Paid Staff

Recent estimates of LTC ombudsman staffing put the number of full-time equivalent (FTE) paid staff at 865 (see Table 2.3).¹ Average state-level staffing (i.e., not including any local staff) is estimated at 2.6 FTEs per state. The number of paid staff of local programs (i.e., not including any state-level staff) ranges from 1 to 153. Kautz (1994) estimated the average statewide staffing (i.e., including both state-level and local staff) to be 15.7 FTEs. Because the mean figure is influenced considerably by a few states with high staffing levels, the median is probably the most indicative measure. Median statewide staffing is 10 FTEs. The ratio of FTEs to beds ranges from 1 to 128 in South Dakota to 1 to 28,370 in New Jersey. The nationwide ratio of FTEs to beds is 1 to 2,698.

TABLE 2.3

Long-Term Care Ombudsman Human Resources, Paid Staff and Volunteers, by State.

The OAA requires states to employ at least one person as the “State LTC Ombudsman,” who “shall serve on a full-time basis.” All states have named such a person, although the committee found that, in several states, that person's time is not devoted solely to the program. For example, since the enactment of the 1992 OAA amendments, several states have named or are considering naming their state ombudsman to lead or coordinate the Elder Rights (Title VII) programs. This work involves such unrelated activities as insurance counseling and monitoring all cases of elder abuse, including abuse that occurs outside of nursing facilities or B&C homes.

Salaries of LTC ombudsmen vary greatly. A recent study found that one state ombudsman made $18,000 per year, whereas another made $56,000 (NORC, 1994a). The median salary range of a state ombudsman is $30,000-$35,000. No correlations were found between the state ombudsman's salary and the size of the program, the ombudsman's education or experience, or the program's reputation for quality. The committee found that salaries of local ombudsmen were considerably lower than those of their state counterparts; most commonly, local ombudsmen were paid in the low $20,000s. The committee also found that most state and local programs had very little, sometimes no, clerical support.

Volunteers

Volunteers perform a variety of functions in the ombudsman program. Many volunteers are designated official representatives of the program and are given all the rights and responsibilities afforded to paid ombudsmen. Other volunteers serve as “friendly visitors” and assist the ombudsmen in maintaining a presence in the facilities, keeping residents informed of their rights and of the LTC ombudsmen's services, and identifying problem conditions, which they refer to a paid ombudsman for resolution. Many programs believe that the use of volunteers adds authenticity to the program and helps to keep it focused on the resident in a way that a typical government bureaucracy cannot.

The number of volunteers has more than doubled since 1982—from 3,306 in 1982 to 6,751 in 1994 (Schiman and Lordeman, 1989b; AARP, 1994a). Thirteen states reported no volunteer activity; California, with 1,325 volunteers, reported the most (AARP, 1994a).

Volunteer efforts are not without their costs, however. Programs must spend much time recruiting, training, and supervising volunteers. Paid staff-to-volunteer ratios average 1:8 nationally and range from 1:1 in four states to a high of 1:100 (Oregon) (AARP, 1994a).

Ensuring that Residents Have Regular and Timely Access to the Program

The regular presence of persons from outside of facilities has been identified as an important factor in improving quality of care and quality of life in facilities (IOM, 1986; Barney, 1987; Feder et al., 1988; Glass, 1988; Cherry, 1991, 1993; Nelson, 1993; Arcus, 1994). Many LTC ombudsmen and other LTC professionals think that proactive, routine on-site presence is essential. They argue that it builds awareness of the program, establishes resident confidence, detects concerns about residents' conditions before these become serious, and creates and maintains positive working relationships with the facility administration and staff. Such factors as increased percentage of residents with mental incapacities, isolation of residents from families, and difficult access to telephones strengthen the claim for continuous, predictable visitation by LTC ombudsmen.

