Form 1 Local Director Survey

Process Evaluation and Special Studies Related to the Long-Term Care Ombudsman Program

Local-Directors-Survey

Local Directors/Regional Representaitves and Local Representatives

OMB: 0985-0055

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Write In Your Start Time: __________________________

Process Evaluation of the Long-Term Care Ombudsman Program (LTCOP) Local Directors/Regional Representatives Survey



PURPOSE OF THE STUDY:

NORC at the University of Chicago, with funding from the Administration for Community Living/Administration on Aging (ACL/AoA) is conducting an evaluation of the Long-Term Care Ombudsman Program. This survey is voluntary and is not part of an audit or a compliance review. The information you provide is confidential. We do not include names of respondents in any reports or in any discussions with supervisors, colleagues, or ACL/AoA. This survey will take approximately 30 minutes to complete. Please complete and return this form using the pre-paid envelope, or by scanning and emailing it to ________, or fax it to: _____.

Please contact NORC at _____ or [email protected] if you have any questions or concerns about this survey.

Name of person completing survey __________________________

Position/Title __________________________

Phone number __________________________

Email address __________________________



SURVEY TOPICS:

  1. Background Info

  2. Structure and Resources

  3. State and Local Level Coordination

  4. Program Activities

  5. Program Quality Assurance

  6. Demographic Information

__________________________________________________________________________________


Burden Statement


Under the Paperwork Reduction Act, we cannot ask you to respond to a collection of information unless it displays a currently valid OMB control number.  The survey will be sent to staff of local ombudsman programs. The average time required to complete the survey is estimated at 30 minutes. Send comments regarding this burden estimate or any aspect of this survey, including suggestions for reducing this burden, to the _____. Do not send your completed form to this address.

BACKGROUND INFORMATION

We’d like to begin by asking you a few questions about your position and your experience prior to working for the Long-Term Care Ombudsman Program (LTCOP).

  1. What is your current position with the LTCOP? __________________________________

  2. How long have you been working with the LTCOP in your current position?

{enter number years} ___ ___

+ {enter number months} ___ ___

  1. How long have you worked with the Ombudsman program overall?

{enter number years} ___ ___

+ {enter number months} ___ ___

  1. In what state does your program operate? __________

  2. Do you work full-time or part-time for the LTCOP?

1 Full-time

2 Part-time

  1. Do you share your time with any other program or entity (such as an Area Agency on Aging)?

1 Yes, I work part-time for another agency or within the same agency (This includes those who are full-time employees but who only dedicate part of their time to the LTCOP.)

2 No (Skip to Q9)

  1. What percentage of your time do you spend on the LTCOP?

{enter %} ___ ___

  1. What other programs do you spend your time on?

___________________________________________________________________________

____________________________________________________________________________

  1. What motivated you to work for the LTCOP? {Check all that apply}

1 Personal fulfillment (e.g., enjoyment in helping others)

2 Career development

3 Interest in the program’s mission

4 Family/relatives received long-term services and supports

5 Personal experience with the program

9 6 Other (Please specify): ______________________

  1. What was your job immediately prior to working at the LTCOP?

______________________________________________________________________________

  1. Have you held previous positions in the LTCOP?

1 Yes

If Yes, please describe: ________________________________________________________

____________________________________________________________________________

  1. No

  1. Had you ever interacted with the LTCOP or any other ombudsman program (as a client, facility staff member, etc.) before being hired?

1 Yes

2 No


STRUCTURE AND RESOURCES

Next, we’d like to discuss the organizational structure and resources of your local LTCOP.

1. Which of the following characterizes the structure of your program?

1 My state has local programs that are created through contract (or another arrangement such as an MOU) with an Area Agency on Aging (AAA) or other entity.

2 My state has a centralized structure where we do not have separate local programs. (Skip to Q4)

9 7 Don’t know

2. How often do you personally interact with any representatives from the Office of the State LTCO (state office staff)? This interaction may take any form (i.e., communication in person, by phone, or by email).

1 Daily

2 Several times a week

3 Once a week

4 Twice a month

5 Once a month

9 6 Other (Please specify): ________________________

  1. Not applicable (I work in the State Office.)

3. Overall, how would you describe the relationship between the Office of the State LTCO and your local Ombudsman entity(ies), if applicable?

1 Very effective

2 Somewhat effective

3 Neutral

4 Somewhat ineffective

5 Very ineffective

9 7 Don’t know

  1. Not applicable (My program does not have local Ombudsman entities.)

4. Does the structure of your program enable your program to carry out its individual advocacy activities?

1 Yes

2 No

If No, please describe: ________________________________________________________

____________________________________________________________________________

9 7 Don’t know

5. Does the structure of your program enable your program to carry out systems advocacy activities (e.g., speak with the media, support legislation)?

