Official Site of The State of New Jersey

New Jersey Office of the State Long-Term Care Ombudsman Overview

The New Jersey Office of the Long-Term Care Ombudsman (LTCO) is an independent advocate promoting person centered treatment and services for individuals receiving long-term care. Representatives of the LTCO work with individual residents to help them address challenges they face. The LTCO also seeks opportunities to bring about change on the local, state, and federal levels by advocating for policy and legislative initiatives and participating in activities that support the core mission of advancing the rights, dignity, and self-determination of individuals living in long-term care.

The LTCO operates five programs:

• Investigations and Advocacy: The LTCO's primary function is to investigate and resolve complaints made by or on behalf of residents in long-term care facilities.
• Volunteer Advocate Program: Highly trained Volunteer Advocates are placed with nursing homes throughout the state to observe the quality of services provided by long- term care communities and advocate for residents' rights.
• I Choose Home NJ: In partnership with the New Jersey Department of Human Services, the LTCO promotes the federally funded Money Follows the Person program, known in New Jersey as I Choose Home NJ. The program provides services and supports to empower willing and eligible nursing home residents to transition back to living in the community.
• Regional Ethics Committees: These committees provide education, conflict resolution, and ethical guidance to residents, families and long-term care facility staff as they navigate difficult medical decisions.
• Social Isolation Project: This program is intended to address social isolation and loneliness among long-term care residents who had been restricted to their facility, and often to their rooms, for as long as a two years. Social workers proactively visit with long-term care residents to assess their quality of care and quality of life

Investigations and Advocacy:

Guidance, Support, Advocacy
The LTCO's office is authorized by federal and state law to:

• Accept confidential complaints from any source, or anonymously, via phone, fax, mail, or email;
• Investigate those complaints and resolve or refer them to regulatory or law enforcement entities for further action;
• Conduct public or private hearings;
• Subpoena documents or personal testimony;
• Access residents of long‐term care facilities and their records without restriction; and
• Work with nursing home resident councils to empower residents to advocate for themselves.

Once a case is opened and assigned, the Investigator/Advocate makes an unannounced visit to the facility, meets the resident to obtain consent to proceed, conducts a complete review of the facts, obtains records, and interviews the resident, staff, and other relevant witnesses.

The primary purpose of the investigation is to resolve the problem to the satisfaction of the resident and to ensure that the resident is safe and that their rights and dignity are being upheld.

If the Investigator/Advocate verifies or suspects the resident has been the victim of abuse, neglect or exploitation, the Investigator/Advocate will refer the findings to a regulatory or law enforcement entity for possible further investigation and action.

Investigations and Advocacy Spotlight

Case Example: A long-term care facility restricted visitation to 30 minutes once a week for a family member who was recognized as a compassionate caregiver—a designation that should have allowed unlimited visits. The assigned Long-Term Care Ombudsman (LTCO) investigator educated the facility's executive director on visitation guidelines and advocated for unrestricted visits by the compassionate caregiver.

Outcome: The executive director agreed to allow the resident to have a visitor with no time constraint. The resident was happy with the results of the LTCO's involvement.

Case Example: A resident was reportedly not receiving medication that had been prescribed for a seizure disorder. The LTCO investigator found the facility was having an issue with its pharmacy and did not have a protocol in place to ensure that patients received all necessary medications. The physician was never notified. The investigator verified the facility's neglect and referred the case to the New Jersey Department of Health (DOH) for further investigation.

Outcome: The resident received the necessary medication, and the facility was required to submit a plan to the DOH to correct systemic issues and prevent similar situations in the future.

Case Example: A facility attempted to involuntarily discharge a resident, claiming a change in the level of care. However, the LTCO investigator assigned to the case determined there was no change in the resident's health or the necessary level of care. The investigator consulted with the state Medicaid case manager assigned to the resident, who was unaware of the discharge notice and concurred there was no change in the level of care.
Outcome: LTCO's intervention enabled the resident to stay.

Activities and Accomplishments In FFY 2022, the LTCO:

FIELDED 9,196 calls made to the LTCO toll-free intake line (1-877-582-6995). Approximately 2,100 complaints were received by email or fax.

