Form 1 National OMBudsman Reporting System

State Annual Long-Term Care Ombudsman Report

Form_final2015

State Annual Long-Term Care Ombudsman Report

OMB: 0985-0005

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OMB NO.: 0985-0005
State: _____________________ Federal Fiscal Year: October 1, 20

EXPIRATION DATE: 07/31/2015

to September 30, 20

State Annual Ombudsman Report to the Administration on Aging
Agency or organization which sponsors the State Ombudsman Program:
Part I — Cases, Complainants and Complaints
A. Provide the total number of cases opened during reporting period.
Case: Each inquiry brought to, or initiated by, the ombudsman on behalf of a resident or group of residents involving
one or more complaints which requires opening a case and includes ombudsman investigation, strategy to resolve, and
follow-up.

B. Provide the number of cases closed, by type of facility/setting, which were received from the types of
complainants listed below.
Closed Case: A case where none of the complaints within the case require any further action on the part of the
ombudsman and every complaint has been assigned the appropriate disposition code.
Complainants:

Nursing
Facility

B&C, ALF,
RCF, etc.*

Other
Settings

1. Resident

__________

2. Relative/friend of resident

__________

3. Non-relative guardian, legal representative

__________

4. Ombudsman/ombudsman volunteer

__________

5. Facility administrator/staff or former staff

__________

6. Other medical: physician/staff

__________

8. Unknown/anonymous

__________

9. Other: Bankers, Clergy, Law Enforcement, Public Officials, etc.

__________

7. Representative of other health or social service agency or program

Total number of cases closed during the reporting period:

_______

C. For cases which were closed during the reporting period (those
counted in B above), provide the total number of complaints received:

_________

Complaint: A concern brought to, or initiated by, the ombudsman for investigation and action by or on behalf of one
or more residents of a long-term care facility relating to health, safety, welfare or rights of a resident. One or more
complaints constitute a case.

OMB NO.: 0985-0005
State: _____________________ Federal Fiscal Year: October 1, 20

EXPIRATION DATE: 07/31/2015

to September 30, 20

* Board and care, assisted living, residential care and similar long-term care facilities, both regulated and unregulated

State: ___ Federal Fiscal Year: October 1, 20

to September 30, 20

D. Types of Complaints, by Type of Facility
Below and on the following pages provide the total number of complaints for each specific complaint
category, for nursing facilities and board and care or similar type of adult care facility. The first four major
headings are for complaints involving action or inaction by staff or management of the facility. The last
major heading is for complaints against others outside the facility. See Instructions for additional
clarification and definitions of types of facilities and selected complaint categories.
Ombudsman Complaint Categories
Residents' Rights

Nursing
Facility

B&C, ALF,
RCF. similar

A. Abuse, Gross Neglect, Exploitation
l.

Abuse, physical (including corporal punishment)

__________

Abuse, sexual

__________

Abuse, verbal/psychological (including punishment, seclusion)

__________

Financial exploitation (use categories in section E for less severe financial
complaints)

__________

Gross neglect (use categories under Care, Sections F & G for non-willful forms of
neglect)

__________

Resident-to-resident physical or sexual abuse

__________

Not Used

Access to Information by Resident or Resident’s Representative

Access to own records

__________

Access by or to ombudsman/visitors

__________

10.

Access to facility survey/staffing reports/license

__________

11.

Information regarding advance directive

__________

12.

Information regarding medical condition, treatment and any changes

__________

13.

Information regarding rights, benefits, services, the resident’s right to complain

__________

14.

Information communicated in understandable language

__________

15.

Not Used

State: ___ Federal Fiscal Year: October 1, 20

to September 30, 20

Part I, Types of Complaints, cont.
C.

Nursing
Facility

B&C, ALF,
RCF. similar

Admission, Transfer, Discharge, Eviction

16.

Admission contract and/or procedure

__________

17.

Appeal process - absent, not followed

__________

18.

Bed hold - written notice, refusal to readmit

__________

19.

Discharge/eviction - planning, notice, procedure, implementation, inc. abandonment __________

__________

20.

Discrimination in admission due to condition, disability

__________

21.

Discrimination in admission due to Medicaid status

__________

22.

Room assignment/room change/intrafacility transfer

__________

23.

Not Used

Autonomy, Choice, Preference, Exercise of Rights, Privacy

24.

Choose personal physician, pharmacy/hospice/other health care provider

__________

25.

Confinement in facility against will (illegally)

__________

26.

Dignity, respect - staff attitudes

__________

27.

Exercise preference/choice and/or civil/religious rights, individual’s right to smoke __________

__________

28.

Exercise right to refuse care/treatment

__________

29.

Language barrier in daily routine

__________

30.

Participate in care planning by resident and/or designated surrogate

__________

31.

Privacy - telephone, visitors, couples, mail

__________

32.

