STATE OF DELAWARE OFFICE OF THE STATE LONG TERM CARE OMBUDSMAN Annual Report Federal Fiscal Year 2007 DELAWARE HEALTH AND SOCIAL SERVICES DIVISION OF SERVICES FOR AGING AND ADULTS WITH PHYSICAL DISABILITIES www.dhss.delaware.gov/dsaapd 1-800-223-9074 Annual Report State of Delaware Office of the State Long Term Care Ombudsman Federal Fiscal Year 2007 Delaware Health and Social Services Division of Services for Aging and Adults with Physical Disabilities (DSAAPD) Main Administration Building, First Floor 1901 North DuPont Highway New Castle, Delaware 19720 (302) 255-9390 or (800) 223-9074 (302) 255-4445 (fax) www.dhss.delaware.gov/dsaapd Kent/Sussex Counties Milford State Service Center 18 North Walnut Street Milford, Delaware 19963 (302) 424-7310 or (800) 223-9074 (302) 422-1346 (fax) Administration Office of the State Long Term Care Ombudsman May 29, 2008 Dear friends of long term care residents: We are pleased to present the 2007 Annual Report of DelawareÕs Long Term Care Ombudsman Program. DelawareÕs Long Term Care Ombudsman Program is responsible for advocating for 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 to provide a blanket of protections for the rights of long term care residents. This report for Federal Fiscal Year 2007 reflects the efforts of all the agencies involved as well as our dedicated Ombudsmen, Volunteer Ombudsmen, families, advocates, and citizens who present 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. We hope that this report will be useful to you as you work to improve the lives of our fellow Delawareans who need long term care. Please contact us if we can be of assistance. Sincerely, Victor Orija, MPA State Long Term Care Ombudsman TABLE OF CONTENTS Accomplishments..................................................................................................... 1 Mission and History ......................................................................................................................2 Long Term Care Overview ............................................................................................................3 Program Operations.....................................................................................................................5 Budget and Expenditures ................................................................................................19 Volunteer Ombudsman Corps .................................................................................................... 20 Public Awareness and Outreach ................................................................................ 22 Public Policy and Advocacy ................................................................................. 23 Consumer Information ........................................................................... 27 Attachments/ORT Report.........................................................................................30 www.dhss.delaware.gov/dsaapd 1-800-223-9074 ACCOMPLISHMENTS OF THE OFFICE OF THE STATE LONG TERM CARE OMBUDSMAN DURING FISCAL YEAR 2007 Made 1,178 visits to long term care facilities - 50 nursing homes, 32 assisted living facilities, and 113 board and care homes. Served 7,365 residents of long term care facilities. Received 490 complaints on behalf of long term care facility residents. Verified 367 (75%) of the complaints that were received. Resolved 429 (88%) of the complaints (28% partially and 60% fully). Major complainants were facility staff (46%), relatives and friends (28%). Major complaints included admission/discharge (22%), care plan (20.4%), choice/resident rights (13.9%), and family conflicts (7.6%). 46 community education sessions were conducted in the community and/or in long term care facilities. Promoted quality improvement in long term care facilities. Notable was the Advancing Excellence in Nursing Home campaign. In March 2007, we developed an intensive schedule of visitations to board and care homes. Between March and December 2007, we visited 63 of the 113 homes. Volunteers donated 5,760 hours of service. 1 www.dhss.delaware.gov/dsaapd 1-800-223-9074 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 was 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 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 officially mandated by the Secretary of Delaware Health and Social Services to investigate grievances of residents of long term care facilities pursuant to Delaware law. Delaware's Ombudsmen have been investigating complaints in long term care facilities for 29 years. In 1979, the program received a total of 53 complaints. In 2007, the Ombudsman Program investigated 490 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 residentsÕ 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 both agencies. 2 www.dhss.delaware.gov/dsaapd 1-800-223-9074 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 likely to grow as well. 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 Persons Aged 60+ Percent Change 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 www.dhss.delaware.gov/dsaapd 1-800-223-9074 Year Population Projections Persons Aged 75+ Percent Change 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 Persons Aged 85+ Percent Change 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 www.dhss.delaware.gov/dsaapd 1-800-223-9074 PROGRAM OPERATIONS The program's accomplishments are summarized on page 1. The Ombudsman Program serves residents of nursing homes. assisted living, board and care, and residential care facilities throughout Delaware. Type of Facility Number of Facilities Number of Beds Nursing Homes 50 5,174 BC & RC 113 303 Assisted Living 32 1,888 What is an Ombudsman? The word "Ombudsman" is Swedish and means "one who speaks on behalf of another." The Ombudsman is an advocate for residents of long term care facilities (nursing homes and residential care facilities). 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. Consultation to Facilities: Provides information and education on resident rights and long term care issues to staff of long term care facilities. 5 www.dhss.delaware.gov/dsaapd 1-800-223-9074 Legislation and Advocacy Participated in national and state level conferences on aging and long term care issues. Commented on proposed federal regulations on Long Term Care Ombudsman Programs. Member of Policy and Law Sub-Committee on State Council for Persons with Physical Disabilities. Member of subcommittees of The GovernorÕs Commission on Community-Based Alternatives for People with Disabilities. Subcommittees include: Assessment, Employment, Healthcare, Housing, Money Follows The Person, Transportation, and Workforce Development. Volunteer Recruitment and Coordination Fielded 47 volunteers who provided 5,760 hours of service. Witnessed 300 Advance Directives. Made 157 interventions on behalf of residents. Revisited the innovative program to expand volunteersÕ advocacy role. Public Awareness and Outreach Community outreach and training on the Role of the Ombudsman. Community outreach on residents' rights. Celebrated Resident's Rights Week; Governor's Proclamation. Co-sponsored Sixth Annual Residents' Rights Rally. Television/Press interviews highlighting how to select a nursing home and resident's rights. Statewide presentation about end of life issues with the End of Life Coalition. Training and Education Co-sponsored and coordinated Region 3 Ombudsman training event in Maryland with DC, and MD Ombudsmen programs. Participated in national quality training. Participated in national and state advocacy training. Provided statewide bi-monthly training for volunteers. Provided training on long term care issues for staff of long term care facilities, and state unit on aging staff. Inter-agency Coordination Participated in Delaware Nursing Home ResidentsÕ Quality Assurance Commission meetings. Participated in the State Council for Physical Disabilities Policy and Law Subcommittee. Attended Quality Improvement Initiative training events sponsored by Quality Insights of Delaware. 