STATE OF DELAWARE OFFICE OF THE STATE LONG TERM CARE OMBUDSMAN Annual Report Federal Fiscal Year 2005 Delaware Health and Social Services Division of Services for Aging and Adults with Physical Disabilities May 8, 2006 Dear Colleagues: On behalf of the Office of the Long Term Care Ombudsman for the State of Delaware, I am pleased to share with you this annual report of our activities for Fiscal Year 2005. Delaware's Long Term Care Ombudsman Program is responsible for protecting the rights of all residents in long term care and related facilities. We strive to fulfill this responsibility every day by providing prompt and fair resolution of resident rights, complaints and by advocating on public policy issues to enhance the quality of care for residents. Our activities are coordinated with the Division of Long Term Care Residents Protection, the Office of the Attorney General, the Office of the Public Guardian and others that provide a blanket of protections for the rights of residents. We are proud of our dedicated Ombudsmen, Volunteer Ombudsmen, families, advocates, and citizens who are a voice for the residents of long term care facilities. These caring and compassionate individuals also help alleviate loneliness and isolation of residents by simply visiting the residents to talk, listen, and be a friend. I want to acknowledge my predecessor, Tim Hoyle, who resigned in September 2005 for his contributions and helpful insights. I assumed the role in December 2005. Please contact me if you have any questions about our program or information in our report. Respectfully yours, Victor Orija, MPA State Long Term Care Ombudsman TABLE OF CONTENTS Accomplishments 1 Mission and History 2 Program Operations 5 Budget and Expenditures 12 Volunteer Ombudsman Corps 13 Public Awareness and Outreach 16 Consumer Information 17 Public Policy and Advocacy 20 Attachments/NOR Report 23 ACCOMPLISHMENTS OF DELAWARE'S LONG TERM CARE OMBUDSMAN PROGRAM DURING FISCAL YEAR 2005 Administration Ombudsman Office transition (See attachments) Program Operations Investigated and resolved 465 complaints Made 23,040 visits to long term care residents Made 1,355 visits to long term care facilities Hired two staff members to replace vacancies Legislation and Advocacy Participated in national and state level White House Conference on Aging planning event. Commented on proposed federal regulations on Long Term Care Ombudsman Programs. Advocated for additional staff for the Office of Public Guardian Supported legislation on long-term care insurance tax benefits Member of Policy and Law Sub-Committee on State Council for Persons with Physical Disabilities Assisted with development of revised PM-46 policy memorandum on Abuse and Neglect Commented on state and federal regulations for paid feeding assistance Volunteer Recruitment and Coordination Recruited and trained new volunteers Fielded 44 volunteers who provided 3,185 hours of service Witnessed 300 Advance Directives Made 147 interventions on behalf of residents Revisited innovative program to expand volunteers' advocacy role Public Awareness and Outreach Published "How to Select Long Term Care" and DVD Video in Delaware (Winner of Mature Media Award) Celebrated Resident's Rights Week; Governor's Proclamation Co-sponsored fourth Annual Residents' Rights Rally Television/Press interviews highlighting how to select a nursing home and resident rights News Journal newspaper articles on Advance Directives Training and Education Sponsored and coordinated regional Ombudsman training event with PA, WV, VA, DC, and MD Participated in national quality training Provided bi-monthly training for volunteers Provided training for staff of long term care facilities, and state unit on aging staff. Inter-agency Coordination Testified/Commented at Delaware Nursing Home Residents' Quality Assurance Commission Participated in the State Council for Physical Disabilities Policy and Law Subcommittee Participated on Quality Improvement Initiative training events Treasurer for NASOP 1 Intra-agency Collaboration Collaborated with Delaware Medicare Fraud Alert staff to train staff and volunteers on Medicare Part D. Collaborated with Alzheimer's Association staff to train Ombudsman a staff on Alzheimer issues. MISSION AND HISTORY DELAWARE'S LONG TERM CARE OMBUDSMAN PROGRAM PHILOSOPHY: All residents of long term care facilities are entitled to be treated with dignity, respect and recognition of their individual needs and differences. VISION: All long term care residents will have the highest possible quality of life. Their individual choices and values will be honored and supported in all care environments. Mission For the past 30 years, Ombudsman programs have been advocating for residents rights. Delaware's Ombudsman Program began in 1976. The Long Term Care Ombudsman Program (LTCOP) in Delaware is mandated by state and federal laws to protect the health, safety, welfare and rights of residents of nursing homes and related institutions. The program investigates complaints on behalf of residents and their families, and includes a community-based corps of Volunteer Ombudsmen. History The Long Term Care Ombudsman Program in Delaware traces its origin to an innovative federal program established in 1972. The program made permanent and codified in law through amendments to the Older Americans Act (OAA) of 1975, which enabled state agencies on aging and other public and private not-for profit organizations to assist with the promotion and development of Ombudsman services for residents of nursing homes. By 1978, the OAA mandated the expenditure of funds for an Ombudsman at the state level to receive, investigate, and act on complaints by older individuals who are residents of long term care facilities. In 1976, Delaware's then Division of Aging, now the Division of Services for Aging and Adults with Physical Disabilities (DSAAPD), established the Patient Rights Unit. On September 7, 1984, the Patient Rights Unit was officiallly mandated by the Secretary of Delaware Health and Social Services to investigate grievances of residents of long term care facilities pursuant to 16 Del. C. 1128. Delaware's Ombudsmen have been investigating complaints in long term care facilities for 28 years. In 1979, the program received a total of 53 complaints. In 2004, the Ombudsman Program investigated 504 complaints. Upon the creation in 1999 of the Division of Long Term Care Residents Protection (DLTCRP) within the Department of Health and Social Services, the Ombudsman Program ceased to take the lead on abuse, neglect and financial exploitation cases, and became the primary agency responsible for investigations of residents' rights and quality of care. This was a significant change in our mission, and significantly changed our operations. In 2000, the DLTCRP and the Ombudsman Program signed a Memorandum of Agreement establishing a process for complaint referrals between the two agencies. 