close between 65 and 75 

percent of complaints; and 21 percent come to closur on less than 65 percent of their complaints 

in a 12 month period. Of these, one State with limited staf and no volunteers reports coming to 

closure on only 25 percent of their complaints in a given year. One State does not even keep this 

statistic. 

SUCCESSFUL PROGRAMS OBTAIN ADEQUATE FUNDING AND SUPPORT 

States report innovative fund-raising techniques.


All States link adequate funding with having more professional staf, which allows them to visit 

facilities more frequently; to improve response tie to complaints; to train and supervise staff 

and volunteers, and to become more involved in legislative planning and decision-making. Most 

States would give priority to hirng more professional staf if additional funds were made 

available. An ombudsman from a rural western State stated, "There is a direct correlation 

between funding and effectiveness, it allows for more sta. 

Many successful State ombudsmen enhance their budgets through innovative fund-raising 

techniques. Some use ttaditional methods such as bake sales, auctions and $100-a-plate dinners, 

while others have developed more sophisticated approaches. 

One Western State imposes a $3 surcharge on nursing home and board and care licensing fees, 

thus raising about $140,000 a year. Deposited into a special fund controlled by the State Board 

on Aging, this money is given to the Ombudsman progr for use in education, parcularly the 

ttaining and organizing of resident s councils. Another top State has a similar bed tax which 

goes to the Ombudsman program. 

A local program in a Southern State has a budget of $250,000 with only $30,000 coming from 

the Federal and State governments through the AAA. Not housed in any State or local 

government agency, it is able to secure funds from the United Way, mayors and other 

organizations. Its dynamic distrct director spends much of her time raising funds, a task she 
, , 

. , 

feels is made easier because the agency is private and non-profit. A State or local government 

agency would have a diffcult time getting such donations. The fund raising is seen as having 

the additional benefit of enhancing community education and outreach for the ombudsmen 

progr. 

Other programs sell their knowledge to generate income. For instance, one program has 

developed a game called "Resident Bingo," which is sold nationally to long term care facilties 

to help famliarze residents with their rights and with how to refer problems to ombudsmen. A 

Midwestern progr is located outside of the State government so it can charge facilities, such 

as nuring homes and hospitals, for in service trning, mileage, and materials such as brochures. 

A local ombudsman in this State said, "We take full advantage of the language in the OAA which 

mentions the ' opportunity to donate 

Strong enabling legislation and legal support strengthen programs. 

Five of the top programs were cited by other ombudsmen for their strong enabling legislation 

which is comprehensive, succinct and easy to understad. One such statute gives the 

ombudsman immunity from liabilty when acting in good faith. AnOther State s legislation 

allows the ombudsmen to grant confidentiality and immunity to all complainants and issue 

subpoenas for documents or testimony. 

Strong legal support is also cited as important. Several successful programs have ombudsmen 

who ar lawyers. One large progr in the West reports that each one of its 35 local programs 

has access to legal support. Other top programs contract with an attorney or a law firm for legal 

support. 

Independence and other intangible factors make a difference. 

Many ombudsmen consider progrm independence importnt for success. Several programs 

contrct with outside agencies for ombudsman services in order to obtain such independence. 

One ombudsman reflected the feeling of others when he said Ombudsmen should be 

independent to avoid conflict of interest. " AnOther said, "We should be independent.. .location of 

the progr is the real issue...advocacy and service delivery don t combine. 

The Office of Ombudsman in a Northeastern State is independent and exempt from conttol or 

supervision by any deparent of the State government by statute. The Offce reports directly to 

the Governor and Legislature. This administrtive autonomy allows the ombudsman to act 

quickly and effectively, responding in 24 hours or less. Another advantage is a high profie and a 

certn amount of clout because of its close association with the Governor. 

Other intagible factors involved in successful performance include: the personality and 

leadership style of the State ombudsman (when respondents recommended model programs they 

often mentioned this as an important factor); the ability of the program to influence legislation or 

change policy ( as one very successful State ombudsman said "We have systematic impact, we 

solve problems through .regulatory reform ), and the relationship of the ombudsman program 

with other State agencies and providers. A successful ombudsman said, "We are widely 
recognized and respected by the provider community." Another remarked, "We have an 

excellent relationship with major agencies, an excellent image in the State. 

OMBUDSMEN WANT ADDITIONAL SUPPORT 

More than hal, 54 percent, of the State respondents say that they ar not kept informed about 

best practices. Only 25 percent of the ombudsmen report receiving this information from the 

National Resource Center. They report this information is not circulated systematically. Best 

practices may be highlighted in the Resource Center s newsletters, a newsletter from a State 

Ombudsman progr or in material received from other soures. 

