Older Americans Act: Long-Term Care Ombudsman Program

Older Americans Act: Long-Term Care
Ombudsman Program
Kirsten J. Colello
Analyst in Gerontology
Domestic Social Policy Division
Summary
The purpose of the Long-Term Care Ombudsman Program (LTCOP), established
under Title VII of the Older Americans Act (OAA), is to investigate and resolve
complaints made by, or on behalf of, older persons who are residents of residential long-
term care facilities. There are 53 state LTCOPs operating in all 50 states, the District
of Columbia, Guam, and Puerto Rico. They are funded by two separate titles of the
OAA, other federal sources, state funds, and other nonfederal funds. The program
receives significant support from volunteers. In FY2006, about 1,301 paid staff and
over 13,000 volunteers investigated over 285,000 resident complaints. In FY2006,
resident care issues were the chief complaint in nursing homes, followed by residents’
rights. Among residents in other long-term care facilities, the top complaint categories
were residents’ rights and quality of life. An evaluation conducted by the Institute of
Medicine (IOM) in 1995 concluded that the program is understaffed and underfunded
to carry out its broad and complex responsibilities. This report will be updated
occasionally.
Background. The purpose of the Long-Term Care Ombudsman Program
(LTCOP) is to respond to the needs of residents facing problems in long-term care
facilities, including nursing homes, assisted living facilities, board and care homes, and
other similar adult residential care settings. Ombudsmen are available to help all long-
term care facility residents, not only those residents in facilities certified by Medicare
and/or Medicaid. Created in 1972 as a Public Health Service (PHS) demonstration
project in five states, authority for administering the ombudsman demonstration program
was transferred to the Administration on Aging (AoA) within the Department of Health
and Human Services (DHHS) in 1974. The results of the demonstration effort led to
statutory authority under the Older Americans Act (OAA)¹ in 1978 (P.L. 95-478). In

¹ Congress in 1978 amended the OAA (P.L. 95-478) to include a requirement that each state
develop a LTCOP in order to protect the health, safety, welfare, quality of care, and rights of the
institutionalized residents in nursing facilities, board and care homes, assisted living facilities,
(continued...)

1987, the program was given a separate authorization of appropriations (P.L. 100-175)

and, in 1992, the program was incorporated into a new Title VII of the Act authorizing
vulnerable elder rights protection activities (P.L. 102-375). Also in 1992, a provision was
added to the OAA amendments requiring AoA to establish a permanent National
Ombudsman Resource Center. The most recent amendments to the OAA in 2006 (P.L.

109-365) made no major changes to the program.

There are 53 state LTCOPs operating in all 50 states, the District of Columbia,
Guam, and Puerto Rico, and 569 local programs as of 2006.² The AoA’s National
Ombudsman Reporting System (NORS) compiles national statistics relating to
ombudsman activities. This information includes number, status, and type of cases
reported to state and local ombudsman programs; data on staff, volunteers, and funding;
and, other ombudsman activities.
Function. The OAA requires state units on aging to establish an Office of the
Long-Term Care Ombudsman. The functions of the state ombudsman programs are
mandated by law and include identifying, investigating, and resolving resident complaints;
protecting the legal rights of residents; advocating for systemic change; providing
information and consultation to residents and their families; and publicizing issues of
importance to residents. Complaints investigated by ombudsmen relate to actions,
inactions, or decisions of long-term care providers or other agencies that adversely affect
the health, safety, welfare, or rights of residents. Among its other responsibilities, the
Office is to analyze and monitor federal, state, and local policies that affect residential
long-term care facilities.
The law requires that a full-time ombudsman administer the program at the state
level; local ombudsmen may be designated by the state and are considered to be
representatives of the Office. According to AoA, most state ombudsman programs are³
located in state units on aging, but programs in 15 states and the District of Columbia are
located in other types of organizational settings, such as non-profit organizations.
Variations exist partly because the OAA gives each state leeway in determining many
aspects of the ombudsman program. For example, states can decide (a) where
ombudsman programs may be located organizationally within the state, (b) whether
enabling legislation should be passed at the state level, and (c) whether additional funding

