The 2.3 million elderly or disabled people living in nursing homes or assisted-living centers might not know it, but they've got an advocate, someone who's supposed to look out for their health, safety and rights.
But some of those watchdogs face threats to their independence.
In 2011, state long-term care ombudsmen -- assisted by hundreds of local ombudsmen programs and thousands of volunteers -- responded to 204,000 complaints nationwide. They ranged from roommate conflicts to lack of privacy to allegations of abuse or neglect. State ombudsmen also are expected to testify before the legislature, talk to the media and take a public stance on long-term care issues, without interference by government officials.
But that's not always the case. While ombudsmen in some states maintain their autonomy, in other states, conflicts have erupted, and government officials have been accused of trying to muzzle ombudsmen, especially when they publicly disagree with state policies or battle industry officials.
Among recent controversies:
In Florida, the state ombudsman -- for years considered a thorn in the long-term care industry's side -- was ousted in 2011 under orders from newly elected Gov. Rick Scott. That prompted a legislative hearing and a federal investigation, which found that the action "raised troubling concerns" and that Florida had violated the spirit of the Older Americans Act, which created the ombudsman program.
In Iowa, the state Department on Aging's director resigned in 2010 amid allegations that the administration had tried to thwart the state's ombudsman.
In California, local ombudsmen campaigned to strengthen the state ombudsman's independence, arguing that he wasn't able to take positions on issues that clashed with state officials. In 2012, the Legislature enacted a bill that beefs up the ombudsman's independence.
"Ombudsman independence has been a longstanding hot-button issue in a number of areas, both at the state and local level," says Lori Smetanka, director of the National Long-Term Care Ombudsman Resource Center, which provides support and training to ombudsmen. Smetanka says she and her staff regularly hear from ombudsmen who say their ability to speak out is being challenged or limited. "It's a sensitive topic, because some of these ombudsmen are worried about being fired or reprimanded."
Lending a helping hand
The $87 million-a-year ombudsman program dates to 1972 and today operates in every state, the District of Columbia, Puerto Rico and Guam. It includes 576 local ombudsmen programs, serving all long-term care residents. The program, funded mostly by the federal government and states, has 1,185 paid staffers and 9,065 trained volunteers nationwide.
Ombudsmen can't impose sanctions or levy fines, but the law requires them to investigate complaints and advocate for improvements to the long-term care system. They usually refer serious violations to state licensing officials.
Among the most frequent complaints they investigate: improper discharge or eviction; lack of respect from staff; poor-quality food; and medication problems.
In Maryland, an ombudsman assisted a nursing home resident, 68, with Parkinson's disease in getting her wheelchair repaired; it had been broken for months. In Oregon, an ombudsman helped a veteran, 95, in a nursing home get a refund after he was scammed by a telemarketer. In Michigan, an ombudsman helped a woman, 49, with multiple sclerosis transition out of a nursing home to an apartment after a legal battle to remove her guardian.
For Bob Jones, 84, having an ombudsman was "a great relief." The former chef wanted to leave his Walla Walla, Wash., nursing home. Jones, a stroke victim with mild dementia and pulmonary disease, was depressed, and had lost 47 pounds. Volunteer ombudsman Carolyn Mosebar, 78, a retired nurse, helped Jones move to a family care home owned by a couple he knew.
"Carolyn was an advocate, and she was a darn good one. She got my confidence back. By being there, she gave me hope," says Jones, who also worked as a stuntman in Hollywood and used to fish with Roy Rogers.
Differing programs in states
While local ombudsmen have the freedom to help individuals, it's a slipperier slope when it comes to state ombudsmen advocating publicly on long-term care issues.
Part of the controversy revolves around how states have structured ombudsmen programs. Most are part of state government, which some experts argue can undermine their independence. But many ombudsmen say that the state's culture is more important than the program's location.
"For some states, it has been an awkward fit. We're actively working with a number of them so they don't have the situation in which ombudsmen would be muzzled," says Becky Kurtz, director of the federal Office of Long-Term Care Ombudsman Programs, which administers the program.
Brian Lee was Florida's state ombudsman for almost eight years until he was forced to resign. "The nursing home industry and the adult care industry hated me. I was very outspoken," says Lee, now executive director of Families for Better Care, a Tallahassee-based advocacy group.
In January 2011, everything came to a head when Lee asked nursing homes to provide him detailed corporate ownership information, citing a provision in the Affordable Care Act. Less than two weeks later, the governor's office told state officials that it was time for Lee to go.
Florida officials maintained that Lee's departure was part of the normal turnover that occurs with a change of administration. They said the governor's office wanted the ombudsman program to "go in a new direction," according to an investigative report by the federal Administration on Aging.
Four days after Lee was ousted, the state retracted the request for corporate ownership information.
Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a non-profit, non-partisan health policy research and communication organization not affiliated with Kaiser Permanente.
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