States often set standards for how often a facility should be visited by an ombudsman or volunteer (Table 2.5). Kautz (1994) found that, of the 36 states he studied, 29 had instituted visitation standards, but only 18 of these states generally met their standard across all facilities. None of the states that had instituted a weekly routine visit standard was able to achieve that goal across all facilities. In some states where ombudsmen are concentrated around certain large cities, the state reported that some areas achieved a 100 percent annual visitation rate but that others were not visited at all (AoA/OIG, 1993).

TABLE 2.5

Visitation Standards, by State.

The frequency of visitation is closely related to the number of paid ombudsman staff and their proximity to facilities. In Kautz's study (1994), of the 17 states with the highest visitation rate, 9 reported a staff of more than 0.75 FTEs per 1,000 beds; only 5 of the 17 states with the lowest visitation rate had this level of FTEs per bed. Kautz also reviewed the relevance of commuting distance and visitation rates. He found that 15 of the 17 states with the highest visitation rates reported that more than 80 percent of the facilities in the state had a certified ombudsman within a one-hour commute; by contrast, only 4 of the 17 states with the lowest rates had an ombudsman within one hour of 80 percent of all facilities.

A low routine visitation standard may not reflect the actual visitation rate or ombudsmen presence in LTC facilities (Chaitovitz, 1994b). Several state LTC ombudsmen stated that their overall visitation standard was low, but that they often visited certain problem facilities on a weekly basis for months in order to respond to complaints. Other visits were made but were not necessarily counted toward meeting the visitation standard, for example, visits to train facility staff and organize resident or family councils.

Kautz (1994) found that 9 states had instituted no nursing facility visitation standard at all, 6 only visited annually, 9 visited quarterly, 4 visited monthly, and 8 visited weekly or biweekly. B&C homes are visited far less frequently than nursing facilities; 13 states had no visitation standard at all, 9 only visited annually, 5 visited quarterly, 3 visited monthly, and 6 visited weekly or biweekly.

Investigating and Resolving Complaints

Throughout the nation, LTC ombudsmen advocate on behalf of residents of LTC facilities, including those who cannot speak for themselves, and work to empower all residents and their agents to be stronger advocates on their own behalf. However, state and local programs differ in the way this end is achieved. In many instances, individual ombudsmen within the same local program differ in the way they operate. Some programs and individual ombudsmen assume an aggressive and adversarial, or “contest,” approach to their work, whereas others take a more neutral, or “collaborative,” approach (Nelson, 1993).

Ombudsmen may play a variety of roles in their efforts to resolve complaints. These include four main types—friendly visitor, mediator, educator, and advocate (National Center for State LTC Ombudsman Resources, 1992).

Friendly Visitor. An ombudsman may simply provide companionship or social activity to a resident. Some providers feel that this is the most legitimate and helpful role an ombudsman can assume. By contrast, most ombudsmen, while acknowledging that the friendly visiting function may be an important step in getting to know residents and establishing trust, would hardly view this as their primary role.

Educator. An ombudsman may work to educate residents, families, facility staff, friends, and potential consumers about their rights and responsibilities in a facility. An ombudsman must, therefore, have a working knowledge of current federal and state residents' rights in order to answer questions. Ombudsmen also may provide information to concerned individuals who wish to advocate for themselves, but do not know how to go about it. Handbooks (e.g., “How to Select a Nursing Home” or “Resident Rights Handbook”) can be used to provide supplementary information.

Mediator. An ombudsman may serve as a mediator between residents and staff, government agency, other residents, or family. In this role, the ombudsman may act as a spokesperson for the resident, communicating their concerns in an effort to resolve the problem. In this role, ombudsmen do not impose their own answers but help those involved to find and agree upon a mutually acceptable solution.

Advocate. An ombudsman may work actively on behalf of a resident in resolving complaints that have been substantiated and require specific strategies to alleviate the problem. Advocacy may mean negotiating with an administrator or other staff, filing a complaint on behalf of the resident, working with a residents' council, representing the interests of residents before governmental agencies, or seeking administrative, legal, and other remedies. Although “advocate” is often used as the generic term for ombudsmen, in the context of roles it has a very different meaning and function.