Ombudsman generally feel the Resource Center is helpful. One said, "I would like to see the 

Resource Center continued." Other ombudsman recommend that the Resource Center get 

involved in ttaiing as well as more active in cirulating infonnation about best practices and 

other ombudsman issues. 

Over half of the ombudsmen report receiving infonnation diectly from the AoA, but consider it 

limited and not always helpful. Many (40 percent) would like more direct involvement with 

AoA. Some mentioned a designated AoA focal point. One ombudsman said, "We need more 

Federal diection. " Another requested, "n. more guidace from AoA on how the program should 

be admnistered, more Federal guidelines. " And another agreed saying, "We need clear 

regulations and model guidelines. 
RECOMMENDATIONS


The Administration on Aging should work with the States to address the concerns of the 

ombudsmen by: 

Developing model operational guidelines in aras such as frquency of visits; staf-to-bed 

ratios; volunteer-to-bed ratio; complait response time; complaint resolution percentages; 

recruitment, trning and retention of staf and volunteers; and progr publicity. 

Providing technical assistace regarding the use of volunteers, fund-raising, obtaning 

legal support, confidentiality and other areas of concern. 

Assurng that information about successful programs and effective techniques (including 

that obtained in this inspection) is disseminated to States in a systematic and detailed way 

with recommendations for implementation. 

Respondig to the concerns of ombudsmen about sttengthening the role of the Resource 

Center to provide information about best practices and model States in a more systematic 

way and provide trning on a regular basis. 

COMMENTS 

Comments received from AoA were generaly supportive of our findings and recommendations. 

However, AoA is concerned that we do not acknowledge the extent to which the National 

Resoure Center is involved in supportng the Long Term Car Ombudsman Progrm. We 

should note that it was not within the scope of our study to evaluate the Center, itself, but rather 

to obtain the sentiments of the ombudsmen regarding the Center. We have added AoA' 

information about the Center to the background of the report. It may be helpful for AoA to 

communicate more fully with ombudsmen about the activities of the Resource Center. 

The comments of AoA essentially respond to the study recommendations. These comments are 

in Appendix A. 
APPENDIX A


Comments To The Draft Report 
\....... 

., /::(

('.0 n.. .L .-n.. IC'II" 

AN SERVICES 

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Washington , D. C. 20201 

Administration on Aging 


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TO:	 Richard P. Kusserow


Inspector General


FROM:	 u. s. Commissioner on Aging 

SUBJECT:	 OIG Draft Report "Successful Ombudsman Programs,


OEI-02-90-02120


Recently your office requested that the Administration on Aging


(AoA) review and provide comments as appropriate on the above-


ref erenced draft report. 

AoA staff have reviewed the draft and, while we do not fully


support all the conclusions, we believe that it contains a great
 deal of useful information. The draft certainly describes 

effective operational models and should prove to be a useful tool 

in compiling information on exemplary ombudsman programs and 

practices. Our specific comments are outlined briefly below. 

A numer of the concerns raised in the draft focus on the 

National Center for State Long Term Care Ombudsman Resources. 

Recommendations 2-4 on p. iii of the Executive Sumary and page 

10 of the draft report are particularly relevant to the work of 

the National Center. Indeed, recommendation # 4 specifically 

refers to the perceived need to " strengthen" the Center I s role. 

In general, we believe that the Center has been more active and

aggress i ve in supporting the Ombudsman Program than the draft

suggests. 

As the draft indicates, the Center is operated by the National 

Association of State units on Aging in cooperation with the 

National citizens Coalition for Nursing Home Reform. AoA has 

provided the Center with considerable financial support. In each 

of the first two years of operation (FY' s 1988 and 1989), the 

Center for State Long Term Care Ombudsman Resources received more 

Title IV funds ($387, 488 in FY 88, $500, 000 in FY 89) than any of 

the other National Aging Resource Centers which AoA supported. 

The Center also received $500, 000 in Title IV funding in FY 1990. 

The goal of the National Center for state Long Term Care 

Ombudsman Resources is to enhance' the capacity of the nation I s 

state Agencies on Aging in the design, development and 

administration of statewide long term care Ombudsman Programs. 
.

