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Specialized Information for:
Nursing HomesAssisted Living/Board & Care Home and Community Based Services
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Specialized Information for:
Nursing HomesAssisted Living/Board & Care Home and Community Based Services
This page contains answers to frequently asked questions regarding the revised National Ombudsman Reporting System (NORS) - effective October 1, 2019. The answers were developed with input from members of the Workgroup to Improve NORS Consistency (WINC) and in coordination with the Administration on Aging/Administration for Community Living (click on “Answer” to read the answer to the question). View these FAQs in a PDF here.
Throughout these frequently asked questions, (FAQs) “Ombudsman” is used as a generic term that may mean the state Ombudsman, a representative of the Office, or the Ombudsman program.
If you have questions to suggest for additional FAQs, please email ombudcenter@theconsumervoice.org.
Abuse, Neglect, and Exploitation
Q - Does the Ombudsman program investigate complaints alleging abuse, neglect, or exploitation?
A - Yes, the Ombudsman program investigates complaints or concerns including abuse, neglect, or exploitation. Per 45 CFR 1324.19 (b)(1) … The Ombudsman or representative of the Office shall investigate a complaint, including but not limited to a complaint related to abuse, neglect, or exploitation, for the purposes of resolving the complaint to the resident's satisfaction and of protecting the health, welfare, and rights of the resident. The Ombudsman or representative of the Office may identify, investigate and resolve a complaint impacting multiple residents or all residents of a facility.
The Ombudsman program investigates these complaints in accordance with program policies and procedures, which address obtaining consent to take action, consent to disclose, and actions to take when a resident is unable to communicate informed consent.
The Ombudsman program investigates solely for gathering necessary information to resolve the complaint to the satisfaction of the resident, not to determine whether any law or regulation has been violated for purposes of a potential civil or criminal enforcement action. If the Ombudsman program receives a referral from Adult Protective Services, licensing agency, or law enforcement, the Ombudsman should visit with the resident to determine if the resident wants the Ombudsman’s assistance and if they do want help then establish an open case. See quiz questions 6 and 7, NORS Training Part I Case, Complaint, Complainant, and Information and Assistance Quiz Answer Sheet as examples.
Ombudsmen should use their best judgement in coding a complaint based on knowledge obtained from the complainant and/or resident, and their fact-finding. For example, at times it will be difficult to distinguish if a complaint such as “rough handling by staff” is willful mistreatment of a resident (A01 physical abuse) or a staffing issue (J03 Staffing) or possibly two complaints (A01 and J03).
For additional information about the Ombudsman program role in investigating allegations of abuse, visit the NORC Abuse, Neglect, and Exploitation in Long-Term Care Facilities issue page and review the Responding to Allegations of Abuse: Role and Responsibilities of the Long-Term Care Ombudsman Program LTCOP Reference Guide.
Q - Why is there a perpetrator code for abuse, neglect, or exploitation complaints?
A - The perpetrator code was added to NORS to assist ACL and Ombudsman programs in understanding who is most commonly suspected of causing abuse, neglect, or exploitation in long-term care facilities and to better analyze NORS data. This also reduced duplicate complaint codes, which had caused coding confusion.
A perpetrator is a person or persons who appear to have caused the abuse, neglect or exploitation. The codes include CD-05 – 01 Facility Staff, 02 Another Resident, 03 Family, Resident Representative, Friend, and 99 Other. The Perpetrator data codes are only used for Abuse, Gross Neglect, and Exploitation complaints A01 to A05. There may be multiple perpetrators for each complaint (see the Administration for Community Living (ACL) NORS Table 1 Part A, B, and C- Case and complaint codes, values, and definitions and Table 2 Complaint Codes and Definitions for more information, available here).
While the perpetrator code does not include “alleged” perpetrator in the label, the definition does state “person(s) who appears to have caused the abuse or neglect or exploitation.”
NORS does not require states to report personally identifiable data on complainants, residents or perpetrators.
Q - When there are multiple people involved with one complaint how do we choose the complainant? For example, a daughter calls the Ombudsman program with a complaint. The Ombudsman visits with the resident and the resident shares her daughter’s concerns and gives the Ombudsman permission to investigate the complaint.
A - The daughter (representative, friend, or family) is the complainant.
The definition of a complainant is an individual who requests Ombudsman program complaint investigation services regarding one or more complaints made by, or on behalf of, residents.