The primary activity required of LTC ombudsmen by the OAA and clearly performed by the program is the identification, investigation, and resolution of individual complaints relating to the residents of LTC facilities. The total number of complaints received by LTC ombudsmen increased 94 percent, from 102,231 to 197,820, between 1988 and 1993 (Schiman and Lordeman, 1989a; AoA, 1994c). More than 154,400 people lodged complaints with the LTC ombudsmen in FY 1993. About 75 percent of all complaints were lodged against nursing facilities, 16 percent against B&C facilities, 3 percent against regulatory and reimbursement agencies, and 6 percent against others (such as family members). Many of the complaints dealt with resident care (35 percent) and resident rights (17 percent) (AoA, 1994c).

When numbers of complaints are analyzed in terms of the number of LTC beds served by programs, complaint rates vary widely across states (Table 2.6). Nationwide, ombudsmen received 85 complaints per 1,000 LTC beds; the median is 67; the range is 14 in Iowa and North Dakota to 743 in the District of Columbia.

TABLE 2.6

Long-Term Care Ombudsman Complaints per 1,000 Beds, by State.

The General Accounting Office (GAO) observed similar variation in the 1988 complaint data and concluded that ombudsman programs may operate quite differently in different states. The GAO found that the rate of complaints received may be determined by the use of volunteers, the number of B&C residents served by the programs, the emphasis placed by programs on reaching B&C homes, the varying definitions of complaints used by the states, and the aggressiveness of programs in seeking out problems and identifying residents with complaints (GAO, 1992b).

Kautz (1994) found a positive correlation between routine visitation rates and number of complaints per bed. Of the states with the highest one-third of complaints per bed, 81 percent routinely visited more frequently than once a year, whereas 67 percent of those in the middle third did so, and only 36 percent of those in the lowest third did so. Kautz found notable exceptions to these relationships, however. Ohio, where visits take place at a relatively high rate, receives only 35 complaints per 1,000 beds, whereas Delaware, where no routine visits take place, experiences one of the highest complaint rates (195 complaints per 1,000 beds) in the nation. Some ombudsmen believe that routine visitation may deter poor care and conditions and, thereby, decrease the number of complaints (Arcus, 1994). They also suggest that, where few human resources are available, ombudsmen place less emphasis on complaint activity and more often seek to carry out their missions by educating and empowering residents, and these efforts are not reflected in complaint data.

Working Cooperatively with Other Agencies

As in more traditional ombudsman models, much of the work done by the LTC ombudsmen involves working with government agencies to improve residents' situations and the LTC system. Many governmental agencies are involved with regulating and reimbursing both nursing facilities and B&C homes and protecting the residents in both types of facilities. Such agencies include Health Care Financing Administration, SUAs, AAAs, departments of health, divisions of licensure and certification, adult protective services (APS), professional boards (e.g., Board of Nursing Home Administrators), police, and district attorneys. Advocacy organizations such as protection and advocacy systems (P&As), as well as citizens' groups, are also involved in providing oversight and advocacy to residents in these facilities. The interactions between the ombudsman program and three of these programs—licensure and certification, APS, and P&As—are described in more detail below.

Licensure and Certification. The ombudsman program was created, in part, to address some of the limitations and shortcomings of the regulatory system. Initially, many ombudsman programs spent considerable effort in developing memoranda of understanding (MOUs) with regulators to clarify the responsibilities of each party. Over the years and continuing today, however, the relationship between ombudsmen and licensure and certification staff has sometimes been marked with frustration and even confrontation rather than understanding and clarity about the actions each should take (Buford, 1984; Chaitovitz, 1994b). Ombudsmen and others cite evidence that most surveys are inadequate, enforcement is rare, and information about specific facilities (the availability of which is required by law) is not easily accessible to ombudsmen or the public (IOM, 1986).