6 www.dhss.delaware.gov/dsaapd 1-800-223-9074 Intra-agency Collaboration Collaborated with Senior Medicare Patrol staff to train staff and volunteers on Medicare Part D. Collaborated with Alzheimer's Association staff to train Ombudsman staff on Alzheimers issues. Collaborated with Quality Insights of Delaware, Delaware Health Care Facilities Association, Alzheimers Association, and the Pain Management Initiatives to promote the Advancing Excellence in Nursing Home Quality Initiative in Delaware. The Year in Review In Delaware, there are 50 nursing homes that provide care for 5,174 residents on any given day. In addition, there are 32 assisted living facilities serving 1,888 residents. An additional 113 licensed rest (family care) homes are located throughout the state, providing long term care to 303 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. An important addition was the ÒUniform Assessment Instrument.Ó This tool was designed to ensure that applicants interested in assisted living were appropriate and met eligibility standards. Furthermore, it was to help determine the appropriate level of care. The Long Term Care Ombudsman Program investigated and resolved 490 complaints during fiscal year 2007. In addition, the program witnessed 300 Advance Directives and provided scores of in-service training sessions and outreach. The program accomplished this with four full-time Long Term Care Ombudsmen, a Volunteer Services Coordinator, and a State Long Term Care Ombudsman. Location The program operates out of two offices, one located on the 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. In our complaint handling, the Ombudsman respects the resident, the complainant, and their confidentiality. The complaint resolution focuses on the residentÕs stated wishes. A complaint is 7 www.dhss.delaware.gov/dsaapd 1-800-223-9074 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. Most Frequent Complaints Complaint investigations are the primary responsibility of the Long Term Care Ombudsman Program. Ombudsman staff works closely with residents and facility staff to offer guidance and correct substantiated complaints. In fiscal year 2007, staff investigated 490 complaints. Most of the complaints included discharge, care plan, family conflict, resident conflict, resident rights and billing errors. There are 9 categories of ÒcomplainantsÓ who referred complaints on behalf of residents to the Ombudsman. Below is the distribution. Five types of complainants were grouped into the "others" category. There were 490 complaints during FY 2007. 8 www.dhss.delaware.gov/dsaapd 1-800-223-9074 Typical Case/Case Study The typical resident served by the Ombudsman Program is 75 years old, has resided in a nursing home for two years. The Ombudsman spent about ten hours on the case, and required 80 days to complete the case. Most complaints involved discharge and care plan issues. In most cases, they demand urgent attention. Per long term care policy, cases should be resolved within ninety days. To reduce case time, the program has explored the possibility of expanding the role of the volunteer from Òfriendly visitorÓ to include helping the Ombudsman resolve complaints. This possibility has yet to be implemented. 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 resident received a discharge notice. The facility was not being paid, hence the discharge proceeding was initiated. It was a case where the responsible family member was not paying as scheduled. The Ombudsman contacted the family member and facilitated arrangements to repay the facility. Once the repayment arrangement was finalized and intact, the facility withdrew the discharge notice. Meanwhile, the residentÕs care was not impacted. In another case, the resident had a diagnosis of AlzheimerÕs disease and wanders frequently. Facility issued a discharge on the basis of safety. 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 with family and facility staff. Joint resolution was placement in an Alzheimer's day program. The resolution was helpful to the resident. 9 www.dhss.delaware.gov/dsaapd 1-800-223-9074 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 the Ombudsman's Activities Ombudsman staff meets monthly to review program responsiveness and overall performances. Information and Assistance: Ombudsmen provided information regarding residentsÕ rights, care, admission procedure, discharge procedure, abuse, neglect, and exploitation. 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 provided 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. The residents and their families must have a voice in the care of residents. As such, we have renewed our efforts to reenergize Resident and Family Councils by offering our services and letting them know that we are available to speak at council meetings, and willing to offer suggestions on issues. Inter-agency 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. Public Quality Measure Data from STAR site. The facility-level quality measure data on the nursing home STAR site are the data publicly reported by the Centers for Medicare & Medicaid Services (CMS) on Nursing Home Compare . The quality measures are derived from the Minimum Data Sets that are submitted quarterly. 10 www.dhss.delaware.gov/dsaapd 1-800-223-9074 The graph below shows Physical Restraint scores for Delaware and nation over time: Year Quarter State Average* National Average* 2003 3 3 8 2003 4 3 8 2004 1 3 8 2004 2 3 8 2004 3 3 7 2004 4 2 7 2005 1 2 7 2005 2 3 7 2005 3 3 7 2005 4 3 7 2006 1 3 6 2006 2 3 6 2006 3 3 6 2006 4 2 6 2007 1 2 6 2007 2 2 5 2007 3 1 5 2007 4 2 5 * - State and national averages are the average of facility scores as reported on NH Compare. 11 www.dhss.delaware.gov/dsaapd 1-800-223-9074 The graph below shows High-Risk Pressure Ulcer scores for Delaware and nation over time: Year Quarter State Average* National Average* 2003 3 14 14 2003 4 16 14 2004 1 15 14 2004 2 14 14 2004 3 15 13 2004 4 15 13 2005 1 17 14 2005 2 16 14 2005 3 15 13 2005 4 14 13 2006 1 13 13 2006 2 12 13 2006 3 12 12 2006 4 13 13 2007 1 12 13 2007 2 12 12 2007 3 12 12 2007 4 11 12 * - State and national averages are the average of facility scores as reported on NH Compare. 12www.dhss.delaware.gov/dsaapd 1-800-223-9074 The graph below shows Depression scores for Delaware and nation over time: Year Quarter State Average* National Average* 2003 3 15 15 2003 4 15 15 2004 1 15 15 2004 2 14 15 2004 3 14 15 2004 4 14 15 2005 1 14 15 2005 2 14 15 2005 3 14 14 2005 4 14 14 2006 1 15 15 2006 2 12 14 2006 3 13 14 2006 4 14 14 2007 1 14 14 2007 2 13 14 2007 3 13 14 2007 4 12 14 * - State and national averages are the average of facility scores as reported on NH Compare. 