2 State OMBudsmen Survey
Process Evaluation and Special Studies Related to the Long-Term Care Ombudsman Program
State-Ombudsmen-Survey
State Ombudsman Interview Protocol and Survey
OMB: 0985-0055
Write In Your Start Time: __________________________
Process Evaluation of the Long-Term Care Ombudsman Program (LTCOP) – State Ombudsmen
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 by faxing it to: _____.
Please contact NORC at _____ or _____@norc.org if you have any questions or concerns.
Name of person completing survey __________________________
Position/Title __________________________
Phone number __________________________
Email address __________________________
SURVEY TOPICS:
Background Information
Structure and Resources
State and Local Coordination
Program Activities
Program Quality Assurance
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 State Ombudsmen. 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).
How long have you been working with the LTCOP as the State Ombudsman?
{enter number years} ___ ___
+ {enter number months} ___ ___
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): ______________________
What was your job immediately prior to working at the LTCOP?
______________________________________________________________________________
Had you ever interacted with the long-term care ombudsman program or any other ombudsman program before being hired?
-
Yes
If Yes, please describe: ____________________________________________________________
2
No
STRUCTURE AND RESOURCES
Next, we’d like to explore the organizational structure and resources of your state LTCOP.
On average, how often does your office interact with representatives of your local Ombudsman entities (if applicable)? 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): ________________________
9
8 Not
applicable (My program is characterized by a centralized structure.)
During the last year, on what topics did your state office provide technical assistance or training to your state and/or local programs? {Check all that apply}
1
Case
guidance
2
Systems
advocacy
3
State
mandates, regulations
4
Legal
advice or consultation
5
Outreach
to consumers and stakeholders
6
LTCOP
financial concerns
7
LTCOP
policies and procedures
8
Trends
in long-term care that impact the program (e.g., growing aging
population, nursing home use of psychotropic medication, etc.)
9
NORS
reporting
1
0 Volunteer
management
9
6 Other
(Please specify): ________________________
9
8 Not
applicable
Are lines of authority and accountability clearly defined for representatives of the Office at the state level (state office staff)?
1
Yes
2
No
If No, why not? _________________________________________________________________
Are lines of authority and accountability clearly defined for designated representatives of the Office at the local level (local office staff)?
1
Yes
2
No
If No, why not? _________________________________________________________________
9
8 Not
applicable
Overall, how would you describe the effectiveness of the LTCOP statewide?
1
Very
effective
2
Somewhat
effective
3
Neutral
4
Somewhat
ineffective
5
Very
ineffective
9
7 Don’t
know
Overall, how would you describe the relationship between the Office of the State LTCO and local Ombudsman entities (if applicable)?
1
Very
effective
2
Somewhat
effective
3
Neutral
4
Somewhat
ineffective
5
Very
ineffective
9
7 Don’t
know
9
8 Not
applicable (My program is characterized by a centralized structure.)
Overall, how would you describe the relationship between the Office of the State LTC Ombudsman and Federal ACL/AoA?
1
Very
effective
2
Somewhat
effective
3
Neutral
4
Somewhat
ineffective
5
Very
ineffective
9
7 Don’t
know
Overall, how would you describe the relationship between the Office of the State LTC Ombudsman and your Regional ACL/AoA office?
1
Very
effective
2
Somewhat
effective
3
Neutral
4
Somewhat
ineffective
5
Very
ineffective
9
7 Don’t
know
Program Resources
Next, we have questions about your program’s resources. Which of the following resources sufficiently meets 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, software, mobile phones to call from the
field, etc.)
7
Administrative
support
8
Communication
methods to share information with consumers and stakeholders
9
Training
and technical assistance
9
6 Other
(Please specify): _______________________
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
Quarterly
nursing home
facility visits, not in response to a complaint
3
Quarterly
board and care
facility visits, not in response to a complaint
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 Facilitation
with public comments on proposed legislation, laws, regulations,
policies, and actions
1
4 Volunteer
recruitment and retention
9
6 Other
(Please specify): _______________________
Are you able to determine the use of the fiscal resources appropriated or otherwise available for the operation of the LTCOP at the state level?