1 Yes

2 No

If No, please describe: ________________________________________________________

____________________________________________________________________________

  1. Don’t know

6. In the last year, on which of the following topics did your Office of the State LTCO provide training and technical assistance to you or your local program? {Check all that apply}

1 Case guidance

2 Legislation

3 State mandates, regulations

4 Legal advice or consultation

5 Outreach to consumers and stakeholders

6 LTCOP fiscal/budget information

7 LTCOP policies and procedures

8 Trends in long-term care that impact the program (e.g., growing aging populations, nursing home use of psychotropic medication, etc.)

9 NORS reporting

1 0 Systems advocacy

96 Other (Please specify): _____________________________

9 8 Not applicable

7. Overall, how would you describe the effectiveness of your Office of the State LTCO?

1 Very effective

2 Somewhat effective

3 Neutral

4 Somewhat ineffective

5 Very ineffective

  1. Don’t know

8. How often do you interact with volunteers?

1 Daily

2 Weekly

3 Every other week

4 Monthly

9 6 Other (Please specify): ________________________

9 8 Not applicable

9. Are lines of authority and accountability clearly defined for all staff (including volunteers)?

1 Yes

2 No

If No, please describe: ________________________________________________________

____________________________________________________________________________



Program Resources

  1. Next, we have questions about your program’s resources. Which of the following resources sufficiently meet the program’s needs? {Check all that apply}

1 Fiscal resources

2 Legal counsel

3 # of paid staff

4 # of volunteers

5 # of volunteer hours

6 Data/information systems (e.g., computers, mobile phones to call from the field, etc.)

7 Administrative support

8 Communication methods to share information with consumers and stakeholders (e.g., policymakers)

9 Training/technical assistance

  1. Other (Please specify): ________________________

  1. Have any of the following activities not been carried out as fully as you would have liked because of a lack of LTCOP resources? {Check all that apply}

1 Complaint investigation and resolution activities

2 Regular nursing home facility visits, not in response to a complaint

3 Regular board and care home facility visits, not in response to a compliant

4 Training for facility staff

5 Consultations to facilities

6 Information and consultations to individuals

7 Resident and family education at facilities

8 Resident and family council development and support

9 Community education activities

1 0 Legal assistance for residents

1 1 Analyzing and monitoring federal, state, and local law, regulations, and other

government policies and Actions

1 2 Research and policy analysis to inform systems advocacy work

1 3 Facilitate public comment on proposed legislation, laws, regulations, policies, and actions

1 4 Volunteer recruitment and retention

9 6 Other (Please specify): _______________________

  1. Are you able to determine the use of the fiscal resources appropriated or otherwise available for the operation of the LTCOP at the local level?

1 Yes

2 No

3 Partially

  1. Does your local Ombudsman program secure additional financial resources (e.g., grants) and/or in-kind contributions (e.g., donated office space) beyond the Federal, State, and local funds allocated?

  1. Yes

If Yes, what kind? _____________________________________________________________

2 No

9 8 Not applicable – The local program does not have the ability to secure additional financial resources or in-kind contributions.



Legal Counsel

  1. Does your local ombudsman program have dedicated legal counsel for technical representation and support on issues?

1 Yes

2 No (Skip to Q16)

  1. Don’t know

  1. Where does your program get legal counsel to provide consultation and/or representation for the Ombudsman program? (e.g., for complaint resolution, systems advocacy) {Check all that apply}

1 Legal services attorney

2 Agency/department attorney

3 Private attorney

9 6 Other (Please specify): _______________________

9 7 Don’t know

  1. Who provides legal representation to the Ombudsman or any representative of the Office against whom suit or other legal action is brought or threatened in connection with the performance of the official duties? {Check all that apply}

1 Yes

2 No (Skip to Q18)

  1. Don’t know

  1. Where does your program refer residents for legal representation (e.g., related to a complaint)? {Check all that apply}

1 Attorney General’s office

2 LTCOP employed in-house attorney(s)

3 State unit on aging has in-house attorney(s) assigned to serve residents on behalf of the LTCOP

4 Contracts or other arrangements with private attorneys

5 Legal assistance developer

6 Legal services agencies (including those funded by Title IIIB legal assistance programs)

9 6 Other (Please specify): _______________________

9 7 Don’t know

9 8 Not applicable

  1. Have you ever requested and not been able to obtain timely legal assistance?

1 Yes

If Yes, what was the nature of the legal issue for which you were requesting assistance?