2 LONG TERM CARE OVERVIEW In the past ten years Delaware's aging population has increased dramatically. In fact, persons 85 years old and above grew 47.7%, outpacing the national average by more than ten points. The baby boom generation is projected to grow significantly in the next decade. By the year 2020, Delawareans over the age of 50 will increase by 100,000 people. (Source: Profiles in Long Term Care, Public Policy Institute ­ 2002). The need for long term care services is also likely to grow. According to the Division of Public Health - Bureau of Health Planning, admissions to nursing homes more than doubled between 1991 and 2001. As the demand for long term care services continues to rise, the demand on institutions and community- based healthcare providers to offer more care will also increase. Although admissions have risen significantly in the past ten years, so have discharges. As a result, the nursing home population from year to year has been relatively stable. In fact, the number of licensed nursing home beds has only increased by 1.3% since 1991. Furthermore, occupancy rates in nursing homes have not changed significantly in the past decade, averaging around 86% since1991. The national occupancy rate in 2005 was approximately 85.4%. According to Steve Gold, a Philadelphia-based attorney and disabilities advocate, Delaware had an occupancy rate of 84.65% in 2005. Population Projections State of Delaware Persons Aged 60+, 75+, and 85+ Year Population Projections Percent Change Persons Aged 60+ From Year 2000 2000 134,400 NA 2005 153,578 14.3 2010 179,608 33.6 2015 208,831 55.4 2020 243,728 81.4 2025 276,689 105.9 2030 296,739 120.8 *** 3 Year Population Projections Percent Change Persons Aged 75+ From Year 2000 2000 45,463 NA 2005 54,048 18.9 2010 60,127 32.3 2015 64,807 42.6 2020 73,328 61.3 2025 88,056 93.7 2030 104,067 128.9 *** Year Population Projections Percent Change Persons Aged 85+ From Year 2000 2000 10,575 NA 2005 13,802 30.5 2010 17,425 64.8 2015 19,940 88.6 2020 21,533 103.6 2025 22,964 117.2 2030 26,824 153.7 Source: Delaware Population Consortium, Annual Population Projections September 23, 2003, Version 2003.0 4 PROGRAM OPERATIONS What is an Ombudsman? Advisor: Provides information and counsel to authorities charged with operation and regulation of the long term care system. Advocate: Represents a complainant or group of concerned residents to encourage resolution of complaints. Catalyst: Helps mobilize the public and/or organizations to generate action to resolve issues and problems. Coordinator: Brings together individuals with authority so they can share information, develop strategies, assign responsibilities, and take action to resolve problems and issues. Facilitator: Establishes communication channels to bring concerns and problems needing solutions directly to decision makers. Mediator: Encourages reconciliation by serving as an impartial third party mediating disputes over services or issues. Referral Agent: Refers those seeking assistance to the responsible agencies that can help resolve a problem. Whenever possible, such referrals are monitored. Witness: Witnesses all Advance Directives written by and/or for residents of long term care facilities. The Year in Review In Delaware, there are 48 nursing homes that provide care for 4,973 residents on any given day. In addition, there are 29 assisted living facilities serving approximately 1,743 residents. An additional 276 smaller group homes and related institutions are located throughout the state, providing long term care to 2,738 seniors and persons with disabilities. The largest growth in long term care facilities was in the combined category of assisted living, small group homes, and related institutions. This growth has resulted in an increase in the number of options residents have when seeking long term care. Assisted living regulations were strengthened in 2002 to add more safeguards for residents in long term care. Among important changes was a new "Uniform Assessment Instrument." This tool was designed to ensure that applicants interested in assisted living were appropriate and met eligibility standards and to determine the appropriate level of care. The Long Term Care Ombudsman Program investigated and resolved 465 complaints during fiscal year 2005. In addition, the program witnessed 300 Advance Directives and provided scores of in-service training sessions and outreach. The program accomplished this with three and a half full-time Ombudsman staff 4.5 Full time employees (FTEs), a Volunteer Services Coordinator, and a Program Administrator. In our complaint handling, the Ombudsman respects the resident, the complainant, and their confidentiality. The complaint resolution focuses on the resident's stated wishes. A complaint is defined as information that requires an action or inaction. Also, it could adversely affect the health, safety, welfare, or rights of residents of long term care facilities. 5 Most Frequent Complaints Complaint investigations are the primary responsibility of the Long Term Care Ombudsman Program. Ombudsman staff work closely with residents and facility staff to offer guidance and correct substantiated complaints. In fiscal year 2005, staff investigated 465 complaints in four categories: residents' rights, residents' care, quality of life and administration. Within these categories, the most frequent complaint was care planning. 6 Top Five Complaints in FY-05 (of 162 categories) There are 9 categories of "complainants" who referred complaints on behalf of residents to the Ombudsman. However, most of these complaints came from: 7 Typical Case/Case Study The typical resident served by the Ombudsman Program is a 78-year old who has been residing in a nursing home for two years. The Ombudsman spent about ten hours on the case, and took 80 days to complete the case. Most complaints involved care planning issues and were usually resolved within about three months. Long Term Care Ombudsman Program policy states that cases should be closed within ninety days. To reduce case time, the program explored the possibility of expanding the role of the volunteer from "friendly visitor" to include helping the ombudsman resolve complaints. However, this new concept is yet to be implemented. Some variables must be in place prior to successful implementation. To facilitate the transition, we must develop a new volunteer training program focused on assisting with investigations and resolving complaints, and be able to attract those who desire this new role. At the moment, most volunteers prefer to be "friendly visitors." In our case study, a male resident has a diagnosis of Alzheimer's Disease and wanders frequently. The family is concerned because he is easily agitated and needs some intervention or activity to help him calm down. The family wants him restrained. However, regulations do not permit the use of a restraint. The Ombudsman reviews the care plan and recommends participation in an Alzheimer's day program. After two weeks in the program, his behavior is not acute and he is non-combative. Location The program operates out of two offices, one located on DuPont Highway in New Castle, serving the City of Wilmington and New Castle County. The other office is located in Milford, and serves both Kent and Sussex Counties. In addition, we rely on our Volunteer Ombudsmen to assist with being our eyes and ears in long term care facilities by visiting residents and assisting with interventions to correct problems as they arise. This proactive approach helps to resolve issues early and often. Program Impact/Outcomes Ombudsmen work closely with the families of residents and facility staff to resolve each complaint by identifying the basis of the complaint, making recommendations, and referring violations of regulations to the state Division of Long Term Care Residents Protection. Ombudsmen respond to each resident's concern in person, interview staff, and review records during the course of an investigation. Resolution is made based on findings. An Overview of Ombudsman's Activities Ombudsman Staff meet monthly to review program responsiveness and overall performances. Information and Assistance: Ombudsmen provided information regarding residents' rights, care, admission procedure, discharge procedure, abuse, neglect, and exploitation reporting. 