1
Yes
2
No
3
Partially
Where local Ombudsman entities are designated, do you approve the allocations of Federal and State funds provided to such entities (subject to applicable Federal and State laws and policies)?
1
Yes
2
No
9
8 Not
applicable
Does your Office of the State Ombudsman secure additional financial resources (e.g., grants) and/or in-kind contributions (e.g., donated office space) beyond the Federal and State funds allocated?
-
Yes
If Yes, what kind? _________________________________________________________________
2
No
9
8 Not
applicable – The office does not have the ability to secure
additional financial resources or in-kind contributions.
Legal Counsel
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
Attorney
General’s office
2
LTCOP
employs in-house attorney(s)
3
State
Unit on Aging has in-house attorney(s) available to serve the LTCOP
4
Contracts
or other arrangements with private attorneys
5
Legal
assistance developer
9
6 Other
(Please specify): _______________________
9
7 Don’t
know
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
Attorney
General’s office
2
LTCOP
employs in-house attorney(s)
3
State
Unit on Aging has in-house attorney(s) available to serve the LTCOP
4
Contracts
or other arrangements with private attorneys
5
Legal
assistance developer
9
6 Other
(Please specify): _______________________
9
7 Don’t
know
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
employs 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
Does the legal counsel assigned to, or contracted by your program also provide counsel to designated representatives of the Office at the local level (if applicable)?
1
Yes
2
No
9
7 Don’t
know
9
8 Not
applicable
What is the scope of this legal assistance at the state level (i.e., for the Office of the state Ombudsman program)? {Check all that apply}
1
Represent
individual residents in legal matters
2
Consultation
on legal issues related to complaints (e.g., public benefits,
guardianships)
3
Consultation
on complaints against State/local ombudsmen
4
Civil
remedies (e.g., injunction)
5
Representation
in the event of a lawsuit
6
Requests
for information (e.g., response to a subpoena, litigation discovery
request,
Freedom of Information Act (FOIA) request)
7
Legislative
or regulatory advocacy
8
Administrative
appeals
9
Whatever
issue that I need to consult about
9
6 Other
(Please specify): _______________________
9
7 Don’t
know
Have you ever requested and not been able to obtain timely legal assistance?
1
Yes
If Yes, why? ___________________________________________________________________
2
No
Is the legal counsel assigned to your program knowledgeable about BOTH ombudsman programmatic issues and long-term care issues?
1
Yes
2
No
9
7 Don’t
know
Overall, how effective is the legal assistance that your program receives?
1
Very
effective
2
Somewhat
effective
3
Neutral
4
Somewhat
ineffective
5
Very
ineffective
9
7 Don’t
know
Next, we have questions about program autonomy. {Please answer yes or no to each question}
|
Yes |
No |
|
1
|
2
|
|
1
|
2
|
|
1
|
2
|
|
1
|
2
|
STATE AND LOCAL LEVEL COORDINATION
Next we’d like to understand your program’s relationships with other organizations.
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 state Ombudsman office staff have worked with or have coordinated efforts with that entity on a regular basis 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 2 9 |
1 2 9 |
1 2 9 |
1 2 9 |
1 2 9 |
|
1 2 9 |
1 2 9 |
1 2 9 |
1 2 9 |
1 2 9 |
|
1 2 9 |
1 2 9 |
1 2 9 |
1 2 9 |
1 2 9 |
|
1 2 9 |
1 2 9 |
1 2 9 |
1 2 9 |
1 2 9 |
|
1 2 9 |
1 2 9 |
1 2 9 |
1 2 9 |
1 2 9 |
|
1 2 9 |
1 2 9 |
1 2 9 |
1 2 9 |
1 2 9 |
|
1 2 9 |
1 2 9 |
1 2 9 |
1 2 9 |
1 2 9 |
|
1 2 9 |
1 2 9 |
1 2 9 |
1 2 9 |
1 2 9 |
|
1 2 9 |
1 2 9 |
1 2 9 |
1 2 9 |
1 2 9 |
|
1 2 9 |
1 2 9 |
1 2 9 |
1 2 9 |
1 2 9 |
Overall, does the nature of the relationship that your program has with the following entities support enable you and your staff to meet resident and program needs?
