An investigative report on the Arizona Long-term Care Ombudsman Program
By Paula Blankenship, Melanie MacEachern and Emma Ascott
It’s a seemingly foolish question to ask during a pandemic that’s killed more than 2,500 in long term care in Maricopa and Pima County, but it’s no joke.
The Hertel Report started with that simple question in September 2020. As a local and solutions-focused small newsroom we wanted to tell the story of how this critical program supports and advocates for Arizona’s most vulnerable citizens during a global pandemic.
We expected to tell the stories of local advocates making a difference; a short, sweet tale with a hint of heroism. We can’t tell that story. Nearly seven months later, we’re still asking,
Where are all the Arizona Long-term Care Ombudsman?
We still don’t have a clear answer.
Non-profit executives who reviewed expenditure and financial records of the program’s spending of grant funds awarded to the LTC Ombudsman program to advocate for vulnerable seniors in Arizona long-term facilities deemed the documentation provided by the Arizona Department of Economic Security to be “almost worthless,” while official reports on the program’s effectiveness before and during the pandemic are nearly non-existent or at best, not made publicly available.
The program’s advocacy is supported by a piece of the annual $9 million budget earmarked for Aging and Adult Services through the Department of Economic Security (DES) and expects an additional $650,000 in pandemic-related funding this year. Transparency about how taxpayer money is spent and how Arizona LTC Ombudsman advocate for long-term care residents during heightened fear and isolation deserves scrutiny and answers, according to industry watchdogs.
National elder-care advocates have heralded new approaches and celebrated innovative strategies during the health crisis. Deborah Stone-Walls, president of The National Association of Area Agencies of Aging (n4a), explained, “Almost overnight, our members revamped their critical supportive programs to meet the rapidly growing needs among existing and new clients, determined to protect and serve the most vulnerable in their communities,”
“We have to keep doing everything we can to prevent the spread of the coronavirus,” said Navajo Nation President Jonathan Nez on September 1, 2020, the month our reporting began. That is when the Hertel Report learned there was no LTC Ombudsman in Navajo County — a telling admission for a county that led the globe in COVID-19 spread, but the only pertinent fact gleaned from months of phone calls, web searches and email queries to every Arizona LTC Ombudsman office across the state, the Department of Economic Security and stakeholders in Maricopa and Pima counties.
The Hertel Report is accustomed to analyzing the effectiveness of policy and innovative programs across the care continuum; data being the precursor to accountability for whatever is being measured.
Documentation is a real thing in healthcare. If it’s not written down, it didn’t happen.
There has been activity in the program, but there is no scrutable data to measure demand and response.
Searching for Help
Ombudsman Program Flowchart
Department of Economic Security –> State Long-term Care Ombudsman Program –> Arizona Area Agencies on Aging
Bills To Watch
SB 1512: Introduced by Senator Wendy Rogers (R-Flagstaff). Requires LTC Ombudsman to enter every facility 2 times per year. $1m from the state budget to the program. Waiting on House vote.
SB 1377: Introduced by Senator Vince Leach (R-Saddlebrooke). Civil liability protection for businesses including LTCs with regards to the spread of COVID-19. Passed.
The community’s concern for the 74,000 Arizona long-term residents in Arizona came from the state’s top executive, Arizona Governor Doug Ducey.
“Throughout this pandemic, we have focused on protecting those most at risk, especially our seniors and vulnerable adults,” said Governor Ducey when establishing the state’s Task Force on Long-Term Care in late July 2020. The Task Force remains active and convenes monthly to develop recommendations and benchmarks to reopen visitation in long-term care facilities. It hasn’t been easy.
Task force member and Arizona Representative Jennifer Longdon was paralyzed in a random shooting, making her a fierce advocate for disability rights and frequent defender of the adult disabled community. Longdon understands that the Arizona Ombudsman program is ‘valuable and vital.’”
“I think this is an important program and as an individual who has, by nature of my injuries, spent a great deal of time in a long-term care facility,” she explained. “I have the experience of dealing directly with the ombudsman.”
As part of the Task Force’s March 19 meeting minutes, one Arizona woman whose father is in a long-term care facility expressed the type of concern tailor-made for the Arizona LTC Ombudsman program because it addresses problems related to the health, safety, welfare, and rights of people who live in LTC facilities.