8 Education and Outreach: Ombudsmen provided community education and outreach on the rights of residents, the services of the Ombudsman program, facility regulations and enforcement and elder abuse. Education and outreach was done for individuals, families, groups and facility staff. Routine Visit to Facilities: Ombudsmen routinely visit facilities and residents to ensure that they are visible and accessible to the residents, their families, and facility staff. In this respect, they are available for consultation. Resident and Family Councils: On invitation, Ombudsmen attend resident and family council meetings. They answer questions and where appropriate, are available to help establish these councils. Interagency Coordination: Ombudsmen worked closely with regulatory, advocacy, social services, law enforcement and appropriate agencies to ensure that long term care facility residents are accorded their rights. Specifically, we refer all cases of abuse, neglect, mistreatment, and financial exploitation to the Division of Long Term Care Residents Protection. 9 Percent of Nursing Home Surveys Resulting in Citation for Substandard Quality of Care ­ "2001 Nursing Home Data Compendium" - Source CMS/OSCAR Data Quality Indicators - Delaware vs National Average Nursing homes in Delaware compare favorably with most states, with an average of 4.2 hours per patient day (ppd), while the national average was 3.9 ppd, according to the Centers for Medicare and Medicaid Services (CMS). Adequate staffing is important in assuring sufficient care for residents. Delaware has more survey findings per facility (8) than the national average. In 2004, findings per facility was 10. This is an evidence of an improvement. It is remarkable that Delaware's use of physical restraints is 4% below national average. However, survey deficiencies were less likely to show substandard quality of care than in the rest of the nation. (see map) Delaware was typical of most states with regards to performance of quality indicators, as established by the Centers for Medicare/Medicaid Services (CMS). However, Delaware's performance was slightly below average in helping residents with activities of daily living, restricted movement, ambulation, and urinary tract infection. Delaware National Average Staffing+ 4.2 ppd 3.9 ppd Survey Findings 13.4 9.9 Source: Harrington, et.al 2005 Complainants with LTCOP/Bed 0.09 0.05 Source: FY05 NORS Data 10 Quality Indicators ADL Pain Bed Sore Rest- raint Depression Incon- tinence Restricted Movement Ambu-lation UTI US 16% 6% 13% 7% 14% 48% 4% 12% 9% Delaware 18% 5% 14% 3% 14% 49% 5% 15% 9% Source: Medicare.gov/NHCompare as of September 2005. See explanations below. Data can fluctuate. Generally, lower percentage is better. ADL­ Activities of Daily Living. It shows the percent of residents whose need for help doing basic daily tasks has increased from the last time it was checked. These activities include feeding oneself, transferring from one chair to another, changing positions while in bed, and going to the bathroom alone. Pain ­ It shows the percent of residents who were reported to have moderate to severe pain during the assessment period. Pain can be caused by a variety of medical conditions. Checking for pain and pain management are very complex. Bed sore ­ It shows the percent of residents with a high risk of getting pressure sores, or who get a pressure sore in the nursing home. A resident has a high risk for getting pressure sore if in a coma, if unable to get needed nutrients or cannot move or change position without assistance. Restraint ­ It shows the percent of residents in the nursing home who were physically restrained daily during the assessment period, A physical restraint is any device, material, or equipment attached or adjacent to a resident's body, that the individual cannot remove easily, which keeps a resident from moving freely or prevents resident normal access to body. Depression ­ It shows the percent of residents who have become more depressed or anxious in the nursing home since their last assessment. Incontinence ­ It shows the percent of residents who often loose control of their bowels or bladder. It is based on residents who have a low risk. A low risk means if resident has severe dementia (memory loss) or resident has limited ability to move around. Restricted movement ­ It shows the percent of residents who spent most of their time in bed or a chair in their room during the assessment period. This restriction could be due to a decline in physical activity, muscle loss, joint stiffness, fear of injury, worsening illness, or depression. Ambulation ­ It shows the percent of residents whose ability to move about, either by walking or using a wheelchair, in their room and hallway near their room, worsened since last assessment. Urinary Tract Infection (UTI) ­ It shows the percent of residents who had an infection in their urinary tract anytime during the 30 days before their most recent assessment. 11 BUDGET AND EXPENDITURES State funds and Title III federal funds support six full-time positions for the Long Term Care Ombudsman Program. In addition, Title VII, Chapter III funds are directed towards training, outreach for abuse prevention, and community awareness. The Ombudsman Program also receives an annual allocation from the U.S. Administration on Aging to support its operations. Operational funds are the lifeblood of the program and empower the program to fund new initiatives, recruit volunteers, and sustain an effective outreach mission. Since 1996, the Ombudsman Program has experienced a 187% increase in Title VII appropriations for its operations. Increased funding has enabled the program to reach out to more residents and families and help to recruit potential volunteers. Budget Category Amount Federal ­ Title VII, Chp II $ 70,101.00 (outreach) Federal ­ Title VII, Chp III $ 25,377.00 (APS training) Federal ­ Title III at State Level $213,000.00 (salaries 14% increase) Federal ­ Title III at AAA Level -0- Other Federal -0- State Funds $129,349.00 (salaries 11% increase) Local -0- Total Program Funding $437,827.00 Best Practices The Long Term Care Ombudsman Program continues to embrace and use best practices in Delaware and has worked on implementing Ombudsman best practices to improve overall program performance. To that end, the program has initiated a 360 degree review process using the Self Evaluation Tool developed as a national standard that all programs use. The goal of this instrument is to provide State Long Term Care Ombudsmen with a tool for assessing their own statewide program. The instrument has two purposes. First, it identifies the components and elements that must be present in order to have a strong, effective Ombudsman program. Second, the instrument allows the State Long Term Care Ombudsman to assess, using a rating scale from 1 to 5, whether each element is in place and, if so, how successfully and consistently the element is utilized. The purpose of this document is to highlight the efforts that Delaware's Long Term Care Ombudsman Program is making towards implementing the Bader Report's Recommendations for best practices. The Bader Report, published in 2003, identified six core areas to improve and develop Ombudsman programs: independence, systems advocacy, training, data, program effectiveness, and meeting the changing needs of the elderly population. Delaware, like the National Association of State Ombudsman Program (NASOP), has been working on implementing the Bader Report recommendations. Ombudsmen in Delaware participate in regional and national training sessions which are aimed at program effectiveness. It is