Co-Chairs and Members of the Older Americans Caucus: On behalf of
the Administration on Aging (AoA), I appreciate the opportunity to
testify about a topic of great concern to older Americans - elder
abuse in nursing homes and other long-term care settings. Your
interest and leadership in this area is important to this
Administration and to the national aging network, and I Recommend
you for calling this hearing today.
I have been asked to address the role of long-term care ombudsmen
from the perspective of the Administration on Aging. We at AoA are
proud of the activities of the long-term care ombudsman program
staff and volunteers across our nation. For more than two decades,
they have worked on the front lines on a daily basis protecting the
rights of and advocating for the approximately 2.5 million
vulnerable older Americans living in nursing homes, board and care
facilities, and other long-term care facilities. ombudsmen are
usually the first and sometimes the only people from outside the
facility to see cases related to abuse and are more likely to
intercede immediately to prevent, correct or report these cases than
any other single source.
The Long-Term Care Ombudsman Program under the older Americans
Act was initiated in 1972 by the Nixon Administration in response to
the continuous reports of shocking conditions in America's nursing
homes. The late Dr. Arthur S. Flemming launched the program in
response to numerous recommendations from states and national
associations representing older persons, and since that time states
have worked to develop statewide ombudsman programs to provide a
community presence in long-term care facilities. Today, a total of
565 ombudsman programs, 913 paid ombudsmen and 11,580 volunteers
(6,421 of whom were trained and certified to investigate complaints)
serve residents of nursing homes and a growing number of similar
adult care facilities.
Ombudsmen are able to monitor both private and publicly
subsidized care as concerned citizens and officials, rather than as
government regulators. By statute, they are required to identify
problems that impact residents and make recommendations for ways to
address those problems. In Fiscal Year 1995, ombudsmen investigated
over 218,000 complaints made by over 162,000 individuals. Over 70%
of these complaints were resolved or partially resolved to the
residents' or complainants' satisfaction. While these complaints
covered a wide range of concerns, clearly we know that abuse does
occur in long-term care settings. What we do not know is the full
scope of this abuse. In a soon-to-be published article, Dr. Rosalie
Wolf of the Institute on Aging at the Medical Center of Central
Massachusetts states:
"In spite of all the anecdotal information, media exposes,
ethnographic studies, and licensure and certification reports on
nursing homes, little is known about the incidence of abuse in
institutional settings although all agree that it does exist."
We have all heard horrendous stories of the heinous abuse and
gross neglect of nursing home residents, and as Dr. Wolf's statement
implies, the media has helped to spread the word. one example is of
a case related in our annual report that occurred in California. An
anonymous caller to the ombudsman program alleged that a frail
elderly female resident of a board and care home was being ove r
medicated with an unprescribed psychotropic drug with intent to
cause her death. The ombudsman went to the facility and found the
resident in a catatonic state. The ombudsman then contacted the
local law enforcement agency, Adult Protective Services, and an
ambulance service which transferred the resident to an acute
emergency center for respiratory failure. Further investigation
revealed an intricate conspiracy between the owner of the facility,
an ex-son-in-law, and a treating physician. The ombudsman played a
significant role in pulling all of the investigatory forces together
and collecting information that ultimately led to a criminal
conviction of the guilty parties.
The Senate Special Committee on Aging hearing on October 22,
1997, and the recent Time magazine article on malnourishment in
nursing homes highlighted one particularly shocking type of abuse'.
Other forms of abuse may be slightly more subtle, but nevertheless,
ultimately rob individuals of their dignity and freedom. I was
recently told about a New York State case of an older gentleman who
was admitted to a nursing home after a hospital discharge. It was
questionable whether or not he would recuperate sufficiently from a
stroke to return to his home for which he had "life use". A heavy
amount of therapy was immediately started and he spoke every day
about returning home.
A nursing home ombudsman reassured the man that she would go to
his home and check to see that everything was in order. When she got
there, she found that the home was empty and undergoing renovations.
A neighbor, who possessed the nursing home resident's power of
attorney, told the ombudsman he was renovating the home to prepare
it for rental, and that, in fact, it was to be rented the next
month. The ombudsman asked about the "life use" of the property and
the neighbor simply stated he did not anticipate the elderly man
ever coming home again, and reported that the nursing home
resident's personal belongings had been burned and his hunting dog
given away. The ombudsman salvaged half of a grocery bag of old
photographs for the nursing home resident and assisted in commencing
legal action on his behalf. Although valiant efforts were made by
the ombudsman in this situation, the man's health continued to fail
so-that he was no longer able to return home. He eventually gave up
pursuing legal action.
This case is a very sad situation, but indicates the depths that
abuse can reach, whether it be physical, mental or emotional, and
the compassionate efforts made by ombudsmen across the country in
similar situations.
These are only two of the many examples where ombudsmen step in
to represent the interests of vulnerable older persons. As ..others
here today will relate in their statements, it is clear that
unspeakable tragedies would occur every day across our country were
it not for the vigilance and devotion of ombudsmen to their duty.
That is why this Administration has continued to advocate for
preserving the ombudsman program through the Older Americans Act,
both in the pending reauthorization as well as through the
appropriations process.