“I know several of the staff in his group home have chosen not to get the vaccine. I don’t understand why he would not be allowed to stay with me for a weekend since the staff does not have a vaccine, but we all do. This has been hard for all of the family and my father would like to see his son before he dies.”
Task Force Long-term Care Meeting
For years, the Arizona LTC Ombudsman program has taken grant funding from the Administration for Community Living (ACL), including $443,000 in 2019. The program also got a boost in funding last March from the Coronavirus Aid, Relief and Economic Security Act of 2020, doubling the program’s funding in FY 2021 to $772,500. The recently passed American Rescue Plan sweetens the pot by $200,000 through 2023.
The program also receives funding from the Arizona Area Agency on Aging. But its slice of almost $9 million from the state’s general fund earmarked for Aging and Adult Services remains a mystery, even to administrators responsible for managing the funds.
“I don’t know how it comes out in the state budget,” said Maddy Bynes, statewide coordinator for the agency, when asked how the $9 million was allocated. But Bynes nevertheless concludes that the Arizona Long-term Care Program needs more financial support because it’s “understaffed and has been before the pandemic and continues to be during the pandemic.”
Information about how the Arizona Department of Economic Security administers the $443,000 grant and what the Arizona Agency on Aging spends it on is unclear. Documents provided to The Hertel Report to account for quarterly grant spending include transactions with undefined recipients for 2017-2019 – a document dump that could be generously described as inscrutable. Review it Here
“There is no way to determine from these documents what the products were and/or what value was created,” said a former director of an Arizona non-profit boasting more than 3.5 million members. “If I were doing a program audit to determine the value of the program, these documents are almost worthless.”
Still, more funding may be on the way.
Arizona legislators, including Longdon, are throwing their support behind a bill that would provide an additional $1 million from the state budget to the Arizona Long-term Care Ombudsman program. The legislation, SB1512, passed in the Senate and as of March 29 was awaiting a House floor vote.
The legislation requires ombudsmen to visit every Arizona long-term care facility twice a year, without prior notice, to speak to each resident.
Despite the lack of financial detail in records kept by the Arizona Agency on Aging, Maddy Bynes, the agency’s statewide coordinator, contends the LTC Ombudsman Program is underfunded.
An average of 4,000 cases were reported annually to the Arizona Long Term-care Ombudsman program from 2008-2012, according to the National Ombudsman Reporting System (NORS). In 2019, NORS reported 1,719 cases for the state. For Fiscal Year 2020, Bynes told The Hertel Report 1,910 cases were resolved through the LTC Ombudsman Program; according to documents received a few hours before press time, DES reports 4,536 complaints were made to the program in FY2020.
Arizona’s neighbors have much more robust and transparent systems for their LTC Ombudsman public reporting. The Texas program publishes a quarterly report from the Health and Human Services Ombudsman Managed Care Assistance Team, as is required by state code. These reports include information about contacts made, complaint data, types of providers and insurers involved in the complaints, and other pertinent data. Colorado and Utah’s state codes also mandate detailed reporting, providing government agencies, legislators, taxpayers, and stakeholders with opportunities to exercise oversight.
Since The Hertel Report began its reporting on the Arizona Long-term Care Ombudsman Program in September, more than 1,200 more people in Maricopa and Pima County long-term care and skilled nursing facilities are dead, including vulnerable seniors who rely on the Ombudsman program. Even though elders residing in congregate settings are most threatened by COVID-19, vaccine hesitation among staff was 38% from mid-December to mid-January. Arizona’s testing and vaccine rollouts to long-term care residents was frustratingly slow as families eagerly waited to re-connect with their loved ones.
“During the summer months we advocated for the Long-Term Care Task Force to address concerns about visitation restrictions,” explained AARP Arizona State Director Dana Kennedy. “It also came to our attention that ombudsman were not going into facilities.”
AARP May 2020
Arizona’s Task Force on Long Term Care touted the success of the CDC Pharmacy Partnership Program, which brought private nurses and technicians to long-term-care facilities to administer vaccines. The CDC partnership includes competitors CVS and Walgreens, along with Managed Health Care Associates. Fewer than half of all Arizona long-term care facilities — about 1,500 — are enrolled, with 126,451 shots completed.
Colby Bower, assistant director of policy and intergovernmental affairs for the Arizona Department of Health Services (DHS), told the governor’s task force members that as of March 17 the pharmacy partnership program has administered vaccines in 1,500 Arizona skilled nursing and assisted living facilities enrolled in the program. Bower did not respond when asked by The Hertel Report about how the Task Force communicated with the 3,327 assisted-living facilities in Arizona about the partnership program.