Because ombudsmen and regulators operate within differing organizational structures and under separate protocols for evidence and reporting, ombudsmen frequently encounter difficulties in obtaining the level of support for enforcement that they feel is warranted to remedy problems in the care and treatment of residents. For example, ombudsmen may witness poor care or conditions first hand or their investigations may turn up clear evidence of violations. Yet when regulatory investigators respond to complaints, they may report finding no evidence and therefore cite no violations. Regulators point out that they must adhere to strict rules of evidence, and these often preclude citing a violation based upon an eyewitness report.

The 1987 legislative changes referenced earlier have strengthened links between the ombudsman programs and regulators. For instance, federal regulations require that regulators contact ombudsmen early in the survey of any Medicare or Medicaid facility so that ombudsmen may share information with surveyors on complaints and conditions in the facility.² Because these visits are scheduled on short notice, the ombudsmen sometimes cannot rearrange their schedules to accommodate such sharing of information. Also, the ombudsmen's data systems typically cannot retrieve facility-specific complaint data in the short time they are given to provide such information to surveyors. Additionally, federal law also allows ombudsmen to attend the exit conference as observers at the close of the survey. Several states report that staff and volunteer shortages curtail ombudsman involvement in this activity. For example, Kansas' annual report (KDOA, 1993) noted that a representative of the program was able to attend none of the 600 exit conferences held in the state (Kansas has a FTE to bed ratio of 1:7,340).

A few states conduct joint training sessions with licensing agencies. In at least one state, the state ombudsman sits on the advisory board of the licensing agency and volunteer ombudsmen sit in on surveyors' interviews of residents during the survey. In other states, the licensing agency is represented on the ombudsman advisory council and local ombudsmen hold regular meetings with survey agency staff.

Currently, survey data must be gathered from hard copies provided by cooperative regulatory agencies. Ombudsmen suggest that, when such data can be provided to ombudsmen in electronic form, they will be more capable of providing to the public clear explanations of facility track records. This is currently being done in Indiana: LTC ombudsmen are equipped with the same laptop computers as surveyors, and they have instant access to survey data for all facilities in the state. Another positive development has occurred in Massachusetts where the two programs have ended years of bitter opposition and have begun to work cooperatively. Complaints lodged by Massachusetts ombudsmen are now given priority for investigation by the licensure and certification agency. The state ombudsman and the head of licensing and certification have made several joint visits to facilities and plan to continue to do so in the future.

Adult Protective Services. Although not federally mandated to do so, most states have APS units. These units generally investigate instances of abuse, neglect, and exploitation of anyone over age 18 and provide protective services to those who are found to be maltreated. How these various units operate throughout the country varies considerably from state to state. Some are operated by the SUA, others by the social service department. In at least four states, APS is expressly prohibited from investigating complaints about the residents of LTC facilities; in many others, the committee found their involvement in LTC facilities to be very limited.

Because both LTC ombudsman and APS workers receive complaints regarding abuse, neglect, and exploitation of vulnerable older people, the responsibilities of the two programs overlap somewhat. Their roles in resolving these types of complaints are quite different, however. APS workers act as agents of the state, whereas LTC ombudsmen act as agents of the resident. When the two programs interact, APS workers and LTC ombudsmen work jointly on cases, make referrals, and attend joint staff training and meetings. In the canvass conducted by Chaitovitz (1994b), 23 state LTC ombudsman programs (n=50), or about half, reported good relations with APS. Only one state LTC ombudsman cited a poor or hostile relationship. Being housed within the same agency frequently enhances good relationships: 13 LTC ombudsman programs are located in the same agency as APS, and 9 of these programs report close or excellent relationships (Chaitovitz, 1994b). In several states, some LTC ombudsmen also have APS responsibilities.

