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Friday, September 15, 2017
Volume 4, Issue 1

When Disaster Strikes: Emergency Preparedness and Long-Term Care

Recent natural disasters have significantly impacted several states, including consumers of long-term care services and supports, and like the rest of the country, we have been extremely concerned about all those affected.  

These disasters always act as a reminder about the importance of emergency preparedness, both professionally and personally.

In September 2016, CMS published a final rule regarding emergency preparedness for Medicare and Medicaid participating providers and suppliers. 

The final rule applies to all 17 provider and supplier types and requires long-term care providers to: 

(1) create coordinated emergency plans and policies; 

(2) install and maintain emergency power systems; and 

(3) create plans regarding missing residents in the wake of an emergency.  

There are four core elements that all emergency preparedness programs must have: risk assessment and planning; policies and procedures; a communication plan; and a training and testing program. Each part of the emergency preparedness program must be reviewed and updated annually and should include the following:

  • Risk Assessment and Planning: Providers must develop an emergency plan using all hazards approach, plan and identify in advance essential functions and who is responsible in a crisis.
  • Policies and Procedures: These must be developed and implemented based on the plan and risk assessment and address a variety of issues such as medical documentation, evacuation or shelter and place, subsistence needs, tracking residents, etc. 
  • Communication Plan: A communication plan must comply with federal and state laws and include an alternate means of communication; contact information for staff, hospitals, volunteers, state and local emergency preparedness officials; and a process for sharing medical and resident information among involved care providers. 
  • Training and Testing Program: Providers must develop and maintain training and conduct drills and exercises to test emergency plans train staff and test the plan through drills

CMS has more information and training materials (e.g., PowerPoint overview of rule, online training module, FAQs) on their website

You can find emergency preparedness resources for individuals, facilities, and Ombudsman programs here.

What Can Ombudsman programs do regarding emergency preparedness?

  • Learn more about emergency preparedness for yourself, your program, and the long-term care consumers you serve. 
  • Connect with your local/regional or statewide emergency planning team. 
  • Share information about emergency preparedness with providers, residents, and family members. 
  • Ask providers about their emergency preparedness plans and share information and materials about the final rule (for applicable Medicaid and Medicare providers and suppliers) and emergency preparedness resources.
  • Provide training about the Ombudsman program role in emergency preparedness, as well as preparation tips, with program representatives. 

Additional Information

CMS Final Rule: Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. Here

Emergency Preparedness and Response: Model Policies and Procedures for State Long-Term Care Ombudsman Programs. Office of Long-Term Care Ombudsman Programs, Administration on Aging (AoA), Administration for Community Living (ACL), November 2015. Here.

Emergency Preparedness and LTCOPs Report (NORC). Includes best practices, training examples, and considerations for Ombudsman programs regarding emergency preparedness. Here.

Emergency Preparedness: Questions Consumers Should Ask (Fact Sheet)

Emergency Preparedness Toolkit. Here.

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New and Updated NORC Resources

NEW! LTCOP Volunteer Management: Model Materials and Sharing Best Practices Webinar Materials
This 90-minute webinar is applicable to all staff representatives who recruit, train, and work with volunteer Ombudsman program representatives. The speakers shared the new model volunteer intake and risk management materials (e.g., application form, interview questions, code of ethics, acknowledgement form) and highlighted recruitment ideas. Speakers include Amity Overall-Laib, Director, National Ombudsman Resource Center; Carol Scott, Ombudsman Specialist, National Ombudsman Resource Center; and Lenè Garrett, Volunteer Recruitment Specialist, Oregon Long-Term Care Ombudsman Program.

NEW! Information from CMS Added to the Transfer/Discharge Issue Page
Two new notices from CMS were posted in the “Information from CMS” section on the Transfer/Discharge issue page here. The first document is clarification from CMS on discharge Medicare recipients. The second document is a CMS Survey and Cert Memo on copies of transfer/discharge notices being sent to the ombudsman program.

UPDATED! Federal Nursing Home Regulations Page
Online Surveyor Training- Implementation of Revised Requirements
CMS has developed online surveyor training regarding implementation of the revised nursing home requirements. CMS developed the training for Regional Offices, State Survey Agencies, providers, and other stakeholders and it includes information about the regulations, revised surveyor guidance, and the survey process. The Phase 1 Implementation training was available through July 2017. Phase 2 Implementation Training is available now. Launch the course from this page or visit the CMS Survey and Certification Group Integrated Surveyor Training website, choose “I am a Provider,” select the “Course Catalog” button on the top of the screen, choose “Long-Term Care” in the menu, click on “LTC Survey Process SME” videos from the list of courses, and launch the course.  More information about this training is available in this memo.