______________________________________________________________________________

______________________________________________________________________________

2 No

9 8 Not applicable

  1. Overall, how effective is the legal assistance your program receives?

1 Very effective

2 Somewhat effective

3 Neutral

4 Somewhat ineffective

5 Very ineffective

9 7 Don’t know


STATE AND LOCAL LEVEL COORDINATION

Next, we’d like to understand your program’s relationships with other organizations.

  1. Below is a list of entities that have responsibilities relevant to the health, safety, well-being or rights of residents of long-term care facilities. For each one, please indicate if you or your local Ombudsman program staff works on a regular basis with that entity and then indicate the purpose of that interaction. {Please check “Yes,” “No,” or “Don’t know” in all four columns for each item}



Regular interaction?

Purpose?



Individual Resident Advocacy

Systems Advocacy

Education/

Outreach

Other

  1. Area Agency on Aging

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

  1. Aging and Disability Resource Center

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

  1. Adult Protective Services

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

  1. Protection and Advocacy Systems

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

  1. Facility and long-term care provider licensure and certification program

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

  1. State Medicaid fraud control

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

  1. Victim assistance programs (for people who have been victimized by a crime such as rape, assault, financial exploitation, etc.)

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

  1. State and local law enforcement agencies

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

  1. Courts

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

  1. State legal assistance developer and legal assistance/legal aid programs

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

1 Yes

2 No

9 7 Don’t Know

  1. Overall, does the nature of the relationship that you or your staff have with the following entities support sufficient coordination to meet resident and program needs?


Yes

No

Not Applicable

  1. Area Agency on Aging

1

2

98

  1. Aging and Disability Resource Center

1

2

98

  1. Adult Protective Services

1

2

98

  1. Protection and Advocacy Systems

1

2

98

  1. Facility and long-term care provider licensure and certification program

1

2

98

  1. State Medicaid fraud control

1

2

98

  1. Victim assistance programs (for people who have been victimized by a crime such as rape, assault, financial exploitation, etc.)

1

2

98

  1. State and local law enforcement agencies

1

2

98

  1. Courts

1

2

98

  1. State legal assistance developer and legal assistance/legal aid programs

1

2

98

  1. If you answered “No” to any of the questions above, what would help the relationship(s) to meet resident and program needs?

______________________________________________________________________________________________________________________________________________________________



  1. Does your program work with any of the following entities not listed above? {Check all that apply.}

1 Managed Care Organizations (MCOs)

2 Quality Improvement Organizations (QIOs)

3 Centers for Independent Living

4 Senior Medicare Patrol (SMP)

5 Consumer Advocacy Groups

6 Physician Groups

7 Veterans Administration – State

8 Veterans Administration – Federal

  1. Other (Please specify): __________

Does your program work with any of the following local level or state level work groups? {Check all that apply.}

1Rectangle 6 Culture change coalitions

2Rectangle 5 WINGS (guardianship groups)

3Rectangle 4 Elder abuse task forces

4Rectangle 3 Ethics committees

5Rectangle 2 LANEs (Advancing Excellence for Nursing Homes)

9Rectangle 1 6 Other (Please specify): __________

  1. Overall how would you describe the effectiveness of your program’s relationship with the following types of facilities and providers?


A majority of the relationships are effective

Some of the relationships are effective

A few of the relationships are effective

None of the relationships are effective

Not Applicable

  1. Nursing homes

1

2

3

4

98

  1. Board and care homes and similar facilities*

1

2

3

4

98

*Board and care homes and similar facilities include residential care facilities, adult congregate living facilities, assisted living facilities, foster care homes, and other adult care homes similar to a nursing facility or board and care home which provide room, board, and personal care services to a primarily older residential population.


  1. Please describe the factors that went into your response above. ______________________________________________________________________________________________________________________________________________________________

  2. Does your program have the authority to serve consumers of in-home services?

1 Yes

2 No (Skip to next section)

  1. Overall, how would you describe the effectiveness of your program’s relationship with in-home service providers?


A majority of the relationships are effective

Some of the relationships are effective

A few of the relationships are effective

None of the relationships are effective

Not Applicable

  1. In-home service providers

1

2

3

4

98


  1. Please describe the factors that went into your response above. ______________________________________________________________________________________________________________________________________________________________


PROGRAM ACTIVITIES

Next we’d like to explore the role you play in your LTCOP and the activities that you and your program carry out.

