The Role of Ombudsmen in Assuring Quality for Residents of Long-Term Care Facilities: Bac kg ro u n d Straining to Make Ends Meet P a p e r No. 71 Carol V. O’Shaughnessy, Principal Policy Analyst December 2, 2009 OVERVIEW — Assuring quality of care for residents in long-term care facilities has been a serious and continuing concern of policymakers for decades. The Older Americans Act’s long-term care ombudsman program is a consumer advocacy model intended to improve quality of care by help- ing the 2.5 million residents of almost 67,000 nursing and other residential care facilities resolve complaints about their care and protect their rights. Despite broad recognition of its value in assisting residents and its efforts to complement federal and state oversight of long-term care facilities, some observers are concerned about the program’s ability to meet its legislative mandates. Limited funding affects the ability of many states to meet minimum staffing goals recommended by the Institute of Medicine (IOM). Also, in most states, ombudsmen do not conduct regular quarterly visits to long- term care facilities. This background paper discusses the role of long-term care ombudsmen and highlights selected issues regarding the capacity of the program to promote quality care and advance the rights of residents. December 2, 2009 National Health Policy Forum National Health Policy Forum Contents 2131 K Street, NW Suite 500 Trends in Nursing Homes and Other Washington, DC 20037 Residential Care Facilities...............................................................4 T 202/872-1390 Assessing Quality in Long-Term Care Facilities..........................5 F 202/862-9837 E nhpf@gwu.edu OBRA Requirements for Nursing Facilities....................................5 www.nhpf.org State Oversight of Residential Care Facilities.................................6 Judith Miller Jones Long-Term Care Ombudsman Program: Director A Consumer Advocacy Model.......................................................6 Sally Coberly, PhD Deputy Director Ombudsman Presence in Facilities: Heart of the Program.............8 Monique Martineau Resident Complaint Investigation.................................................9 Director, Publications and Online Communictions CMS Complaint Investigation Procedures.....................................10 Ombudsman Complaint Investigation: Reports to the AoA..........10 Table 1: Top Six Complaints Reported to State Long-Term Care Ombudsmen by Residents of Nursing Homes and Other Residential Care Facilities, 2008..........11 Ombudsman Program Capacity....................................................12 Federal Funding...........................................................................14 Figure 1: Long-Term Care Ombudsman Program Funding Sources, FY 2008...........................................................15 Wide State Variation in Funding. .................................................15 . Staffing Goals and Regular Visitation...........................................15 Figure 2: States Meeting Goal for One Full-time Ombudsman per 2,000 Beds and Quarterly Facility Visitation Measure, Fiscal Year 2008............................................17 Some Unfinished Business ...............................................................18 Role of Ombudsmen in Residential Care Facilities.........................18 Role of Volunteers.......................................................................19 Conclusion........................................................................................20 Endnotes............................................................................................20 The National Health Policy Forum is a Appendix: Long-Term Care (LTC) Facility Beds nonpartisan research and public policy per Paid Ombudsman Staff and Percentage of organization at The George Washington University. All of its publications since 1998 LTC Facilities Visited at Least Quarterly, FY 2008....................................25 . are available online at www.nhpf.org. 2 Bac kg ro u n d www.nhpf.org P a p e r No. 71 Unanswered calls for help, improper medication administration, discharge or eviction without proper notice, lack of respect for resi- dents, unsafe buildings or equipment—these are complaints made by some of the 2.5 million residents of nursing and other residential care facilities to state and local long-term care ombudsmen across the nation. The long-term care ombudsman program is a consumer advocacy model intended to improve quality of care by helping resi- dents of nursing homes and other residential care facilities resolve complaints about their care and rights. It was established as part of the Older Americans Act in 1978 and is administered by the U.S. Administration on Aging (AoA). Despite significant public and private spending for care in nursing homes and other residential care facilities, assuring quality of care and resident rights has been a serious and continuing concern of long-term care consumers and policymakers for decades. Almost as soon as nursing facility care became a benefit under Medicare and Medic- aid in 1965, Congress began to be con- Ombudsman Program History cerned about the quality of care pro- Under the Older Americans Act of 1965 vided by these facilities. Between 1969 The long-term care ombudsman program began as a Public Health and 1976, it held 30 hearings on prob- Service demonstration in 1972. It was given statutory authority lems in the nursing home industry and in the Act’s 1978 amendments that required all states to establish in 1987 passed landmark nursing home programs. In 1987, Congress added a specific authorization of funds reform legislation to address concerns for the program. And in 1992, Congress added a new title to the about nursing home quality and resi- Act for vulnerable elder rights protection activities, which include dent rights. Oversight of implementa- ombudsman activities. tion of the legislation continues today with frequent congressional reports and hearings, including a series of reports by the Government Ac- countability Office (GAO).1 Policymakers have also been concerned about oversight of quality of care and resident rights in other resi- dential care settings, such as assisted living facilities.2 The ombudsman program aims to improve the quality of life and care in facilities by assisting residents to resolve complaints about care they receive and assuring that their rights are protected. Ombudsmen complement efforts of federal and state staff who, under statute and/ or regulation, are required to review and enforce nursing home qual- ity of care. Many analysts and practitioners believe that the program’s ability to meet its full potential as a robust consumer advocacy pro- gram is constrained by limited resources. Fiscal constraints affect the 3 December 2, 2009 National Health Policy Forum ability of many states to meet minimum staffing goals recommended by the Institute of Medicine (IOM) and of ombudsmen to conduct reg- ular quarterly visits to long-term care facilities. T ren ds i n N u r s i n g H o m es a n d Ot her Resi den t i a l C a re Fac i l i t i es About 1.5 million residents live in more than 16,000 nursing facili- ties.3 The nation spends a substantial amount on nursing home care: about 6 percent ($131.3 billion) of the more than $2 trillion spent on health care in 2007 was for nursing home care. The federal-state Medicaid program accounted for over 42 percent of all nursing home spending; the next largest share (27 percent) was paid out-of pocket by individuals and families.4 The nursing home population is exceedingly frail. According to the 2004 National Nursing Home Survey, over three-quarters of resi- dents had four or more limitations in activities of daily living (ADLs), and more than half were either totally dependent or required ex- tensive assistance in bathing, dressing, toileting, and transferring. Just under half of residents took nine or more medications. About 56 percent of nursing home residents resided in the facility for at least one year or more.5 In June 2009, about 47 percent of residents had a diagnosis of dementia.6 In addition to traditional nursing