Privacy in treatment, confidentiality

__________

33.

Response to complaints

__________

34.

Reprisal, retaliation

__________

35.

Not Used

Billing/charges - notice, approval, questionable, accounting wrong or denied (includes
overcharge of private pay residents)
__________

__________

E.
36.

Financial, Property (Except for Financial Exploitation)

State: ___ Federal Fiscal Year: October 1, 20

to September 30, 20
Nursing
Facility

Part I, Types of Complaints, cont.
37.

B&C, ALF,
RCF. Similar

Personal funds - mismanaged, access/information denied, deposits and other money
not returned (report criminal-level misuse of personal funds under A.4)
__________

__________

38.

Personal property lost, stolen, used by others, destroyed, withheld from resident

__________

39.

Not Used

Resident Care
F. Care
40.

Accident or injury of unknown origin, falls, improper handling

__________

41.

Failure to respond to requests for assistance

__________

42.

Care plan/resident assessment - inadequate, failure to follow plan or physician orders
(put lack of resident/surrogate involvement under D.30)
__________

__________

43.

Contracture

__________

44.

Medications - administration, organization

__________

45.

__________

46.

Personal hygiene (includes nail care & oral hygiene) and adequacy of dressing &
grooming
Physician services, including podiatrist

__________

47.

Pressure sores, not turned

__________

48.

Symptoms unattended, including pain, pain not managed, no notice to others of
changes in condition

__________

49.

Toileting, incontinent care

__________

50.

Tubes - neglect of catheter, gastric, NG tube (use D.28 for inappropriate/forced use) __________

__________

51.

Wandering, failure to accommodate/monitor exit seeking behavior

__________

52.

Not Used

G. Rehabilitation or Maintenance of Function
53.

Assistive devices or equipment

__________

54.

Bowel and bladder training

__________

55.

Dental services

__________

56.

Mental health, psychosocial services

__________

57.

Range of motion/ambulation

__________

State: ___ Federal Fiscal Year: October 1, 20

to September 30, 20

Part I, Types of Complaints, cont.

Nursing
Facility

B&C, ALF,
RCF. Similar

58.

Therapies — physical, occupational, speech

__________

59.

Vision and hearing

__________

60.

Not Used

H. Restraints - Chemical and Physical
61.

Physical restraint - assessment, use, monitoring

__________

62.

Psychoactive drugs - assessment, use, evaluation

__________

63.

Not Used

Quality of Life
I. Activities and Social Services
64.

Activities - choice and appropriateness

__________

65.

Community interaction, transportation

__________

66.

Resident conflict, including roommates

__________

67.

Social services - availability/appropriateness/ (use G.56 for mental health,
psychosocial counseling/service)

__________

68.

Not Used

J. Dietary
69.

Assistance in eating or assistive devices

__________

70.

Fluid availability/hydration

__________

71.

Food service - quantity, quality, variation, choice, condiments, utensils, menu

__________

72.

Snacks, time span between meals, late/missed meals

__________

73.

Temperature

__________

74.

Therapeutic diet

__________

75.

Weight loss due to inadequate nutrition

__________

76.

Not Used

State: ___ Federal Fiscal Year: October 1, 20

to September 30, 20

Part I, Types of Complaints, cont.
K. Environment
77.

Nursing
Facility
Air/environment: temperature and quality (heating, cooling, ventilation, water,noise) __________

B&C, ALF,
RCF. similar
__________

78.

Cleanliness, pests, general housekeeping

__________

79.

Equipment/building - disrepair, hazard, poor lighting, fire safety, not secure

__________

80.

Furnishings, storage for residents

__________

81.

Infection control

__________

82.

Laundry — lost, condition

__________

83.

Odors

__________

84.

Space for activities, dining

__________

85.

Supplies and linens

__________

86.

Americans with Disabilities Act (ADA) accessibility

__________

Administration
L. Policies, Procedures, Attitudes, Resources (See other complaint headings, of above, for
policies on advance directives, due process, billing, management residents' funds)
87.

Abuse investigation/reporting, including failure to report

__________

88.

Administrator(s) unresponsive, unavailable

__________

89.

Grievance procedure (use C for transfer, discharge appeals)

__________

90.

Inappropriate or illegal policies, practices, record-keeping

__________

91.

Insufficient funds to operate

__________

92.

Operator inadequately trained

__________

93.

Offering inappropriate level of care (for B&C/similar)

__________

94.

Resident or family council/committee interfered with, not supported

__________

95.

Not Used

Communication, language barrier (use D.29 if problem involves resident inability to
communicate)
__________

__________

Shortage of staff

__________

M. Staffing
96.

97.

__________

State: ___ Federal Fiscal Year: October 1, 20

to September 30, 20

Part I, Types of Complaints, cont.