13www.dhss.delaware.gov/dsaapd 1-800-223-9074 The graph below shows Chronic Care Pain scores for Delaware and nation over time: Year Quarter State Average* National Average* 2003 3 6 7 2003 4 6 6 2004 1 6 6 2004 2 6 6 2004 3 6 6 2004 4 6 6 2005 1 5 6 2005 2 5 6 2005 3 5 6 2005 4 5 6 2006 1 4 5 2006 2 5 5 2006 3 5 5 2006 4 4 5 2007 1 5 5 2007 2 4 4 2007 3 4 4 2007 4 4 4 * - State and national averages are the average of facility scores as reported on NH Compare. 14www.dhss.delaware.gov/dsaapd 1-800-223-9074 The graph below shows Post Acute Care Pain scores for Delaware and nation over time: Year Quarter State Average* National Average* 2003 3 2003 4 2004 1 2004 2 2004 3 2004 4 2005 1 21 22 2005 2 20 22 2005 3 22 23 2005 4 21 23 2006 1 21 22 2006 2 22 21 2006 3 22 22 2006 4 23 22 2007 1 23 21 2007 2 21 20 2007 3 21 21 2007 4 21 21 * - State and national averages are the average of facility scores as reported on NH Compare. 15www.dhss.delaware.gov/dsaapd 1-800-223-9074 The graph below shows Post Acute Care Pressure Ulcer scores for Delaware and nation over time: Year Quarter State Average* National Average* 2003 3 2003 4 2004 1 2004 2 2004 3 2004 4 2005 1 22 20 2005 2 22 20 2005 3 20 19 2005 4 19 18 2006 1 18 18 2006 2 17 18 2006 3 16 17 2006 4 17 17 2007 1 18 17 2007 2 17 17 2007 3 16 16 2007 4 15 15 * - State and national averages are the average of facility scores as reported on NH Compare. 16www.dhss.delaware.gov/dsaapd 1-800-223-9074 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 (14) than the national average of 9. It is remarkable that DelawareÕs use of physical restraints is 2%, well below national average of 4%. Delaware National Average Staffing+ 4.2 ppd 3.9 ppd Survey Findings+ Source: CMS 14 9 Complaints with LTCOP/Bed Source: FY05 NORS data 0.09 0.05 Quality Indicators ADL Pain Bed Sore Restraint Depression Incontinence Restricted Movement Ambulation Urinary Tract Infection (UTI) US 15% 4% 12% 5% 14% 49% 4% 11% 9% DE 15% 4% 11% 2% 12% 46% 5% 12% 10% Source: Medicare.gov/NHCompare as of December 2007. See explanations below. Data fluctuates quarterly. Generally, lower percentage is better. ADL- Activities of Daily Living. 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 -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 -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 Ð 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 residentÕs body, that the individual cannot remove easily, which keeps a resident from moving freely or prevents resident normal access to body. 17 www.dhss.delaware.gov/dsaapd 1-800-223-9074 Depression Ð Shows the percent of residents who have become more depressed or anxious in the nursing home since their last assessment. Incontinence Ð 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 Ð 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 Ð 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) Ð Shows the percent of residents who had an infection in their urinary tract anytime during the 30 days before their most recent assessment. NH Compare December 2007. *Lower is better NH Compare December 2007. *Higher is better 18www.dhss.delaware.gov/dsaapd 1-800-223-9074 NH Compare December 2007. *Higher is better 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 capability. 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 Ð Title VII, Chapter II $ 74,680.00 (outreach) Federal Ð Title VII, Chapter III $ 24,789.00 (APS training) Federal Ð Title III at State Level $233,915.00 (salaries) Federal Ð Title III at AAA Level -0 Other Federal -0 State Funds $129,349.00 (salaries) Local -0 Total Program Funding $462,733.00 19www.dhss.delaware.gov/dsaapd 1-800-223-9074 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 Delaware's 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 process is to highlight the efforts that DelawareÕs Long Term Care Ombudsman Program is making towards implementing the Bader ReportÕs 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. VOLUNTEER OMBUDSMAN CORPS Volunteers Working on Behalf of Delaware Residents to Resolve Problems, Advocate and Improve Care: Volunteered 5,760 hours Witnessed 300 Advanced 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 division's website, www.dhss.delaware.gov/dsaapd, offers an online application for people interested in volunteering. Also, we 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 residentsÕ 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 20 www.dhss.delaware.gov/dsaapd 1-800-223-9074 embrace the current and actual need of a volunteer. Again, this will resemble some of the best practices by other Ombudsmen across the country. To accommodate volunteers, we have contemplated weekend training. The age range of volunteers is about 60 to 84 years. The challenge is to target new recruits in a lower age bracket. Our current cadre is dedicated and hard working, but we must look to the future when they will decide to retire from active volunteerism. 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 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 volunteers for mileage Provides ongoing and active communication and training with a Volunteer Service Coordinator The current mileage reimbursement rate is not keeping up with the high cost of gasoline. This is a challenge for the OmbudsmanÕs office and several statewide organizations whose volunteers are retired citizens with fixed incomes. Some volunteers have resigned because reimbursement of the low reimbursement from the state. 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 Òfriendly visitors.Ó 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 Òfriendly visitingÓ role, there was 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 the shrinking volunteer pool. Nationwide, Volunteer Ombudsmen investigate complaints related to quality of care and residents' rights. Ombudsman Volunteers The Ombudsman's Volunteer Coordinator manages volunteer activities. "Volunteer Visitors'" visit residents in long term care facilities. When Volunteer Visitors learn of complaints they request that the full time Ombudsman contact the complainant to handle the investigation and resolution. 21 www.dhss.delaware.gov/dsaapd 1-800-223-9074 Recruiting Volunteer Ombudsmen The Ombudsman Program is looking for volunteers. We are dedicated to protecting the dignity and rights of elders and persons with disabilities who are residents in DelawareÕs long term care facilities. 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, a Certified Volunteer Ombudsman may assist the Ombudsman staff by investigating and working to resolve complaints in some instances. 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. PUBLIC AWARENESS AND OUTREACH Outreach Ð 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. Residents' Rights Rally each October brings together stakeholders, agency officials, and residents to increase awareness of, and celebrate the 33 resident rights guaranteed by state and federal law. In addition to raising awareness, this 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 residentsÕ rights and advocacy in the 22 www.dhss.delaware.gov/dsaapd 1-800-223-9074 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. Senior Citizen Newspaper: Delaware's statewide monthly newspaper for seniors and caregivers includes frequent articles about the Ombudsman Program. Brochure: Program brochures are available at the division website www.dhss.delaware.gov/dssapd to inform the general public about the Long Term Care Ombudsman Program and its services. In some cases, we have English and Spanish versions. 