our goal to continually improve our performance and to ensure full compliance with the Older Americans Act. 12 VOLUNTEER OMBUDSMAN CORPS Volunteers Working on Behalf of Delaware Residents to Resolve Problems, Advocate and Improve Care: Traveled 12,225 Miles -Making 70 round trips between New Castle County and Sussex County Made 20,000 visits to residents -average of four visits per resident Volunteered 3,185 hours ­ almost equivalent to 2.0 full time positions Intervened 147 times -equivalent to cases worked by paid staff Witnessed 300 Advance Directives Volunteer Recruitment The Long Term Care Ombudsman Program conducts volunteer training classes each year. Volunteers receive a 15-hour training program. They are recruited by a statewide multimedia outreach campaign that includes media releases, brochures, public service announcements, and civic group presentations. In addition, the state's Internet site, www.dsaapd.com, offers an online application for people interested in volunteering. We also work closely with the Retired and Senior Volunteer Program (RSVP) and other community based organizations to promote volunteer opportunities. After our initial training program, volunteers enter an orientation phase of their training. In addition, they participate in bi-monthly trainings to keep volunteers up to speed on the latest developments in long term care. Each Volunteer Ombudsman must have excellent communication skills to establish and nurture relationships with residents of long term care facilities. In addition, individuals must be effective advocates and knowledgeable in residents' rights as well as current practices in long term care facilities. Volunteers are our eyes and ears in a facility, and they make a real difference in the lives of those living in nursing homes and assisted living facilities. In the near future, the initial 15-hour training may be revised to embrace the current and actual need of a volunteer. Again, this will resemble some of the best practices by other Ombudsmen across the country. Volunteer Retention Delaware's Volunteer Ombudsman Program believes that building successful, trusting relationships with residents is not only the foundation of good advocacy, but also is a primary key to volunteer retention. When volunteers establish meaningful, rewarding contacts within a facility, they are more likely to fulfill their volunteer responsibilities and many will contribute well beyond what is asked of them. To retain volunteers and recognize their achievements and service-above-self dedication, the Ombudsman Program: · Sponsors an annul recognition event to award service pins and recognize achievement · Provides professional training and experience · Reimburses Ombudsmen for mileage · Provides ongoing and active communication and training with a Volunteer Service Coordinator 13 The current mileage reimbursement rate is not keeping up with the high cost of gasoline. This is a challenge for the Ombudsman's office and several statewide organizations whose volunteers are retired citizens with fixed incomes. Every effort must be made to improve the reimbursement rate if we are to retain our volunteers. There was an effort to expand the role of Volunteer Ombudsmen during the year. Volunteers have historically been'"friendly visitors." Friendly Visitors make a real impact on residents who are isolated. Many residents need a caring heart and a warm hand to help them feel connected to their community. In fact, almost 40% of residents do not receive regular visitations. In addition to their "friendly visiting" role, there was a consideration to expand the role of Volunteer Ombudsmen duties to include assisting Long Term Care Ombudsman Program staff with complaint investigations. This has not materialized because of required training, certification, and the willingness of current volunteers for such a gigantic undertaking. Nationwide, Volunteer Ombudsmen routinely investigate complaints related to quality of care and residents' rights. In fact, 62% of all Volunteer Ombudsmen in the nation are certified to investigate complaints. We revised our training manual, and are redirecting our recruitment efforts to reflect this new and expanded role of our Volunteer Ombudsmen who will enhance our capabilities to serve the 5,000 residents living in long term care facilities in Delaware. Ombudsman Volunteers The Ombudman's Volunteer Coordinator manages volunteer activities. "Volunteer Visitors" visit residents in long term care facilities. When Volunteer Visitors learn of complaints they request that a Certified Ombudsman contact the complainant to handle the investigation and resolution. Become a Volnteer Ombudsman! The Ombudsman Program is looking for volunteers. We are dedicated to protecting the dignity and rights of elders and persons with disabilities statewide. Ombudsman Volunteer Visitors are trained to listen to the concerns and problems of long term care residents. Key volunteer qualities include compassion, respect, and common sense. A positive attitude, ability to communicate effectively, and available time are important attributes. All volunteers receive initial and ongoing training. With additional training, Certified Volunteer Ombudsmen help residents by investigating and working to resolve concerns at an any stage. 14 Alice has been a volunteer for ten years. She started as a volunteer in New Castle County and continued after relocating to Sussex County. She cherishes the opportunity to be helpful to her new-found friends in long term care facilities. She is particularly proud about making a difference in the lives of nursing home residents and believes in advocating for their rights. At this point, staff are receptive to her suggestions. One improvement she wants to see is additional training for some Certified Nursing Assistants (CNAs). Alice is retired and volunteers at Hospice, Alzheimer's, and Ombudsman. Equipping Volunteers to Communicate and Interact In order to build relationships, volunteers must communicate well. Consequently, communications is a crucial training goal. New training materials prepare and encourage volunteers to communicate with residents who can show little or no response to their presence or with those who are maladjusted, depressed or have dementia. Success stories of interactions are shared at bi-monthly, in-service meetings. Shy or hesitant volunteers gain confidence to reach out when hearing what others are accomplishing. Bill has been a volunteer for eight years. He volunteers in a New Castle County nursing home. According to him, if and when residents get to know you, they are likely to tell you the truth that they do not share with family and staff. It is a bond of friendship. Bill believes in the quality initiative of "culture change" which is promoting home-like environment in a facility. Bill says " when we bring people to nursing homes, we forget that they are human beings who used to live in their own homes." He reminds us that the residents are human beings who should be treated with dignity and decency. Public officials, state agencies, and long term care facilities must continue to collaborate in the interest of facility residents. Bill started volunteering because he feels obligated to "give back" to the community. Bill is an accountant and insurance agent by profession. Meet Alice Williams, Volunteer Ombudsman "Alice is faithful in visits and has an uncanny ability to become so close to a resident that she can often speak the difficult truth and make it sound like gentle familial advice from a caring mother. Her skills, watchful eyes, and outspoken manner make her a tremendous advocate." Meet William (Bill) White, Volunteer Ombudsman "A Volunteer Ombudsman for eight years, Bill is a faithful visitor and superb advocate. He is an excellent ambassador for the program. Bill believes that long term care facilities have improved tremendously in the last three to four years, contrary to what everyone reads in the newspapers." 