INITIATED 6,626 investigations and closed out 6,039 investigations involving 13,255 separate complaints.
RESOLVED or partially resolved 96 percent of these complaints to the satisfaction of the resident.
CONSULTED with 13,757 individuals seeking information on a wide variety of topics including: residents' rights, LTCO services, care concerns and involuntary discharge.
PROVIDED information to 8,034 facility staff on a range of topics including: emergency transfer requirements, involuntary discharge, mandatory reporting and residents' rights.
ATTENDED 448 resident council meetings.
PROVIDED information and input to state surveyors in 44 facilities. ENGAGED the community during 72 community education sessions. Types of Complaints

LTCO Jurisdiction / Budget

Long-Term Care: 380
Skilled Nursing: 51,809
Board and Care
Assisted Living Residence, Residential Dementia Care, Residential Health Care: 536 Boarding Homes, Freestanding RHCF, Comp. Personal Care Home: 29,497
Other
Adult Day Health Care Services, Independent Living of CCRC, Developmental Center, Specialty Hospital, Comprehensive Rehabilitation, Psychiatric Hospital, Adult Family Care Homes, Assisted Living Programs, Social Daycare Facilities
Federal Fiscal Year 2022 Spending Federal Funds: $1,964,976
State Funds: $2,829,461
Total: $4,794,437
State Fiscal Year 2022 Appropriation Federal Funds: $1,141,000
State Funds: $2,630,000
Total: $3,771,000

Volunteer Advocate Program: Making a Difference through Advocacy

Volunteer Advocates fill a crucial role for the Office of the Long-Term Care Ombudsman (LTCO), proactively visiting nursing homes to help solve problems for residents and ensure they are treated with dignity and respect.

They deal with issues such as staff responsiveness; food and nutrition; hygiene; lack of activities; and missing personal belongings. Volunteers are trained on when and how to intervene and advocate for residents. When serious issues such as abuse, neglect or exploitation are identified, the LTCO will assign a full-time Investigator/Advocate to investigate and resolve them. Jeff Findlay, Manager of Statewide VAP Field Operations & Advocacy Services, manages the Volunteer Advocate Program at the state level while five Regional Coordinators manage the program at the regional level:

• Region I: Essex, Hudson, Morris & Union
• Region II: Bergen, Passaic, Sussex & Warren
• Region III: Middlesex, Mercer, Somerset, Hunterdon & Monmouth
• Region IV: Burlington, Cumberland, Camden, Gloucester & Salem
• Region V: Ocean, Atlantic & Cape May

Volunteer Advocate Program Training

Volunteer Advocates receive 36 hours of in-depth, virtual and in-person training that provides an overview of the Volunteer Advocate Program and covers subjects such as:

• Demographics of the Elderly Population.
• Normal and Abnormal Conditions of Aging.
• Medication and the Elderly.
• Communication Skills.
• The Long-Term Care Setting.
• Social, Financial, Legal, and Ethical Issues.
• Residents' Rights.
• Elder Abuse, Neglect, and Exploitation.
• The LTCO Complaint Process.
• Visiting a Long-Term Care Facility.

The training curriculum was recently updated to reflect industry changes, trends, and new federal nursing home regulations. The training sessions are led by the Volunteer Advocate Program Statewide Trainer.

Volunteer Advocates must pass a certification exam after completing the training. Once certified, new Volunteer Advocates shadow experienced Advocates until they are ready for placement in a nursing home near where they live. The Regional Coordinators handle the new Advocates' placement and orientation.

Continuing Education

Ongoing training is essential to the success of the program. Volunteer Advocates keep up-to-date on their role in the long-term care setting by attending quarterly regional meetings or annual state conferences. Training curricula and methods are continuously reevaluated and revised as needed. Experts in geriatrics, disability services, visual impairment, cultural diversity, long-term care assessment and licensing, activities, person-centered care, and residents' rights have presented to Volunteer Advocates and LTCO staff.

CERTIFIED VOLUNTEER ADVOCATES: 138 TOTAL VOLUNTEER HOURS: 26,496

Volunteer Advocate Spotlight: Rick Kalish

Rick Kalish joined the Volunteer Advocate Program in 2022 and made quite an impression in a short time with his compassionate, tireless advocacy for the residents of Grove Park Healthcare and Rehabilitation Center in East Orange.

Rick—who had participated in a similar volunteer program in Massachusetts before moving to New Jersey in 2021—said he first got involved because he had lost his parents, aunts and uncles, and he missed having contact with older people.

He was also searching for an activity to keep him busy after retiring from his career working with adults and children with intellectual and developmental disabilities. Rick thought it would be somewhat different from his professional career, yet he found that the knowledge and experience from his professional life have helped him connect with residents with disabilities who may have difficulty communicating.