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 frontline 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 residentsÕ rights into the Spanish language. A poster of rights for long term care facilities is another way of reaching our diverse population. Quality of Care/Staffing This paragraph was included in a previous report. However, it is being repeated because staffing and quality of care are essential to quality of life in a facility: 23 www.dhss.delaware.gov/dsaapd 1-800-223-9074 Staffing has long been held to be a crucial link to quality of care (Harrington.) In Delaware, the Ombudsman program has strongly supported minimum staffing legislation, and continues to do so. A slight correlation can be found (-0.30) between staffing and survey findings. As staffing increases, survey findings decline (LTCOP report 2004). ItÕs 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, quality improvement initiatives, 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, staff retention, and improved benefits for direct support staff. 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 been introduced 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 at the on set. Others have continued to experiment with the concept as appropriate. The Quality Insights Organization of Delaware, The AlzheimerÕs Association of Delaware, the Delaware Health Care Facilities Association, Delaware Pain Management Initiatives, Inc. have collaborated with the Long Term Care Ombudsman Program to sponsor the Advancing Excellence in Nursing Homes Campaign. in Delaware. As of this writing, 21 nursing homes are participating in the campaign. In addition to participation by a nursing home, every nursing home stakeholder is encouraged to participate. A stakeholder can participate as a LANE (Local Area Networks for Excellence) or as a consumer. There are 10 LANES, and 4 consumers participating. For further information about the campaign, visit www.nhqualitycampaign.org. Advancing Excellence in AmericaÕs Nursing Homes is a two-year, coalition-based campaign focused on with how we care for elderly and disabled citizens. This voluntary campaign, which commenced in September 2006, and still continues, will: Monitor key indicators of nursing home care quality Promote excellence in care-giving for nursing home residents Acknowledge the critical role nursing home staff have in providing care 24 www.dhss.delaware.gov/dsaapd 1-800-223-9074 Campaign Goals Participating nursing homes will work on at least three of eight measurable goals: 1. Reducing high risk pressure ulcers; 2. Reducing the use of daily physical restraints; 3. Improving pain management for longer term nursing home residents; 4. Improving pain management for short stay, post-acute nursing home residents; 5. Establishing individual targets for improving quality; 6. Assessing resident and family satisfaction with the quality of care; 7. Increasing staff retention; and Improving consistent assignment of nursing home staff, so that residents regularly receive care from the same caregivers. Advancing Excellence in Nursing Homes Ð Delaware Profile Highlights in Advocacy In 2007, the Long Term Care Ombudsman Program advocated for residentsÕ rights and promoted quality of care in DelawareÕs 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. We also worked closely with Quality Insights of Delaware to promote the Centers for Medicare/Medicaid ServicesÕ initiatives to improve quality of care in nursing homes. 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. National Delaware (Rank) % of NHs enrolled 43.20% 46.7% (27) Pressure Ulcers* 12.00% 12.0% (26) Restraints* 4.90% 2.0% (8) Chronic Pain* 4.20% 4.0% (18) Acute Pain* 20.90% 21.0% (24) 25www.dhss.delaware.gov/dsaapd 1-800-223-9074 Emergency Preparedness After Hurricane Katrina and the disaster in the Gulf region, long term care facilities and community agencies renewed efforts for emergency preparedness. Every facility is required to revisit their preparedness plans, and drills. Procedures should focus on the safety of facility residents. A good emergency preparedness plan should include: 1. How to provide adequate and accessible transportation 2. Role clarification for staff pre-and-post evacuation 3. How to provide complete information about individual evacuees to the host long term care facilities upon admission 4. How to provide good communication to families about their loved ones 5. How to provide long term care residents with access to the Federal Emergency Management Agency, Red Cross, and other disaster response services ResidentsÕ Rights Week Residents' Rights Week originated in 1981 at an annual meeting of the National Citizens Coalition on Nursing Home Reform. In 2007, 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 residentsÕ rights to vote, and provided residents an opportunity to register to vote at the rally. It was the sixth annual ResidentsÕ Rights Week. About 250 residents and facility staff joined advocates, ombudsmen and others to celebrate the event. Promoting Quality of Care Implemented program to adopt national standards/best practices Worked with the Centers for Medicare/Medicaid Services and Quality Improvement Organizations to develop and monitor quality standards in nursing homes Ombudsmen Fighting for ResidentsÕ Rights/Public Outreach Celebrated Annual ResidentsÕ Rights Week Continued to work on various subcommittees about issues: Nursing Home Staffing, Psychiatric Care, Long Term Care, Home Community-Based Services, and Nursing Home Diversion. Reviewed some of our publications for content and effectiveness Translated some brochures into Spanish The Long Term Care Ombudsman Program identified three issues in last year's annual report that required additional focus and attention in 2007: 1) Nursing Home Staffing Issues: The Long Term Care Ombudsman Program 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 educated consumers and stakeholders about staffing requirements. 26 www.dhss.delaware.gov/dsaapd 1-800-223-9074 2) Psychiatric Care in Long Term Care: We continued to dialog with sister agencies and stakeholders about ways to explore and enhance psychiatric services in Delaware, and how to enhance and improve access to mental health services for residents in nursing homes. 3) Cost of Care: Finally, we participated on the GovernorÕs Commission on Community Based Alternatives for People with Disabilities, offering input on how to expand care options and scope of community services to residents in long term care seeking less restrictive and more integrated settings, when appropriate. Improving the scope of available community services will enable citizens of Delaware to age in place. Consumer Information This section has been reproduced from the divisionÕs website, www.dhss.delaware.gov/ dsaapd. 