|
Yes |
No |
Not Applicable |
|
1
|
2
|
98
|
|
1
|
2
|
98
|
|
1
|
2
|
98
|
|
1
|
2
|
98
|
|
1
|
2
|
98
|
|
1
|
2
|
98
|
|
1
|
2
|
98
|
|
1
|
2
|
98
|
|
1
|
2
|
98
|
|
1
|
2
|
98
|
If you answered “No” to any of the questions above, what would help the relationship(s) to meet resident and program needs?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Does your program work with any of the following entities not listed above? {Check all that apply.}
1
Managed
Care Organizations (MCO)
2
Quality
Improvement Organizations (QIO)
3
Centers
for Independent Living
4
Senior
Medicare Patrol (SMP)
5
Provider
Associations
6
Consumer
Advocacy Groups
7
Physician
Groups
8
Veterans
Administration – State
9
Veterans
Administration – Federal
9
6 Other
(Please specify): __________
Please describe an example of a successful partnership that your office engages in.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Overall how would you rate 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
|
2
|
3
|
4
|
98
|
|
1
|
2
|
3
|
4
|
98
|
*Board and care homes and similar facilities (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.
Please describe the factors that went into your response above: ______________________________________________________________________________________________________________________________________________________________
Does your state program have the authority to serve consumers of in-home services?
1
Yes
2
No
(Skip to next section on “Program Activities.”)
Overall how would you rate 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
|
2
|
3
|
4
|
98
|
Please describe the factors that went into your response above: ______________________________________________________________________________________________________________________________________________________________
PROGRAM ACTIVITIES
Next we’d like to explore the role you play in your state LTCOP and the activities that you carry out.
Does your state have minimum standards on frequency of visitation of long-term care facilities?
1
Yes
2
No
(Skip to Q3)
What are your state’s minimum standards for visitation?
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
(Please specify): _____________
Does your program have a visit protocol or procedure to use when staff and volunteers visit facilities?
-
Yes
1
Yes,
some activities are required but others can be changed as needed.-
No
(Skip to Q5)
Thinking about this protocol or procedure, what topics are included? {Check all that apply}
1
Suggested
duration of visit (for example, 1-3 hours)
2
How
to obtain resident list (census)
3
Verification
that the LTCOP poster is accessible
4
Visiting
strategies in small personal care/adult family homes
5
Visiting
strategies in large buildings
6
Meeting
with residents
7
Ensuring
privacy of visit
8
Meeting
with family members or legal representatives (e.g., guardian or
conservator)
9
Observing
care provided to residents (while respecting resident privacy)
1
0 Observing
a meal time
1
1 Observing
a shift change
1
2 Observing
a scheduled social activity
1
3 Walking
around and looking into residents’ rooms (while respecting
privacy)
1
4 Walking
around and looking into common area rooms
1
5 Reviewing
the posted activity schedule
1
6 Reviewing
the posted meals
1
7 Keeping
some “office” hours by being in a designated area
1
8 Talking
with a facility administrator or lead staff
1
9 Talking
with direct care staff
2
0 Talking
with nurse(s), if applicable
2
1 Talking
with social worker(s), if applicable
9
6 None
of the above. If you selected this, please describe what your visit
plan includes:
_______________________________________________________________________________
_______________________________________________________________________________
Does your program have documentation standards (e.g., a standard form to be completed) for facility visits?