15 PUBLIC AWARENESS AND OUTREACH Outreach ­ Mandate to Educate Delaware's Long Term Care Ombudsman staff takes seriously the mandate of the Older Americans Act to educate the community about the need for good care and dignified treatment of elderly and disabled residents. Well-trained staff and volunteers speak frequently to families, resident/family councils, and providers on resident rights, quality of care, and advocacy. Ombudsmen also give presentations to local colleges and nursing programs. Speaking to students about resident rights before they enter into a healthcare or long term care facility is vital to their understanding of the Ombudsman Program and its mission. We also provide in-service training to providers on Advance Directives, Powers of Attorney, and conflict resolution. The Long Term Care Ombudsman Program actively partners with other organizations and individuals to enhance awareness of long term care issues in the community. The program worked closely with Sandy Dole, long term care advocate, to sponsor the Residents' Rights Rally in October 2005. The rally brought together stakeholders, elected officials, and residents to bring awareness to, and celebrate the 33 resident rights guaranteed by state and federal law. In addition to raising awareness , this'annual event opens the door of nursing homes to the community. Grassroots events like the rally help educate the general public about long term care issues and promote advocacy for elderly and disabled residents. The Long Term Care Ombudsman Program has a strong presence in the Delaware media and in the community because of past and current promotional activities. The State Long Term Care Ombudsman was interviewed about resident rights and volunteering on several local television stations and by local print media. We continue to promote residents' rights and advocacy in the news media. In the past, the program developed a guide to selecting nursing homes in Delaware. This first-of-its-kind handbook helps families and residents understand the process of going into a long term care facility. It walks people through the application process, explains Medicaid, and gives options to families and residents looking for long term care services. The Long Term Care Ombudsman Program continues to work hard to increase the public's awareness about the program. As such, we continue to participate in the following outreach and media activities: Ad Campaign: A series of professionally designed advertisements to promote the Long Term Care Ombudsmen Program and its advocates. Table Top Display: Panels that include information and graphics for various target audiences. Nursing Home Poster: For statewide placement. This will be available in English and Spanish. Brochure To inform the general public about the Long Term Care Ombudsman Program and its services, with emphasis on the advocates and their advocacy on behalf of nursing home residents. The publication will be accessible on the division's Internet site. Also, it will be available in English and Spanish. 16 PUBLIC POLICY AND ADVOCACY Self-Advocacy/Public Awareness Advocacy has been the centerpiece of the Long Term Care Ombudsman Program since its inception. However, self-advocacy is the key component. Patient and resident advocates help to fight for the rights of long term care facility residents. The work of patient advocates is important to ensure that dignity and respect are observed and quality of care is provided. Self-advocacy is a learned skill. Residents who know their rights, and families who are involved, can be the front-line defense against inadequate care and potential abuse. Self-advocacy can go a long way toward prevention. The Long Term Care Ombudsman Program published and disseminated a guide for nursing home residents to promote awareness of rights and help with self-initiated advocacy efforts. Effort is on-going to translate Residents' Rights into the Spanish language. At press time, poster of Rights would have been translated, printed, and distributed to long term care facilities. This is another way of reaching our diverse population. In addition, we sponsored a Residents' Rights Rally that promoted awareness. Rally was attended by public officials and some legislators. On an annual basis, events are planned to continue promoting self-advocacy. Quality of Care/Staffing This paragraph featured in the 2004 report. However, it is being repeated because staffing and quality of care are essential to quality of life in a facility. Staffing has long been held to be a crucial link to quality of care. In Delaware, the Ombudsman program has strongly supported minimum staffing legislation, and continues to do so. Several studies have indicated that there is a slight correlation between staffing and survey findings. As staffing increases, survey findings decline. It's important to understand that staffing regulations are not a panacea, and that other factors must be in place to ensure that quality of care improves in our nursing homes. These factors include: culture change, training, pay, leadership, and public and private accountability. Consequently, we continue to support minimum staffing, but after analyzing the relationship between staffing and survey findings, more should be done to enhance provider quality. Quality Management and Culture Change Making long term care institutions into communities requires a new perspective on service delivery. Historically, nursing homes operated under a medical model which limited options for residents and created an environment which did not embrace or promote feedback. Residents of nursing homes felt they did not have a voice in their treatment. New service delivery models have swept the country and transformed long term care. The latest program is the Culture Change concept. It is similar to some of its predecessors such as the Eden Alternative, Pioneer, and Well Spring. It is opening nursing homes up to the community. This quality management practice transforms a nursing home from an institution into a home by using modern methods of participatory management, infusing the building with plants and animals to humanize the facility, and creating a program that encourages customer feedback. In Delaware, twelve nursing homes voluntarily participated in this initiative. Progress will be evaluated in due course. 