New Interpretive Guidelines from CMS
The Centers for Medicare and Medicaid Services (CMS) issued a Survey & Certification Memo announcing the release of several new documents related to the revised federal nursing home regulations, and information about the new survey process and training resources. In the memo, CMS also revealed it will impose a one-year restriction of enforcement remedies for specific Phase 2 requirements and hold constant for one year the Nursing Home Compare health inspection rating for any surveys conducted after November 28, 2017.

  • Revised Interpretive Guidelines. These are contained in Revised State Operations Manual (SOM) Appendix PP. The guidelines are effective November 28, 2017.  They include clarification to existing unchanged requirements, guidance for new requirements implemented in Phase 1, as well as guidance for the new Phase 2 regulations. 
  • A Crosswalk of Old F-Tags to New F-Tags. Since the regulatory sections in the revised rules were re-structured, CMS renumbered the F-Tags. Some tags were combined, and some tags were split into multiple subparts.  These new F-Tags will be used after November 28, 2017.  The crosswalk shows you old F-Tags and the corresponding new F-Tag(s).
  • Survey Process. CMS is launching a new, computer-based Long Term Care survey system at the same time that Phase 2 is implemented. Information about the survey process is available here, which includes a slide deck outlining the survey process.
  • List of Revised F-Tags. Read the list of revised F-Tags here.

UPDATED! Ombudsman Program History Web Page
The Ombudsman Program web page now includes information about the 2015 LTOP Final Rule and the 2016 Reauthorization of the Older American’s Act. View the Long-Term Care Ombudsman Program’s milestones from 1972 to 2016 as a PDF here.

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News from the Network...

Hawaii Long Term Care Ombudsman Program Successful in Restoring State Staff Positions

In Hawaii the Long Term Care Ombudsman Program was successful in getting the Legislature to restore the Ombudsman Specialist position for Oahu and also received funding to hire part-time Ombudsman program representatives for Kauai County, Maui County (which includes Molokai and Lanai), and Hawaii County.  The funding is for 2 years and totals $157,168. Oahu has 1,407 long term care facilities with 9,180 beds. Kauai has 36 LTC facilities with 533 beds. Maui has LTC 67 facilities with 799 beds and Hawaii County has 182 LTC facilities with 1,594 beds.  These numbers are always increasing; however, currently the only paid staff is the State Ombudsman.

The LTCOP is confident that these positions can be filled before the opening of the next legislative session on January 17, 2018.

Baltimore County, Maryland Long-Term Care Ombudsman Program Holds a Sensitivity Training for Caregivers

Part of the Maryland Long-Term Care Ombudsman Program's mission is to educate resident caregivers. The Ombudsman Program, via two nursing trained volunteers, conducted Sensitivity Training for staff. The facility sent staff from every department to participate in the training.

Sensitivity Training is a way to momentarily experience how it feels to be living with aging senses. The staff were divided into small groups and attempted to complete daily living activities while recreating the added challenges of aging senses, to learn what it’s like for residents. They buttoned up shirts while wearing rubber gloves to experience what it’s like to get dressed without the full use of your hands, tried to read a menu with glasses that mimic eye disorders like macular degeneration or cataracts, and tried to maneuver wheelchairs with the use of only one arm.

These exercises help staff get a glimpse of life from the residents' perspective. This training also reminds staff to be more patient with residents as they attempt to do things for themselves and why it's often necessary for caregivers to help with these tasks.

Ohio Website Shows Where Nursing Homes Excel and Fall Short

The lack of information regarding the quality of care in nursing homes presents a challenge for potential consumers looking to choose a facility that is the right fit for them. In Ohio, a solution for residents has been created to aid future consumers in this dilemma. Similar to review websites like Yelp, the Ohio Department of Aging has collaborated with the Scripps Gerontology Center at Miami University to create an online guide composed of specialized surveys from current nursing home consumers that focus on several areas including care and services, environment, facility culture, how time is spent, meals, quality of the caregivers, and whether a facility provides enough information and is helpful when a resident moves in. Ohio has also included state health inspection results, information about available services, and accepted payment methods at each of the facilities. Although the Ohio guide was created as a tool for those that are looking for a nursing home, it has also been utilized by facilities to help make improvements in their care quality. This guide gives facilities the opportunity to understand and repair the disconnect between the residents’ needs and preferences and the care they are given. Read the full article here.

Ombudsmen Program Representatives at the Pioneer Network Conference

Ombudsmen and program representatives from around the nation came together at the Pioneer Network Conference in Chicago to hear innovative thoughts and best practices in the long-term care culture change movement, and to advocate for quality long-term care.