1
Yes
-
No
(Skip to Q7)
Which of the following are included in your facility visit documentation? {Check all that apply}
1
Date
2
Name
of facility
3
Duration
of visit
4
Verification
of accessibility of LTCOP poster/accuracy of information
5
NORS
activities:
5
a Consultations
to facility staff
5
b Information
and consultations to individuals
5
c Complaints
5
d Attendance
at family or resident councils
5
e Training
of facility staff
6
Other
general impressions regarding:
6
a Cleanliness
6
b Safety
(e.g., clearly marked exits)
6
c Sufficient
staffing (e.g., sufficient response time to resident calls)
6
d Residents
are being treated with respect
6
e A
current calendar of activities is available
6
f Residents
appear to have freedom of movement
6
g Residents
have access to use a telephone for private conversation
6
h Residents
are able to send and receive mail/email privately
6
i Residents
are able to have visitors including private visits with spouses
6
j Accommodation
of individual preferences (e.g., wake up times, bed times)
7
Complaints
raised by staff
8
Consultations
requested by staff
-
Concerns
raised by residents, family, or legal representatives (guardian)
1
0 None
of the above
Is it your program’s practice to change the day of the week or time of day that your staff/volunteers visit in order to see different shifts, weekend shifts, or to be available to families visiting after their work days?
-
Yes
2
No
Do you personally visit nursing homes?
1
Yes
-
No
(Skip to Q11)
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): ___________________________
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
-
Other
(Please specify): _____________
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
|
2
|
3
|
|
1
|
2
|
3
|
|
1
|
2
|
3
|
|
1
|
2
|
3
|
|
1
|
2
|
3
|
Resident Care |
|||
|
1
|
2
|
3
|
|
1
|
2
|
3
|
|
1
|
2
|
3
|
Quality of Life |
|||
|
1
|
2
|
3
|
|
1
|
2
|
3
|
|
1
|
2
|
3
|
Administration |
|||
|
1
|
2
|
3
|
|
1
|
2
|
3
|
Not Against Facility |
|||
|
1
|
2
|
3
|
|
1
|
2
|
3
|
|
1
|
2
|
3
|
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 population.
12. Do you personally visit board and care homes?
1
Yes
-
No
(Skip to Q15)
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): ___________________________
14. 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
-
Other
(Please specify): _____________
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
|
2
|
3
|
|
1
|
2
|
3
|
|
1
|
2
|
3
|
|
1
|
2
|
3
|
|
1
|
2
|
3
|
Resident Care |
|||
|
1
|
2
|
3
|
|
1
|
2
|
3
|
|
1
|
2
|
3
|
Quality of Life |
|||
|
1
|
2
|
3
|
|
1
|
2
|
3
|
|
1
|
2
|
3
|
Administration |
|||
|
1
|
2
|
3
|
|
1
|
2
|
3
|
Not Against Facility |
|||
|
1
|
2
|
3
|
|
1
|
2
|
3
|
|
1
|
2
|
|
Program Strengths and Challenges
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 in transitions 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, 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): ______________________________
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 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
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): __________________________________
Does your program have particular 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 or
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, and transgender (LGBT) community
7
Veterans
8
Tribal
elders
9
6 Other
(Please specify): __________________________________
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
What type of orientation, training, or support did you receive when you were first hired as the State Ombudsman? {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 the National
Ombudsman Resource Center)
3
In-person
classroom training
4
Mentoring/shadowing
with State Ombudsman
5
Mentoring/shadowing
with experienced staff
6
Training
in a nursing home setting or board and care home setting
7
Attending
a resident or family council meeting
8
NORC
webinar for new SLTCOs
9
NORC
in-person training for new SLTCOs
1
0 Introduction
to key stakeholders in my state
1
1 Outreach
by Federal or Regional ACL/AoA staff
1
2 Outreach
by State Ombudsmen from the National Association of State Long-Term
Care Ombudsman Programs (NASOP)
1
3 Training
by legal counsel
1
4 None
-
Other
(Please specify): ___________________________
2. How effective was the orientation training you received in preparing you for your role as a State Ombudsman?
1
Very
effective
2
Somewhat
effective
3
Neutral
4
Somewhat
ineffective
5
Very
ineffective
9
7 Don’t
know
-
Not
applicable (I did not receive an orientation training.)