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 DirectiveÓ) 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 withdrawal of artificial nutrition, hydration, cardiopulmonary resuscitation, and mechanical resuscitation. Medically appropriate care necessary to ensure pain relief will be provided. Space is also available for you to include any additional 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. 27 www.dhss.delaware.gov/dsaapd 1-800-223-9074 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 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 to 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 agentÕs authority, he or she may 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. 28 www.dhss.delaware.gov/dsaapd 1-800-223-9074 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. 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. 29 www.dhss.delaware.gov/dsaapd 1-800-223-9074 Attachments/ORT Report ATTACHMENTS Exhibit 1 STATE OF DELAWARE ANNUAL OMBUDSMAN REPORT TO THE U.S. ADMINISTRATION ON AGING FISCAL YEAR 2007 Submitted by Division of Services for Aging and Adults with Physical Disabilities Delaware Health and Social Services Part I -Cases, Complainants and Complaints A. Cases Opened Provide the total number of cases opened during reporting period. 312 Case: Each inquiry brought to, or initiated by, the ombudsman on behalf of a resident or group of residents involving one or more complaints which requires opening a case and includes ombudsman investigation, strategy to resolve, and follow-up. 30 www.dhss.delaware.gov/dsaapd 1-800-223-9074 Part I -Cases, Complainants and Complaints B. Cases Closed, by Type of Facility Provide the number of cases closed, by type of facility/setting, which were received from the types of complainants listed below. Closed Case: A case where none of the complaints within the case require any further action on the part of the ombudsman and every complaint has been assigned the appropriate disposition code. Nursing B&C, ALF, Other Complainants: Facility RCF, etc.* Settings 1. Resident 2. Relative/friend of resident 3. Non-relative guardian, legal representative 4. Ombudsman/ombudsman volunteer 5. Facility administrator/staff or former staff 6. Other medical: physician/staff 7. Representative of other health or social service agency or program 8. Unknown/anonymous 9. Other: Bankers, Clergy, Law Enforcement, Public Officials, etc. 17 7 0 72 17 0 2 0 0 1 0 0 111 32 0 3 3 0 1 2 0 1 4 0 24 16 0 Total number of cases closed during the reporting period: 313 * Board and care, assisted living, residential care and similar long-term care facilities, both regulated and unregulated Part I -Cases, Complainants and Complaints C. Complaints Received 31www.dhss.delaware.gov/dsaapd 1-800-223-9074 For cases which were closed during the reporting period (those counted in B above), provide the total number of complaints received: 490 Complaint: A concern brought to, or initiated by, the ombudsman for investigation and action by or on behalf of one or more residents of a long-term care facility relating to health, safety, welfare or rights of a resident. One or more complaints constitute a case. Part I -Cases, Complainants and Complaints D. Types of Complaints, by Type of Facility Below and on the following pages provide the total number of complaints for each specific complaint category, for nursing facilities and board and care or similar type of adult care facility. The first four major headings are for complaints involving action or inaction by staff or management of the facility. The last major heading is for complaints against others outside the facility. See Instructions for additional clarification and definitions of types of facilities and selected complaint categories. B&C, Residents' Rights Nursing ALF, RCF, Facility etc. A. Abuse, Gross Neglect, Exploitation 1. Abuse, physical (including corporal punishment) 2. Abuse, sexual 3. Abuse, verbal/psychological (including punishment, seclusion) 4. Financial exploitation (use categories in section E for less severe financial complaints) 5. Gross neglect (use categories under Care, Sections F & G for non-willful forms of neglect) 6. Resident-to-resident physical or sexual abuse 7. Not Used 0 0 2 0 1 0 1 0 1 0 1 1 B. Access to Information by Resident or Resident's Representative 8. Access to own records 9. Access by or to ombudsman/visitors 10. Access to facility survey/staffing reports/license 11. Information regarding advance directive 12. Information regarding medical condition, treatment and any changes 13. Information regarding rights, benefits, services, the resident's right to complain 14. Information communicated in understandable language 15. Not Used 3 0 0 0 0 0 1 0 5 0 0 0 0 0 C. Admission, Transfer, Discharge, Eviction 16. Admission contract and/or procedure 17. Appeal process - absent, not followed 18. Bed hold -written notice, refusal to readmit 19. Discharge/eviction -planning, notice, procedure, implementation, inc. abandonment 20. Discrimination in admission due to condition, disability 1 0 0 0 3 3 62 29 0 0 32 www.dhss.delaware.gov/dsaapd 1-800-223-9074 21. Discrimination in admission due to Medicaid status 22. Room assignment/room change/intrafacility transfer 23. Not Used 0 0 5 5 D. Autonomy, Choice, Preference, Exercise of Rights, Privacy 24. Choose personal physician, pharmacy/hospice/other health care provider 25. Confinement in facility against will (illegally) 26. Dignity, respect - staff attitudes 27. Exercise preference/choice and/or civil/religious rights, individual's right to smoke 28. Exercise right to refuse care/treatment 29. Language barrier in daily routine 30. Participate in care planning by resident and/or designated surrogate 31. Privacy - telephone, visitors, couples, mail 32. Privacy in treatment, confidentiality 33. Response to complaints 34. Reprisal, retaliation 35. Not Used 0 0 5 3 13 0 14 0 9 3 0 0 6 1 2 2 2 1 0 0 4 2 E. Financial, Property (Except for Financial Exploitation) 36. Billing/charges - notice, approval, questionable, accounting wrong or denied (includes overcharge of private pay residents) 37. Personal funds - mismanaged, access/information denied, deposits and other money not returned (report criminal-level misuse of personal funds under A.4) 38. Personal property lost, stolen, used by others, destroyed, withheld from resident 39. Not Used 12 3 3 0 6 3 Resident Care F. Care 40. Accidental or injury of unknown origin, falls, improper handling 41. Failure to respond to requests for assistance 42. Care plan/resident assessment - inadequate, failure to follow plan or physician orders (put lack of resident/surrogate involvement under D.30) 43. Contracture 44. Medications - administration, organization 45. Personal hygiene (includes nail care & oral hygiene) and adequacy of dressing & grooming 46. Physician services, including podiatrist 47. Pressure sores, not turned 48. Symptoms unattended, including pain, pain not managed, no notice to others of changes in condition 49. Toileting, incontinent care 50. Tubes - neglect of catheter, gastric, NG tube (use D.28 for inappropriate/forced use) 51. Wandering, failure to accommodate/monitor exit seeking behavior 52. Not Used 6 1 4 0 41 5 0 0 11 2 5 0 3 1 2 0 6 1 3 1 2 0 4 2 G. Rehabilitation or Maintenance of Function 53. Assistive