17 The Delaware Nursing Home Residents Quality Assurance Commission has established three subcommittees, including a subcommittee on improving quality management. The State Long Term Care Ombudsman volunteered to assist and make recommendations to these subcommittees. Highlights in Advocacy In 2005, the Long Term Care Ombudsman Program advocated for residents' rights and promoted quality of care in Delaware's long term care facilities. The State Long Term Care Ombudsman worked on national issues as a board member of the National Association of State Ombudsman Programs (NASOP.) We also worked closely with Quality Insights of Delaware to promote the Centers for Medicare/Medicaid Services (CMS) initiative to improve nursing homes by establishing quality indicators. We continue to evaluate the use of the Program Effectiveness Tools and develop training to assist us in the use of these tools. We provided resources on specific topics which impact long-term care residents, for example, discharge, transfer, and relocation. In improving our awareness of the issues related to transfer trauma and relocation and impact on long term care residents, we educated some facility staff about similar issues. In recent years, national trends dictate that Ombudsmen and facility staff must be adequately equipped to handle such trauma. The Long Term Care Ombudsman Program continues to utilize several national and organizational resources to improve skills and training. Emergency Preparedness As noted below, the FY 2004 Report included a section on Hurricane Isabel. It is appropriate to reproduce it, and then be reminded about the ever-increasing need for emergency preparedness. Hurricane Isabel caused many facilities in Delaware to lose power. Some facilities lost power for several hours while others lost power for several days. Facilities in Kent and Sussex counties fared the best during the hurricane as most facilities had power restored within two to three hours. The longest a facility went without power downstate was eight hours. Many of the facilities downstate do not have Conectiv as their power provider because there are many small companies that supply power throughout the two lower counties. New Castle County facilities, except for those located within the City of Newark, have Conectiv as their primary power source. New Castle County facilities reported power outages lasting from four hours or less to as long as four days. A report by the Long Term Care Ombudsman Program staff identified problems with reenergizing facilities and recommended that nursing homes be prioritized for re-connection, a recommendation that Conectiv voluntarily adopted. We need to recall what the country witnessed in the past year in the Gulf area. We saw how it impacted long term care facility residents, families and staff. As such, we must be prepared and also encourage long term care facilities to be prepared for eventualities be they natural or otherwise. It is encouraged that emergency procedures be implemented as a precaution. Procedures should focus on the safety of facility residents. 18 Residents' Rights Week Residents' Rights Week originated in 1981 at an annual meeting of the National Citizens Coalition on Nursing Home Reform. In 2005, we renewed our commitment and our dedication to the 33 resident rights that protect and preserve the rights of older persons to be fully informed about their care, to participate in their care, to make independent choices, to privacy, to dignity, to stay in their home, and to make complaints when necessary and appropriate. The Long Term Care Ombudsmen focused on promoting residents' rights to vote, and provided residents an opportunity to register to vote at the rally. Promoting Quality of Care · Implemented program to adopt national standards/best practices · Worked with the Centers for Medicare/Medicaid Services and Quality Improvement Organizations (QIO) to develop and monitor quality standards in nursing homes · Ombudsmen Fighting for Residents' Rights/Public Outreach · Celebrated Fourth Annual Residents' Rights Week · Continued to work on various subcommittees about issues: Nursing Home Staffing, Psychiatric Care, Long Term Care · Reviewed some of our publications for accuracy · Translated some of our information into Spanish · The Long Term Care Ombudsman Program (LTCOP) identified three issues in last year's annual report that required additional focus and attention in 2005: · 1) Nursing Home Staffing Issues: The LTCOP encouraged consumers to check facility staffing at each facility by referring to the Medicare.gov web page, as well as asking the facility. Additionally, we helped to educate consumers with our new staffing calculator to assist residents and their families to make an informed choice. · 2) Psychiatric Care in Long Term Care: We produced a new video on signs and symptoms of Alzheimer's Disease for consumers considering long term care. We also started a dialog with the Division of Substance Abuse and Mental Health about ways to explore and enhance psychiatric services in Delaware, will continue to work with stakeholders in 2005 to enhance and improve access to mental health services for residents in nursing homes. · 3) Cost of Care: Finally, we participated on the Governor's Commission on Community Based Alternatives to expand care options to residents in long term care seeking less restrictive and more integrated settings, when appropriate. Community-based care settings may be an option for some that can promote more independence and reduce health care costs. 19 Consumer Information This section has been reproduced from the division's Internet site. It addresses the following: 1. What are Advance Directives and Living Wills? 2. Are Advance Directives mandatory? 3. What is a Power of Attorney for health care? 4. What is HIPAA? What are Advance Directives and Living Wills? "Living Will" is another name for "Advance Health Care Directive". The term "Advance Health Care Directive" (or simply "Advance Directive") is used, because that is the name used in the Delaware law related to this subject. An Advance Directive is established by completing an Advance Health Care Directive Form. An Advance Directive enables you to: · Give instructions about your own health care. Part I of the Advance Directive form lets you give specific instructions about health care decisions.Choices are provided for you to express your wishes regarding the provision, withholding, or withdrawal of treatment to keep you alive if you have a terminal medical condition or if you become permanently unconscious, including the provision, withholding, or withdrawalof artificial nutrition, hydration, cardiopulmonary resuscitation, and mechanical resuscitation. Medically appropriate care necessary to ensure pain relief will be provided.Space isalso availablefor you toinclude anyadditional health care instructions. · Name an agent to make health care decisions for you if you become incapable of making your own decisions. Part II of the form allows you name another individual as an agent to make health care decisions for you if you can no longer make your own decisions. You may also name an alternate agent. This section of the form is called a Power of Attorney for Health Care. For more details, see What is a power of attorney for health care? · Express an intention to donate bodily organs and/or tissue following your death. Part III of the form is optional. It allows you, if you wish, to designate anatomical gifts to take effect upon your death. Are Advance Directives mandatory? Completing an Advance Health Care Directive form is strictly voluntary. If you have not given advance instructions for your health care or have not named an agent in a health care power of attorney and you become unable to make your own decisions, a surrogate 20 will be asked to make those decisions for you. The persons listed below would be asked to assume the role of surrogate in the following order of priority: 1. Spouse 2. Adult child 3. Parent 4. Adult brother or sister 5. Adult grandchild 6. Niece or nephew 7. An adult who has exhibited special care and concern for you, if appointed as guardian for that purpose by the Court of Chancery What is a Power of Attorney for health care? Delaware's Advance Health Care Directive form allows you to name another individual as an "agent" to make health care decisions for you if you become incapable of making your own decisions. It also enables you to name an alternate agent to act for you if your first choice is not willing, able, or reasonably available to make decisions for you. This part of the form is a Power