  1. In your role, which of the following program management functions do you perform? {Check all that apply}

1 Program administration

2 Data management, including entry, quality control, reporting, etc.

3 Data collection, including documenting activities and cases/complaints

4 Analysis of trends and sharing findings, such as with Office of State LTCO or sharing of facility information with surveyors prior to survey, etc.

5 Developing partnerships

6 Providing staff training

  1. Other (Please specify): _____________________________

  2. Not applicable

  1. How are decisions made about facility visits? {Check all that apply}

  1. Ombudsmen are assigned to a specific facility or group of facilities to visit, based on geographic region.

  2. Ombudsmen are assigned to a specific facility or group of facilities to visit, based on facility characteristics (e.g., size, ownership).

3 Ombudsmen visit facilities in response to information about facility problems and

resident complaints.

  1. Other (Please specify): ____________________________

  1. Do you personally handle, investigate or resolve complaints or assist representatives with complaints?

1 Yes

  1. No (Skip to Q8)

  1. What types of complaints do you handle?

1 I handle all types of complaints

  1. I handle only some types of complaints

  1. Please describe the types of complaints that you handle:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

  1. How do you handle complaints? {Check all that apply}

1 I handle complaints on my own

2 I support other program staff as they handle complaints

3 I consult with other program staff, as needed

4 I refer the complaint to the appropriate entity when I have resident consent

  1. Other (Please specify): ___________________________________________________

  1. Do you investigate and work to resolve complaints of abuse, gross neglect and/or exploitation?

1 Yes

  1. No

  1. Does your program use a standard method/procedure for conducting investigations into abuse/neglect/financial exploitation?

1 Yes

  1. No (Skip to Q10)

  1. Which of the following steps are included in the complaint investigation protocol your program uses for conducting investigations into abuse/neglect/financial exploitation? {Check all that apply}

1 Begin the investigation within a certain time frame (i.e., standard of promptness for beginning an investigation)

2 Assure that the resident’s perspective, wishes and goals are identified, including protection from abuse, neglect, and exploitation when this is the goal

3 If the resident was not the person making the complaint, meet with the resident to advise that a concern has been raised

4 Secure consent from resident or resident’s representative to conduct investigation

5 The resident or resident’s representative consent is documented

6 Determine the wishes of the resident (or resident representative, where applicable) with respect to resolution of the complaint

7 Advise the resident of the resident’s rights

8 a The identity of the complainant is kept confidential and not disclosed without consent

8 b The identity of the resident(s) at issue is not disclosed without consent

9 Observe location in which the event(s) were alleged to have occurred

1 0 Interview other people who may have knowledge or information relevant for the

investigation. (This could include facility staff and managers, family members, legal representatives of the resident, resident’s roommate, therapists, medical providers, etc.)

1 1 Review relevant resident records maintained by the facility

1 2 Review other documentation (not maintained by the facility such as banking activity or a Will) relevant to investigation

1 3 Interview alleged perpetrator(s)

1 4 Consult with the supervisor in the LTCO program on investigation and resolution strategies

1 5 Consult with legal counsel, as needed

1 6 Make appropriate referrals for complaint resolution when the resident (or resident representative) consents to such disclosure

1 7 Complete investigation within a certain number of days (i.e., standard of promptness for completion of investigation)

1 8 Write up an investigation report that documents your investigation steps and impressions

of what happened. Include whether the alleged abuse/neglect/exploitation complaint is verified for not.

1 9a When investigation is complete, communicate the investigation findings to the complainant and/or resident (or resident’s representative).

1 9b Document these communications.

2 0 Complete resolution within a certain number of days (i.e., standard of promptness for completion of resolution).

2 1 Check with the resident (or resident’s representative) to determine whether the issue was resolved to the resident’s satisfaction.

2 2 Make a follow-up contact to the resident (or resident’s representative) to determine whether the issue continues to be resolved.

9 6 Are there other items included in your investigation plan? ______________________________________________________________

______________________________________________________________________

______________________________________________________________________

  1. Do you personally visit nursing homes? (Check all that apply)

  1. Yes

  2. No (Skip to Q18)

  1. What type of nursing home visit do you conduct: {Check all that apply}

1 Visit on a routine basis (not complaint driven)

2 Visit in response to facility problems and resident complaints

9 6 Other (Please specify): ___________________________

  1. How many nursing homes do you typically visit in a quarter?

{enter number} ___ ___

  1. How often do you typically visit nursing homes?

1 Weekly

2 Less than weekly but at least once a month

3 Less than monthly but at least once every quarter

4 Twice a year

5 Once a year

9 6 Other: _____________

  1. For each routine visit (non-complaint), on average how much time do you spend at the nursing home facility?

1 Less than an hour

2 Between 1 to 2 hours

3 Between 1 to 3 hours

4 More than 3 hours

9 8 Not applicable (I do not conduct routine visits.)