homes, about 50,000 other residential care facilities provide room, board, and supportive services to about one million people who may not have sustained nursing needs but need some assistance with their ADLs.7 Depending upon state policy and practice, these settings are referred to as assisted living facilities, adult foster care homes, group homes, supportive living arrange- ments, board and care homes, personal care homes, and community residential settings, among many others. (For purposes of this back- ground paper, facilities that are not nursing homes will be referred to as residential care facilities.) Financing for care in residential care facilities comes from a host of sources, including out-of-pocket pay- ments from individuals, state and local funds, and Medicaid. In response to older consumers’ preference for more home-like set- tings and privacy than are found in many traditional nursing homes, the residential care market has burgeoned with newer assisted liv- ing models in recent years. Between 1990 and 2002, the supply of li- censed residential care beds increased by 97 percent; in comparison, 4 Bac kg ro u n d www.nhpf.org P a p e r No. 71 the number of licensed nursing home beds increased by 7 percent.8 While residents of assisted living are, Medicare and Medicaid Nursing on average, less frail than those in nursing homes, a Facility Survey and Certification sizable proportion need substantial assistance; a re- Requirements cent survey of assisted living facilities showed that 42 percent of residents needed assistance with two OBRA 1987 and subsequent amendments and Centers for Medicare & Medicaid Services (CMS) or more ADLs.9 The presence of cognitive disabilities regulations define quality standards that nursing is often one of the key factors leading to admission facilities must meet in order to participate in Medi- to an assisted living facility; estimates of the propor- care and Medicaid. Nursing facilities are subject tion of assisted living residents who have Alzheim- to surveys to determine their compliance with er’s disease or other dementia range from 45 percent standards in 15 categories, such as resident care, to 67 percent.10 quality of life, resident assessment, quality of care, transfer and discharge rights, resident behavior and facility protocols, and nursing services. Nursing Assess i n g Qua l i t y i n facility surveys must be unannounced and must be Lo n g -T erm C a re Fac i l i t ies conducted on each nursing facility at least every 15 Both federal and state governments have major re- months, with a statewide average interval between sponsibilities for oversight of care in nursing facili- surveys not to exceed 12 months. Facilities with poor histories of compliance with quality standards ties. Nursing facility standards are established by may be surveyed more frequently. The survey pro- federal law and regulation. State and local govern- cess is conducted by a team that may include nurses, ments have responsibility for establishing standards social workers, pharmacists, and others. Survey for, and oversight of, residential care facilities. inspections are required to be resident-centered and outcome-oriented. CMS contracts with state O B RA Re q uire m e n t s fo r N u r s in g Fa cili tie s agencies that conduct the surveys. The primary way the federal government reviews Source: CMS, "Survey and Enforcement Process for Skilled Nursing Facilities and Nursing Facilities," State Operations quality of care in Medicare- and Medicaid-certified Manual, chap. 7, rev. 1, May 21, 2004; available at www.cms. nursing facilities is by assessing facility compliance hhs.gov/manuals/downloads/som107c07.pdf. with federal conditions of participation required by the Omnibus Budget Reconciliation Act (OBRA) of 1987 and subsequent amendments. The OBRA sur- vey and certification requirements for nursing facilities are focused on resident care, quality of life, nursing services, and transfer and discharge rights, among other things. The federal government con- tracts with states to perform surveys of facilities to determine their compliance with federal requirements. States are required to con- duct surveys on each nursing facility at intervals of not more than 15 months, with the statewide average interval between surveys not to exceed 12 months (see text box). A host of investigations by GAO has documented many serious quality problems in nursing facilities as well as inadequate federal 5 December 2, 2009 National Health Policy Forum and state oversight of facility deficiencies.11 GAO has found that a substantial proportion of surveys understate serious care problems in nursing facilities and miss deficiencies involving poor quality of care. Quality of care issues that come up between the 15-month visit cycles may not be picked up by surveyors, unless complaints come to their attention in the interim. GAO has pointed to weaknesses in state surveyors’ investigative skills and their ability to integrate and analyze information to make a deficiency determination.12 Federal funding and state staff surveyor shortages hamper investigations of facilities. GAO found that funding for surveys of all health care facilities, including nursing facilities, which comprise most of the survey workload, fell by 9 percent, in inflation-adjusted terms, from fiscal year (FY) 2002 through FY 2007.13 St a te O ve r s ig h t of Re s i d e n tial C a re Fa cili tie s Oversight of quality of care and resident rights in residential care facilities is the province of state and local governments, which are responsible for regulation, licensure and inspection. Federal over- sight of state quality measures and enforcement activities is mini- mal.14 Generally, there is variation among states, and sometimes within states, in the use of terminology that applies to residential care facilities. Some states have varying levels and types of resi- dential care that may target multiple population groups, for exam- ple, the elderly and people with physical, cognitive, or intellectual disabilities. Requirements for assuring quality vary widely, and of- ten oversight responsibilities are shared among multiple state and local agencies. Lo n g -T erm C a re Ombu dsm a n P ro g r a m : A Co n su m er A dvo c ac y M o del The Older Americans Act long-term care ombudsman program ad- dresses quality of care and resident rights in nursing facilities and other residential care facilities through consumer advocacy. The long- term care ombudsman role grew out of the classic ombudsman model conceived by the Swedish parliament in the 19th century, in which a neutral party intercedes between a citizen and a governmental entity or other form of authority. Unlike the classic model, the long-term care ombudsman function stresses active advocacy and representation on behalf of long-term care facility residents. Ombudsmen may intercede 6 Bac kg ro u n d www.nhpf.org P a p e r No. 71 with providers on behalf of residents in areas related to the quality of life, care, Functions of the State Ombudsman and rights.15 As Set Out in the Older Americans Act of 1965 Since 1978, the Older Americans Act “The state long-term care ombudsman shall serve on a full-time has required states to establish long- basis, and shall, personally or through representatives of the term care ombudsman programs to Office”: advocate for and protect the rights of • Identify, investigate, and resolve complaints made by long-term care facility residents. Om- residents that relate to action, inaction, or decisions by long- budsmen are charged with advocat- term care and health and social providers or public agencies ing for individual residents by iden- that adversely affect resident health, safety, welfare, or rights tifying, investigating, and resolving complaints that adversely affect their • Provide services to help residents protect their health, safety, welfare, and rights health, safety, welfare, or rights—a function known as individual advo- • Inform residents about means of obtaining services pro- cacy. They are also required to carry vided by long-term care and health and social service provid- out broader functions through systems ers or public