Nursing
Facility

B&C, ALF,
RCF. similar

__________

100. Staff unresponsive, unavailable

__________

101. Supervision

__________

102. Eating Assistants

__________

103. Access to information (including survey)

__________

104. Complaint, response to

__________

105. Decertification/closure

__________

106. Sanction, including Intermediate

__________

107. Survey process

__________

108. Survey process - Ombudsman participation

__________

109. Transfer or eviction hearing

__________

111. Access to information, application

__________

112. Denial of eligibility

__________

113. Non-covered services

__________

114. Personal Needs Allowance

__________

115. Services

__________

117. Abuse/neglect/abandonment by family member/friend/guardian or, while on visit out
of facility, any other person
__________

__________

118. Bed shortage - placement

__________

98.

Staff training

99.

Staff turn-over, over-use of nursing pools

Not Against Facility
N. Certification/Licensing Agency

110. Not Used
O. State Medicaid Agency

116. Not Used
P. System/Others

__________

State: ___ Federal Fiscal Year: October 1, 20

to September 30, 20

Part I, Types of Complaints, cont.
119. Facilities operating without a license

Nursing
Facility
__________

B&C, ALF,
RCF. Similar
__________

120. Family conflict; interference

__________

121. Financial exploitation or neglect by family or other not affiliated with facility

__________

122. Legal - guardianship, conservatorship, power of attorney, wills

__________

123. Medicare

__________

124. Mental health, developmental disabilities, including PASRR

__________

125. Problems with resident's physician/assistant

__________

126. Protective Service Agency

__________

127. SSA, SSI, VA, Other Benefits/Agencies

__________

128. Request for less restrictive placement

__________

Total, categories A through P

Q. Complaints About Services in Settings Other Than Long-Term Care Facilities or
By Outside Provider in Long-Term Care Facilities (see instructions)
129. Home care

__________

130. Hospital or hospice

__________

131. Public or other congregate housing not providing personal care
132. Services from outside provider (see instructions)

__________
__________

133. Not Used
__________

Total, Heading Q.

____________________

Total Complaints*
*(Add total of nursing facility complaints; B&C, ALF, RCF, similar complaints and
complaints in Q, above. Place this number in Part I, C on page 1.)

State: __ Federal Fiscal Year: October 1, 20

to September 30, 20

E. Action on Complaints: Provide for cases closed during the reporting period the total number of complaints,
by type of facility or other setting, for each item listed below.

1. Complaints which were verified

Nursing
Facility

B&C, ALF,
RCF, similar

Other
Settings

__________

Verified: It is determined after work [interviews, record inspection, observation, etc.] that the circumstances
described in the complaint are generally accurate.

2. Disposition: Provide for all complaints reported in C and D,
whether verified or not, the number:
a. For which government policy or regulatory change or
legislative action is required to resolve (this may be
addressed in the issues section)

__________

b. Which were not resolved* to satisfaction of resident or
complainant
__________

__________

c. Which were withdrawn by the resident or complainant
__________
or resident died before final outcome of complaint
investigation
d. Which were referred to other agency for resolution and:
1) report of final disposition was not obtained

__________

2) other agency failed to act on complaint
3) agency did not substantiate complaint

__________
__________

e. For which no action was needed or appropriate

__________

f. Which were partially resolved* but some problem
remained

__________

g. Which were resolved* to the satisfaction of resident or
complainant
__________

__________

Total, by type of facility or setting

Grand Total (Same number as that for total complaints on pages 1 and
7)

______________________

*Resolved: The complaint/problem was addressed to the satisfaction of the resident or complainant.

Legal Assistance/Remedies (Optional) - For each type of facility, list the number of legal assistance
remedies for each of the following categories that were used in helping to resolve a complaint: a) legal
consultation was needed and/or used; b) regulatory endorsement action was needed and/or used; c) an
10

State: __ Federal Fiscal Year: October 1, 20

to September 30, 20

administrative appeal or adjudication was needed and/or used; and d) civil legal action was needed and/or
used.
F. Complaint Description (Optional): Provide in the space indicated a concise description of the most
interesting and/or significant individual complaint your program handled during the reporting period. State
the problem, how the problem was resolved and the outcome.
Part II — Major Long-Term Care Issues
A. Describe the priority long-term care issues which your program identified and/or worked on during the
reporting period. For each issue, briefly state: a) the problem and barriers to resolution, and b)
recommendations for system-wide changes needed to resolve the issue, or how the issue was resolved in your
State. Examples of major long-term care issues may include facility closures, planning for alternatives to
institutional care, transition of residents to less restrictive settings, etc.

Note: Do not use attachments when entering this material on the data input program provided for
the report — the material will be lost. Enter the material in the box provided for this purpose in the
data input program.
Part III - Program Information and Activities
A. Facilities and Beds:
1. How many nursing facilities are licensed in your State?