  1. How frequently does your program experience problems in getting access to residents in nursing homes?

1 Often

2 Sometimes

3 Rarely

4 Never

  1. How frequently does your program experience problems with unannounced visits to nursing homes?

1 Often

2 Sometimes

3 Rarely

4 Never

  1. How frequently does your program experience problems in obtaining timely access to resident records in nursing homes?

1 Often

2 Sometimes

3 Rarely

4 Never



  1. Please indicate the category of complaint that a) your program is most effective at resolving, b) your program finds most challenging to resolve, and c) takes up most of your program’s time with regard to nursing homes. { Select one in each column.}


Most effective at resolving

Most challenging to resolve

Takes up most of program’s time

Resident’s Rights

  1. Abuse, gross neglect, exploitation

1 Rectangle 8

2 Rectangle 7

3 Rectangle 6

  1. Access to information by resident or resident’s representative

1 Rectangle 4

2 Rectangle 3

3 Rectangle 2

  1. Admission, transfer, discharge, eviction

1 Rectangle 9

2 Rectangle 10

3 Rectangle 11

  1. Autonomy, choice, preference, exercise of rights, privacy

1 Rectangle 12

2 Rectangle 13

3 Rectangle 14

  1. Financial, property (except for financial exploitation)

1 Rectangle 15

2 Rectangle 16

3 Rectangle 17

Resident Care

  1. Care

1 Rectangle 18

2 Rectangle 19

3 Rectangle 20

  1. Rehabilitation or maintenance of function

1 Rectangle 21

2 Rectangle 22

3 Rectangle 23

  1. Restraints – chemical and physical

1 Rectangle 24

2 Rectangle 25

3 Rectangle 26

Quality of Life

  1. Activities and social services

1 Rectangle 27

2 Rectangle 28

3 Rectangle 29

  1. Dietary

1 Rectangle 30

2 Rectangle 31

3 Rectangle 32

  1. Environment

1 Rectangle 33

2 Rectangle 34

3 Rectangle 35

Administration

  1. Policies, procedures, attitudes, resources

1 Rectangle 36

2 Rectangle 37

3 Rectangle 38

  1. Staffing

1 Rectangle 39

2 Rectangle 40

3 Rectangle 41

Not Against Facility

  1. Certification/Licensing Agency

1 Rectangle 42

2 Rectangle 43

3 Rectangle 44

  1. State Medicaid Agency

1 Rectangle 45

2 Rectangle 46

3 Rectangle 47

  1. System/Others

1 Rectangle 48

2 Rectangle 49

3 Rectangle 47



Board and care home visits

Next, we have questions about board and care homes. Board and care homes and similar facilities include residential care facilities, adult congregate living facilities, assisted living facilities, foster care homes, and other adult care homes similar to a nursing facility or board and care home which provide room, board, and personal care services to a primarily older residential population.

  1. Do you personally visit board and care homes?

1 Yes

  1. No (Skip to Q27)

  1. What type of board and care visit do you conduct: {Check all that apply}

1 Visit on a routine basis (not complaint driven)

2 Visit in response to facility problems and resident complaints

9 6 Other (Please specify): ___________________________

  1. How many board and care homes do you typically visit in a quarter?

{enter number} ___ ___

  1. How often do you typically visit board and care homes?

1 Weekly

2 Less than weekly but at least once a month

3 Less than monthly but at least once every quarter

4 Twice a year

5 Once a year

  1. Other (Please specify): _____________

  1. For each routine visit (non-complaint), on average how much time do you spend at the board and care home facility?

1 Less than an hour

2 Between 1 to 2 hours

3 Between 1 to 3 hours

  1. More than 3 hours

9 8 N Not applicable (I do not conduct routine visits.)

  1. How frequently does your program experience problems in getting access to residents in board and care homes?

1 Often

2 Sometimes

3 Rarely

4 Never

  1. How frequently does your program experience problems with unannounced visits to board and care homes?

1 Often

2 Sometimes

3 Rarely

4 Never

  1. How frequently does your program experience problems in obtaining timely access to resident records in board and care homes?