Advocates of the Arizona LTC Ombudsman Program point to communication challenges within the Arizona assisted-living community as one reason that not all assisted-living facilities in Arizona participated in the pharmacy partnership program.
Non-profit associations like the Arizona Health Care Association and the Arizona Assisted Living Federation of America court the attention of lawmakers on behalf of skilled nursing and assisted living centers. These organizations do the political lifting for businesses with a lot on the line in times of public health uncertainty and rely on constant communication and feedback from their members. Smaller, home-based facilities will often require the help of membership organizations like these to ensure that their concerns are heard and their needs are met.
One owner of several assisted living homes in Maricopa County told The Hertel Report she never heard about the pharmacy partnership program. She also hasn’t seen an ombudsman since the pandemic began. Before the pandemic hit, monthly visits at all three homes were common, she said. As of last week, all 25 of her residents have received at least one shot, but only after months of waiting.
According to Dave Voepel, CEO of the Arizona Health Care Association, under the pharmacy program skilled nursing facilities (SNF) were first in line for vaccines through Jan. 18 and roughly three weeks later, assisted living facilities began to see their first shots in arms. In March, the CDC pharmacy partnership program completed its vaccination rounds to participating Arizona SNFs and assisted living facilities participating in the partnership program stands at 94%. Maricopa County enrolled 1,040 in its vaccination program roll-out to long-term care facilities.
After contacting nearly 20 SNFs and long-term care facilities in Maricopa and Pima County, large care facilities reported all residents were vaccinated, while 75% of smaller home-based facilities contacted by The Hertel Report were unfamiliar with the pharmacy partnership program and one home reported they had not started vaccinations.
“The Ombudsman is often the last resort for a vulnerable adult, said Rhonda Montgomery a long-time senior advocate with experience in Maricopa and Pima counties. “When no family or friends are willing to act on behalf of an individual, you go to the Ombudsman.”
For vulnerable adults in long-term care, assisted living and adult foster care homes, the Ombudsman program represents residents with concerns to access to services (such as vaccines) quality of life (visitor restrictions), quality of care (unvaccinated workforce) and other complaints.
From the Area Agency on Aging’s website:
According to the Administration for Community Living, the LTC Ombudsman program was established to promote policies and consumer protections. The OAA requires Ombudsman programs to “identify, investigate and resolve complaints made by or on behalf of residents” and to “ensure that residents have regular and timely access to ombudsman services.”
Bynes said local ombudsmen were facing challenges during the pandemic to overcome the additional pressure of scarce and expensive Personal Protection Equipment necessary to maintain safe access to long-term care facilities. Bynes contends the Long-term Care Task Force recommended ombudsman continue to access facilities even when community spread was substantial. “We’ve been going into facilities,” she said.
According to Mary Beals-Luedtka, Director of Northern Arizona Council of Governments, there’s, “so much more than just resolving cases when it comes to being an Ombudsman.”
“Ombudsman visit homes as often as they are able, building relationships with residents so when issues arise, the residents feel confident in the ombudsman and will reach out for assistance,” explained Bynes.
But Bynes’ characterization is at odds with the goals of the Older Americans Act, which requires Ombudsman programs to not just respond when called, but actively develop relationships with residents of assisted-living facilities. According to experts, a boots on the ground approach positions ombudsman to fulfill their mission to:
- Identify, investigate, and resolve complaints made by or on behalf of residents;
- Provide information to residents about LTSS;
- Ensure that residents have regular and timely access to ombudsman services
- Represent the interests of residents before governmental agencies and seek administrative, legal, and other remedies to protect residents; and
- Analyze, comment on, and recommend changes in laws and regulations pertaining to the health, safety, welfare, and rights of residents.
Arizona’s long-term care market is unique to the country, with the vast majority of care coming from 3,166 home-based, residential facilities verses only 161 skilled nursing facilities. It’s a community of caregivers that Dave Voepel, CEO of the Arizona Health Care Association knows well.
“In assisted living facilities, it’s a mixed group of folks with 10% from the skilled world, the other 90% are made up of folks from the Home and Community Based Settings, or HCBS world,” he explained.