¹ (...continued)
and other similar facilities. For further information, see CRS Report RL31336, Older Americans
Act: Programs, Funding, and 2006 Reauthorization (P.L. 109-365) by Carol O’Shaughnessy and
Angela Napili.
² Guam’s ombudsman program is for all elderly, not just those residing in long-term care
facilities. In addition, ombudsman programs in 12 states are authorized or mandated under state
law advocate on behalf of consumers who receive home and community-based care. For further
information, see M. Miller, Home Care Ombudsman Programs Status Report: 2007, National
Association of State Units on Aging, November 2007.
³ Based on CRS discussions with Sue Wheaton, Ombudsman Program Specialist, Administration
on Aging, as of November 2006, programs in Alaska, Colorado, Connecticut, District of
Columbia, Kansas, Kentucky, New Hampshire, New Jersey, Maine, Oregon, Rhode Island,
Virginia, Vermont, Washington, Wisconsin, and Wyoming are either free-standing programs or
located in private, non-profit agencies or a larger government ombudsman program.

will be made available through state and local sources.⁴ These differences mean that the
structure, operation, and effectiveness of the ombudsman programs can vary from state
to state.
Authorization and Funding. The OAA Amendments of 2006 (P.L. 109-365)
reauthorized the ombudsman program for five years through FY2011. Ombudsman
services are authorized under two separate titles of the OAA: Title III (Grants for States
and Community Programs on Aging) and Title VII (Vulnerable Elder Rights Protection
Activities). Title III authorizes grants to states for supportive services and senior centers
which provide for a wide range of social services, including long-term care ombudsman
services. Title VII has two separate authorizations for support of ombudsman activities:
Chapter 2 (the long-term care ombudsman program) and Chapter 3 (the elder abuse⁵
prevention program).
While the majority of federal funding for ombudsman activities comes from
appropriations for Titles III and VII of the OAA, the program also receives substantial
non-federal support. Table 1 shows total support for ombudsman activities in FY2006.
Total FY2006 funding for ombudsman activities from all sources combined (federal and
non-federal) was $77.8 million. Of that total, 33.5% came from Title III funds; 21.8%
from Title VII funds; and 4.7% from other federal funds. In FY2006, nonfederal funding
represented 40% of total support. Overall, the share of funding from non-federal sources
has increased since FY1996 (from 36.7% in FY1996 to 40.0% in FY2006).
Table 1. Long-Term Care Ombudsman Program Funding, by
Source, FY2006
Total FY2006 funds ⁽ⁱⁿ^m^illioⁿ^s⁾$77.8100%
Federal fundsTotal$46.660.0%
Title III, OAA$26.133.5%
Title VII, OAAChapter 2: ombudsman program$15.019.3%
Chapter 3: elder abuse prevention$1.92.5%
Other$3.74.7%
State funds$25.332.5%
Local funds$5.97.5%
^Note:^{Data m}^a^yⁿ^o^{t su}^m^to^to^{tals d}^u^{e to}^r^o^uⁿ^dⁱⁿ^g^.
^Source:^Ao^A,^{2006 N}^a^tⁱ^onal^O^m^buds^m^{an Repor}^tⁱ^{ng Sys}^t^em^D^a^t^a^T^abl^es^:^T^a^bl^{e A}^-^{9 L}^T^C^O^m^bu^ds^m^aⁿ
^P^r^o^g^r^a^m^Fundⁱ^ng.

⁴ For further information, see J. Harris-Wehling, J. Feasley, and C. Estes, eds., Real People Real
Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older American
Act, Washington, DC: Institute of Medicine (IOM), 1995.
⁵ Under Chapter 3, states may use funds to support the LTCOP if they choose.