Rick said the relationships he has built with residents at Grove Park is the strongest factor that keeps him dedicated to the cause. Many residents lack regular visits from family and friends, and Rick has become a dependable source of conversation and support, understanding the importance of providing a listening ear.

The residents Rick advocates for at Grove Park have unique life stories. They led vibrant lives prior to admission that included spouses, children, jobs, and personal accomplishments. Rick stresses the significance of respecting and acknowledging their past lives, as well as discussing the challenges they may have faced, such as health issues and addiction.

He ensures that residents have the opportunity to share their experiences, and he addresses their individual circumstances, whether they are actively working towards leaving or if Grove Park is their long-term home. Rick recalled a particular incident early in his time at Grove Park when a resident had been denied a pass to leave the facility due to a previous incident during a visit. Rick successfully negotiated between the resident and the administration, upholding the resident's rights while reinforcing the importance of adhering to facility rules while on a pass.

In a different vein, Rick took the initiative, with the support of the facility staff, in helping residents vote in the most recent general election. He worked closely with the Essex County Clerk's office to facilitate voter registration and the application for mail-in ballots, ensuring that interested residents could exercise their right to vote and engage in civic participation. To those considering joining the program, Rick's advice is straightforward: "Do it!"

Rick finds great satisfaction in being a supportive listener and a friend to the residents, making a positive impact on their lives. Advocating for the residents is a rewarding pursuit, highlighted by the relationships he has made, the stories the residents share, and his meaningful contributions to helping improve their lives in long-term care.

Social Isolation Project: Engaging Residents Where They Live

The LTCO Social Isolation Project (SIP) sprung from the need to combat the social isolation of residents during the COVID-19 pandemic. SIP staff proactively visit nursing homes to ensure that residents are connected to their families and to each other, and that in-person visitation, meals, activities, and connective technologies are available.

SIP staff also conduct an in-depth review of facility conditions, speak directly to residents to resolve any outstanding concerns in real time, and provide education to facility staff about social isolation, residents' rights, and quality of care. Because of its proactive nature, SIP can identify facilities that are declining in quality and may need more intervention or assistance from state partners. SIP staff also work to ensure that the care plans for each resident is person-centered. Person-centered planning is a process by which the resident selects and organizes the services and supports that they need.

Social Isolation Project Spotlight:

In November 2021, the LTCO Social Isolation Program learned of a woman living in a lovely and well-run assisting living facility who was struggling and socially isolated in her new home. Although the facility in question was immaculate, with a large open lobby, floor–to-ceiling windows, a horticulture therapy garden in the living room, and plentiful activities, this woman, Ellie, was isolated. She rarely left her room or engaged in the activities that were offered.

Jennifer McMahon, LTCO's Chief of Advocacy Services, is a Certified Therapeutic Recreation Specialist and handles most cases related to recreation or activities. She also manages the Social Isolation Project, which focuses on improving a resident's experience in their long-term care home.

McMahon arrived at Ellie's door and knocked. She was welcomed inside, and it became immediately obvious that Ellie had led an interesting life. Her room was decorated in glitz and glam, with multiple black-and-white photographs that looked as if they were taken by a professional photographer.

Poetry books were strewn about the bed. McMahon soon learned that Ellie had been an accomplished actress in her career. Ellie talked about how she missed her thespian community and speaking to like-minded people. She had no complaints about the care she was receiving—she even said the food was good. She was just lonely and felt like she could not talk to anyone about things that were important to her.

In northeastern New Jersey, about 15 minutes away from Ellie's brother and sister-in- law, is an assisted living and skilled nursing facility specifically for retired members of the arts and theater. McMahon told Ellie about the facility and asked if she would be interested in living there. Ellie was cautiously enthusiastic.

In February 2022, Ellie moved to her new home. "She called me the day before Valentine's Day overcome with emotion and excitement," recalled McMahon.

Ellie said: "I am about to do my first poetry reading and performance in over five years! There are concerts here almost every day performed by residents. I am meeting people that speak the same language as I do. I could not be happier."

This experience taught the Social Isolation Program team that isolation comes in different forms. Sometimes it is choice, and sometimes it is because the environment presented does not accommodate a person's specific needs. When care decisions are made by the resident and are person-centered, residents experience greater satisfaction and well-being.