HCBS is a generally-supported strategy to provide assisted services to Arizonans in home settings. Its advocates include the Centers for Medicare and Medicaid Services, the Arizona Health Care Cost Containment System and managed care organizations providing integrated healthcare services to almost 63,000 in the Arizona Long Term Care System (ALTCS).
Since January 2021, AHCCCS has kept its own tabs on non-skilled, in-home services, an area of rampant fraud, by implementing Electronic Visit Verification. A timekeeping system, EVV is used to verify when, where, by whom and for whom services are provided.
The technology has now evolved to include global positioning systems (GPS) and biometric visit data. Such digitized records of care are viewed widely as the most accurate way for states and managed care organizations to track the delivery of publicly funded healthcare services.
“In addition to meeting billing requirements, EVV is essential for ensuring the delivery of proper care,” said Lisa Ferden, co-founder and VP of Generations Homecare System.
Arizona’s Medicaid program uses EVV to help track and monitor in-home services, and to ensure they are provided on time to beneficiaries in its Arizona Long Term Care Program. The added bonus: it reduces administrative paperwork. The Arizona Long-term Care Ombudsman program, on the other hand, has nowhere near that level of accountability or transparency.
EVV Data Collection
EVV Data Collection
The EVV system must, at a minimum, electronically verify:
• Type of service performed
• Individual receiving the service
• Date of the service
• Location of service delivery
• Individual providing the service
• Time the service begins and ends
After an examination of public records , interviews with dozens of stakeholders and experts across the care continuum, the Arizona Long-term Care Program’s activities, finances and operations remain opaque, just as the program is set to receive another $200,000 in targeted pandemic relief along with a shot at another $1M from Arizona state coffers if SB1512 passes during the Arizona legislative session.
“Who is supporting our most vulnerable Arizonans?” asked Montgomery, who often played the role of an ombudsman to help local managed care organizations work with their ALTCS beneficiaries on any concerns, complaints, and even conflicts with care or management. “This is especially concerning during a global pandemic when even people with resources are struggling.”
Local LTC Ombudsman Sounds the Alarm
As Governor Ducey was prioritizing immediate testing of all Arizona’s long-term residents and staff and COVID-19 cases raged across the country, the first red flag about the role of long-term-care ombudsmen was raised from a Flagstaff LTC Ombudsman during an Arizona AARP Town Hall May 6. The discussion with U.S. Senator Kyrsten Sinema and other community health officials and stakeholders was designed as an informational session at a time when Arizona had reported 651 coronavirus deaths.
I’m a long-term care Ombudsman for Region 3, which is in Northern Arizona. I’d like to know if there’s any plan in place to address re-opening, visitation and lifting restrictions at long-term care facilities?
Are these facilities going to have specific standards in place during a phase of re-opening?” she asked. Will there be a soft reopening proposed? What will the role of the long-term care Ombudsman be during this?
These questions led to action by powerful stakeholders, including Arizona AARP, Senator Sinema and Governor Ducey, who wanted to ensure that families and facilities received streamlined information to help them make informed decision about reopening.
“That was the genesis of the task force,” Kennedy explained, “The Governor’s office reached out to me and said, ‘What do we need to do?’”
Voepel joined the task force early on to support the efforts to re-unite families and protect residents, recognizing the importance of communicating guidelines to facilities and community support organizations like the LTC Ombudsman Program. He’s also unclear how to follow the money to determine the program’s effectiveness.
“You have these taxpayer dollars going from the feds to the state and then to the Areas Agency on Aging and DES,” he explained, expressing concerns about the transparency of the LTC Ombudsman Program’s finances.
“What does a million dollars do?” he asked. “Is this a $20 million program and you’re adding $1 million to it? Or is this a $500,000 program and you’re adding a $1 million to it.”
The importance of the Arizona LTC Ombudsman program during the pandemic, a year of heartbreaking losses compounded by heightened fear and isolation for families of residents of long-term care facilities, isn’t lost on Kennedy.
Although she acknowledges the lockdown was necessary, Kennedy said she was concerned about families getting access to their loved ones and isolated residents having access to their number one advocate, the LTC Ombudsman. “If you’re going to lock down and lock people out, at least get their number one advocate. I mean when I was talking to families, if they suspected abuse or neglect the only number I could them to call was 911.”
In Arizona, very few long-term care residents can afford a private bed. Most payments to skilled nursing and assisted living facilities are publicly supported, with Medicaid covering 70% of stays and Medicare taking the remaining 30%.