agencies advocacy by representing the interests • Ensure that residents have regular and timely access to of residents before governmental agen- ombudsman services and that residents and complainants cies, seeking administrative and legal receive timely responses to their complaints from ombuds- remedies to protect their rights, and man representatives monitoring the implementation of laws • Represent the interests of residents before governmental and regulations affecting residents. agencies and seek administrative, legal, and other remedies Examples of systems advocacy include to protect residents’ health, safety, welfare, and rights efforts of state ombudsmen during dis- • Provide administrative and technical assistance to local cussions leading up to the OBRA 1987 ombudsman entities nursing home reform requirements and subsequent implementation of • Analyze, comment on, and monitor the development and the reforms by states; state activities to implementation of federal, state, and local laws, regulations, establish standards for assisted living and other governmental policies and actions that pertain to residents’ health, safety, welfare, and rights, with respect to the facilities; and efforts to advocate for adequacy of long-term care facilities and services in the state wider availability of community al- ternatives to divert people from nurs- • Recommend changes to, and facilitate public comment ing homes.16 (See text box for a list of on, laws, regulations, policies, and actions affecting residents legislated functions of long-term care • Train representatives of the ombudsman ombudsmen.) • Promote development of citizen organizations and resident The Older Americans Act charges om- and family councils to protect the well-being and rights of budsmen with complaint investigation residents and resolution in nursing facilities as Source: Adapted from the Older Americans Act of 1965, Title VII, Section well as a vast array of other residential 712(a)(3). care facilities. In FY 2008, slightly more 7 December 2, 2009 National Health Policy Forum than 1,300 ombudsmen (full-time equivalent, or FTE, staff) were re- sponsible for working to resolve complaints of residents of 67,000 nursing and other residential care facilities that had over 2.5 million residents. The program operates in all states, the District of Colum- bia, and Puerto Rico. In most states, the program is administered by state agencies on aging; most of the 572 local ombudsman programs are administered by area agencies on aging under the direction of state ombudsmen.17 States are required to ensure that ombudsmen have access to resi- dents and their medical and social records if the resident or his or her legal representative grants permission or if it is necessary to in- vestigate a complaint when the resident is unable to grant permis- sion, as well as access to facility administrative records and policies. To ensure that ombudsmen are independent and have the freedom to carry out their consumer advocacy role, programs must be sepa- rate from agencies that regulate, license, or certify long-term care services and from associations of long-term care facilities. States are required to prohibit long-term care facilities from retaliating or mak- ing reprisals in the event that residents, employees, or others file a complaint investigated by the program, and to prohibit any inter- ference with ombudsmen who carry out their official duties. State agencies must provide ombudsmen with legal counsel to assist them in carrying out their official functions and in the event that legal ac- tions are taken against them. O m b u d s m a n P re s e n ce in Fa cili tie s : H ea r t of th e P ro g ra m Key to the ombudsman function is regular facility and resident visitation by paid and volunteer ombudsmen. The AoA has defined regular visitation as no less than quarterly.18 Through their visits, ombudsmen can act as sentinels regarding quality of care and resi- dent right issues. Their interactions and familiarity with residents can potentially alert facility staff to issues before they become actual complaints. Their visits to facilities may act as a deterrent to issues negatively affecting the quality of care and the lives of residents and prevent the need for costly interventions by state officials later. Ombudsman availability in facilities can assist residents and family members in knowing how and when to report concerns about qual- ity and about abuse and neglect and in making reports promptly. 8 Bac kg ro u n d www.nhpf.org P a p e r No. 71 Ombudsmen stress the importance of their role as representatives of the community in facilities and the personal connection that they have with residents. Some describe the “watchdog” function of om- budsmen as crucial in assisting older people who are too frail or afraid to draw attention to problems with their care. Because many nursing home residents do not have informal support systems or families and friends who visit regularly, an independent advocate can play a critical role in helping residents with their care and rights. Although investigation and resolution of complaints are their prima- ry responsibilities, ombudsmen also play other roles, such as educat- ing residents and families about resident rights and acting as media- tors between residents and facility staff and government agencies.19 They may also assist residents who are making the transition from nursing homes to home or to other nonfacility care and play a role in state programs that seek to prevent people from entering nursing homes. These efforts have taken on added significance with the Cen- ters for Medicare & Medicaid Services’ (CMS’) national implementa- tion of the Money Follows the Person Medicaid demonstration pro- gram, which is designed to transition nursing home residents from facilities to their own homes or other home and community-based settings, and with the establishment of AoA nursing home diver- sion, or community living, programs in several states.20 As federal and state governments expand home and community-based services and nursing home transition efforts, ombudsmen may be expected to step up the intensity and scope of their activities in these areas in the future. Beyond facility complaint investigation and resolution, some state ombudsmen also extend services to home care recipients. However, these services are not among the ombudsman activities financed by the Older Americans Act; states that carry out these ac- tivities do so with funding from sources other than those designated for federally authorized ombudsman activities.21 Res i den t Co mpl a i n t I n v est i g at i o n Both CMS, through state agencies, and AoA, through ombudsmen, have responsibilities for investigating and collecting information on resident complaints in nursing facilities, though the scope of their responsibilities differs. State ombudsmen have responsibili- ties for investigation of complaints in residential care facilities; this 9 December 2, 2009 National Health Policy Forum information is reported to AoA, along with nursing facility com- plaint information. C M S C o m p lain t I nve s tig a tio n P ro ce d u re s Medicare and Medicaid statutes require states, under contract with CMS, to maintain procedures and staff to investigate and report on nursing home complaints they receive about Medicare- or Medicaid- certified facilities.22 Complaint investigations are intended to be a response system for health and safety concerns and allow states to evaluate the quality of care between survey and certification visits.23 States are required to investigate complaints alleging immediate res- ident jeopardy within two business days and those alleging serious harm within 10 business days. State investigators must consult with ombudsmen to determine if they have substantiated any complaints similar to those reported to state investigators.24 A 1999 GAO report found that state complaint investigation proce- dures were inadequate. It indicated that states understated serious complaints and failed to investigate complaints promptly and that state reporting systems did not collect timely, consistent, or complete information.25 In