of Attorney for Health Care. An agent may not be an operator or employee of a residential long term health care facility at which you are receiving care, unless that person is related to you. An agent's authority becomes effective if your attending physician determines that you lack the capacity to make your own health care decisions. The agent's obligation is to make health care decisions for you in accordance with the instructions you have given in your advance directive and any other wishes, to the extent that they are known. To the extent that wishes are unknown, health care decisions made by an agent are to conform as closely as possible with what that agent determines you would have done or intended under the circumstances. In these situations, the agent will take into account what he or she determines to be in your best interest, and will consider your personal values to the extent that they are known by the agent. If you are not in a terminal condition or in a permanently unconscious state, your agent may make all health care decisions for you except for decisions to provide, withhold or withdraw a life sustaining procedure. Unless you limit the agent's authority, he or shemay consent or refuse any care treatment, service, or procedure to maintain, diagnose, or otherwise affect a physical or mental condition (unless it is a life-sustaining procedure or otherwise required by law). An agent can also select or discharge health care providers and health care institutions. If you are in a terminal condition or in a permanently unconscious state, your agent may make all health care decisions for you, including consent for or refusal of life-sustaining procedures such as cardiopulmonary resuscitation. He or she can also direct the providing, withholding or withdrawing of artificial nutrition, hydration, and all other forms of health care. 21 HIPAA Privacy Notice What is HIPAA? HIPAA stands for the Health Insurance Portability and Accountability Act. It is a federal law which protects the privacy of your medical information. Rules under this law, which became effective on April 14, 2003, give you more knowledge about and control over who is using your medical information and for what purposes. 22 Attachments/NORS Report 23 Exhibit 1 January 10, 2006 To All Staff: Please join me in congratulating Victor Orija as the new State Long Term Care Ombudsman. Victor officially assumed his new position on December 26th and reports to the Director. As many of you know, he began his tenure with the Division in 2002, initially as a Contract Manager and most recently as the Administrator for the Federal Systems Change Grant - Passport to Independence Program (PIP). As administrator for the PIP program Victor played a key role in helping transition persons with disabilities from nursing homes to more appropriate settings in the community. Other responsibilities included, Program analysis, issue resolution, technical assistance, budgeting and contract management. Victor has a Bachelor of Science (BS) Degree in Business Administration from the University of Delaware, and a Master of Public Administration (MPA) Degree from the University of North Carolina. Victor also briefly attended John Marshall Law School in Atlanta, GA. Victor's experience and knowledge of the community is truly an asset to the Division. Victor is very excited about directing the Ombudsman Program and promoting resident's rights throughout the state. I look forward to working with Victor and I am confident that he will become a strong member of the division's team. Thank you, Allan R. Zaback Exhibit 2 STATE OF DELAWARE ANNUAL OMBUDSMAN REPORT TO THE U.S. ADMINISTRATION ON AGING FISCAL YEAR 2005 Submitted by Division of Services for Aging and Adults with Physical Disabilities Delaware Health and Social Services Part I Cases, Complainants and Complaints A. Provide total number of cases opened during reporting period 206 B. Provide the number of cases closed, by type of facility/setting, which were received from the types of complainants listed below Complainants Complainants Nursing Facility Board & Care* Other Settings Resident 32 7 0 Relative 76 16 0 Non-Relative/Guardian 2 0 0 Ombudsman/Volunteer 4 1 0 Facility Administrator 83 22 0 Other medical 2 0 0 Rep. of other health agency 4 5 0 Unknown 0 0 0 Other 29 12 0 Total number of cases closed during the reporting period 295 C. For cases which were closed during the reporting period (those counted in B above), provide the total number of complaints received 465 * Board & Care includes assisted living 24 D. Types of Complaints, by Type of Facility 25 Ombudsman Complaint Categories Resident Rights Nursing B&C, Facility similar A. Abuse, gross neglect, exploitation 1 Abuse, physical 0 0 2 Abuse, sexual 0 0 3 Abuse, verbal 1 0 4 Financial exploitation 1 0 5 Gross neglect 0 0 6 Resident-to-resident physical abuse 0 0 7 Other ­ specify 0 0 B. Access to information by resident 8 Access to own records 1 0 9 Access to ombudsman/visitors 0 0 10 Access to facility survey 0 0 11 Information regarding advance directives 0 0 12 Information regarding medical condition 2 0 13 Information regarding rights, benefits 0 0 14 Info communicated in understandable language 0 0 15 Other-specify 0 0 C. Admission, transfer, discharge, eviction 16 Admission contract/procedure 1 2 17 Appeal process 0 0 18 Bed hold ­ written notice, refusal to readmit 3 2 19 Discharge/eviction ­ planning, notice 29 8 20 Discrimination in admission due to condition, disability 0 0 21 Discrimination in admission due to Medicaid status 1 0 22 Room assignment/room change/intra-facility transfer 5 1 23 Other 0 0 D. Autonomy, choice, preference, rights, privacy 24 Choose personal physician, pharmacy 1 1 25 Confinement in facility against will 16 2 26 Dignity, respect, - staff attitude 9 3 27 Exercise preference/choice and or/civil/religious rights 16 3 28 Exercise right to refuse case/treatment 6 0 29 Language barrier in daily routine 1 0 30 Participate in care planning by resident or surrogate 3 0 31 Privacy ­ telephone, visitors 2 0 25 Resident Rights Nursing B&C, Facility similar 32 Privacy in treatment, confidentiality 2 0 33 Response to complaints 1 1 34 Reprisal, retaliation 1 1 35 Other ­ specify 2 0 E. Financial, property (except for financial exploitation) 36 Billing charges ­ notice, approval, wrong or denied 11 4 37 Personal funds ­ access/information denied 3 0 38 Personal property lost, stolen, used by others, destroyed 11 2 39 Other ­ specify 2 0 F. Resident Care 40 Accidental or injury of unknown origin, improper handling 7 1 41 Call lights, response to for assistance 7 1 42 Care plan/resident assessment 41 4 43 Contracture 0 0 44 Medication 11 5 45 Personal hygiene 6 2 46 Physician services 3 0 47 Pressure sores 2 0 48 Symptoms unattended 4 0 49 Toileting, incontinent care 3 0 50 Tubes ­ neglect of catheter, NG tube 0 0 51 Wandering, failure to accommodate/monitor 7 0 52 Other ­ specify 1 1 G. Rehabilitating or maintenance of function 53 Assistive devices or equipment 4 1 54 Bowel and bladder training 0 0 55 Dental Services 0 0 56 Mental health 0 0 57 Range of motion/ambulation 1 0 58 Therapies ­ physical, occupational, speech 6 0 59 Vision and hearing 0 0 60 Other ­ specify 1 0 H. Restraints ­ chemical and physical 61 Physical restraint 0 0 62 Psychoactive drugs 1 0 63 Other ­ specify 0 0 26 Quality of life Nursing B&C, Facility similar I. Activities and social services 64 Activities 3 2 65 Community interaction/transportation 0 0 66 Resident conflict 5 5 67 Social services 0 0 68 Other ­ specify 0 0 J. Dietary 69 Assistance in eating or assistive devices 5 0 70 Fluid availability/hydration 