NORS allows for only one complainant per case. Establish the complainant in a case record as the first person who makes a concern known and requests assistance to resolve the complaint.3 The initial complainant in the case would not change during the investigation. For example, in quiz question 12 of the Part I Case, Complaint, Complainant, and Information and Assistance Quiz Answer Sheet the first complainant is the daughter recorded in NORS as complainant code 02 for resident representative, friend, or family.
3See the FAQ regarding the Ombudsman as the complainant as an exception.
Q - When should the Ombudsman program be the complainant?
A - The Ombudsman program may be the complainant in a variety of circumstances. The most common examples include general observations about the facility environment that need attention; this may include circumstances where residents agree with the problem and want it addressed but do not want to be the complainant of record. The Ombudsman program may be the complainant when a resident needs assistance but is unable to communicate informed consent and has no resident representative available.
See quiz question #8 in the Part I Case, Complaint, Complainant, and Information and Assistance Quiz Answer Sheet for additional information.
The Ombudsman program rule at 1324.19(b) (1)&(2) encourages resident participation regardless of the complainant and affirms that the Ombudsman program can be the complainant.
(1) With respect to identifying, investigating and resolving complaints, and regardless of the source of the complaint (i.e. complainant), the Ombudsman and the representatives of the Office serve the resident of a long-term care facility. The Ombudsman or representative of the Office shall investigate a complaint, including but not limited to a complaint related to abuse, neglect, or exploitation, for the purposes of resolving the complaint to the resident's satisfaction and of protecting the health, welfare, and rights of the resident. The Ombudsman or representative of the Office may identify, investigate and resolve a complaint impacting multiple residents or all residents of a facility.
(2) Regardless of the source of the complaint (i.e. the complainant), including when the source is the Ombudsman or representative of the Office, the Ombudsman or representative of the Office must support and maximize resident participation in the process of resolving the complaint.
It is typical for the Ombudsman to educate a resident about their rights and share an observation about the individual resident’s health, safety or welfare. This discussion may result in the resident requesting Ombudsman assistance to resolve the complaint. In this example, the process of educating the resident encouraged the resident to request assistance; therefore, the resident is the complainant.
See quiz question #10 in the Part I Case, Complaint, Complainant, and Information and Assistance Quiz Answer Sheet for additional information.
Q - When do you assign complaint codes? For example, if a family member contacts your office with a concern and requests action or do you code it after you have spoken with the resident and received their consent to investigate the issue?
A - Assign complaint code(s) upon receipt of the complaint based on the problem or problems identified by the complainant.
NORS does not provide specific guidance and states may have policies and procedures in place that direct the representatives of the Office as to when to code complaints. However, it is important to take the information from the complainant and identify both the initial complainant, their complaint and any direction to resolve the problem. If the complainant is not the resident, the direction may change based on the perspective of the resident.
For example, if a family member contacts your office with a complaint, the family member is the complainant and you would assign complaint codes immediately based on the concerns shared by the family member. When you visit the resident for consent to take further action, if the resident agrees with those concerns, gives you consent, and shares additional concerns then you can open another case with the resident as the complainant and include complaint codes for the resident’s additional concerns.
Conversely, if the resident does not agree with the family member and asks you not to proceed, you would close the case as withdrawn or no action needed. The program still had a complaint, and it might be legitimate, but to honor the resident’s direction did not act.
Q - When a complainant has two complaints/issues that would fall under the same code do I only record the code once?
A - Record one complaint and work to resolve all issues raised. If a complainant has two complaints that are under one code, such as code I05 Housekeeping, Laundry and Pest Abatement, the Ombudsman will open the with one complaint code (I05 in this example). Refer to NORS Training Part II, Beyond the Basics Quiz and Answer Sheet directions that states “use only one complainant per case and only one complaint code for each complaint.”
Q - If there is a case where the complaint could be documented under two different codes, do I choose one code?
A - Yes, choose one code. Use your best judgement in determining which complaint code to use if there are two very similar codes that describe the complaint. If there are multiple, distinct complaints, identify codes for each complaint.
Q - When is it appropriate to add another complaint to an existing case or establish a new case?
A - Refer to applicable state-specific Ombudsman program policies and procedures and/or State Ombudsman discretion. Your state may have a policy with criteria for when to open and close cases and when to consider adding more complaints in the “open” case. Use your best judgement if there is no policy. For example, if the case is open, the complainant is the same and casework is on-going, then add the new complaint to the current case. If the case was closed and the complainant has a new complaint, then open a new case.
Q - How do I determine the disposition code if the resident dies during the investigation?