response to GAO recommendations for more time- ly state investigations of serious complaints and for stronger federal monitoring of state investigations, CMS has taken a series of steps to address complaint investigations procedures. These have included in- structions to states to investigate complaints within 10 business days of receipt as well as requirements for in-facility complaint investiga- tion. CMS has also instructed states to notify local law enforcement agencies and/or Medicaid Fraud Control Units of allegations or con- firmation of abuse. In efforts to strengthen federal oversight of state investigation procedures, CMS implemented a national automated complaint tracking system in 2004.26 Continuing reporting problems exist, according to a 2009 GAO review. Further, state officials say that inadequate funding hampers their complaint investigations.27 O m b u d s m a n C o m p lain t I nve s tig a tio n : Re p o r t s to th e AoA The ombudsman role in investigating resident complaints is to advo- cate for residents regarding their care and rights. While their efforts may complement the role of federal and state surveyors, ombudsmen do not enforce the federal OBRA nursing home reform requirements and cannot sanction facilities for poor performance. 10 Bac kg ro u n d www.nhpf.org P a p e r No. 71 Ombudsmen are required to report complaint data to AoA as part of its National Ombudsman Reporting System (NORS).28 AoA col- lects data on over 100 types of resident complaints. In FY 2008, om- budsmen investigated about 272,000 complaints.29 Table 1 shows the complaint types that fall within about the top 25 percent of all complaints reported. The complaints shown are the most frequent types in recent years, although the frequency changes slightly from year to year. Many of the complaints about both nursing homes and residential care facilities reported to AoA related to inadequate or unrespon- sive staff. Most frequent complaints were related to staff failure to respond to resident requests for assistance; food service lacking in quality, quantity or variation; failure to properly plan for discharge Table 1 Top Six Complaints Reported to State Long-Term Care Ombudsmen by Residents of Nursing Homes and Other Residential Care Facilities, 2008 Rank nursing Homes Rank Residential Care Facilities Includes, for example, requests * Food service lacking in quality, unanswered or not answered in a Failure to respond to resident quantity, variation, choice; lack timely manner. 1 1 requests for assistance* of timely delivery and removal † Includes, for example, discharge of food trays or eviction to an inappropriate environment; notices not given to Failure to properly plan for Failure to properly administer 2 2 resident, representative, or ombuds- resident discharge or eviction† medication§ man or not given on a timely basis; Failure to properly plan for notices improperly documented; and 3 Lack of respect for residents‡ 3 level of care change made against resident discharge or eviction† resident’s will. Food service lacking in Equipment or building in ‡ Includes, for example, resident being quality, quantity, variation, disrepair or hazardous, treated with rudeness, indifference 4 4 or insensitivity. choice; lack of timely delivery inadequate safety procedures, § and removal of food trays including fire safety Includes, for example, medications not given on time or not at all; medi- Failure to properly administer cation administered improperly, not 5 5 Lack of respect for residents‡ medication§ secured, or improperly labeled. ¶ Failure to assist residents with Includes, for example, resident not Cleanliness, pests, general bathed in a timely manner, not 6 personal hygiene, grooming, 6 housekeeping** clean, not bathed at all, allowed to and dressing¶ remain in soiled clothing, diaper, bed, chair; hands and face not washed after meals; teeth/dentures Source: Administration on Aging, “Top 20 Complaints by Category for Nursing Facilities” and “Top 20 not cleaned. Complaints by Category for Board and Care Facilities,” 2008 National Ombudsman Reporting System Data **Includes, for example, uncleanli- Tables; available at www.aoa.gov/AoARoot/AoA_Programs/Elder_Rights/Ombudsman/National_State_Data/2008/ ness or pests (insects, vermin) in Index.aspx. AoA collects compliant types in over 100 categories; the complaints shown are the most frequent resident’s room or other facility area; types in recent years, although the frequency has changed slightly from year to year. The table presents ant, snake, rat, or mosquito bites. complaints in about the top 25 percent of all complaints made. 11 December 2, 2009 National Health Policy Forum or eviction; failure to properly ad- Example: Ombudsman Complaint Investigation minister medications; and accidents Regarding Quality Care or injuries of unknown cause. A recurring issue is the unplanned When Mrs. Brown visited her husband in the nursing home, she discov- ered him sitting naked and unattended in the shower stall, while the aide or improper discharge of residents. was talking on her cell phone. Mrs. Brown was upset that Mr. Brown, Ombudsmen report that discharge who was confused due to Alzheimer’s disease, was not receiving the notices are not given on a timely assistance he needed. She noted there was a bruise on his back and no basis or are improperly document- one had provided her with an explanation of its origin….When she didn’t ed or that a level of care change is receive the response she needed from facility staff, Mrs. Brown asked made against the resident’s will. the ombudsman for help. With Mrs. Brown’s permission, the ombuds- Ombudsmen interviewed for this man reviewed Mrs. Brown’s concerns with the Director of Nursing, who paper indicated that, especially in started investigating the unattended shower issue and the bruising. Later the case of residential care facilities, that week, the Office of Regulatory Services was conducting a standard discharges are frequently made be- survey, so the ombudsman and Mrs. Brown described their concerns cause the person’s care needs go to the surveyors. The surveyors substantiated Mrs. Brown’s concerns, beyond what the facility can pro- citing several violations of federal regulations by the nursing home. The vide.30 In some cases, state law pro- facility took disciplinary actions with staff who had failed to meet Mr. Brown’s needs. hibits facilities from keeping resi- dents whose needs cannot be met. Source: Georgia Department of Human Resources, Office of the State Long-Term Care (See text boxes on this and follow- Ombudsman, “Ombudsmen Advocate for Quality Care,” in Ombudsman Long-Term Residents’ Advocate: 2008 Annual Report, p. 9; this and other examples available at ing pages for examples of ombuds- www.georgiaombudsman.org/docs/AnnualReport.pdf. man complaint investigations and assistance.) Ombu dsm a n P ro g r a m C a pac i t y A consumer advocacy model in which ombudsmen have direct ac- cess to residents and maintain a regular presence in facilities has the potential to produce more immediate improvements in resident care than less frequent state surveys and inadequate complaint systems. Ombudsmen’s interactions with residents may prevent quality issues from becoming serious complaints and can serve as an alarm system, alerting facility administrators and nursing staff to problems on a re- al-time basis. Some nursing home administrators work closely with ombudsmen to anticipate and resolve resident care and rights issues. Although ombudsmen are responsible for maintaining regular visits to facilities, the scope of their activities and implementation of their functions varies by state. Ombudsman visits to nursing facilities and their access to residents have the potential to strengthen and complement efforts of federal 12 Bac kg ro u n d www.nhpf.org P a p e r No. 71 and state surveyors. State survey agencies are required to notify om- budsmen when surveyors will be in facilities and to obtain any in- formation about facilities and complaints ombudsmen want to share with the survey team. After the survey is completed, state surveyors are required to notify ombudsmen of nursing facilities’ noncompli- ance with