1 Often

2 Sometimes

3 Rarely

4 Never

  1. Please indicate the category of complaint that a) your program is most effective at resolving, b) your program finds most challenging to resolve, and c) takes up most of your program’s time with regard to board and care homes? {Select one in each column.}


Most effective at resolving

Most challenging to resolve

Takes up most of program’s time

Resident’s Rights

  1. Abuse, gross neglect, exploitation

1 Rectangle 8

2 Rectangle 7

3 Rectangle 6

  1. Access to information by resident or resident’s representative

1 Rectangle 4

2 Rectangle 3

3 Rectangle 2

  1. Admission, transfer, discharge, eviction

1 Rectangle 9

2 Rectangle 10

3 Rectangle 11

  1. Autonomy, choice, preference, exercise of rights, privacy

1 Rectangle 12

2 Rectangle 13

3 Rectangle 14

  1. Financial, property (except for financial exploitation)

1 Rectangle 15

2 Rectangle 16

3 Rectangle 17

Resident Care

  1. Care

1 Rectangle 18

2 Rectangle 19

3 Rectangle 20

  1. Rehabilitation or maintenance of function

1 Rectangle 21

2 Rectangle 22

3 Rectangle 23

  1. Restraints – chemical and physical

1 Rectangle 24

2 Rectangle 25

3 Rectangle 26

Quality of Life

  1. Activities and social services

1 Rectangle 27

2 Rectangle 28

3 Rectangle 29

  1. Dietary

1 Rectangle 30

2 Rectangle 31

3 Rectangle 32

  1. Environment

1 Rectangle 33

2 Rectangle 34

3 Rectangle 35

Administration

  1. Policies, procedures, attitudes, resources

1 Rectangle 36

2 Rectangle 37

3 Rectangle 38

  1. Staffing

1 Rectangle 39

2 Rectangle 40

3 Rectangle 41

Not Against Facility

  1. Certification/Licensing Agency

1 Rectangle 42

2 Rectangle 43

3 Rectangle 44

  1. State Medicaid Agency

1 Rectangle 45

2 Rectangle 46

3 Rectangle 47

  1. System/Others

1 Rectangle 48

2 Rectangle 49

3 Rectangle 50

Program Strengths and Challenges

  1. Are there any areas for which your program has specific expertise? {Check all that apply}

1 Providing advocacy in board and care facilities

2 Elder abuse (e.g., task forces, staff training/in services)

3 Culture change (e.g., person-centered service planning, dementia-competent

care, etc.)

4 Assisting residents transitioning out of facilities

5 Providing support during bankruptcy proceedings

6 Providing advocacy around inappropriate drug use

7 Supporting residents re: End of life care (e.g., advance directives, access to

hospice services, facility practices when someone dies)

8 Supporting residents re: Managing family conflicts (e.g., power of attorney)

9 Supporting residents re: Involuntary discharge/transfers

1 0 Systems advocacy

1 1 Developing a volunteer program

9 6 Other (Please specify): ______________________________

  1. What challenges does your program face? {Check all that apply}

1 Insufficient funding

2 Insufficient program autonomy

3 Insufficient legal counsel

4 High turnover of paid staff

5 High turnover of volunteers

6 Difficulty hiring qualified paid staff

7 Difficulty recruiting and supporting volunteers

8 Working with facility administrators, corporate owners, and provider associations

9 Working with other organizations

1 0 Working with family members

1 1 Working with resident councils

1 2 Working with family councils

1 3 Offering greater peer-to-peer support to share what works and what does not

1 4 Receiving more training in areas where I need to be knowledgeable

9 6 Other (Please specify): __________________________________

  1. Does your program have any difficulty serving any of the following populations? {Check all that apply}

1 People who live in rural areas

2 People who have disabilities including physical, intellectual, developmental, mental

health, or communication disabilities (e.g., deafness or blindness)

3 People with cognitive limitations, such as Alzheimer’s, dementia, and related diseases

4 People who speak a language other than English

5 People of diverse cultural backgrounds

6 People from the lesbian, gay, bisexual or transgender (LGBT) community

7 Veterans

8 Tribal elders

9 6 Other (Please specify): __________________________________

  1. Which of the following experiences, skills, and characteristics/styles do you bring to your role as an ombudsman? {Check all that apply}

Experience

1 Training caring for people who are ill, assisting older adults or working with persons with

disabilities (e.g., as a doctor, nurse, health aide, social worker, etc.)