Protection and Advocacy Systems. P&As are established by federal law in all 50 states, the District of Columbia, and U.S. territories to protect the legal and human rights of individuals with disabilities. P&As serve four distinct populations: (1) persons with developmental disabilities; (2) persons with mental illness; (3) persons covered by the Rehabilitation Act of 1978; and (4) through the 1992 amendments to the Rehabilitation Act, all persons with disabilities who are not eligible for services under the other three programs.

P&As investigate and negotiate problems faced by persons with disabilities (such as discrimination, denial of benefits, and abuse and neglect), providing information, legal counsel, and representation, and promoting legislative and administrative changes to benefit persons with disabilities. To date, much of their efforts have focused on younger persons with disabilities, particularly those who are mentally ill or developmentally disabled, rather than older disabled individuals. However, many individuals typically served by the program are aging, and since the P&As mandate was expanded under the 1992 Rehabilitation Act amendments, the number of older clients is growing. Of over 70,000 individuals served by P&As in FY 1992, nearly 6,000 (9 percent) were age 60 or older (NAPAS, 1992).

The OAA requires the Office of the State LTC Ombudsman to coordinate ombudsman services with these organizations since they share similar concerns and mandates regarding such matters as statutes and regulations affecting the disabled, inadequate care in LTC facilities, and resident rights issues such as improper discharges and placement of individuals in inappropriate environments (although there is no similar mandate for P&As to coordinate with ombudsmen).

The 1992 survey of 20 state ombudsman programs (AoA/OIG, 1993) revealed several methods for coordination, including joint meetings, MOUs, joint training, and referral by the ombudsman to the P&As. In Colorado, the state LTC ombudsman program resides within the same agency that houses the P&As. The Louisiana ombudsman has developed a unique relationship with its P&As, the Advocacy Center for the Elderly and Disabled, or ACED (Kautz, 1994). The SUA and Office of the State LTC Ombudsman contract with ACED for legal support for state and local ombudsmen and LTC residents. Local ombudsmen have access to an attorney who is a full-time employee of ACED and a specialist in nursing facility and elder law. Not only has ACED pursued various remedies on behalf of residents and assisted the program in legislative and administrative systemic advocacy, but the relationship has also facilitated coordination activities between ombudsmen and ACED staff attorneys working on behalf of mentally ill or disabled nursing facility residents.

Coordination and cooperation are not universal, however. Several ombudsmen report that the P&As in their states give priority to those who live in the community or to school-age children (Chaitovitz, 1994b). These P&As maintain little, if any, involvement with residents of institutions. In addition, differences in philosophy and strategies may make coordination less desirable, as some state P&As take a more adversarial and litigious approach to advocacy than do ombudsmen.

Providing Technical Assistance and Training to Representatives of the Program

To fulfill their responsibilities, ombudsmen must have a thorough and up-to-date knowledge of many topics—the laws and regulations governing nursing facilities and B&C homes, investigation and mediation techniques, geriatrics and the medical and emotional needs of persons with disabilities, and the like. Both state and local ombudsmen provide training—initial and ongoing—and technical assistance to ensure that program representatives are as well prepared as possible. Additionally, since 1988, AoA has supported a national resource center for the LTC ombudsman program (the National Ombudsman Resource Center) whose mission is to train, provide technical assistance, and disseminate information. The center is currently sponsored jointly by the National Citizen's Coalition for Nursing Home Reform and the National Association of State Units on Aging.

To ensure that ombudsmen have a core level of knowledge to carry out their responsibilities, in the 1992 amendments to the OAA, Congress mandated AoA to establish procedures for the training of ombudsman program representatives, including unpaid volunteers. At the time of this writing, no such procedures have been established, however (see further discussion in Chapter 3).

Evaluating Laws and Regulations

The OAA directs state and local ombudsmen to analyze, comment on, recommend changes in, and monitor the development and implementation of laws affecting residents. Ombudsmen typically achieve this requirement through legislative, judicial, or administrative advocacy.