survey and certification requirements and any adverse ac- tions taken against facilities. State survey agencies must have a writ- ten policy that establishes a process for sharing information between the agencies and state ombudsmen.31 Despite broad recognition of the ombudsman program’s potential to assist thousands of residents and to complement federal and state oversight of facilities, some observers indicate that its ability to meet its legislative mandates is severely restricted by its limited resources. The most extensive national evaluation of the program was conduct- ed by the IOM in 1995. The report, which reviewed the extent of com- pliance with federal mandates, pro- Example: Ombudsman Assistance Regarding a gram effectiveness, and adequacy of Resident’s Legal Rights resources to operate the program, In October 2007, the [North Dade, Florida] ombudsman office received concluded that that the program a complaint from a resident of an assisted living facility with about 120 “serves a vital public purpose” and residents. Several months prior, Dade County’s guardianship program has improved the long-term care had temporarily placed her in the facility for her safety. She stated that system. However, the report point- she was removed from her home under the allegation that she was un- able to care for herself. The resident stated that all of her valuables…were ed out that not all long-term care removed from her home by the guardian and a social worker. According facility residents had meaningful to the resident and the facility’s administrator, the guardian never visited access to the program, the degree of the facility. The case was assigned to an ombudsman who...contacted the implementation was uneven within resident and initiated the process to restore the resident’s legal rights. and among states, and the program The ombudsman guided the resident though the legal process, and they lacked sufficient resources to fulfill appeared in front of the probate judge to discuss the resident’s request its basic mission.32 for restoration of her rights. Upon hearing the resident’s story and cor- roborating testimony from a medical doctor, the judge restored all of Other than the rather dated IOM the resident’s rights and ordered the county guardianship program to study, there has not been another return all of her belongings immediately.…Upon contacting the resident major national evaluation of the for follow-up, the ombudsman confirmed that she had moved to a new program. A 1998 study on ombuds- apartment, but many of her belongs were still missing. The ombudsman man program capacity by the Of- helped her make arrangements to receive guidance from the local Legal fice of the Inspector General (OIG) Aid office on how to recoup the remainder of her personal items. at the U.S. Department of Health Source: “Florida’s Long-Term Care Ombudsman Program: Our Two Cents Is No Small and Human Services also pointed Change,” Annual Report 2007–2008, p. 18; this and other examples available at www. to the value of the program in pro- ltcombudsman.org/sites/default/files/norc/FL-0708-AnnualReport.pdf. moting quality of care but echoed 13 December 2, 2009 National Health Policy Forum the IOM concerns about program capacity and funding. The OIG recommended that AoA develop guidelines for a minimum level of program visibility that include criteria for frequency and length of visits and highlight strategies for recruiting, training, and su- pervising additional volunteers.33 Another study that interviewed ombudsmen about their perceived effectiveness also pointed to concerns about program capacity.34 F e d e ral Fu n din g In FY 2008, total program support was $86.4 million (see Figure 1, next page). State and local sources provide 42 percent of this funding, well over the amount required by federal law to receive federal matching funds.35 Because of the significant contributions of unpaid ombuds- man volunteers, the program’s effective resources are higher. The program receives Older Ameri- cans Act funds from two sources: Example: Ombudsman Complaint Investigation • Separate federal appropriations Regarding Involuntary Resident Discharge or Transfer under Title VII—one for ombuds- In FY 2008, the Washington State Ombudsman Program received over man services and one for elder abuse 700 complaints regarding nursing home or assisted living residents’ prevention, from which a small per- discharges or transfers. This was a 47 percent increase from the previous centage is used for ombudsman ser- year. Included in those complaints were reports of death, diminished vices. These sources represented 21 quality of life caused from losing connections with friends and family, de- percent of all funds for the ombuds- pression, anxiety, anger, fearfulness, confusion, sleep disturbance, weight man program in FY 2008. loss, unexplained seizures and increased hospitalization. Residents were • A portion of Title III supportive involuntarily discharged from assisted living facilities, primarily as a services appropriations designated result of assisted living facilities’ decisions to no longer accept Medicaid by state and area agencies on aging payment for personal care services provided to residents, even though for use by the ombudsman program. the residents’ needs had not changed. The program had some legislative (The Title III supportive services ap- success in helping to enact a state law that now prevents assisted liv- propriation funds many different ing facilities from involuntarily discharging their current residents on services, including information and Medicaid when the facility chooses to terminate their Medicaid contracts. assistance, and home and communi- The state ombudsman program was also successful in securing nursing ty-based services; with a few excep- home residents’ return to facilities by prevailing at hearings before an tions, states have wide discretion in administrative law judge. determining how to spend Title III Source: Louise Ryan, Washington State Ombudsman Program, e-mail communication funds.) Title III represented 31 per- with author, November 6, 2009. cent of funds for the ombudsman program in FY 2008. 14 Bac kg ro u n d www.nhpf.org P a p e r No. 71 W i d e St a te Va ria tio n in Fu n din g The amount spent by the program nationally from both federal and state sources is the equivalent of about $30 per bed annually. Twenty-nine states and the District of Columbia spent the same as or more than the national average of $30 per bed. But per bed spend- Figure 1 Long-Term Care Ombudsman Program Funding ing across all states varies widely, Sources, FY 2008 ranging from $6.27 per bed in Ne- braska to $131.61 in Alaska. The Total funding — $86.4 million variation in per bed spending is strongly affected by how much each state supplements the federal funds. Variation in per bed spend- 31% Title III (Federal) ing also is affected by the number State and Local $26.9 million 42% of beds each state has. $36.5 million The formula for distributing Older Title VII (Federal) Americans Act funds is based on 21% $18.4 million a state’s proportionate share of the 6% population age 60 and older, not on Other Federal the number of beds.36 Some state $18.4 million officials have suggested that the formula allocation method be re- Source: Administration on Aging, “2008 National Ombudsman Reporting System Data Tables,” viewed when the Older Americans Table A-9; available at www.aoa.gov/AoARoot/AoA_Programs/Elder_Rights/Ombudsman/National_ State_Data/2008/Index.aspx. Act is considered for reauthoriza- tion by Congress in 2011.37 Other formula factors have been considered in the past. The 1995 IOM report suggested that the formula be revised to account for the number, size, and type of long-term care facilities across states and for variations in state economic factors.38 A formula factor based on the number of beds in each state could pose implementation difficulties because of a potential lack of accurate data, especially for residential care facilities, and variations in facility occupancy levels across states. St af f in g G o al s a n d Re g ula r V i s i t a tio n The 1995 IOM study recommended that the