World Elder Abuse Awareness Day Events Across the Nation

Montgomery County Maryland

The Montgomery County Maryland Long-Term Care Ombudsman Program held a Senior Safety event in recognition of World Elder Abuse Awareness Day. The event included presentations on the red flags of abuse, older adults and money, identify theft, senior IT safety, and stress relief and music making.

California Long-Term Care Ombudsman Program

The California Long-Term Care Ombudsman Program made a mandated reporter flowchart to recognize WEAAD. The chart also includes State and Federal Mandated Reporting Guidelines for Long-Term Care Facilities. View the flow chart here.

Arizona Long-Term Care Ombudsman Program

Area Agency on Aging, Region III, Long-Term Care Ombudsman representatives participated in the Arizona “Sonshine” event, held at the Prescott Valley Event Center on June 15th. The event featured vendor tables with facts and information about the issue of elder abuse and advocacy services, along with service providers who offered free medical, vision, dental, mental health and legal services regardless of age and income. Over 900 people attended the event.

On June 15th the second community observance of World Elder Abuse Awareness Day was brought to Lake Havasu City.  Brian Morris, retired Los Angeles County Sheriff’s Department Detective Sergeant assigned to the Fraud and Cyber Crimes Bureau, was the keynote speaker. The event also featured a panel discussion and several vendors providing facts, information and responding to questions about the issues of elder abuse.

This "News from the Network" article appears in every issue in order to highlight your work and news. We invite and encourage you to send your advocacy successes, best practices, program management examples, and resources so we can learn from you and share your experience with your peers.

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TA Hot Topic

Technical Assistance (TA) FAQs- NEW!

In addition to providing training, resources, and support to State Ombudsmen and program representatives, NORC is responsible for responding to technical assistance requests. NORC staff respond to a variety of requests from across the country. Technical assistance requests often involve questions regarding program management, issue advocacy, systems advocacy, and ombudsman skills training. In order to share our technical responses more broadly, this page archives frequently asked TA requests in a concise format. To get to this page, hover over the "Support" tab on the homepage and then click "Technical Assistance FAQs" in the drop down menu.

Click here to visit the new page and contact us with TA requests.

NORS Corner

"NORS Corner" is a new article that will be in every issue in order to highlight frequently asked questions about NORS, share NORS training materials, and examples of program practices regarding NORS. 

“NORS Next” is the familiar name of the Administration for Community Living (ACL) data design for the next phase of the National Ombudsman Reporting System for Title VII (Long-Term Care Ombudsman Program) of the Older Americans Act. This will be the first major renovation of the reporting system since its inception.

Ombudsman programs across the country record the work they do on behalf of residents, including visits to facilities, complaints, consultations, and more. This information is collected and reported to ACL, to be summarized into NORS. (The 2015 NORS report can be found on the NORC website.)

Conversations began in 2012 regarding the need to update NORS to better support ACL’s ability to report on the work of Ombudsman programs. After many meetings (both internal at ACL and with State and local Ombudsman programs) and numerous drafts, “NORS Next” is getting closer to becoming a reality. The major reasons for updating NORS is:

Improve reliability of data

  • There are many inconsistencies across states on the major categories of NORS data.

Improve clarity of ACL-provided instructions and definitions

  • Ombudsmen report finding it difficult to categorize complaints when several categories apply.

Enhance ACL’s ability to understand and report on:

  • LTCO program operations
  • Experience of long-term care facility residents, and
  • Long-term supports and services policies, research, and practices.

The most significant changes will be:

1. Reduction in the number of complaint categories.
NORS Next will have approximately 57 codes, as opposed to the current 119.

2. Case and complaint data will be extracted and uploaded for reporting. No manual entry of complaint data will be possible. Complaint data tables (with no identifying information) will provide ACL with disaggregated data which provides the capacity to analyze complaint resolution by type of complainant, complaint types and other data elements. Disaggregated data will also be useful for further study and research that supports advocacy, accountability, consumer information, and training through comparisons, and trend analysis.

Currently, six state Ombudsman program are testing and providing feedback on the early software development and design; ACL anticipates full pilot testing to begin in early 2018, with training on the system and data collection elements to follow.

Training on the data definitions (elements) and NORS consistency will be developed by NORC and all webinars and other materials will be available on-demand. Training for state Ombudsmen and others who will submit the report to ACL will be provided by the data software developer, ICF.

Stay tuned for more updates on NORS Next! 