Legislative advocacy. Most ombudsmen work directly with legislators to advocate on behalf of residents. For example, the West Virginia state ombudsman lobbied successfully for a new guardianship law. The law guarantees residents and others the ability to pursue the “least restrictive alternative” by allowing for the designation of “limited” services for guardians and conservators, who are appointed by the court to handle a person's personal affairs. Ombudsmen also lobby on the federal level through their membership association, the National Association of State LTC Ombudsman Programs (NASOP). NASOP members worked extensively on the 1992 reauthorization of the OAA that led to the creation of the new elder rights title.

Judicial advocacy. Sometimes ombudsmen make use of the judicial process to advocate on behalf of residents. The District of Columbia ombudsman program, for instance, successfully sued the city government in order to end the practice of distinguishing between skilled and intermediate levels of care and to bring local laws regulating Medicare and Medicaid facilities into compliance with the 1987 Nursing Home Reform Law. The Florida state ombudsman program employs a “legal advocate” who, although he has never directly filed a lawsuit on behalf of a resident, has written numerous amicus briefs and legal articles in support of residents' rights.

Administrative advocacy. Less visible, but equally effective, systemic advocacy may occur within the administrative rule-making process or during policy implementation. In Oklahoma, for example, the ombudsman helped convene a series of meetings with six different state divisions to develop a system of intermediate sanctions for nursing facilities. The Connecticut state ombudsman worked with other agencies in monitoring the implementation of a law against Medicaid discrimination in nursing facility admissions. The Michigan ombuds-man program convinced the state Medicaid agency to change its reimbursement policy to cover either disposable or cloth diapers for nursing facility residents, at the resident's choice, in order to protect the dignity and privacy of incontinent residents.

Providing Education to the Public and Facility Staff

Many LTC ombudsmen have invested considerable resources in disseminating information about LTC and raising public interest in quality of life in facilities. The Office of the Inspector General (1991a) found that the 12 programs it termed the most successful “make themselves very visible in the aging community” through the use of posters, brochures, toll-free numbers, community outreach efforts, media spots, and inservice training for facility staff. These programs also regularly inform new facility residents of their rights and of the role of the ombudsman. States with limited capacity to visit facilities often enhance their effectiveness by offering statewide telephone hotlines. Virginia, for example, answered 8,930 requests for information made to its hotline in 1992 (VDOA, 1993).

Many state and local LTC ombudsmen address public meetings and support groups. They use such appearances not only to discuss with the public the current issues in quality of care and quality of life but also to recruit volunteers for their programs. Moreover, they sometimes use public forums to develop support for legislative advocacy. LTC ombudsmen provide information on such subjects as how to select a nursing or B&C home, how to contact the ombudsman or regulatory agencies, new laws governing facilities, and state-of-the-art treatment practices such as reducing restraint use.

Training of nursing facility and B&C home staffs and hospital discharge planners is another of the educational activities of LTC ombudsmen. Such audiences have found ombudsmen helpful in developing an understanding of residents' rights and in discussing creative means of improving care and living environments. California hired a public relations firm to publicize its program and produced television commercials and public service announcements (OIG, 1991 a). Texas and Massachusetts recruited their governors and other well-known persons to appear in public service announcements about their programs (OIG, 1991a).

Disseminating Program Data

The OAA requires states to prepare an annual report on their LTC ombudsman activities. These reports must include complaint data, descriptions of problems and issues, and recommendations. Most states prepare only a perfunctory annual report focusing on complaint analysis with few recommendations or comments on policy. Chaitovitz (1994a) nonetheless found that 16 out of 20 states reported giving these annual reports to the licensure and certification program; 12 gave them to the governor or legislature. Many also gave their reports to both LTC providers and consumer groups. Florida, Michigan, New Mexico, Ohio, Oklahoma, Oregon, Tennessee, and Texas use their annual reports to bring systemic issues to the attention of the legislature and the public. Oklahoma and Colorado publish information regarding the deficiencies of individual nursing facilities that are cited in surveys by the state's licensure and certification program.