________

2. How many beds are there in these facilities?

________

3. Provide the type-name(s) and definition(s) of the types of board and care, assisted living, residential
care facilities and any other similar adult care home for which your ombudsman program provides
services, as authorized under Section 102(18) and (32), 711(6) and 712(a)(3)(A)(i) of the Older
Americans Act. If no change from previous year, type “no change” at space indicated.
a) How many of the board and care and similar adult care facilities described above are regulated
in your State?
________
b) How many beds are there in these facilities?

______________

State: __ Federal Fiscal Year: October 1, 20

to September 30, 20

B. Program Coverage
Statewide Coverage means that residents of both nursing homes and board and care homes (and similar
adult care facilities) and their friends and families throughout the state have access to knowledge of the
ombudsman program, how to contact it, complaints received from any part of the State are investigated and
documented, and steps are taken to resolve problems in a timely manner, in accordance with federal and
state requirements.
B.1. Designated Local Entities
Provide for each type of host organization the number of local or regional ombudsman entities (programs)
designated by the State Ombudsman to participate in the statewide ombudsman program that are
geographically located outside of the State Office:
Local entities hosted by:
Area agency on aging

____________

Other local government entity

____________

Legal services provider

____________

Social services non-profit agency

____________

Free-standing ombudsman program

____________

Regional office of State ombudsman program

____________

Other; specify:

____________

Total Designated Local Ombudsman Entities

____________

State: __ Federal Fiscal Year: October 1, 20

to September 30, 20

B.2 Staff and Volunteers
Provide numbers of staff and volunteers, as requested, at state and local levels.
Type of Staff
Paid program staff

Paid clerical staff
Volunteer ombudsmen certified to
address complaints at close of
reporting period.
Number of Volunteer hours donated

Other volunteers (i.e., not certified)
at close of reporting period.

Measure
FTEs
Number people working fulltime on ombudsman program
FTEs
Number volunteers

State Office

Local Programs

Total number of hours donated
by certified volunteer
Ombudsman
Number of volunteers

Certified Volunteer: An individual who has completed a training course prescribed by the State
Ombudsman and is approved by the State Ombudsman to participate in the statewide Ombudsman
Program.

State: __ Federal Fiscal Year: October 1, 20

to September 30, 20

C. Program Funding
Provide the amount of funds expended during the fiscal year from each source for your statewide program:
Federal - Older Americans Act (OAA) Title VII, Chapter 2, Ombudsman

$______________

Federal - Older Americans Act (OAA) Title VII, Chapter 3, Elder Abuse Prevention

$______________

Federal - OAA Title III provided at State level

$______________

Federal - OAA Title III provided at AAA level

$______________

Other Federal; specify:

$______________

State funds

$______________

Local; specify:

$______________

Total Program Funding

$______________

State: __ Federal Fiscal Year: October 1, 20
D

to September 30, 20

Other Ombudsman Activities
Provide below and on the next page information on ombudsman program activities other than work on
complaints.
Activity 1: Training for ombudsman staff and volunteers
Measure

State

Local

Number sessions
Number hours
Total number of trainees that attended any
of the training sessions above (duplicated
count)
3 most frequent topics for training

Activity 2: Technical assistance to local ombudsmen and/or volunteers
Measure

State

Local

State

Local

Estimated percentage of total staff time

3. Training for facility staff
Measure
Number sessions
3 most frequent topics for training

State: __ Federal Fiscal Year: October 1, 20

to September 30, 20

4. Consultation to facilities
(Consultation: providing information and technical assistance, often by telephone)

Measure

State

Local

3 most frequent topics for training
Number of consultations
5. Information and consultation to individuals (usually by telephone)
Measure

State

Local

3 most frequent requests/needs
Number of consultations
6. Facility Coverage (other than in response to complaint)
Measure

State

Local

Number Nursing Facilities visited
(unduplicated)
Number Board and Care (or similar)
facilities visited (unduplicated)
7. Participation in Facility Surveys
Measure

State

Local

State

Local

Number of surveys

8. Work with resident councils
Measure
Number of meetings attended

State: __ Federal Fiscal Year: October 1, 20

to September 30, 20

9. Work with family councils
Measure

State

Local

State

Local

State

Local

Number of meetings attended

10. Community Education
Measure
Number of sessions

11. Work with media
Measure
3 most frequent topics
Number of interviews/discussions
Number of press releases
12. Monitoring/work on laws, regulations, government policies and actions
Measure

State

Estimated percentage of total paid staff
time (Note: the total of the percentage at
each level in this item and item 2 should
not add to more than 100 %.)

Local

File Type	application/pdf
File Title	State Annual Ombudsman Report to the Administration on Aging
Author	Administration on Aging
File Modified	2015-07-09
File Created	2012-07-30