devices or equipment 4 1 33www.dhss.delaware.gov/dsaapd 1-800-223-9074 54. Bowel and bladder training 55. Dental services 56. Mental health, psychosocial services 57. Range of motion/ambulation 58. Therapies -physical, occupational, speech 59. Vision and hearing 60. Not Used 0 0 1 0 2 0 1 0 12 0 2 0 H. Restraints -Chemical and Physical 61. Physical restraint - assessment, use, monitoring 62. Psychoactive drugs - assessment, use, evaluation 63. Not Used 0 0 0 0 Quality of Life I. Activities and Social Services 64. Activities - choice and appropriateness 65. Community interaction, transportation 66. Resident conflict, including roommates 67. Social services - availability/appropriateness/ (use G.56 for mental health, psychosocial counseling/service) 68. Not Used 2 2 1 0 17 4 3 1 J. Dietary 69. Assistance in eating or assistive devices 70. Fluid availability/hydration 71. Food service - quantity, quality, variation, choice, condiments, utensils, menu 72. Snacks, time span between meals, late/missed meals 73. Temperature 74. Therapeutic diet 75. Weight loss due to inadequate nutrition 76. Not Used 4 11 0 0 0 2 00 0 2 0 1 0 K. Environment 77. Air/environment: temperature and quality (heating, cooling, ventilation, water, noise 78. Cleanliness, pests, general housekeeping 79. Equipment/building -disrepair, hazard, poor lighting, fire safety, not secure 80. Furnishings, storage for residents 81. Infection control 82. Laundry - lost, condition 83. Odors 84. Space for activities, dining 85. Supplies and linens 86. Americans with Disabilities Act (ADA) accessibility 1 1 1 3 2 2 0 0 3 0 0 0 0 0 0 0 3 0 0 0 Administration 1-800-223-9074 www.dhss.delaware.gov/dsaapd 34 L. Policies, Procedures, Attitudes, Resources (See other complaint headings, of above, for policies on advance directives, due process, billing, management residents' funds) 87. Abuse investigation/reporting, including failure to report 88. Administrator(s) unresponsive, unavailable 89. Grievance procedure (use C for transfer, discharge appeals) 90. Inappropriate or illegal policies, practices, record-keeping 91. Insufficient funds to operate 92. Operator inadequately trained 93. Offering inappropriate level of care (for B&C/similar) 94. Resident or family council/committee interfered with, not supported 95. Not Used 1 1 4 0 1 0 4 1 0 0 0 0 0 0 0 0 M. Staffing 96. Communication, language barrier (use D.29 if problem involves resident inability to communicate) 97. Shortage of staff 98. Staff training 99. Staff turn-over, over-use of nursing pools 100. Staff unresponsive, unavailable 101. Supervision 102. Eating Assistants 0 0 2 0 1 0 0 0 1 2 0 0 2 0 Not Against Facility N. Certification/Licensing Agency 103. Access to information (including survey) 104. Complaint, response to 105. Decertification/closure 106. Sanction, including Intermediate 107. Survey process 108. Survey process -Ombudsman participation 109. Transfer or eviction hearing 110. Not Used 0 0 0 0 0 0 0 0 0 0 0 0 0 0 O. State Medicaid Agency 111. Access to information, application 112. Denial of eligibility 113. Non-covered services 114. Personal Needs Allowance 115. Services 116. Not Used 0 0 2 0 0 0 0 0 0 0 P. System/Others 117. Abuse/neglect/abandonment by family member/friend/guardian or, while on visit out of facility, any other person 118. Bed shortage -placement 119. Facilities operating without a license 6 0 1 0 0 0 35 www.dhss.delaware.gov/dsaapd 1-800-223-9074 120. Family conflict; interference 121. Financial exploitation or neglect by family or other not affiliated with facility 122. Legal -guardianship, conservatorship, power of attorney, wills 123. Medicare 124. Mental health, developmental disabilities, including PASRR 125. Problems with resident's physician/assistant 126. Protective Service Agency 127. SSA, SSI, VA, Other Benefits/Agencies 128. Request for less restrictive placement Total, categories A through P 33 4 3 4 12 2 1 0 0 0 0 0 0 0 0 0 3 1 391 99 Q. Complaints About Services in Settings Other Than Long-Term Care Facilities or By Outside Provider in Long-Term Care Facilities (see instructions) 129. Home care 130. Hospital or hospice 131. Public or other congregate housing not providing personal care 132. Services from outside provider (see instructions) 133. Not Used Total, Heading Q. 0 0 0 0 0 Total Complaints* 490 * (Add total of nursing facility complaints; B&C, ALF, RCF, similar complaints and complaints in Q, above. Place this number in Part I, C on page 1.) Part I -Cases, Complainants and Complaints E. Action on Complaints Provide for cases closed during the reporting period the total number of complaints, by type of facility or other setting, for each item listed below. Nursing B&C, ALF, Other Settings 1. Complaints which were verified: Facility RCF, etc. 318 49 0 Verified: It is determined after work [interviews, record inspection, observation, etc.] that the circumstances described in the complaint are generally accurate. 2. Disposition: Provide for all complaints reported in C and D, whether verified or not, the number: a. For which government policy or regulatory change or legislative action is 0 0 0 required to resolve (this may be addressed in the issues section) b. Which were not resolved* to satisfaction of resident or complainant 20 6 0 36 www.dhss.delaware.gov/dsaapd 1-800-223-9074 0 1 0 c. Which were withdrawn by the resident or complainant or resident died before final outcome of complaint investigation d. Which were referred to other agency for resolution and: 1) report of final disposition was not obtained 2) other agency failed to act on complaint 3) agency did not substantiate complaint e. For which no action was needed or appropriate f. Which were partially resolved* but some problem remained g. Which were resolved* to the satisfaction of resident or complainant Total, by type of facility or setting Grand Total (Same number as that for total complaints on pages 1 and 7) 0 0 0 0 0 0 0 0 0 31 3 0 117 20 0 223 69 0 391 99 0 490 * Resolved: The complaint/problem was addressed to the satisfaction of the resident or complainant. Part II - Program Information and Activities A. Facilities and Beds: 1. How many nursing facilities are licensed in your State? 2. How many beds are there in these facilities? 3. Provide the type-name(s) and definition(s) of the types of board and care, assisted living, residential care facilities and any other similar adult care home for which your ombudsman program provides services, as authorized under Section 102(18) and (32), 711(6) and 712(a)(3)(A)(i) of the Older Americans Act. If no change from previous year, type "no change" at space indicated. 50 5,154 No change a) How many of the board and care and similar adult care facilities described above are regulated in your State? b) How many beds are there in these facilities? 