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Nursing HomesAssisted Living/Board & Care Home and Community Based Services

NORS Frequently Asked Questions (FAQs) - NEW

This page contains answers to frequently asked questions regarding the coding and recording of Ombudsman activities. The questions are categorized by the NORS Ombudsman Activities to which they pertain. The answers were developed with input from the Administration on Aging/Administration for Community Living (click on “Answer” to read the answer to the question).

For more information on the NORS and the Ombudsman Activities, view Part IV: Ombudsman Activities of the NORS training and the Instructions for Completing the State Long Term Care Ombudsman Program Reporting Form for The National Ombudsman Reporting System (NORS).

To submit a question, please email ombudcenter@theconsumervoice.org.

Reminder! The work that Long-Term Care Ombudsmen do is extremely valuable to residents, their families, facility staff and the community at large.  Note that the activities reported to the Administration on Aging through the National Ombudsman Reporting System (NORS) must fall within the twelve categories listed below - not all activities that Ombudsmen conduct are reported. Also, states may have additional reporting requirements for state purposes; follow guidance from your State Long-Term Care Ombudsman for state-specific reporting.

NORS Activity Coding Questions and Answers


Topic areas:

 

Training for LTCO Staff and Volunteers


Q - How do we code staff development and/or in-services attended by ombudsman volunteers and staff?

Answer

A - If ombudsmen provided or otherwise arranged for the training, then it would be counted in NORS as training for ombudsman staff and volunteers.  If staff where required to attend an agency in-service, it would not be a NORS activity because it was not arranged for or provided by an ombudsman.

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Technical Assistance to LTCO staff and/or Volunteers


Q - We understand that Technical Assistance to Ombudsmen and Volunteers is a percentage.  Our question is, "What can be included as technical assistance to ombudsman and volunteers?"

For example: There are five Regional Ombudsmen planning a community education event.  Each Ombudsman is responsible for certain parts of the event and spends hours preparing.  Only one Ombudsman counts the Community Education event, since it is one event.  Can the four other ombudsmen count this as a “Technical Assistance to Ombudsman” counting their time spent preparing & conducting the Community Education event? This event does not involve developing and delivering training specifically for Ombudsmen or Volunteers, (but volunteers may be in attendance).

Answer

A - The time spent by the four staff ombudsmen would not be countable towards technical assistance because it is not training designed for ombudsmen. The training is a community education event and is counted once by one ombudsman.  Examples of technical assistance can include assisting volunteers with complex case resolution; volunteer/ombudsman training; introducing to a facility, etc.

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Training for Facility Staff


To submit a question, please email ombudcenter@theconsumervoice.org.

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Consultation to Facilities


To submit a question, please email ombudcenter@theconsumervoice.org.

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Information & Consultation to Individuals


To submit a question, please email ombudcenter@theconsumervoice.org.

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Facility Coverage


NEW

Q - Is the Ombudsman program required to visit nursing homes and board and care facilities quarterly?

Answer

 

A - No, the Administration for Community Living/Administration on Aging (ACL/AOA)  does not require quarterly visits. ACL/AoA provides a definition in NORS on what is considered “regular basis” for purposes of measuring routine access provided to long-term care residents. States may choose to set their own requirements regarding routine visits. The Instructions for the National Ombudsman Reporting System (NORS) require the submission of data on Facility Coverage. Facility coverage is defined in the current instructions.

Document the number of facilities (unduplicated count) covered on a regular basis, not in response to a complaint, by paid and volunteer Ombudsmen. Regular basis means no less frequently than quarterly.  Note that the information requested is the unduplicated number of facilities visited, not the number of visits. If there is no visitation program, type N.A. (p. 10)

  • Louise Ryan, Ombudsman Program Specialist, ACL/AoA, issued a clarification of the definition of facility coverage for NORS reporting.

After reviewing the history and completing an internal AoA review, it was determined that the NORS “facility coverage” instruction of “no less frequently than quarterly” is best interpreted as, at a minimum, one visit per calendar quarter. August 10, 2011

Facility Coverage Guidance 2011

  • The LTCOP Rule states that residents are to have access to ombudsman services. In the comments and responses, additional clarification from ACL/AoA is included regarding the purpose and frequency of access.

§1324.13  Functions and Responsibilities of the State Long-Term Care Ombudsman

(4) Ensure that residents have regular and timely access to the services provided through the Ombudsman program and that residents and complainants receive timely responses from representatives of the Office to requests for information and complaints;

Response: Currently there is wide variation among States’ Ombudsman programs in providing ‘‘regular visits.’’… Some Ombudsman programs have minimum standards related to frequency of these visits that are responsive to the variables in that State. We strongly encourage development of minimum standards to provide consumers, providers, and others with an expectation of the frequency of regular visits. We note that standards also provide an important mechanism for Ombudsman program accountability. …

We also encourage Ombudsman programs and States to consider, in developing minimum standards, that providing ‘‘regular access’’ requires more than providing visits to facilities by representatives of the Office. Ombudsman programs should be easily accessible to residents, complainants, and others—including individuals with limited English proficiency—because, among other things, they have multiple methods of communication available to the public (such as telephone, email, facsimile, Web site, TTY (text telephone) and other communication services, and mail, as well as in-person visits).