ombudsman program’s staffing ratio be at least one paid FTE staff member to every 2,000 beds.39 This staffing level is still the recommended measure used to assess program performance and to determine the amount of re- sources needed. In FY 2008, the program had 1,300 paid FTE staff. On 15 December 2, 2009 National Health Policy Forum average, across all states, there was one paid FTE staff member for every 2,200 beds, a level approaching the IOM-recommended mini- mum staffing guideline. Twenty-three states, the District of Colum- bia, and Puerto Rico met the recommended paid-staff-to-bed ratio in FY 2008. (See Figure 2 on next page and Appendix). Nevertheless, wide variation in the ratio of paid ombudsmen to beds exists across states. The ratio ranged from one paid FTE staff member per 791 beds in the District of Columbia to one per 6,692 beds in Oregon. AoA data show that the amount spent on the ombudsman program is partially related to whether or not states meet the IOM-recom- mended paid staff-to-bed ratio of one to 2,000. Of the 29 states plus the District of Columbia whose combined federal and state per bed spending equaled or exceeded the national average of $30 per bed in FY 2008, 21 states and the District of Columbia met the IOM goal. Seven of the remaining states approached the goal, with a paid staff- to-bed ratio of one to 2,500 or less. Meeting the recommended staff- to-bed ratio depends largely on the dollar amounts states allocate to the program. State contributions averaged about $13 per bed in FY 2008. Twenty-five states and the District of Columbia spent more than the average of $13 and, of those, 19 states and the District of Co- lumbia met the recommended staff-to-bed ratio goal.40 The level of paid staffing is only one factor in effective ombudsman programs, which rely primarily on volunteers to maintain a pres- ence in facilities. Volunteers visit residents, assist them with com- plaints about care or rights, and take the first steps in complaint in- vestigation. In FY 2008, about 12,000 part-time volunteers worked in the program and, of these, about 73 percent were certified to inves- tigate complaints. Ombudsman resources in most states do not appear to support the paid staff and volunteers necessary to perform regular (that is, quar- terly) and timely visits to facilities and residents. (Visits made in re- sponse to complaints are not counted as quarterly visits.) Nationwide, ombudsmen visited about 80 percent of nursing facilities at least quar- terly in FY 2008. Visits were much less regular in residential care facili- ties, only about 46 percent of which were visited quarterly. Wide variation in meeting the federal quarterly visitation report- ing measure exists across states. Ombudsmen in only nine states reported that they performed quarterly visits for 100 percent of both nursing facilities and residential care facilities. More states met the 16 Bac kg ro u n d www.nhpf.org P a p e r No. 71 FIGURE 22 FIGURE States Meeting Goal for One Full-time Ombudsman per 2,000 Beds, and Quarterly Facility Visitation Measure, Fiscal Year 2008 The Institute of Medicine (IOM) recommended that the ombudsman-to-bed ratio be at least one full-time paid ombudsman (FTE) for every 2,000 beds. According to data from the U.S. Administration on Aging (AoA), 23 states, the District of Columbia, and Puerto Rico met this FTE goal in fiscal year (FY) 2008 ( ). The AoA has set a measure that ombudsmen or representative volunteers visit all nurs- ing facilities and other residential care facilities at least quarterly. According to AoA data, only nine states met the quarterly visitation measure for 100 percent of both types of facilities in FY 2008. Shown below are states in which ombudsmen met the quarterly visitation measure for 100 percent of the nursing facilities ( ), residential care facilities ( ), or both ( ). Delaware District of Columbia Alaska Hawaii Puerto Rico Bed / FTE Nursing Facilities Residential Care Facilities Both Source: Prepared by the National Health Policy Forum based on AoA, 2007 National Ombudsman Reporting System (NORS) Data Tables, updated July 21, 2009; available at www.aoa.gov/AoARoot/AoA_Programs/Elder_Rights/Ombudsman/ National_State_Data/2008/Index.aspx. Note: In addition to the states in which ombudsmen visit 100 percent of nursing facilities quarterly, AoA data show that, in nine states, between 90 percent and 99 percent of nursing facilities were visited by ombudsmen quarterly. In one state, ombudsmen visited 99 percent of residential care facilities quarterly. AoA NORS data identify “board and care” facilities. For purposes of this paper, the term “residential care” facilities is used. Data on quarterly visits to residential care facilities in Iowa and Rhode Island are not available. 17 December 2, 2009 National Health Policy Forum visitation measure for nursing facilities than for residential care facili- ties: ombudsmen in 16 states reported that they regularly visited 100 percent of nursing facilities quarterly, while in only 10 states ombuds- men reported regularly visiting 100 percent of residential care facili- ties (Figure 2 and Appendix). In 10 states, ombudsmen visited less than half of nursing facilities quarterly; in 24 states, less than half of residential care facilities received quarterly visits. S o m e U n fi n i shed Bu s i n ess Ombudsmen in many states face a number of challenges in imple- menting the full range of their responsibilities, especially with re- spect to visitation and complaint investigation in residential care facilities. In some areas of the country, the continual need for volun- teer recruitment and training can strain paid staff resources. Ro l e of O m b u d s m e n in Re s i d e n tial C a re Fa cili tie s The recent growth in the number and types of residential care fa- cilities, especially assisted living facilities, is presenting challenges to the program. Ombudsmen interviewed for this paper indicated that the resources available do not allow them to maintain a regular visitation schedule to these facilities. Some indicate that maintaining regular visitation schedules to nursing facilities claims most of their time, leaving them with insufficient staff or volunteers to visit both residential care facilities and nursing facilities.41 Some ombudsmen report that their programs have no assigned volunteers for residen- tial care facilities. In theory, residents of assisted living facilities are, on average, less frail than most people in nursing homes. However, there is a fuzzy line between nursing homes and some types of residential care fa- cilities;42 the levels of impairment of some residents in assisted living facilities are similar to those of people living in nursing homes,43 and dementia is common in both settings. Residents of assisted living facilities who receive services paid by Medicaid home and commu- nity-based waiver funds must meet the state’s definition for nursing home functional eligibility, but because these settings are not subject to federal regulatory requirements, the involvement of ombudsmen may be even more essential to the well-being of their residents. Most states establish and monitor requirements for quality of care, but 18 Bac kg ro u n d www.nhpf.org P a p e r No. 71 oversight can be spotty, making it important to have a consumer advocacy voice for residents to assist state quality inspectors. Experience in several ombudsman programs has shown the benefits of helping assisted living residents understand some of the complex policies of these facilities, such as conditions under which they may be discharged and costs of supplemental services they may receive.44 The tasks of ombudsmen in assisted living facilities may be quite different from those in nursing homes. Unlike nursing homes, assist- ed living facilities stress resident privacy and autonomy. Developing a way to establish ombudsman interaction with these residents may pose challenges. Also, many assisted living residents have individu- alized contracts with facilities specifying what specific services, be- yond room and board, residents will receive from the facility and the cost of those services. In order to help residents