145 2,191 Part II - Program Information and Activities B. Program Coverage 37www.dhss.delaware.gov/dsaapd 1-800-223-9074 Statewide Coverage means that residents of both nursing homes and board and care homes (and similar adult care facilities) and their friends and families throughout the state have access to knowledge of the ombudsman program, how to contact it, complaints received from any part of the State are investigated and documented, and steps are taken to resolve problems in a timely manner, in accordance with federal and state requirements. B.1. Designated Local Entities Provide for each type of host organization the number of local or regional ombudsman entities (programs) designated by the State Ombudsman to participate in the statewide ombudsman program that are geographically located outside of the State Office: Local entities hosted by: Area agency on aging 0 Other local government entity 0 Legal services provider 0 Social services non-profit agency 0 Free-standing ombudsman program 0 Regional office of State ombudsman program 0 Other; specify: 0 Total Designated Local Ombudsman Entities B.2. Staff and Volunteers Provide numbers of staff and volunteers, as requested, at state and local levels. 0 State Local Type of Staff Measure Office Programs FTEs 6.00 0.00 Number people 6 0 Paid program staff working full-time on ombudsman program Paid clerical staff FTEs 0.00 0.00 Volunteer ombudsmen certified to address complaints at close of Number volunteers 44 0 reporting period Number of Volunteer hours donated Total number of hours 5,760 0 donated by certified volunteer Ombudsmen Certified Volunteer: An individual who has completed a training course prescribed by the State Ombudsman and is approved by the State Ombudsman to participate in the statewide Ombudsman Program. Other volunteers (i.e., not certified) at close of reporting period Number of volunteers 0 0 38 www.dhss.delaware.gov/dsaapd 1-800-223-9074 C. Program Funding Provide the amount of funds expended during the fiscal year from each source for your statewide program: Federal - Older Americans Act (OAA) Title VII, Chapter 2, Ombudsman Federal - Older Americans Act (OAA) Title VII, Chapter 3, Elder Abuse Prevention Federal - OAA Title III provided at State level Federal - OAA Title III provided at AAA level Other Federal; specify: $74,680 $24,789 $233,915 $ $129,349 State Funds State funds Local; specify: $ $ Total Program Funding $462,733 Part II - Program Information and Activities D. Other Ombudsman Activities Provide below and on the next page information on ombudsman program activities other than work on complaints. Activity Measure State Local 1. Training for ombudsman staff and volunteers Number sessions 42 0 Number hours 212 0 Total number of trainees that attended any of 420 0 the training sessions above (duplicated 39 www.dhss.delaware.gov/dsaapd 1-800-223-9074 count) 3 most frequent topics for training Communicable diseases and MASR Residents Rights Reporting incidents in long-term care facilities. 2. Technical assistance to local ombudsmen and/or volunteers Estimated percentage of total staff time 25 0 Number sessions 31 0 Residents Rights 3. Training for facility staff 3 most frequent topics for training Advanced Directives Discharge Planning 4. Consultation to facilities (Consultation: providing information and 3 most frequent areas of consultation Discharge Planning Conflict resolution technical assistance, often by telephone) Residents Rights' issues Number of consultations 436 0 5. Information and consultation to individuals (usually by 3 most frequent requests/needs Discharge issues 40www.dhss.delaware.gov/dsaapd 1-800-223-9074 telephone) Care Plan Residents Rights Number of consultations 664 0 6. Facility Coverage (other than in response to complaint) * Number Nursing Facilities visited (unduplicated) 50 0 Number Board and Care (or similar) facilities visited (unduplicated) 112 0 7. Participation in Facility Surveys Number of surveys 42 0 8. Work with resident councils Number of meetings attended 51 0 9. Work with family councils Number of meetings attended 20 0 10. Community Education Number of sessions 46 0 Advanced Health Care Directives 3 most frequent topics Residents Rights 11. Work with media Role of the Ombudsman Number of interviews/ discussions 12 0 Number of press releases 12 0 41www.dhss.delaware.gov/dsaapd 1-800-223-9074 Estimated 40 0 12. percentage of total paid staff Monitoring/work on laws, regulations, government time (Note: the total of the percentage at each level in this policies and actions item and item 2 should not add to more than 100%.) * The number is for facilities receiving at least one visit per quarter, not in response to a complaint. It is not for the number of visits. States which do not have a regular visitation program should enter "0" in lieu of "NA," as this numeric field cannot accept "NA." 42www.dhss.delaware.gov/dsaapd 1-800-223-9074 Exhibit 2 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. 43 www.dhss.delaware.gov/dsaapd 1-800-223-9074 Exhibit 3 These public service advertisements about the Ombudsman Program and ResidentsÕ Rights were published during Fiscal Year 2007 in DelawareÕs statewide newspaper for older persons. 44 www.dhss.delaware.gov/dsaapd 1-800-223-9074 Residents' Rights Week October 7Ð13, 2007 Spotlight on Advancing Excellence A ResidentÕs Perspective on Quality Please join us for our 6th Annual ResidentsÕ Rights Rally Thursday, October 11, 2007 ¥ 1 - 3 p.m. Sheraton Dover Hotel, Sauvignon Champagne Room 1570 North Dupont Highway, Dover, Delaware 19901 For More Information Contact Debbie Reeves, President Delaware Council of Activity Professionals, 302-422-8700 The event affirms and celebrates the 33 rights of nursing home residents provided by law. The rights safeguard and promote dignity, choice and self-determination of nursing home residents and protect their civil, personal and privacy rights. The Division of Services for Aging and Adults with Physical Disabilities is responsible for protecting the health, safety, welfare and rights of residents of nursing homes and related facilities through the Long Term Care Ombudsman Program. The program investigates complaints on behalf of residents and their families, and includes a corps of volunteer ombudsmen. Delaware's Volunteer Ombudsman Program: Improving the quality of life for residents of long term care facilities Most of us would agree that having a few good friends and our personal relationships make our lives more complete. They give meaning to our existence and fulfill deep human needs. Carter Catlett Williams of the Pioneer Network, a group that works to change the culture of nursing homes, says "Relationships are not only the heart of long term care; they are the heart of life, and life should continue wherever we live." Volunteering in a nursing home brings life to those who are still part of our community, but are often out of sight and forgotten because many find a nursing home an uncomfortable place to visit. Consider the following statistics: approximately two million Americans live in nursing homes; only 16% have a living spouse; and thirteen percent never have visitors at all. Volunteer Ombudsmen are friendly visitors and they make life better for those who reside in DelawareÕs long term care facilities. This group of individuals trained in resident rights and armed with big hearts, visit disabled and elderly residents in nursing homes in their communities. A listening ear These advocates give a voice to residents and families who may have concerns they cannot handle themselves. Turning a listening ear to problems ranging from cold coffee to more serious issues, they seek to alleviate the loneliness and isolation felt by residents. Last year they gave