LTCOP Final Regulations Chart with Preamble

 

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Participation in Facility Surveys


Q - How should we report Independent Informal Dispute Resolution (IIDR) activity?  It is not really the survey but it’s related to a survey.  Being as states have differing IIDR processes, but each IIDR has an explicit role for the ombudsman, should all ombudsmen across states report their involvement uniformly?

Answer

A - IIDR’s occur when the facility wishes to dispute a citation issued during a survey or complaint investigation.  Ombudsman participation in IIDRs may or may not be a countable activity depending on the specific facts.  For example, if an ombudsman has already documented a survey activity at the facility in the reporting year, then he or she cannot count it as a survey activity again.  If working on an IIDR in coordination with a resident or other complainant, an ombudsman may report the work as either a consultation or a case, in accordance with NORS complaint and consultation instructions.

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Work with Resident Councils


To submit a question, please email ombudcenter@theconsumervoice.org

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Work with Family Councils


To submit a question, please email ombudcenter@theconsumervoice.org.

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Community Education


Q - We have an ombudsman program that is very active in updating its Facebook page with articles, legislation and other tidbits related to long-term care issues.   I've looked at the current annotated activity chart Instructions, and it doesn't look like these activities can be counted as Community Education.  Do these activities fall under a reportable category, or is it just lost time?

Answer

A - No, it does not fit under a current reportable activity. The current NORS definitions were developed before the rise of social media; however, if your program finds that this is a valuable way to share information, then it should not be considered “lost time."

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Q - Do Community Education sessions have to be conducted by a certified ombudsman in order to count for NORS?  For instance, if an agency that houses the LTCOP also houses a domestic violence shelter and an APS program, can we count it if the PR/Marketing person for the agency attends a health fair and hands out brochures on the LTCOP? 

Answer

A - NORS does not capture the activities of a host agency, only certified ombudsmen.  NORS “Other Ombudsman Activities” instructions state that programs report activities performed by the state office of the State Long-term Care Ombudsman or by designated local or regional ombudsman programs, or individuals designated by the state ombudsman. Non-certified or non-designated staff activities should not be reported in NORS.

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Q - In the past we think we have entered into NORS the number of attendees at an ombudsman community education event.  For example, we would talk to a group of Certified Nursing Assistant (CNA) students about the Ombudsman program, and would enter community education (as if it was a training) with a training topic and the number of attendees.  Is this correct?

Answer

A - No. The 2012 NORS report neither collects the number of attendees nor the topic in the community education activity category.  However, your state may have state level requirements to enter additional information.

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Work with Media


Q - We work with the local Pioneer Coalition.  As part of this collaboration, ombudsmen call all facilities and take notices about quarterly trainings when they visit the facility.  What activity type should be used to document phone calls to facilities informing them of upcoming Culture Change seminars?  Would work with media or monitoring/work on laws, regulations, government policies be an appropriate code?

Answer

A - The described activity does not meet the NORS definition of work with media or monitoring/work on laws, regulations, government policies and actions.

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Q - Would the above described activity meet the NORS definition of working with media or monitoring/work on laws, regulations, government policies and actions if it involved coding attendance at or participation in the Culture Change meeting or event?

Answer

A - Yes.  If an ombudsman participates in the event by presenting information to an audience, it may be countable as community education, or staff training depending on the audience.  Alternatively, if an ombudsman participates in a group that advocates for policy change, time spent researching, educating policy makers and/or influencing policy can be counted towards the estimated percentage of time spent on monitoring/work on laws.

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Q - Can we count Ombudsman articles in the AAA newsletters or Senior Center newsletters as media?

Answer

A - No, this activity is not “work with media."  NORS asks to provide the three most frequent topics discussed with the media, the number of interviews/discussions and the number of press releases at both state and local levels.  Writing an article for a newsletter falls into the category of public relations which is not an activity currently collected by NORS. 

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Monitoring/Work on Laws, Regulations, Policies and Actions


- We sent a letter to all of the mayors that have a long-term care facility in their community asking them to sign and return a proclamation for residents' rights event.  We then took copies of the proclamation to each facility during the resident council meetings. We also created news release to acknowledge mayors who have returned a signed proclamation.

We know the visits to resident council meetings should be recorded in the category of Resident Council Meetings. We know that the news release should be recorded as Work with Media.

Should the time spent contacting the mayors be considered Monitoring/Work on Laws, Regulations, Government Policies and Actions (including informing mayors of Residents' Rights Month, and asking them to sign a proclamation)?

Answer

A - No. The time spent contacting and coordinating the mayors' approval of a proclamation is not a NORS reportable activity. However, this is an excellent example of promoting residents' rights and the role of the ombudsman. 

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NEW

Q - How should we report Ombudsman program participation in meetings where the purpose is to build relationships that would support advocacy down the road?  For example, a community meeting where participants talk about roles and responsibilities of various agencies – maybe around abuse or discharge planning? 

Answer

A - The best fit is Monitoring/work on laws, regulations, government policies and actions which instructs: Provide, for both state and local levels, a best estimate of the percentage of total paid staff time spent working with other agencies and individuals, both inside and outside of government, on laws, regulations, policies and actions to improve the health, welfare, safety and rights of long-term care residents.  

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