Form 1 National OMBudsman Reporting System

OMB NO.: 0985-0005 EXPIRATION DATE: 01/31/2019

State: _____ Federal Fiscal Year: October 1, 20 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		__________		__________		__________
7. Representative of other health or social service agency or program		__________		__________		__________
8. Unknown/anonymous		__________		__________		__________
9. Other: Bankers, Clergy, Law Enforcement, Public Officials, etc.		__________		__________		__________

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.

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

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)	__________	__________
2. Abuse, sexual	__________	__________
3. Abuse, verbal/psychological (including punishment, seclusion)	__________	__________
4. 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)	__________	__________
6. Resident-to-resident physical or sexual abuse	__________	__________
7. Not Used
B. Access to Information by Resident or Resident’s Representative
8. Access to own records	__________	__________
9. 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

Part I, Types of Complaints, cont. C. Admission, Transfer, Discharge, Eviction	Nursing Facility	B&C, ALF, RCF. similar
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

D. 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
E. Financial, Property (Except for Financial Exploitation)
36. Billing/charges - notice, approval, questionable, accounting wrong or denied (includes overcharge of private pay residents)	__________	__________
Part I, Types of Complaints, cont. 37. Personal funds - mismanaged, access/information denied, deposits and other money not returned (report criminal-level misuse of personal funds under A.4)	Nursing Facility __________	B&C, ALF, RCF. Similar __________
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. Personal hygiene (includes nail care & oral hygiene) and adequacy of dressing & grooming	__________	__________
46. 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	__________	__________
Part I, Types of Complaints, cont. 58. Therapies — physical, occupational, speech	Nursing Facility __________	B&C, ALF, RCF. Similar __________
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

Part I, Types of Complaints, cont.

K. Environment	Nursing Facility	B&C, ALF, RCF. similar
77. Air/environment: temperature and quality (heating, cooling, ventilation, water,noise)	__________	__________
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
M. Staffing
96. Communication, language barrier (use D.29 if problem involves resident inability to communicate)	__________	__________
97. Shortage of staff	__________	__________
Part I, Types of Complaints, cont. 98. Staff training	Nursing Facility	B&C, ALF, RCF. similar
99. Staff turn-over, over-use of nursing pools	__________	__________
100. Staff unresponsive, unavailable	__________	__________
101. Supervision	__________	__________
102. Eating Assistants	__________	__________
Not Against Facility
N. Certification/Licensing Agency
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	__________	__________
110. Not Used
O. State Medicaid Agency
111. Access to information, application	__________	__________
112. Denial of eligibility	__________	__________
113. Non-covered services	__________	__________
114. Personal Needs Allowance	__________	__________
115. Services	__________	__________
116. Not Used
P. System/Others
117. Abuse/neglect/abandonment by family member/friend/guardian or, while on visit out of facility, any other person	__________	__________
118. Bed shortage - placement	__________	__________
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.)

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.

	Nursing Facility	B&C, ALF, RCF, similar	Other Settings
1. Complaints which were verified	__________	__________	__________
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	__________	__________	__________
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	__________	__________	__________
other agency failed to act on complaint 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.

3. 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 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? ______________

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 ____________

B.2 Staff and Volunteers

Provide numbers of staff and volunteers, as requested, at state and local levels.

Type of Staff	Measure	State Office	Local Programs
Paid program staff	FTEs
	Number people working full-time on ombudsman program
Paid clerical staff	FTEs
Volunteer ombudsmen certified to address complaints at close of reporting period.	Number volunteers
Number of Volunteer hours donated	Total number of hours donated by certified volunteer Ombudsman
Other volunteers (i.e., not certified) at close of reporting period.	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.

B.3 Organizational Conflict of Interest

Provide a description of any organizational conflicts of interest identified and steps taken by the State agency and the Ombudsman to remedy or remove identified conflicts; indicate (a) the type of conflict as described in 45 CFR §1324.21 and Section 712 (f) (2) of the Older Americans Act; or a brief description of other conflicts of interest that may impact the effectiveness and credibility of the work of the Office (b) indicate if the conflict was at the State Office or at a local Ombudsman entity or both (c) provide a description of steps taken to remedy or remove each conflict of interest. If no conflicts were identified among the state Office or local Ombudsman entities, where applicable, write that none were identified.

Location of Conflict

Identified at: State Office  Local Entity  Both 

For subsequent reporting years:  I certify that I have reviewed the organization conflicts of interest in my state Ombudsman program and report no changes in organization conflicts or the remedies previously implemented.

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 $______________

D 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
Estimated percentage of total staff time

3. Training for facility staff

Measure	State	Local
Number sessions
3 most frequent topics for training

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
Number of surveys

8. Work with resident councils

Measure	State	Local
Number of meetings attended

9. Work with family councils

Measure	State	Local
Number of meetings attended

10. Community Education

Measure	State	Local
Number of sessions

11. Work with media

Measure	State	Local
3 most frequent topics
Number of interviews/discussions
Number of press releases

12. Monitoring/work on laws, regulations, government policies and actions

Measure	State	Local
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 %.)