2 Familiarity with the health care system

3 Case work/client advocacy

4 Legal training

5 Administrative and/or volunteer management

9 6 Other (Please specify): ________________________________

Skills

6 Conflict resolution

7 Cultural competence

8 Mediation

9 Social skills (e.g., enjoy visiting with people, being a resource as a problem solver)

1 0 Communication skills

1 1 Investigative skills

1 2 Speak another language (including sign language)

9 6 Other (Please specify): __________________________________

Characteristics/Style

1 3 Friendly

1 4 Collaborative

1 5 Diplomatic

1 6 Direct

1 7 Assertive

1 8 Persistent

9 6 Other (Please specify): __________________________________

  1. What do you see are the most important systems advocacy issues for your program to address right now?

__________________________________________________________________________________

__________________________________________________________________________________



PROGRAM QUALITY ASSURANCE

In this section, we focus on aspects of the program that are designed to ensure that high quality services are delivered, and that staff receive the training and technical assistance they need to carry out their work.

Training and Support

  1. What type of orientation, training, or support did you receive when you first joined the LTCOP? {Check all that apply}

1 Self-study (on-line training or reviewing materials provided by state program)

2 Self-study (on-line training or reviewing materials provided by NORC)

3 In-person classroom training

4 Mentoring/shadowing with experienced staff

5 Training in a long-term care facility

6 Attending a resident or family council meeting

7 Introduction to key stakeholders in my state

8 Outreach by Federal or Regional ACL/AoA staff

9 Outreach by State Ombudsmen from the National Association of State Long-Term Care Ombudsman Programs (NASOP)

1 0 Training by legal counsel

1 1 None

9 6 Other (Please specify): ___________________________

  1. How effective was the orientation training you received in preparing you for your role?

1 Very effective

2 Somewhat effective

3 Neutral

4 Somewhat ineffective

5 Very ineffective

9 7 Don’t know

  1. What aspect of your training did you find most relevant for doing your job?

__________________________________________________________________________________

__________________________________________________________________________________

  1. Is there training that you did not receive during your orientation period that you think would have been helpful when you began in this role?

1 Yes

If Yes, please describe: ___________________________________________________________

2 No

  1. What type of ongoing training and support do you receive? {Check all that apply}

1 2 Informal support from other staff or representatives of your office

2 Guidance from other local or regional ombudsman offices

3 Guidance from staff in the state ombudsman office

4 Online training such as webinars or conference calls on special topics

5 a Office of State LTCO provides training (via conferences, web-based training, etc.)

5 b Office of State LTCO provides relevant information and support

6 Support from National Ombudsman Resource Center (NORC)

7 Support from National Association of Local Long-Term Care Ombudsmen (NALLTCO)

8 Support from other state or local agencies

9 Conferences (e.g., Consumer Voice Conference)

9 6 Other (Please specify): ___________________________

  1. What additional support would you like from state program staff? {Check all that apply}

1 More information from program staff

2 More opportunities to discuss challenges (e.g., managing volunteers, case consultation and resolution strategies, etc.) with supervisor

3 More professional development opportunities

4 More opportunities to discuss challenges with other ombudsmen

5 More feedback on my performance and effectiveness

6 More formal training (Please specify): ___________________________

  1. How frequently do you receive performance reviews?

1 Semi-annually

2 Annually

96 Other (Please specify): __________

Data Systems & Information Technology

  1. Does your program provide training and assistance on documenting cases, complaints and other Ombudsman program activities? If so, are you expected to submit formal reports?

1 Yes

2 No

97 Don’t know

  1. How frequently do you submit reports?

1 Weekly

2 Monthly

3 Quarterly

9 6 Other (Please specify): ____________

  1. Does your program provide you with a form for submitting reports?

1 Yes

If Yes, please specify the format: _____________________________________

2 No

  1. Does your program offer a way to submit reports online?

1 Yes

2 No

9 7 Don’t know

12. How would you characterize the ease of collecting data and submitting reports?

1 Easy

2 Somewhat easy

3 Somewhat difficult

  1. Difficult

13. Does your program use NORS data for any of the following purposes? {Check all that apply}

1 Program planning and improvement

2 Examining trends for determining advocacy issues to focus on

3 Identifying issues of concern as well as promising practices

4 Comparing my program’s performance against programs in other states

5 Advocacy purposes (e.g., present data to the Governor’s office, legislature, state officials and other stakeholders to convey the scope and depth of problems in the long-term care system)

  1. Don’t know



  1. What types of information technology does your program use to raise the visibility and awareness of the program and communicate its services to the public? {Check all that apply}

1 Website

2 Social media (e.g., Facebook, Twitter)

3 Email contact with clients

4 Alerts/other urgent electronic messaging to stakeholder groups

5 Electronic bulletin boards

6 Publications/brochures/newsletters in English

7 Publications/brochures/newsletters in other languages

96 Other (Please describe): ______________________________________________

  1. What security strategies are in place to protect resident-identifying and complaint-identifying information?

__________________________________________________________________________________

__________________________________________________________________________________

National, State and Local Resources

  1. A number of resources are available to enhance the skills, knowledge and management capacity of program staff. How helpful have the following resources been to you?