over 3,400 hours to visitations and further training, to individual Delaware residents in nursing homes and assisted living facilities. They love what they do.Their lives are enriched.They make a difference. Volunteer Ombudsmen complete a 15 hour initial training program and then attend continuing education classes 3-4 times per year. They are assigned to a facility close to their home and asked to visit regularly. Each volunteer decides how many hours he or she can give to the program. Some give 1 hour per week, some give 6 hours per week, and some give more. It is a highly individualized program and a one-year commitment is requested. Many volunteers stay longer and average 5-6 years in the program. Several are now entering their 9th and 10th years as visitors and advocates.Why do they stay? Because it is rewarding! The relationships are enriching. Volunteers often make the statement, "I get back much more than I give!" Suzanne Kihn, a volunteer in the program for over 5 years, says, "When you have a chance to make a difference in the life of a resident, the satisfaction is far greater than the effort you put forth. This is part of my life, and I cannot imagine it any other way. I think the volunteers in this program give a voice to residents who may have concerns or problems they cannot deal with themselves. When you visit a nursing home, you find a rich variety of people, most of whom are delighted to see a friendly face and chat for a few minutes. If you become a regular visitor, you will see that many residents have tremendous grace and courage under very trying circumstances." Meaningful relationships Volunteer Ombudsmen often can help bring about a profound change in the lives of "their" residents by providing meaningful relationships instead of isolation. Sometimes a volunteer may just pop their head in and say "hello" and hold a hand for a few minutes. Sometimes they just listen. Often they will encourage and many times they are a voice for residents who may no be able to advocate for themselves. The late Dr. Hans Seye reasoned that by doing good for people, you inspire gratitude and affection, and this warmth will help protect you from the stresses of life. The University of Michigan studied a group of people for more than a decade. The results of that study indicated this amazing discovery: "Doing regular volunteer work, more than other activity, dramatically increased life expectancy!" Experience the program If you have ever wanted to visit a nursing home, but were afraid to try, we now have a solution to your dilemma. The Volunteer Ombudsman Program has added a "shadowing" component to its basic program. You can now ÒshadowÓ an experienced volunteer during his or her visit in the field. You will get a chance to be charmed by this incredible group of people who are unique and interesting and longing for companionship. Call us. 1-800-223-9074. Experience the program firsthand; see if it fits your interests. Become an advocate We could easily forget this part of our community, overlook their rights, and forget their needs. The care, concern, training and professionalism of DelawareÕs Volunteer Ombudsmen help assure dignity, respect, and quality of life for the disabled and elderly in long term care facilities in your community. The Volunteer Ombudsman program is a community-based program of the Division Services for Aging and Adults with Physical Disabilities. The care, compassion and professionalism of the Volunteer Ombudsmen helps assure dignity, respect and quality of life for the elderly and disabled in Delaware long term care facilities. DELAWARE HEALTH AND SOCIAL SERVICES Division of Services for Aging and Adults with Physical Disabilities www.dhss.delaware.gov/dsaapd RESIDENTS OF DELAWARE NURSING HOMES AND RELATED FACILITIES HAVE RIGHTS PROTECTED BY THE STATE OF DELAWARE CARE You have the right: to receive considerate, respectful, and appropriate care, treatment and services. to receive reasonable continuity of care. to choose a personal attending physician. to not be transferred or discharged out of a facility except for medical reasons, your own welfare or the welfare of other residents; or for non-payment of justified charges. You will be given 30 days advance notice, except where the situation is deemed an emergency. DIGNITY You have the right: to respect and privacy. to be free from restraints. to privacy in your room. to privacy in visits by your spouse. to retain and use your own clothing and personal possessions. to not have to perform a service for the facility. CHOICE You have the right: to make choices regarding activities, schedules, health care and other aspects of your life. to participate in an ongoing program of activities. to participate in social, religious and community activities. RESPECT You have the right: to receive from the administrator and staff a timely, courteous and reasonable response to requests or grievances Ð in writing, if requested. to associate or communicate the others without restriction. to manage your own financial affairs. to recommend changes or present grievances to the facility staff, the Long Term Care Ombudsman or others. É to be fully informed of all rights and responsibilities. to be free from verbal, physical or mental abuse, cruel and unusual punishment, involuntary seclusion, withholding of monetary allowance, withholding of food, and deprivation of sleep. to receive notice before your room or roommate is changed, except in emergencies, and to have the facility honor requests for a room or roommate whenever possible. to exercise your rights as citizen of the State and the United States of America. INFORMATION You have the right: to receive, prior to or at the time of admission, a written statement of the services provided. to receive a written itemized statement of charges and services. to receive from the attending physician complete and current information concerning your diagnosis, treatment and prognosis. to inspect all records pertaining to you. to have the facility place at your bedside, the name, address, and phone number of the physician responsible for your care. to receive, in writing, information regarding any relationship the facility has with other healthcare or related institutions or service providers. to examine the most recent survey of the facility. to receive information from agencies acting as client advocates and be afforded the opportunity to contact those agencies. to request information regarding minimum acceptable staffing levels as it relates to your care. to request the names and positions of staff members providing care to you. to request an organizational chart outlining the facilityÕs chain of command for purposes of making requests and asserting grievances. If a resident is adjudicated incompetent or determined to be incompetent by his or her attending physician, or is unable to communicate, his or her rights shall devolve to his or her next of kin, guardian or representative. WOULD YOU LIKE A COPY OF THE FULL VERSION OF THESE RIGHTS AS THEY APPEAR IN DELAWARE CODE? DO YOU WANT TO REGISTER A COMPLAINT? YOUR LONG TERM CARE OMBUDSMAN CAN HELP. CALL: 1-800-223-9074 DELAWARE HEALTH AND SOCIAL SERVICES Division of Services for Aging and Adults with Physical Disabilities www.dhss.delaware.gov/dsaapd