2 0 71 Menu/food service 7 1 72 Snacks 0 0 73 Temperature 0 0 74 Therapeutic diet 2 0 75 Weight loss due to inadequate nutrition 1 0 76 Other ­ specify 1 0 K. Environment 77 Air/environment 1 1 78 Cleanliness, pests, general housekeeping 15 4 79 Equipment/building 0 0 80 Furnishings, storage for residents 1 1 81 Infection control 0 0 82 Laundry 0 0 83 Odors 0 0 84 Space for activities 0 0 85 Supplies and linens 3 0 86 Other - specify 0 0 Administration L. Policies, procedures, attitudes, resources 87 Abuse investigation/reporting 5 0 88 Administrator unresponsive, unavailable 1 2 89 Grievance procedure 0 0 90 Inappropriate or illegal policies 0 0 91 Insufficient funds to operate 0 0 92 Operator inadequately trained 0 0 93 Offering inappropriate level of care 0 0 94 Resident or family council interfered with 0 0 27 Nursing B&C, Facility similar Administration 95 Other ­ specify 0 0 M. Staffing 96 Communication, language barriers 0 0 97 Shortage of staff 0 0 98 Staff training, lack of screening 0 0 99 Staff turn-over 0 0 100 Staff unresponsive, unavailable 8 0 101 Supervision 0 0 102 Other ­ specify 0 0 N. Certification/Licensing Agency 103 Access to information 0 0 104 Complaint, response to 4 0 105 Decertification/closure 0 0 106 Intermediate sanctions 0 0 107 Survey process 0 0 108 Survey process ­ ombudsman participation 0 0 109 Transfer or eviction hearing 0 0 110 Other ­ specify 0 0 O. State Medicaid Agency 111 Access to information, application 1 1 112 Denial of eligibility 4 0 113 Non-covered services 1 1 114 Personal needs allowance 0 0 115 Services 1 0 116 Other ­ specify 0 0 P. Systems/Others 117 Abuse/neglect/abandonment by family member 14 0 118 Bed shortage ­ placement 0 0 119 Board and care/regulation 0 0 120 Family conflict; interference 38 4 121 Financial exploitation by family 9 4 122 Legal ­ guardianship, poa, wills 18 4 123 Medicare 1 0 124 PASARR 0 0 125 Resident's physician not available 0 0 126 Protective Service Agency 1 0 127 SSA, SSI, VA, and other benefits 0 0 128 Other, Olmstead 1 0 Total 390 75 28 Nursing B&C, Facility similar Administration Q. Complaints About Services in Other Settings 129 Home Care 0 0 130 Hospital or hospice 0 131 Public or other congregate housing 0 132 Services from outside provider 0 133 Other ­ specify 0 Total, Heading Q 0 Total Complaints 465 Action on Complaints NH B&C Other 1. Verified 185 54 0 2. Disposition a. Regulation Change 0 0 0 b. Not Resolved 12 5 0 c. Withdrawn 8 2 0 d. Referred to other agency 1. Report final disposition not obtained 12 1 0 2. Other agency failed to act 5 1 0 e. No action needed 0 0 0 f. Partially resolved 107 12 0 g. Resolved to satisfaction 246 54 0 Total, by type facility or setting 390 75 0 Grand Total 465 E. Legal Assistance/Remedies (Optional) F. Complaint Description (Optional) 29 Part II Major Long Term Care Issues A. Nurse Shortage B. Psychiatric services for NH residents severely limited Part III Program Information and Activities A. Facilities and Beds 1. Number of Nursing Facilities 48 2. Number of Beds 4,973 29 3. Number of Board and Care Facilities 276 4. Number of Beds 2,738 A. Program Coverage ­ No Change B. Local Programs ­ None 30 D. Staff and Volunteers Type of Staff Measure State Office Local Programs Paid Staff FTE 5.0 Paid Clerical Staff FTE 0.0 Certified Volunteers Number of Vol. 44 Other Volunteers Number of Vol. 0 E. Program Funding Federal ­ Title VII, Chapter II $ 70,101 Federal ­ Title VII, Chapter III $ 25,377 Federal ­ Title III at State Level $213,000 Federal ­ Title III at AAA Level -0- Other Federal -0- State Funds $129,349 Local -0- Total Program Funding $437,827 F. Ombudsman Activities Activity Measure State Local Training for staff Sessions 30 Hours 155 Trainees 536 Tech Assistance % of staff time 20% Training for facility staff Sessions 20 Topic 1 Advance Directives Topic 2 Res. Rights Topic 3 Discharge Consultation to facilities Consults 358 Topic 1 Advance Directives Topic 2 Res. Rights 30 Topic 3 Discharge Issues Information and Consults to Indv. Consults 619 Topic 1 Advance Directives Topic 2 Res. Rights Topic 3 Discharge Issues Resident Visitation No. NF Visited 48 No. B&C visited 15 Participation in surveys No. Surveys 24 Work with Res. Councils (NH/AL) No. meetings attended 27 Community Education No. Sessions 12 Work with media No. of interviews 5 No. of press releases 7 Monitoring Laws and Regs % time 20% 31 Exhibit 3 Role of the Long Term Care Ombudsman Office of the Long Term Care Ombudsman (42 U.S.C. 3058f, Title VII, Sec. 712) 712(a) "A state agency shall, in accordance with this section establish and operate an Office of the State Long Term Care Ombudsman and carry out through the Office of State Long Term Care Ombudsman." A. Identify, investigate, and resolve complaints that are made by, or on behalf of residents and relate to action, inaction, or decision that may adversely affect that health, safety, welfare, or rights of the residents (including the welfare and rights of the residents with respect to the appointment and activities of guardians and representative payees), of providers, or representatives of providers, of long-term care service; public agencies; or health and social service agencies; B. Provide services to assist the residents in protecting the health, safety, welfare, and rights of the residents; C. Inform the residents about means of obtaining services provided by providers or agencies described in subparagraph (A) or services described in subparagraph (B); D. Ensure that the residents have regular and timely access to the services provided through the Office and that the residents and complainants receive timely responses from representatives of the Office to complaints; E. Represent the interests of the resident before governmental agencies and seek administrative, legal and other remedies to protect the health, safety, welfare, and rights of the residents; F. Provide administrative and technical assistance to entities participating in the program; G. Analyze, comment on, and monitor the development and implementation of federal, state, and local law regulations, and other governmental policies and actions, that pertain to the health, safety, welfare, and rights of the residents, with respect to the adequacy of long-term care facilities and services in the State; recommend any changes in such laws, regulations, policies, and actions as the Office determines to be appropriate; and facilitate public comment on the laws, regulations, policies, and actions; H. Provide for training for representatives of the office; promote the development of citizen organizations to participate in the program; and provide technical support for the development of the resident and family councils to protect the well-being and rights of residents; and I. Carry out such other activities as the Commissioner determines to be appropriate." 32 Notes & Appendices: Notes on Methodology for Average Case Time: In FY-05, 465 complaint investigations were completed. The most prevalent complaint category was "care planning/resident assessment" with 45 cases. We also studied the 465 complaints closed this year. On average, complaints were opened for 68 days. In addition the Long Term Care Ombudsman Program closed cases that were initially opened prior the start of FY-05. We found that the median time it took to close all cases was 119 days. Some cases were referred before FY-05 because of a backlog in case closures. Please note that we used the median to express the typical case opened due to outliers that skew the data. Consequently, most cases were closed within 90 days, while older cases took almost four months to close. 33