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LTCO Volunteer Management

Volunteer Retention

Keeping volunteers energized and engaged is a constant struggle. To prevent burnout and retain volunteers, Ombudsman program volunteers need support and connection, especially since they usually work alone in their community and the complaint resolution process can be challenging. Why do some volunteers stay for years and others leave within weeks or months?

There are a variety of reasons for why volunteers leave; however, enhanced support, training, and availability of staff increases volunteer retention. Wayne Nelson’s study “Factors Affecting Volunteer Long-Term Care Ombudsman Organizational Commitment and Burnout,” provides one example of a statewide strategy of how supporting volunteers can make the difference on how long they stay with the program.

The following information comes from VolunteerPro, and while not specific to Ombudsman volunteers, is still very applicable.

Why Volunteers Leave – 4 Things You May Be Missing 

When you think about designing an intervention to increase retention, consider these four areas for better results:

1. Competency — Volunteers must feel they have the required knowledge and skills and are adequately prepared for their assignments.

Questions for You — Do volunteers receive adequate training to feel comfortable and confident in their new roles? Do they have the right tools for the right job?  What other tools and supports can you offer?

2. Participation Efficacy — Similar to feeling they are prepared to do the job, they also need to feel that they are able to be effective, that their time is well used, and that their work makes a concrete difference.

Questions for You — Is their work designed to be efficient with minimal bureaucracy and roadblocks to progress?  Do you report and celebrate with volunteers goals attained, as well as key learning, on a regular basis?

3. Group Integration — This refers to the social aspects of volunteering and feeling that they are part of the “in-group.” Volunteers need to feel that they have positive relationships with both their peers and paid staff.

Questions for You — Do you ensure that new volunteers are fully integrated into the larger group?  Do you actively work against the formation of cliques and “insider” groups?  Do you keep everyone in the loop with emerging information? Do you address volunteer-paid staff relations issues proactively?

4. Organizational Support (varies with age) — This refers to the ability to get help when needed, acknowledgment of work, and feedback on performance. Perhaps surprising, this need varies with age, and research shows that this support does not affect the intent to remain of those over 40 years old.

Questions for You — For your younger volunteers, do you have a plan to provide more in-depth supervision and support?  Do you have a feedback system in place to help volunteer make corrections and work more effectively?

By focusing on these four areas, you are more likely to increase the participation of volunteers. You might also poll volunteers with a satisfaction survey to find out which might be the most important to tackle first.”

Join the LTCO Volunteer Management Network today to connect with your peers, exchange ideas, share resources and talk about LTCO volunteer management. 

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Quick Tips!

Unsafe Wandering or Exit-Seeking Behavior: Protect Residents with Person-Centered Planning

The following tips are from FAQs released by CMS last year concerning Medicaid Beneficiaries in Home and Community-Based Settings who Exhibit Unsafe Wandering or Exit-Seeking Behavior. Read the FAQs here.

Person-centered planning, staff training and care delivery are core components of provider operations to meet HCBS requirements while responding to unsafe wandering or exit-seeking behavior in an individualized manner. Below is a summary of highlights from the CMS FAQs.

1. How can residential and adult day settings comply with the HCBS settings requirements while serving Medicaid beneficiaries who may wander or exit-seek unsafely?

Person-centered planning, staff training and care delivery are core components of provider operations to meet HCBS requirements while responding to unsafe wandering and exit-seeking behavior in an individualized manner. Person-centered services involve knowing individuals, and their conditions, needs, and history and using this knowledge to create strategies to assure that individuals are free to interact with others and the community in the most integrated way possible and still prevent injury for those who wander or exit-seek unsafely. Home and community-based settings must demonstrate that person-centered planning drives their operations and services for each person. The role of person centered planning and the process for realizing this role is described in the final HCBS regulation and in guidance found on the Medicaid.gov website.

Person-centered service plans should be developed with the individual, and include their representatives as appropriate. The person-centered planning process should include a process that:

  • is informed by discussions with family members or other individuals who are important to them about key aspects of daily routines and rituals;
  • focuses on an individual’s strengths and interests;
  • outlines the individual’s reaction to various communication styles;
  • identifies the individual’s favorite things to do and experience during the day, as well as experiences that contribute to a bad day;
  • proposes experiences that the person may enjoy as community engagement, and describes those factors or characteristics that the individuals would find most isolating or stigmatizing.

2. Can provider-controlled settings with Memory Care Units with controlled-egress comply with the new Medicaid HCBS settings rule? If so, what are the requirements for such settings?

Yes, but only if controlled-egress is addressed as a modification of the rules defining home and community-based settings, with the state ensuring that the provider complies with the requirements of 42 C.F.R. 441.301(c)(4)(F), 441.530(a)(vi)(F) and 441.710(a)(vi)(F). Any setting using controlled-egress should assess an individual that exhibits wandering and document the individual’s choices about and need for safety measures in his or her person-centered care plan. The plan should document the individual’s preferences and opportunities for engagement within the setting’s community and within the broader community.