3. 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
Data Systems & Information Technology
Is your program’s data collection system adequate for meeting ACL/AoA requirements for annual reporting?
1
Yes
-
No
9
7 Don’t
know
Does your program use NORS data for any of the following purposes? {Check all that apply}
-
Program planning
1
Program
improvement
3
Examining
trends for determining systems advocacy issues to focus on
4
Identifying
issues of concern as well as promising practices
5
Comparing
program performance against programs in other states
6
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)
What other types of data do you collect?
_______________________________________________________________________________
_______________________________________________________________________________
What other types of data do you not collect, but would be useful to you in your role as the State Ombudsman?
_______________________________________________________________________________
_______________________________________________________________________________
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 specify): ______________________________________________
National, State and Local Resources
A number of entities are available to enhance the skills, knowledge and management capacity of program staff. How helpful have the following resources been to you or your program?
|
Very helpful |
Somewhat helpful |
Not helpful |
Not applicable |
|
1
|
2
|
3
|
98
|
|
1
|
2
|
3
|
98
|
|
1
|
2
|
3
|
98
|
|
1
|
2
|
3
|
98
|
|
1
|
2
|
3
|
98
|
|
1
|
2
|
3
|
98
|
|
1
|
2
|
3
|
98
|
|
1
|
2
|
3
|
98
|
_______________________ |
1
|
2
|
3
|
98
|
How often have you personally used the various resources available through the National Ombudsman Resource Center (NORC)?
Weekly
Monthly
Quarterly
Semi-Annually
Annually
Support not available
Phone/email advice or consultation
1
2
3
4
5
6
Webinar
1
2
3
4
5
6
Access to an expert
1
2
3
4
5
6
Listserv
1
2
3
4
5
6
Posted resource documents
1
2
3
4
5
6
Program promotional materials
1
2
3
4
5
6
Ombudsman Outlook quarterly e-newsletter
1
2
3
4
5
6
Consumer Voice Conference
1
2
3
4
5
6
Annual SLTCO Conference
1
2
3
4
5
6
Other (Pease specify):
_______________________
1
2
3
4
5
6
In general, has the National Ombudsman Resource Center (NORC) been available at the point in time you needed it?
1
Yes
2
No
3
Never
needed to use it
What types of support have you needed in your state role in the past that were either not available or were insufficient for addressing your need/answering your question?
__________________________________________________________________________________
__________________________________________________________________________________
How do you keep informed of developments in long-term care that may impact residents and/or program practices?
1
State
Unit on Aging (SUA)
2
National
Association of State Long-Term Care Ombudsman Programs (NASOP)
3
National
Ombudsman Resource Center (NORC)
4
Administration
for Community Living (ACL)
5
Other
state agencies
6
National
Consumer Voice for Quality Long-Term Care Conference
7 Other national organizations or associations
9
6 Other
(Please specify): _______________________
How satisfied are you with your job as the State Ombudsman?
1
Very
satisfied
2 Somewhat
satisfied
3 Neutral
4
Somewhat
unsatisfied
5 Very
unsatisfied
To what do you attribute your satisfaction or dissatisfaction?
__________________________________________________________________________________
__________________________________________________________________________________
Is there any topic or issue you expected us to cover that was not covered in this survey? 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.
In what year were you born? __________
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
9
6 Other
(Please specify): __________________________
Are you of Hispanic or Latino origin?
1
Yes
2
No
With what gender category do you identify?
1
Female
2
Male
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
Masters’
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:
_____
| File Type | application/msword |
| Author | mumford-elizabeth |
| Last Modified By | Windows User |
| File Modified | 2016-12-16 |
| File Created | 2016-12-16 |
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