I Choose Home NJ: A Nursing Home May Not Be the Only Option Advocacy and outreach

I Choose Home NJ—called Money Follows the Person at the federal level—is a program that provides support services enabling residents of nursing homes and developmental centers to move back to homes in the community. In the process, savings are generated that the state must use for more home- and community-based services. The LTCO works closely with the New Jersey Department of Human Services and the federal Centers for Medicare and Medicaid Services (CMS) to carry out this important work. Since 2008, the I Choose Home NJ team has successfully transitioned nearly 3,800 people into homes in the community for a savings of more than $41 million.

LTCO Outreach and Advocacy Coordinators representing I Choose Home NJ are authorized to freely enter nursing homes, speak confidentially with all residents, and review their records (with consent). The goals are to identify residents who want to move out, fiercely advocate for them, and help resolve any barriers or issues. LTCO staff members also educate nursing home staff, community health care providers, caregivers, families, and the general public about the program.

2008 - 2022

• Older Adults - 1,414
• Intellectual/Developmental Disabilities - 958
• Adults w/ Physical Disabilities - 1,411
• Total transitions - 3,783

2022

• Older Adults - 190
• Intellectual/Developmental Disabilities - 29
• Adults w/ Physical Disabilities - 146
• Total transitions – 365

Helping to Identify and to Create Affordable and Accessible Housing

I Choose Home NJ continues to increase access to housing vouchers through local housing authorities and continued development of the Money Follows the Person Housing Partnership Program (MFPHPP)—a collaboration between the state Department of Human Services and the Housing Mortgage Finance Agency that offers developers capital funding to build affordable housing for people waiting to leaving nursing homes.

The MFPHPP launched in December 2015 and has provided $8.2 million of capital funding to developers in exchange for 92 affordable, accessible apartments. To date, 41 units have been completed and the remaining 51 are in some phase of construction.

About $6.8 million of the $8.2 million total in capital funding has been expended.

I Choose Home NJ: Continued Quality Assurance

In 2022, the I Choose Home NJ Program added a Quality Assurance Specialist position to help reverse a growth in the number of individuals who needed to return to long-term care after their transition to the community. The specialist attempts to outreach I Choose Home NJ participants within 30 days of discharge to address issues that could impact their ability to stay in the community—for example, participants needing more personal care assistance hours, medical equipment, or access to non-medical transportation. The specialist works directly with managed care organization liaisons and other community partners to quickly resolve these issues.

Data collected during this outreach reflects the successes and challenges of I Choose Home NJ and also identifies potential issues in the broader managed long-term services and supports system. This data is shared biannually with managed care and state partners to keep them informed about participant experiences and areas for improvement.

I Choose Home/Long Term Care Stakeholder Group

In May 2022, the I Choose Home NJ/LTCO Stakeholder Group that had met routinely for years prior to the COVID-19 pandemic was restarted. The group brings together nursing home residents, former residents now living in the community, caregivers, advocates, policymakers, providers, researchers, family members, and others. The stakeholders have proposed improvements to I Choose Home NJ services as well as policy and legislation to address challenges in the long-term care system as a whole. Each meeting features open discussion centering residents and caregivers, and allowing space for people to share thoughts and experiences on their journey through long-term care. The group's first meetings coincided with the LTCO's participation in the New Jersey Task Force on Long-Term Care Quality and Safety. LTCO polled stakeholder group members to determine their priorities for long-term care reform and brought those recommendations to the Task Force.

A Nursing Home May Not Be the Only Option: Carmen, ICH-NJ Spotlight:

Carmen, 55, is enjoying her new, furnished apartment in Skillman. She has a Certified Nursing Aide who comes three days a week. Above all, she has her independence after living in a nursing home. "I found a way out" she said. "If I'd found it sooner, I'd have left sooner."

Carmen has vague memories of being ill and hospitalized, and landing in the nursing home. The I Choose Home NJ program helped her move back into the community. She credits Kathleen Filippone, a Nurse Liaison, with helping her. "She got me out of there quick, fast and in a hurry. Kathleen did a great job."

It's clear she prizes her independence. "Yes, I can manage on my own, I'm careful," said Carmen, who uses a wheelchair.

In addition to her aide, her sister and two nieces come by to help her. She also receives visits from a nurse, and transportation services to outside appointments.

Carmen has advice for nursing home residents who would like to move out; "Stay on top of it. If someone tells you no, go to someone else. If you've got it in your head that you've got to get out of there, there are contacts you can talk to."