In situations where a setting uses controlled-egress on an individual basis to support individuals who wander or exit-seek unsafely, consistent with our regulations, the person centered plan must document the individual’s:

  • Understanding of the setting’s safety features, including any controlled-egress,
  • Choices for prevention of unsafe wandering or exit-seeking
  • Consent from the individual and caregivers/representatives to controlled-egress goals for care
  • Services, supports, and environmental design that will enable the individual to participate in desired activities and support their mobility
  • Options that were explored before any modifications occurred to the person-centered plan

3. What are some promising practices that HCBS settings use to serve people who are at risk of unsafe wandering or exit-seeking?


  • Ensure that staff have adequate training in person-centered planning and unsafe wandering or exit-seeking, including how to effectively engage and participate with individuals in both planned and spontaneous activities as well as strategies for addressing the underlying needs and preferences that may motivate wandering or exit seeking.
  • Support individuals to move about freely with staff who help individuals walk or leave the room safely (e.g., providing a walking companion).


  • Prevent under-stimulation by offering activities that engage the beneficiary’s interest. Activities could include music, art, physical exercise, mental stimulation, therapeutic touch, pets, or gardening.
  • Support mobility through engaging activities, such as dog walking, gardening, yoga, and dance

Environmental Design

  • Eliminate overstimulation, such as visible doors that people use frequently; noise; and clutter
  • Use signage to orient the individual to the environment, such as indicating where toilets and bedrooms are, and assuring that there are places for individuals to sit and rest in large spaces within a setting that allow for safe wandering.

4. How can residential and adult day settings promote community integration for people who are at risk of unsafe wandering or exit-seeking? What are some examples of promising practices for implementing the community integration requirements of the regulations defining home and community-based settings and simultaneously assuring the safety of individuals who exhibit these behaviors?

Settings can support community integration, in accordance with each individual’s person centered plan by strategies and practices such as:

  • Finding out during initial assessments what individuals desire in terms of community engagement and educate them about how the setting’s capabilities will meet the individual’s needs and preferences. This should be done before the individual makes a decision about services and settings to allow the best fit between the person and place.
  • Documenting the factors the person identifies as important in a community such as proximity to and involvement of family, connections to communities of faith, specific cultural resources and activities, and others.
  • Providing sufficient staff and transportation to enable individuals’ participation in their activities of choice in the broader community. These could include opportunities for work, cultural enjoyment, worship, or volunteering. The person-centered service plan may also include provider-facilitated opportunities to engage in desired activities in the broader community.
  • Ensuring that visitors are not restricted, and individuals can connect to their virtual communities of choice through social media noting that this alone does not substitute for community activities and integration.

To read the full FAQs and for additional best practices to serve people who are at risk of usage wandering or exit seeking behavior, click here.

Residents' Rights Month: October 2017

October is “Residents’ Rights Month,” an annual event designated by Consumer Voice to honor residents living in all long-term care facilities. The theme for this year's Residents' Rights Month is, "It's All About Me: My Life, My Care, My Choices." The theme focuses on the respect and dignity of every resident and highlights residents’ rights to choose their own schedule and activities, communicate how and with whom they choose, be free from abuse and unsafe environments, and be treated as an individual with unique wants and needs.

Spread the Word

Create a buzz in your local community about Residents' Rights Month by writing a letter to the editor of your local paper, issuing a press release and asking your mayor or governor to proclaim October 2017 Residents' Rights Month. Get ideas for activities and events with our RRM Events Calendar.

Please share any Ombudsman program activities related to Residents' Rights Month with Consumer Voice and NORC.

Residents’ Rights Month Activity Calendar

A printable Residents’ Rights Month Activity Calendar is available here. The calendar provides ideas for events and activities throughout the month of October. Events and activities listed highlight this year’s theme “It’s All About Me: My Life, My Care, My Choices” and provide an opportunity for education, discussion and community-building for residents, staff and family members. Put together a committee to organize Residents’ Rights Month activities; each staff member can lead an event or choose 1-2 events per week to put on. For more information, materials, resources, and activities, click here. 

Residents’ Voice Challenge

We have had a tremendous response to this year's Resident's Voice Challenge.  Consumer Voice will be highlighting submissions throughout the month of October; all entries are posted on Consumer Voice's website here. The Resident's Voice Challenge is an opportunity for residents and all long-term care consumers to share their experiences, raise their voices and reflect on the year's theme.


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