Staffing. In FY2006, there were approximately 1,301 paid staff (full-time
equivalents) in state LTCOPs, an increase of 34% since FY2000.⁶ Despite this increase,
the program still relies heavily on volunteers to carry out program responsibilities. Nine
out of every ten ombudsman staff serve as volunteers. In FY2006, there were 13,402 total
volunteers; 9,183 of which were certified to investigate complaints. A nationwide study
conducted by the National Long Term Care Ombudsman Center found that 45 state
ombudsman programs have volunteer programs and 37 state programs reported having
a certification process for their volunteers as of 1999.⁷
The 1995 IOM evaluation along with a study done by the Office of Inspector General
(OIG) in DHHS (1991) acknowledged the importance of volunteers as a contributing
factor to high complaint resolution rates in this program.⁸ However, the IOM evaluation
advises that adequate methods for recruiting, training, and supervising volunteers are
essential to maximum utilization of ombudsman program volunteers. State programs
have different procedures for certification of volunteers, varying from required classroom
training to tests for certification. Over two-thirds of volunteers (69%) were trained and
certified to investigate complaints in FY2006, a 9% increase since FY2000.
In FY2006, ombudsmen reported just over 16,750 nursing facilities and more than
47,000 other residential long-term care facilities operating nationwide. Since FY2000 the
total number of licensed facilities has increased by 5% from about 60,900 to more than
63,000 in FY2006.⁹ This increase is due to an increase in assisted living facilities, board
and care homes, and other similar facilities, which more than offset the decrease in
nursing homes over the past five years.
Due to the requirement that ombudsmen investigate and resolve complaints of all
residents in residential long-term care facilities, the workload of staff and volunteers is
substantial, as shown by the reported ratio of staff to facilities and beds. The nationwide
ratio of paid ombudsman to facilities was one ombudsman to every 49 facilities in
FY2006, a smaller ratio than reported in FY2000 (one ombudsman to every 62 facilities).
Nationwide, there were a reported 2.8 million facility beds under the program’s
jurisdiction (just over 1.7 million nursing home beds and about 1.1 million beds in other
long-term care facilities) in FY2006. The nationwide ratio of full-time paid ombudsman
to facility beds was about one ombudsman per 2,200 beds, a smaller ratio than reported

⁶ For further information, see 2006 National Ombudsman Reporting System Data Tables, at
[ h t t p : / / www.aoa.go v/ pr of / a oapr og/ e l d er _r i ght s/ LT Comb u d s ma n / N a t i onal _ and_St a t e _Dat a/ 20

06nors/2006tables.xls], visited April 11, 2008.

⁷ G. McInnes and A. Hedt, Volunteers in the Long Term Care Ombudsman Program: Training,
Certification and Liability Coverage, Washington, DC: National Long Term Care Ombudsman
Resource Center, December 1999.
⁸ For further information, see Office of Inspector General (OIG) Report OEI-02-90-02120,
Successful Ombudsman Programs; OEI-02-90-02121, Ombudsman Output Measures; and, OEI-

02-90-02122, Effective Ombudsman Programs: Six Case Studies.

⁹ The number of board and care and similar facilities includes only those licensed by the state as
covered under the LTCOP. The number of unlicensed facilities is unknown, therefore, the actual
number of these facilities may be higher. The number of nursing homes may be slightly higher
than estimates by the Centers for Medicare and Medicaid Services (CMS), which only include
nursing homes certified to participate in Medicare and/or Medicaid.

in FY2000 (one ombudsman per 2,800 beds). However, it is important to note that these
ratios are nationwide, and each state has a unique ratio of paid ombudsman staff per
facility bed.¹⁰ The 1995 IOM study recommended a standard staffing ratio of one paid
full-time equivalent staff per 2,000 long-term care facility beds.
Despite the high number of facilities to be covered by each ombudsman, ombudsman
staff and volunteers visited 83% of nursing homes on a regular basis (defined as at least
quarterly) in FY2006. These visits were not in response to a complaint. The percentage
of nursing homes visited regularly by ombudsman staff outweighs visits to other
residential long-term care facilities. The proportion of regular visits to assisted living and
other long-term care facilities was 43% in FY2006.
Training. State ombudsman programs are responsible for training new and existing
staff. The OAA contains only basic requirements for training and stipulates that the AoA
is to develop model standards for training long-term care ombudsman, both paid and
unpaid volunteers. Furthermore, the law stipulates that the State Long Term Care
Ombudsman is responsible for establishing procedures for training representatives of the
local ombudsman program based on the AoA standards and that training is to be
developed in consultation with representatives of citizen groups, long-term care providers,
and ombudsmen. In the absence of specific federal training requirements and/or required
training materials, many states have developed their own standards. Several states
provide the training directly through an individual who is responsible for conducting all
of the training while some states require local ombudsman programs to conduct training.
State long-term care ombudsman programs have received assistance in developing
training programs from the National Long Term Care Ombudsman Resource Center,
operated by the National Citizen’s Coalition for Nursing Home Reform.¹¹
Program Data and Resident Complaints. In FY2006, AoA data show that
ombudsmen opened just over 190,000 new cases of resident complaints and closed more
than 182,000 cases in all types of facilities. Between FY2000 and FY2006, the total
number of cases closed increased by one-third (33%).
Since 1999, resident care issues have been the primary complaint category in nursing
homes. Poor quality of care in nursing homes has been attributed to insufficient numbers
of staff to care for residents. However, the relationship between staffing and quality of
care is complex and includes a range of staffing-related issues such as wages and benefits,
training, education, experience, and staff turnover.¹²
The top five resident complaints in nursing homes for FY2006 are (1) unheeded
requests for assistance; (2) problems with discharge planning or eviction notification and