resolve complaints, ombudsmen may need access to information contained in resident contracts. These and other tasks that are specific to assisted living facilities may necessitate specialized ombudsman training. Because of the paucity of full-time staff and thin volunteer coverage for assisted living facilities in some states, some ombudsman pro- grams tend to be “complaint-driven” rather than playing the senti- nel or “watchdog” role envisioned by a consumer advocacy model. That is, they are responsive to complaints when they are made but may be not as effective in identifying resident issues before they generate a complaint. In areas with insufficient paid staff or volun- teer coverage, marketing of the program to residents may be weak to avoid creating demand for services that cannot be met.45 In addition, some report that the demands of complaint investigation mean that systems advocacy, a legislatively required activity, may not be effec- tive or complete. Ro l e of Vo lu n te e r s Beyond issues of adequate numbers of volunteers to visit facilities, a program based on volunteer capacity faces issues of recruitment, training, and retention. For example, a study of the California om- budsman program by the California Health Care Foundation found that the annual turnover rate among volunteers was about 30 per- cent and that as many as 50 percent of volunteers who signed up did not complete the state-mandated 36-hour training certification.46 Turnover of volunteers places burdens on paid program staff who 19 December 2, 2009 National Health Policy Forum must continually recruit and train new volunteers. Maintaining a stable pool of volunteers may be affected by the socioeconomic sta- tus of volunteers; some ombudsmen report that periods of economic downturns may cause some volunteers to turn to paid jobs. Recruit- ment of volunteers may also vary across geographic areas and be affected by program management strategies. Ombudsmen strongly support the volunteer model as a way to in- volve the community in long-term care facilities and as a source of support that cannot be met by existing resources. At the same time, some question the viability of a model that relies so heavily on vol- unteers who must master the complexities of complaint investigation and requirements of federal and state law. Volunteers may leave the program if they receive insufficient support from paid staff, neces- sitating a constant cycle of recruitment and training. Recruitment, training, and supervision of volunteers may require an increased paid staff-to-volunteer ratio.47 Co n c lu s i o n Significant federal, state, and out-of-pocket funds are devoted to car- ing for residents in nursing homes and other residential facilities, but the ability of federal and state governments to provide sufficient over- sight of facilities continues to be a serious problem. Ombudsmen are required to serve as advocates for residents and have the potential to play an important role in assisting them with complaints about the quality of their care. They can also complement the federally required survey and certification process for nursing homes and state oversight of residential care facilities. Yet the ability of the program to fulfill its role as a consumer advocate is constrained by limited resources. In many states, the program does not meet recommended staffing goals; in most states, ombudsmen do not conduct regular quarterly visits to nursing and residential care facilities, leaving many consumers with- out access to ombudsman services. En dn ot es 1. U.S. Senate, Special Committee on Aging, Nursing Home Care in the United States; Failure of Public Policy, reports of 93d Congress, 2d session, and 94th Con- gress, 2d session, 1974; supporting papers published in succeeding years. In sub- sequent years, the Government Accountability Office (GAO) has published a host of reports in response to congressional inquires about quality of care in nursing 20 Bac kg ro u n d www.nhpf.org P a p e r No. 71 (endnote 1, continued) homes and board and care facilities. See, for example, GAO, Nursing Homes: Fed- eral Monitoring Surveys Demonstrate Continued Understatement of Serious Care Problems and CMS Oversight Weaknesses, GAO-08-517, May 2008, available at www.gao.gov/new.items/d08517.pdf; GAO, Nursing Homes: More Can Be Done to Pro- tect Residents from Abuse, GAO-02-312, March 2002, available at www.gao.gov/new. items/d02312.pdf. 2. GAO, Board and Care Facilities: Insufficient Assurances That Residents’ Needs Are Identified and Met, GAO/HRD-89-50, February 1989, available at http://archive.gao.gov/ d15t6/138117.pdf; GAO, Assisted Living:, Examples of State Efforts to Improve Consumer Protections, GAO-04-684, April 2004, available at www.gao.gov/new.items/d04684.pdf. 3. Adrienne L. Jones et al., “The National Nursing Home Survey: 2004 Over- view,” National Center for Health Statistics, Vital Health Statistics, series 13, no. 167 (June 2009); available at www.cdc.gov/nchs/data/series/sr_13/sr13_167.pdf. 4. Micah Hartman et al., “National Health Spending in 2007: Slower Drug Spend- ing Contributes to Lowest Rate of Overall Growth Since 1998,” Health Affairs, 28, no. 1 (January/February 2009): 246–261; available at http://content.healthaffairs.org/cgi/ reprint/28/1/246. 5. Jones et al., "National Nursing Home Survey: 2004 Overview.” 6. American Health Care Association, “Medical Condition—Mental Status, CMS OSCAR Data Current Surveys,” June 2009; available at www.ahcancal.org/research_ data/oscar_data/NursingFacilityPatientCharacteristics/MC_mental_status_Jun2009.pdf. 7. Reports from long-term care ombudsman to the Administration on Aging (AoA) estimate about 50,000 “licensed board and care and similar facilities” with slightly more than 1 million beds. See A0A, “2008 National Ombudsman Reporting System Data Tables,” Table A-1; available at www.aoa.gov/AoARoot/AoA_ Programs/Elder_Rights/Ombudsman/National_State_Data/2008/Index.aspx. Another study estimated about 55,000 licensed residential care facilities with slightly more than 1 million beds. See Charlene Harrington et al., “Trends in the Supply of Long- Term Care Facilities and Beds in the United States,” Journal of Applied Gerontology, 24, no. 4 (August 2005): pp 265–282. 8. Harrington et al., “Trends in the Supply of Long-Term Care Facilities.” 9. American Association of Homes and Services for the Aging, American Seniors Housing Association, Assisted Living Federation of America, National Center for Assisted Living, and National Investment Center for the Seniors Housing and Care Industry, 2009 Overview of Assisted Living, 2009; available at the Web sites of each of the sponsoring organizations. Participating in this survey were 500 facili- ties, each of which is defined as a long-term care option that combines housing, supportive services, personalized assistance with activities of daily living, and health care and is licensed, certified, or registered by states. 10. Data are from the Medicare Current Beneficiary Survey and from Joan Hyde, Rosa Perez, and Brent Forester, “Dementia and Assisted Living,” The Gerontologist, 47, special issue III (2007): p. 53; available at http://gerontologist.gerontologyjournals.org/ cgi/reprint/47/suppl_1/51. 21 December 2, 2009 National Health Policy Forum 11. See, for example, GAO, Nursing Homes: Federal Monitoring Surveys. See also other related GAO reports cited in this paper, as well as U.S. Department of Health and Human Services, Office of the Inspector General (OIG), Nursing Home Com- plaint Investigations, OEI-01-04-00340, July 2006; available at http://oig.hhs.gov/oei/ reports/oei-01-04-00340.pdf. 12. GAO, Nursing Homes: Federal Monitoring Surveys. 13. GAO, Medicare and Medicaid Participating Facilities: CMS Needs to Reexamine Its Approach for Funding State Oversight of Health Care Facilities, GAO-09-64, February 2009; available at www.gao.gov/new.items/d0964.pdf. 14. In 1976, Congress enacted an amendment to the Social Security Act amend- ment (known as the Keyes amendment) that requires states to establish, main- tain, and ensure enforcement of standards for any category of institutions, foster homes, or group living arrangements in which a significant number of Supple- mental Security Income (SSI) recipients reside or are likely to reside. Also, Section 1915(c) of the Social Security Act requires states to assure quality of care in home and community-based waiver programs; in some states, assisted living and other residential care facilities are financed through these waiver programs. 