The committee asked the SUA directors whether the state LTC ombudsman provided information to them about trends and issues that affect residents' well-being. The directors responded that they use information from ombudsmen to develop legislation, influence overall program planning of the state office, influence training and community education programs, and develop or justify policy directions. Of the 41 directors who responded, 33 (80 percent) indicated that the ombudsman was either the major source of such information or a key contributor. The other eight state directors reported that the ombudsman provided either limited or no information on trends in LTC. Two significant problems emerged from the comments of these directors: (1) there are inadequate information systems to make use of complaint-based information; and (2) the ombudsman's information tends to be based chiefly on individual complaints and is not always analyzed to be helpful to broad LTC planning activities. Nonetheless, with only a few exceptions, from the perspective of these state officials, ombudsmen participate in a meaningful way in the processes that determine policies and programs affecting the elderly residents of LTC facilities.

Theoretically, use of data also allows ombudsmen to identify and prioritize problems, as well as to extend their influence beyond casework and into the arena of systemic advocacy. However, the current federal reporting forms reveal less-than-desirable information (GAO, 1992b; Netting et al., 1992). Additionally, most programs have only recently begun upgrading their data collection efforts. State and local ombudsman programs differ in how fundamental terms such as case, complaint, complaint response, and statewide coverage are defined and measured (Huber, 1994). Efforts are currently under way in several states to develop more sophisticated and useful data systems, with support from a grant from the Administration on Aging. Over a period of three years and with extensive consultation with ombudsmen, the Administration on Aging developed a new National Ombudsman Reporting System (NORS). Several states are already using the NORS form and all states will be required to do so for FY 1995.

The NORS provides information on the type of complainant, action taken, and disposition of complaint, as well as a detailed breakdown of complaint categories (e.g., resident rights, resident care, quality of life, administration, and problems with outside agency, system, or people). It also allows ombudsmen to report on their systemic advocacy efforts.

Promoting the Development of Citizen Organizations and Resident and Family Councils

Beginning in the late 1960s, citizen groups to improve conditions in nursing facilities formed in many American cities and towns. Today there are at least 70 of these organizations in existence (Filinson, 1994). Their functions vary. Some pursue special functions; for example, they distribute directories of local nursing facilities they have evaluated. Others limit themselves to education and advocacy to reform nursing facilities. Yet others choose to provide oversight of these facilities and supportive services to residents, families, and those in the community considering a nursing facility placement.

Although they have many strengths, citizen groups often face limitations as a result of their lack of legislative authority and guaranteed access to nursing facilities. Although a number of the larger grassroots organizations have staff, most often these groups are completely powered by volunteers. They frequently have few avenues for assuring problem solution besides the media. Further, fear of retaliation against patients who protest poor conditions often keeps families and other interested parties from acting (Monk et al., 1984). Despite these impediments, grassroots citizen activism has strongly influenced the initial and continuing interest in “watchdogging” nursing facilities and the government programs that are charged with monitoring them, including the ombudsman program.

The Nursing Home Reform Law of 1987 reinforced the rights of residents and family members to organize advisory councils in nursing facilities. These councils may provide a variety of benefits to those who participate, including support for residents and families, education and information, a vehicle for action on concerns and complaints, and a means of communication within the home. These councils must receive support from facility staff, if asked, but should operate independently and feel free to voice concerns to facility staff and owners.

Many LTC ombudsmen report that resident and family councils help in solving many problems within a particular facility. For instance, the LTC ombudsman in one program stated that she had spent a great deal of time in one facility resolving complaints about cold food. She helped organize a residents' council that now routinely deals with those complaints. Thus, she is free to work on other issues.