Page 2 - Richard P. Kusserow


The Center I s primary focus is on building statewide systems of 

ombudsman services to address the issues facing older residents 

in long term care facilities. 

numer of 

During its first two years, the Center initiated a 

acti vi ties including: development of a state Ombudsman Resource 

Manual; mUlti-regional teleconferences for information sharing 

wi th and among states; a National Training Conference for 

Ombudsman and state staff; training modules for states to use in legislation; training local ombudsmen; simplified guides to OBRA 


a bi-monthly Center newsletter called the "Ombudsman Reporter"


and, production of a video to introduce the Ombudsman Proqram to


the general public that will also serve as a viable recruitment
 tool. In addition to the Resource Center' s responsibiliti for 

technical assistance and training for states, the Center 

conducted a study of ombudsman services to residents of board and 

care facilities. One section of this study is devoted to use of
 volunteers. 

AoA fully intends to continue to provide on-qoing support to the


Ombudsman Proqram. On April 29, 1991, we issued a Program 

Announcement (AoA-91-2) for awards authorized under Titles II and 

IV of the Older Americans Act to establish a series of "National 

Eldercare Institutes" to work in cooperation with the National


Eldercare Campaign. A portion of the funds awarded under this


announcement will be expended to provide for the continuation of


a national focal point for the ombudsman support activities


currently provided by the National Center for state Long Term
 . within this framework issues to be Care Ombudsman Resources include: addressed pertaining to the ombudsman program will 


legislation; Identification of relevant Federal 


Dissemination of best practice models;


Analysis of program develop trends; and,


Examination of changes needed to improve program


effectiveness . 

March, 1991, AOA convened a Finally, let me note that, in Representatives
 National Roundtable on the Ombudsman Program. 


from state and local programs and from national organizations met


with the AOA to discuss roles of the ombudsman, model services,
 nationwide. and future directions for the ombudsman program

useful. If you have any I hope that you will find these comments
 information, please let me know. 

questions or need further 


Thank you. 
with representatives of the aging network. In a series of 

focus groups, Administration on Aging and National Association 

of state Units on Aging staff discussed these issues with a 

sample of state and Area Agencies on Aging and service 

providers. The Administration on Aging will be following up 

on several of the ideas generated in these discussions. The 

establishment of the Eldercare Volunteer Corps and our 

thinking about expansion of the Corps, builds upon ideas

discussed during these sessions. 

The Administration on Aging will be working closely with state 

and Area Agencies on Aging to assist you in the implementation 

of this important volunteer initiative. Further information 

regarding the Eldercare Volunteer Corps will be forthcoming. 

A press release regarding this announcement is enclosed for


your information. 

INQUIRIES:	 Inquiries should be addressed to Regional 

Program Directors on Aging, HHS Regional

Off ices 

Attachment 
- ,,'-IIDEPARTMENT OF HEALTH. HUMAN SERVICES	 Of of th Se-.y 

l. 

Administration on Aging	 W88ton. D.C. 20201 

APR 2 3 1991 

INFORMTION MEMORADUM


AOA-IM-91-22 

STATE AND AR AGENCIES ADMINISTERING 

PLAS UNDER TITLE III OF THE OLDER 

AMERICANS ACT OF 1965, AS AMDED 

SUBECT	 Older Americans Act Eldercare Volunteer 

Corps 

LEGAL AND RELATED


REFERCES	 Older Americans Act, as amended 

Recently I announced the establishment of the Older Americans Act


Eldercare Volunteer Corps. Volunteers have been the backbone of the


Older Americans Act service system since its inception in 1965 and


curren ly there are nearly 500, 000 volunteers providing services 

and assistance to older persons across the Nation, many of them at 

risk of losing their independence. 

The National Eldercare campaign seeks to broaden the base of 

support and commitment to our Nation' vulnerable elderly 

population by reaching out to organizations and individuals and

invi ting them to participate in solutions to the problems facing 

many of our older citizens. The Eldercare Volunteer Corps provides 

an opportunity for young and old alike to support the National 

Eldercare Campaign by contributing a portion of their time and 

effort to improve the lives of older persons, especially those 

vulnerable elderly who are at risk of losing their independence. 

These at-risk elderly, the beneficiaries and focus of the National Eldercare campaign, can substantially benefit from the 

contributions made by volunteers.


The Eldercare Volunteer Corps is designed to build upon the 

existing efforts of State and Area Agencies on Aging and service 

providers to promote and support volunteer acti vi ties in Older 

Amer icans Act programs. Recrui tment, retention, training and 

supervision are critical components of any volunteer program and, 

in order to determine the most effective means of strengthening 

current efforts, the Administration on Aging recently consulted