15. Jo Harris-Wehling, Jill C. Feasley, and Carroll L. Estes, Eds., Real People, Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act (Washington, DC: Institute of Medicine, 1995), p. 3; available at www. nap.edu/catalog.php?record_id=9059. 16. George Potaracke, former state long-term care ombudsman for Wisconsin, e- mail communication with author, September 16, 2009. 17. For a discussion of the responsibilities of state and area agencies on aging, see Carol V. O’Shaughnessy, The Aging Services Network: Accomplishments and Challenges in Serving a Growing Elderly Population, National Health Policy Forum, Background Paper, April 11, 2008; available at www.nhpf.org/library/background- papers/BP_AgingServicesNetwork_04-11-08.pdf. 18. AoA, “Instructions for Completing the State Long Term Care Ombudsman Program Reporting Form for the National Ombudsman Reporting System (NORS),” p. 10; available at www.aoa.gov/AoAroot/AoA_Programs/Elder_Rights/ Ombudsman/docs/Instructions_Final.doc. 19. Harris-Wehling, Feasley and Estes, Real People, Real Problems, p. 63–65. 20. Centers for Medicare & Medicaid Services (CMS), “Money Follows the Person Grants,” available at www.cms.hhs.gov/DeficitReductionAct/20_MFP.asp; AoA, “Community Living Program Grants,” June 2009, available at www.aoa.gov/ AoARoot/AoA_Programs/HCLTC/NHD/index.aspx; National Association of State Units on Aging, “Nursing Facility Transition Information Bulletin #1,” January 2007; available at www.nasua.org/pdf/InformationBulletin1.pdf. 21. Twelve states have developed ombudsman programs for home care recipients. National Association of State Units on Aging, Home Care Ombudsman Programs Status Report: 2007, November 2007; available at www.ltcombudsman.org/sites/default/ files/Home-Care-Ombudsman-Programs-Status-Report-2007.pdf. 22 Bac kg ro u n d www.nhpf.org P a p e r No. 71 22. CMS, “Complaint Procedures,” in State Operations Manual, chap. 5; available at www.cms.hhs.gov/manuals/downloads/som107c05.pdf. 23. OIG, Nursing Home Complaint Investigations. 24. CMS, “Complaint Procedures.” 25. GAO, Nursing Homes: Complaint Investigation Processes Often Inadequate to Protect Residents, GAO/HEHS-99-80, March 1999; available at www.gao.gov/archive/1999/ he99080.pdf. 26. GAO, Nursing Homes: Despite Increased Oversight, Challenges Remain in Ensur- ing High-Quality Care and Resident Safety, GAO-06-117, December 2005; available at www.gao.gov/new.items/d06117.pdf. 27. GAO, Medicare and Medicaid Participating Facilities. 28. AoA, “National Ombudsman Reporting System (NORS),” updated September 11, 2009; available at www.aoa.gov/AoAroot/AoA_Programs/Elder_Rights/Ombudsman/ NORS.aspx. 29. AoA, “National Ombudsman Reporting System Data Tables,” Table A-1; available at www.aoa.gov/AoARoot/AoA_Programs/Elder_Rights/Ombudsman/National_ State_Data/index.aspx. 30. Interviews with selected state ombudsman were conducted by the author dur- ing the summer of 2008. 31. CMS, “Survey Protocol for Long Term Care Facilities,” in State Operations Man- ual, appendix P, Part I, rev. 42, April 24, 2009, available at www.cms.hhs.gov/Manuals/ Downloads/som107ap_p_ltcf.pdf; CMS, “Communication Between State Survey Agen- cies (SAs) and State Long-Term Care (LTC) Ombudsmen,” S&C-07-26, July 6, 2007; available at www.nasop.org/papers/Policy4.pdf. 32. Harris-Wehling, Feasley, and Estes, Real People, Real Problems, pp. 4–23. 33. OIG, Long-Term Care Ombudsman Program: Overall Capacity, OIE-02-98-00351, March 1999; available at www.oig.hhs.gov/oei/reports/oei-02-98-00351.pdf. 34. Carroll L. Estes et al., “State Long-Term Care Ombudsman Programs: Factors Associated with Perceived Effectiveness,” The Gerontologist, 44, no. 1 (2004): 104– 115, available at http://gerontologist.gerontologyjournals.org/cgi/reprint/44/1/104. 35. States are required to match federal Title III funds with 15 percent in matching funds. There is no required match for Title VII funds. 36. States receive Title III and Title VII ombudsman funding under a formula that is based on a state’s proportionate share of the population age 60 and older (with minimum amounts for low-population states and another minimum amount equal to a prior year’s funding amount). 37. National Association of State Units on Aging officials, telephone interview with author, October 14, 2009. 38. Harris-Wehling, Feasley and Estes, Real People, Real Problems, p. 197. 23 December 2, 2009 National Health Policy Forum 39. Harris-Wehling, Feasley and Estes, Real People, Real Problems, p. 193. 40. State funds include both state and local funds, where local funding data are made, and are available in the AoA/NORS data. 41. GAO, Assisted Living: Examples of State Efforts. 42. Harrington et al., “Trends in the Supply of Long-Term Care Facilities,” p. 279. 43. Catherine Hawes, Miriam Rose, and Charles D. Phillips, A National Study of Assisted Living for the Frail Elderly, U.S. Department of Health and Human Services; available at http://aspe.hhs.gov/daltcp/reports/facres.htm. 44. GAO, Assisted Living: Examples of State Efforts. 45. Jeanne Yordi, “Office of the State Long-Term Care Ombudsman Annual Report 2007,” Iowa Department of Elder Affairs, January 15, 2008; available at http:// publications.iowa.gov/6212/1/2007_Annual_STLCO_Report.pdf. 46. Cheryl Wold, California’s Long Term Care Ombudsman Program: Assessing the Volunteer Experience, California HealthCare Foundation, March 2007; available at www.chcf.org/documents/chronicdisease/OmbudsmanExperienceSurvey.pdf. 47. Mark Miller, New York State Office for the Aging, interview and e-mail corre- spondence with author, September 21, 2009. 24 APPENDIx long-Term Care (lTC) Facility beds per Paid Ombudsman Staff and Percentage of lTC Facilities Visited at least Quarterly, FY 2008 No. of lTC Percent of Facilities No. of lTC Percent of Facilities Facility beds per Visited at least Quarterly* Facility beds per Visited at least Quarterly* Paid Ombudsman Paid Ombudsman Staff (Ftes) Nursing Residential Care Staff (Ftes) Nursing Residential Care U.S. Average 2,200 79.7% 45.8% Nevada 1,515 100% 10% Alabama 1,712 95% 87% New Hampshire 2,019 26% 9% Alaska 1,286 7% 22% New Jersey 4,052 43% 36% Arizona 1,989 100% 65% New Mexico 1,361 100% 83% Arkansas 2,799 100% 100% New York 4,114 75% 33% California 1,494 93% 88% North Carolina 2,310 100% 100% Colorado 1,160 100% 100% North Dakota 2,134 83% 85% Connecticut 3,772 100% 100% Ohio 1,694 65% 14% Delaware 1,223 100% 83% Oklahoma 1,559 94% 89% District of Columbia 791 44% 2% Oregon 6,692 68% 20% Florida 2,364 100% 40% Pennsylvania 2,724 94% 80% georgia 1,169 96% 61% Puerto Rico 1,318 17% 28% Hawaii 2,716 94% 2% Rhode Island 1,137 29% NA† Idaho 1,054 100% 100% South Carolina 1,589 35% 12% Illinois 2,927 88% 85% South Dakota 4,011 67% 42% Indiana 3,674 36% 12% Tennessee 4,299 86% 60% Iowa 6,442 1% NA† Texas 3,041 99% 14% Kansas 3,154 90% 60% Utah 1,113 69% 54% Kentucky 900 100% 100% Vermont 893 100% 99% louisiana 2,207 100% 100% Virginia 2,410 73% 34% Maine 2,505 100% 32% Washington 2,438 81% 62% Maryland 1,212 89% 33% West Virginia 1,287 72% 8% Massachusetts 1,437 100% 100% Wisconsin 2,732 70% 8% Michigan 5,130 71% 1% Wyoming 890 97% 100% Minnesota 5,030 53% 17% * Facilities (unduplicated) visited on a regular basis; not in response to a complaint. "Regular Mississippi basis" is defined as at least quarterly. Represents visits by local projects, except for those states 1,371 100% 100% in which the state office does more visiting. Percentages are based on the local numbers reported Missouri 4,260 77% 41% and may slightly underrepresent the actual number of facilities visited for some states. † Data not available. Montana 832 44% 84% Source: Administration on Aging, National Ombudsman Reporting System FY 2008; available Nebraska 4,449 31% 3% at www.aoa.gov/aoaroot/aoa_Programs/elder_rights/ombudsman/National_State_Data/2008/ index.aspx.