Regional Ethics Committees: Difficult Decision and Ethical Guidance: Difficult Decisions:

As individuals grow older and struggle with advanced illness and frailty, they, their families, and their care providers will likely be faced with difficult decisions about their care. Decisions can include whether to provide or remove particular treatments, such as dialysis or artificial nutrition, adjust medications, or refer to palliative care or hospice.

For individuals in long-term care communities, the LTCO provides support and ensures that decision making is resident-focused and consistent with ethical and legal standards. One way the LTCO does that is through Regional Ethics Committees (RECs), which provide impartial, comprehensive evaluation and assessment of the situation and offer nonbinding recommendations to the individuals involved. RECs provide much-needed education, conflict resolution and ethical guidance to facilities and families when difficult decisions need to be made.

Ombudsman Process:

As with all of the Ombudsman's work, the primary focus of the process is to ensure that the resident's wishes are respected. The LTCO works with the resident, their family and friends, and facility staff to identify the resident's wishes, wherever possible.

In addition to exploring the resident's wishes, the LTCO also gathers clinical information regarding the resident's cognition, condition, and prognosis, to ensure that legal standards for withholding/withdrawing treatment are met.

Regional Ethics Committees (RECs):

Multidisciplinary teams, including social workers, nurses, clergy, and hospice workers.

Established to serve as a resource to residents and health care professionals of Long- Term Care Facilities who face ethical dilemmas related to:

• Treatment decisions.
• Health care conflicts.
• Withholding/withdrawing Life
• Sustaining Treatment.
• Quality of life issues.

Consultation is not required and recommendations are not legally binding, but RECs can often resolve ethical dilemmas as close to the bedside as possible.

• NJ Supreme Court Case Law
• In re Quinlan, 70 N.J. 10 (1976)
• In re Conroy, 98 N.J. 321 (1985)
• In re Farrell, 108 N.J. 335 (1987)
• In re Peter, 108 N.J. 365 (1987)
• In re Jobes, 108 N.J. 394 (1987)

LTCO Policy and Legislative Activities:

Collaborating to Close a Notorious, Poor Performing Nursing Home

In the fall of 2021, it became clear that Woodland Behavioral and Nursing Center in Andover Township (formerly Andover Subacute and Rehabilitation Center) was violating residents' rights and dignity daily, through persistent short staffing, egregious clinical practices, and locking residents with mental health disabilities on a third-floor unit. When LTCO staff learned that nearly all of the 450-plus Woodland residents had mental health disabilities, we began to sound the alarm. A Department of Health facility survey in January 2022 confirmed serious regulatory violations. The facility failed to correct cited problems, and Woodland was set on a path for decertification and permanent closure.

LTCO staff played a pivotal role ensuring that the rights and dignity of residents were centered at every turn during that difficult process. LTCO representatives were present nearly every day for months, making sure residents were informed of their rights and kept up-to-date on what was happening to the facility. The residents would need to be transferred. Our staff worked closely with the residents to find facilities that would provide person-centered care that reflected their preferences.

The LTCO worked closely with Disability Rights NJ, the state departments of Human Services and Health, the Office of the Public Guardian and Medicaid managed care organizations to consistently push back on facility management and ensure residents could meet with outside advocates, move where they preferred, and receive the support they needed.

After Woodland closed, LTCO staff followed up with every person who had relocated to another nursing home and continued to visit with and advocate for all former Woodland residents to ensure they were satisfied in their new environments and receiving person- centered care.

The experience of Woodland and our collaboration with other advocates, such as Disability Rights NJ, served as a catalyst for three emerging policy themes: 1) to think about long-term care from a disability rights perspective and speak about it in those terms; 2) the need for stronger financial transparency to ensure that public dollars going to nursing homes are actually funding patient care; and 3) the need to substantially improve or close poor performing nursing homes.

LTCO Policy And Legislative Activities Continued:

Envisioning Bold, Transformative Long-Term Care Reform:
The New Jersey Task Force for Long-Term Care Quality and Safety began to meet regularly in spring of 2022. The LTCO was a member, and, working with members such as Disability Rights NJ and AARP-NJ, played a crucial role in keeping the Task Force focused on bold and transformative changes needed to truly rebalance New Jersey's long-term care system. The committee's work coincided with the Woodland closure (see page 22) and benefited from lessons learned through that process. The Task Force continued to meet into FY 2023. When the Task Force's final report is published, LTCO is hopeful that it will serve as a blueprint for major reform in New Jersey and across the nation.