¹⁰ For further information, see 2006 National Ombudsman Reporting System Data Tables, at
[ h t t p : / / www.aoa.go v/ pr of / a oapr og/ e l d er _r i g h t s / L T C o mb udsma n/ Nat i onal _ and_St a t e _Dat a/ 20

06nors/2006tables.xls], visited April 11, 2008.

¹¹ For further information on training materials to assist states, see the National Ombudsman
Resource Center website at [http://www.ltcombudsman.org/].
¹² J. Schnelle et al., Relationship of Nursing Home Staffing to Quality of Care. Health Services
Research, 39(2): 225-250, April 2004; R. Kane. Commentary: Nursing Home Staffing — More
Is Necessary but Not Necessarily Sufficient, 39(2): 251-256, April 2004.

procedures; (3) lack of respect for residents by staff; (4) inadequate care plans that do not
reflect residents’ conditions or do not involve families; and (5) improper handling of
residents that resulted in unexplained bruises or cuts. With the exception of (2), the other
four complaints listed above have remained among the top five resident complaints in
nursing homes since FY1999. Similarly, the top five resident complaints in other long-
term care facilities have remained the same since FY1999 and are: (1) problems with
medication administration or organization; (2) lack of quantity, quality, variety, and
choice in food; (3) inadequate discharge or eviction notice or procedure; (4) poor
equipment or building conditions; and (5) lack of respect for residents by staff. In
FY2006, the top five complaints for each facility type accounted for one-fifth of all
complaints for each facility type, respectively.
Program Evaluation. The most recent national evaluation of the ombudsman
program, conducted in 1995 by the IOM, concluded that the program plays an important
role in improving long-term care services, but is understaffed and underfunded to carry
out its broad and complex responsibilities.¹³ In March 1999, DHHS’s OIG recommended
that AoA work with states to strengthen the program by: developing guidelines for a
minimum level of program visibility that include criteria for the frequency and length of
regular visits, as well as the ratio of ombudsman program staff to long-term care beds;
further developing strategies for recruiting, training, and supervising more volunteers; and
establishing ways in which ombudsman programs can enhance collaboration with the state
nursing home survey and certification agencies, which are responsible for oversight of¹⁴
nursing home care quality.
A 2000 study of state ombudsman programs reaffirmed the importance of several
factors identified in the IOM evaluation as key to program effectiveness including
sufficient funding, staff, and volunteers; autonomy of ombudsman program in
organizational placement within the state; a supportive political or social environment;¹⁵
and strong interorganizational relationships. A study of local ombudsman programs
conducted in two states, California and New York, in 2004, found wide variation both
across and within each state’s program in terms of program location (area agency on aging
versus nonprofit organization) and the number of paid staff versus volunteers. Despite
reporting that their program budgets were inadequate to support their mandated
requirements, program coordinators in both states perceived their programs as effective,
more so in the nursing home setting than in board and care facilities. Program
coordinators in both states similarly identified staffing, resident care, and residents’ rights¹⁶

as the most pressing issues.
¹³ J. Harris-Wehling, J. Feasley, and C. Estes, eds., Real People Real Problems: An Evaluation
of the Long-Term Care Ombudsman Programs of the Older American Act, Washington, DC:
Institute of Medicine (IOM), 1995.
¹⁴ OIG Report OEI-02-98-00351, Long-Term Care Ombudsman Program: Overall Capacity.
¹⁵ C. Estes, et al. State Long Term Care Ombudsman Programs: Factors Associated with
Perceived Effectiveness, The Gerontologist, vol. 44(1), pp.104-115, 2004.
¹⁶ C. Estes, Enhancing the Performance of Local Long Term Care Ombudsman in New York Sate
and California: Chartbook, University of California, San Francisco, 2006.