In 1992, Congress created the vulnerable elder rights protection
programs in title VII of the Older Americans Act, which brought
together all parts of the Act dedicated to the protection of the
rights of vulnerable, at-risk seniors. This title includes the
long-term care ombudsman program, elder abuse prevention program,
legal assistance, and pension and benefits counseling. In recent
years, funding has only been provided for the ombudsman and elder
abuse programs. I think it is important to note that-the elder abuse
provisions of title VII also have a direct relationship with the
work of ombudsmen, particularly as it relates to coordination of
services and training. We remain concerned about efforts to
eliminate this title because we believe that doing so will eliminate
critical consumer protection services for especially vulnerable
elders. This year, as part of our reauthorization proposal, we have
recommended a consolidation within title VII, combining the four
separate authorizations into one. This proposal would provide the
states with greater flexibility to address their elder protection
activities consistent with their needs, while maintaining a base
funding level for the long-term care ombudsman program. In other
words, in addition to the ombudsman program, states would have the
complete flexibility in choosing the level of support for consumer
protection services, which could include elder abuse prevention
programs and activities.
The ombudsman program also makes significant contributions toward
combatting fraud and abuse in Medicare and Medicaid. At the 1995
White House Conference on Aging, President Clinton announced
"Operation Restore Trust" (ORT), a major initiative to fight
Medicare and Medicaid fraud. The state ombudsmen in California, New
York, Illinois, Florida and Texas were designated as part of a core
team for ORT, a two-year demonstration project of the U.S.
Department of Health and Human Services involving the coordinated
efforts of the Health Care Financing Administration, the office of
the Inspector General and the Administration on Aging. Under ORT,
ombudsmen in the five states launched ambitious statewide training
programs to educate ombudsmen and other professionals about fraud,
waste and abuse, and strategies for handling it. These activities
have been very successful in returning funds to the Medicare Trust
Funds. For example, in Florida, a relative questioned charges to
Medicare of over $1,000 for an "anticontracture" device for his
family member who lived in a nursing home. The ombudsman went to the
facility and found that an individual had visited the facility and
ordered the brace devices for almost all of the 90 patients. The
contraptions were stored in the residents' closets; they were not
used to help any of the frail, sick people to whom they were given;
and in many cases, they caused pain and skin abrasions. The
ombudsman reported her suspicion of Medicare fraud to the
appropriate authorities, providing documentation for what she had
observed at the facility. The individual was ultimately convicted of
organized fraud in several facilities, sentenced to jail, and
ordered to pay restitution and fines.
One topic of today's hearing, which focuses on background checks
of those who work in long-term care facilities and settings, is an
important one. According to the Administration on Aging's Long-Term
Care Ombudsman Annual Report for FY 1995, the two most frequent
nursing home complaints involved accidents and improper handling,
and issues related to dignity and respect. -The FY 1995 report
analyzed data from 29 states. The FY 1996 data, which is currently
being compiled and analyzed, will be from all 50 states, Washington,
DC and Puerto Rico. This data was collected under the newly
implemented National Ombudsman Reporting System (NORS).
In FY 1995, the 29 states reported over 80,000 complaints. Around
5 percent of these complaints (4,500) were reported for complaint
categories which are specifically defined as abuse. For example,
physical abuse complaints number about 1,800. other complaint
categories such as "dignity, respect, staffattitudes" or "personal
funds mismanaged" include complaints which often involve abuse,
neglect and exploitation. If these cases are added to the specific
abuse complaints, there are over 17,000 complaints, more than 20% of
the total which are received. The line between neglect and abuse is
very hard to draw. The complaints reported under many categories
such as "personal hygiene" and "accidents, improper handling" can
also involve abuse issues. Adding these categories will result in
30,000 complaints or more than 1/3 of the total for nursing
facilities. The 29 states were responsible for less than half of the
complaints reported. The data received from the ombudsmen is not
specifically aimed at measuring abuse but does give an indication of
a significant incidence of abuse in nursing facilities.
Why does such abuse occur so frequently? We knowthat some of
these acts are carried out by individuals who should not be working
in caregiving environments. They have histories of inappropriate
behavior and, unfortunately, some of these types of individuals find
jobs in some long-term care facilities. We also know that many
caring and committed individuals work in nursing homes and other
long-term care settings around the country as well. But for those
who commit crimes, who abuse or neglect, clearly, solutions must be
found to prevent this type of problem from continuing, and ombudsmen
play key roles in identifying the problem in many areas. Many
ombudsmen across the country have indicated a need for a nationwide
system of background checks on applicants. Unquestionably, some form
of advance screening is necessary for those individuals who work on
a daily and hourly basis with our loved ones. Also of equal
importance is training, particularly for those in the criminal
justice system who work with frail and often uncommunicative victims
and witnesses of criminal abuse, as well as training staff in
residents, needs and rights and how to work with residents under
trying conditions. ombudsmen and others in the aging network
throughout the nation carry out such staff training programs on a
regular basis. In addition, I cannot say enough about how important
it is to fully implement the training and certification requirements
of the historic Nursing Home Reform law. Finally, and equally
important, is the expansion of a community presence in facilities
through the Older Americans Act ombudsman program to provide
additional eyes and ears in long-term care facilities..
In conclusion, the Administration on Aging is proud of the many
contributions which the Long-Term Care Ombudsman Program has played
in helping to empower residents and potential residents of nursing
homes and long-term care facilities to resolve problems and receive
quality care as well as providing timely and accurate consumer
information. This is a program that has a proven track record. We
also believe that this successful program, in conjunction with legal
assistance personnel, benefits counselors, information and referral
representatives, and other state and area agency staff, provide a
valuable model for expanding the ombudsman concept into other
arenas, in particular when older persons face a bewildering array of
decisions regarding their health care. The Administration on Aging
has proposed this type of program as part of our reauthorization
efforts for the 105th Congress, and it has been met with interest
and enthusiasm.
I appreciate the opportunity to testify before you today, and
look forward to any questions that you might have.