    Very helpful

    Somewhat helpful

    Not helpful

    Not applicable

    Not familiar with this resource

    1. Website (ltcombudsman.org)

    1

    2

    3

    98

    9

    1. Area Agency on Aging (AAA)

    1

    2

    3

    98

    9

    1. State Unit on Aging (SUA)

    1

    2

    3

    98

    9

    1. Office of the State LTCO

    1

    2

    3

    98

    9

    1. National Association of Local Long-Term Care Ombudsmen (NALLTCO)

    1

    2

    3

    98

    9

    1. National Ombudsmen Resource Center (NORC)

    1

    2

    3

    98

    9

    1. National Association of State Long-Term Care Ombudsman Programs (NASOP)

    1

    2

    3

    98

    9

    1. National Association of States United for Aging and Disabilities (NASUAD)

    1

    2

    3

    98

    9

    1. Administration for Community Living (ACL)

    1

    2

    3

    98

    9

    1. Other (Please specify):

    _______________________

    1

    2

    3

    98

    9

  2. How often have you used the various resources available through the National Ombudsman Resource Center (NORC)?


    Often

    Sometimes

    Rarely

    Never

    Support not available

    Not familiar with this resource

    1. Phone/email advice or consultation

    1

    2

    3

    4

    5

    9

    1. Webinar

    1

    2

    3

    4

    5

    9

    1. Access to an expert

    1

    2

    3

    4

    5

    9

    1. Listserv

    1

    2

    3

    4

    5

    9

    1. Posted resource documents

    1

    2

    3

    4

    5

    9

    1. Program promotion resources

    1

    2

    3

    4

    5

    9

    1. Ombudsman Outlook quarterly e-newsletter

    1

    2

    3

    4

    5

    9

    1. Consumer Voice conference

    1

    2

    3

    4

    5

    9

    1. Other (Please specify):

    _______________________

    1

    2

    3

    4

    5

    9

  3. Where do you go for information and resources to stay informed about developments in long-term care that may impact program practices?

1 Area Agencies on Aging (AAAs)

2 State Unit on Aging (SUA)

3 State Long-Term Care Ombudsman

4 National Association of Local Long-Term Care Ombudsmen (NALLTCO)

5 National Ombudsman Resource Center (NORC)

6 National Consumer Voice for Quality Long-Term Care

7 Administration for Community Living/Administration on Aging (ACL/AoA)

  1. Other (Please specify): ______________________________________________

19. How satisfied are you with your job at the LTCOP?

1 Very satisfied

2 Somewhat satisfied

3 Neutral

4 Somewhat unsatisfied

  1. Very unsatisfied

  1. To what do you attribute your satisfaction/dissatisfaction?

__________________________________________________________________________________

__________________________________________________________________________________

  1. What can be done to make your program more effective? What improvements would you make?

__________________________________________________________________________________

__________________________________________________________________________________

  1. Is there any topic or issue you expected us to cover that we have not brought up yet? Please describe the issue(s) and explain why you think it is/they are important.

__________________________________________________________________________________

__________________________________________________________________________________















DEMOGRAPHIC INFORMATION

The next several questions collect information about your characteristics, such as age, race, and education.

  1. In what year were you born? __________

2. How do you identify your race? {Check all that apply}

1 American Indian or Alaska Native

2 Asian

3 Black or African American

4 Native Hawaiian or Other Pacific Islander

5 White

  1. Other (Please specify): __________________________

3. Are you of Hispanic or Latino origin?

1 Yes

  1. No

4. With what gender category do you identify?

1 Female

  1. Male

5. What is the highest grade or year you completed in school?

1 Less than high school or GED

2 High school or GED

3 College coursework but not degree (may include community college coursework)

4 Associate’s degree

5 Bachelor’s degree

6 Some graduate work

7 Master’s degree

8 Juris Doctorate

9 Doctor of Philosophy

1 0 Medical Degree







Thank you for your participation!



Please send your completed form to NORC using the enclosed postage paid envelope.



You may also return the completed survey by faxing it to:

_____


36



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