My mom fell and broke her hip about 2 weeks ago. While in the hospital for surgery, my dad was allowed to be physically present in her room for several hours per day. Mom has memory issues (dementia) at times and having a familiar face helps to calm and stabilize her. She was moved to a rehab/nursing home last week.
This facility does not allow in-person visits nor do they allow someone to be a designated essential visitor. My dad has been forced to visit through a window for very short periods of time. She’s been there a week and we have not received an update on her medical care, prognosis, or rehabilitation. What good is the task force if facilities defy the recommendation to appoint a designated essential visitor and allow them to have generous visitation? We could really use some help.
Oct. 28 Task Force Public Comments
While Taylor and his family may still be waiting for assistance from someone, anyone, skilled and assisted-living facilities are seeking protection from liabilities related to pandemic deaths and illness, an understandable concern in a market segment suffering huge losses.
Arizona lawmakers are also bending over backwards to protect Arizona long-term care facilities. Legislation SB1377 protects businesses from civil liabilities related to spread of COVID-19 and was on its way to the Governor’s desk March 30.
On March 31, the Department of Economic Security finally provided a few summary details of the Arizona LTC program after seven months and dozens of interviews and requests.
State LTC Program Director Lisa Pollock declined multiple interview requests from The Hertel Report
Here’s what we know. There is no official report.
And Navajo County still doesn’t have a LTC ombudsmen.
This week an Arizona Ombudsman responded to a personal query made to the SENIOR HELP LINE on Saturday. She was kind, compassionate and helpful. She described, as so many others have, the importance of the Ombudsman program.
She was passionate about her work and the volunteers who share her commitment to safeguarding the wellbeing of vulnerable adults in Arizona assisted-living facilities. It was a personal call – It was short, it was sweet, and even a tad heroic.
But the question remains,
Where are all the Arizona Long-term Care Ombudsmen?
Published in honor of my 74-year-old beloved sister and Phoenix ALF resident.
She hasn’t hugged her family in more than a year and is still waiting for her second vaccine.
Correction: This post was corrected; original incorrectly identified Arizona Association of Area Agencies Statewide Coordinator Maddy Bynes as Maddy Burns. We apologize for the error.
Just hours before The Hertel Report closed the deadline on this investigative report, the Department of Economic Security provided us a few summary details on the Arizona LTC program to The Hertel Report. Arizona State LTC Ombudsman Director Lisa Pollock also declined multiple interview requests.
Information received from DES March 31, 2020 on the Arizona Long-term Care Ombudsman Program.
DES confirmed details about the Arizona LTC Ombudsman Program found at the The National Consumer Voice for Quality Long Term Care is basically correct, but noted a few corrections:
- Northern Arizona Council of Governments (NACOG): The new office is located at 3003 Centerpoint Drive E. Prescott, AZ 86301.
- The White Mountain Apache Tribe does not have a paid Ombudsman position at this time.
- Name correction: Navajo Nation-Division of Aging and Long-Term Care Support.
Leadership in Aging & Community Living
Official Statements from DES Received March 31
Ombudsmen across the country slowly began re-entering facilities without COVID-19 cases in late summer. Arizona resumed in-person visitation on September 1, 2020, and Arizona Department of Health Services visitation guidance published in October 2020 specifically stated that the Ombudsman Program was to be allowed to visit in person across all levels of COVID-19 community spread.
Utilizing the confidential Ombudsman database system, Ombudsmen continued to record items such as routine visits, inquiries and progress on cases.
From January 2020 to January 2021, the Long-Term Care Ombudsman Program (LTCOP) received 4,536 inquiries. As was common before the pandemic the most common issue faced by long-term care residents continued to be involuntary discharge.
State Comparison LTC Ombudsman
Arizona vs. South Carolina
• 7+ million population
• 7 ombudsman entities
• OAA Grant funding $392,265
• State funding $845,168
• Total Facilities 2,291
• Facilities Visited Quarterly 726
• 5+ million population
• 10 ombudsman entities
• OAA Grant funding $162,673
• State funding $688,599
• Total Facilities 760
• Facilities Visited Quarterly 696
DES also said the Long-term Care Ombudsman Program has always had access to residents and following CMS guidance, access was mainly in a virtual capacity, primarily through phone contact and virtual communication through Skype or Facetime along with window visits, where available.