Facility Administrator Survey

Evaluation of the Long-Term Care Ombudsman Program (LTCOP)
Facility Administrator 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. The purpose of the survey is to better understand the relationships between the
Long-Term Care Ombudsman Program and the facilities. 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 __ minutes to complete. Please complete and return this form using the pre-paid
envelope, or by scanning and emailing it to [email protected], or by faxing it to 301-634-9582.
Please contact NORC at 1-877-XXX-XXXX or [email protected] if you have any questions or
concerns.
OMB Control No.:
Expiration Date:

SECTION A: Activities and Interactions
1. How regularly does the Ombudsman visit your facility?
______________________
2. How does the Ombudsman spread awareness of the program among residents and their families?
{Check all that apply}
 1.
 2.
 3.
 4.
 5.

Poster in the facility
Brochures and pamphlets in the facility
In-person interaction with residents throughout the facility
In-person interaction targeting new residents
Other (Please specify): __________________________________

3. Does your Ombudsman support or assist the development of resident and family councils in your
facility?
 1. Yes
 2. No
 97. Don’t know
4. Does the LTCOP participate in the licensing survey conducted by the state licensing and certification
agency?
 1. Yes
 2. No
 97. Don’t know

SECTION A: Activities and Interactions (continued)
5. Do you personally interact with the following Ombudsman Program representatives? {Check all that
apply}
 1.
 2.
 3.
 4.

Ombudsman staff
Ombudsman volunteer
State Long-Term Care Ombudsman
Other LTCOP staff
Please note the position of these individuals:___________________________________
______________________________________________________________________
______________________________________________________________________

6. What form does this interaction take? {Check all that apply}
 1.
 2.
 3.
 4.

In person
Phone call
Email
Other (please specify): ____________

7. On average how often do you personally interact with any of the representatives of the LTCOP?
 1.
 2.
 3.
 4.
 5.

Weekly
Monthly
Quarterly
Less than quarterly
As needed

8. What type of interaction have you had with Ombudsman representatives? {Check all that apply}
 1.
 2.
 3.
 4.
 5.
 6.

Discussion about facility compliance issue
Discussion about specific resident complaint
Discussion about pattern in resident complaints and potential solutions
Discussion about disagreement with a resident or resident’s family/friend
Discussion about potential training
Information provided

What was the topic? ______________________________________
 7. Training provided by Ombudsman representative
What was the topic? ______________________________________
 8. Other (please specify): ________________________________________

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SECTION A: Activities and Interactions (continued)
9. Who at your facility interacts with the Ombudsman/Ombudsmen when they visit your facility? {Check all
that apply}
 1. Nurse practitioners (NPs)
 2. Registered nurses (RNs)
 3. Licensed practical nurses (LPNs) / licensed vocational nurses (LVNs)
 4. Certified nursing assistants, nursing assistants, home health aides,
home care aides, personal care aides, personal care assistants, and
medication technicians or medication aides
 5. Social workers—licensed social workers or persons with a bachelor’s
or master’s degree in social work
 6. Activities director and activities staff _____________________
 7. Other (please specify): _______________________________
10. Are there areas where you would like more support from the Ombudsman Program?
 1. Yes
 2. No

If so, please describe: _________________________

11. How could the Ombudsman Program be improved to better serve residents?

________________________________________________________
12. Based on your experience, what are the strengths of the Ombudsman Program?

__________________________________________________________
13. Would you consider the relationship with your primary LTCOP contact to be:
 1.
 2.
 3.
 4.

Very effective
Somewhat effective
Somewhat ineffective
Not at all effective

14. Have you ever reported a complaint about an Ombudsman?
 1. Yes
 2. No

If so, please describe the complaint: _________________________

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SECTION B: Program Outcomes
1. To your knowledge, has the Ombudsman Program contributed to changes in your facility’s policies and
practices?
 1. Yes
 2. No
 97. Don’t know
2. Do you agree with the following statement: Overall, residents benefit from Ombudsman presence in my
facility?
 1.
 2.
 3.
 4.
 5.

Strongly agree
Agree
No opinion
Disagree
Strongly disagree

3. How effectively do Ombudsmen resolve resident complaints in your facility?
 1. Very effectively
 2. Somewhat effectively
 3. Not effectively
 97. Don’t know

SECTION C: Background and Staff Profile
1. How many beds does your facility have?
__________________________
2. What is the type of ownership of this facility?
 1.
 2.
 3.
 4.

Private-nonprofit
Private-for profit
Publicly traded company or limited liability company (LLC)
Government—federal, state, county, or local

3. Is this facility owned by a person, group, or organization that owns or manages two or more long-term
care facilities?
 1. Yes
 2. No
 97. Don’t know
4. What is the total number of years this facility has been operating at this location?
 1.
 2.
 3.
 4.
 5.

Less than 1 year
1 to 4 years
5 to 9 years
10 to 19 years
20 or more years

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SECTION C: Background and Staff Profile (continued)
5. For each staff type below, indicate how many full-time employees and part-time employees this facility
currently has:
Full-Time

a. Nurse practitioners (NPs)

Part-Time

b. Registered nurses (RNs)
c. Licensed practical nurses (LPNs) /
licensed vocational nurses (LVNs)
d. Certified nursing assistants, nursing
assistants, home health aides, home care
aides, personal care aides, personal care
assistants, and medication technicians or
medication aides
e. Social workers—licensed social workers or
persons with a bachelor’s or master’s
degree in social work
f. Activities director and activities staff

THANK YOU FOR COMPLETING THIS SURVEY.

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