A - The Ombudsman program regulation at 1324.19 provides guidance of how to determine complaint disposition in the following order. Communication from:
(1) the resident;
(2) the resident representative – 1324.19(b)(5) the Ombudsman or representative of the Office may rely on the communication of informed consent and/or perspective regarding the resolution of the complaint of a resident representative so long as the Ombudsman or representative of the Office has no reasonable cause to believe that the resident representative is not acting in the best interests of the resident.
(3) The Ombudsman program - 1324.19(b) (2) (iii) Where the resident is unable to communicate informed consent, and has no resident representative, the Ombudsman or representative of the Office shall: (A) Take appropriate steps to investigate and work to resolve the complaint in order to protect the health, safety, welfare and rights of the resident; and (B) Determine whether the complaint was resolved to the satisfaction of the complainant.
The Ombudsman program regulation above and examples below provide direction about how to determine disposition when a resident dies before the conclusion of the investigation.
Examples
The complainant is the resident. The resident died before all the complaints were resolved. The Ombudsman will need determine disposition based on the circumstances of the complaint or information from a resident representative. See questions #9 and #11 in the Part III Verification, Disposition, Referral, and Closing the Case Quiz Answer Sheet for more information.
The complainant is a family member. The Ombudsman visits the resident and the resident is unable to communicate. The Ombudsman investigates, helps resolve some issues, and then the resident died. The Ombudsman took direction from the complainant because the resident was unable to communicate. The disposition of the case is chosen based on the family member’s (complainant) satisfaction. The case is then closed. See question 11 in the Part III Verification, Disposition, Referral, and Closing the Case Quiz Answer Sheet for more information.
Q - A resident asks an Ombudsman for help and provides consent to investigate. After the Ombudsman shares information about residents’ rights and the facility’s responsibilities, she decides to use the information you provided to address her concerns on her own and doesn’t want Ombudsman program assistance. Is it a case or information and assistance?
Answer
A - It is an instance of information and assistance. In this scenario, the resident asks for help and you were able to provide information without beginning an investigation.
Q - When do you open a case?
A - Open a case as soon as possible after the complainant communicates the complaint and asks for Ombudsman assistance to resolve the complaint.1
As defined in the revised NORS, the definition of a complaint is, “an expression of dissatisfaction or concern brought to, or initiated by, the Ombudsman program which requires Ombudsman program investigation and resolution on behalf of one or more residents of a long-term care facility” (defined in NORS Tables 1 and 2).
NORS data collection requires case open and close dates but does not specify policy and procedures for timelines. Your State LTCOP may provide policy and procedure for documenting receipt of a complaint, resident visitation, and preferred timeline for opening a case.
NORS allows for only one complainant per case. Establish the complainant in a case record as the first person who makes a concern known. The initial complainant in the case would not change during the investigation.
1 State LTCOP policy may specify timeframes for when a case should be opened and documented in the electronic reporting system.
Q - When do you close a case?
Answer
A - Close the case when the investigation is complete.2 Completion includes documentation of complaint verification status, a referral code, and disposition code for each complaint in the case and closure dates for all complaints within the case. See NORS Training Part III Verification, Disposition, Referral, and Closing the Case Basic Principles and Quiz for more information.
2 State LTCOP policy may specify timeframes for supervisory review of cases prior to closure and timeframes for when to close a case and documentation in the electronic reporting system.
Q - You have the resident’s permission to investigate a complaint and started to investigate, then the resident changed their mind doesn’t want you to continue the investigation and resolution activities.
Is it still a case?
A - It is a case. In this scenario, the resident has requested assistance and then changed their mind and asked the Ombudsman to stop the investigation. This is still a case with a complaint disposition code of 02 – “Withdrawn or no action needed by the resident, resident representative or complainant.”
The amount of time spent on a case/complaint does not affect whether it is a case/complaint. A complaint requires Ombudsman action towards resolution, which is different from just providing information and assistance. Despite closing the case as “withdrawn/no action needed,” you were following resident direction, as the Ombudsman program is required.
Q - The program receives a complaint from someone other than the resident, upon an initial investigation the Ombudsman speaks with the resident who does not agree with the complaints and does not want assistance from the program. Is this a case?
A - Yes, this is a case. The complainant identified a problem that affects the health, safety, welfare or rights of one or more resident and requested the Ombudsman program to take action to resolve the identified problem. However, the Ombudsman program is to determine the perspective of the resident and take direction from the resident.
The resident communicated to the Ombudsman that they do not share the same concerns of the complainant and/or do not wish for you to pursue an investigation, so the case is closed. The complaint disposition code would be 02 - “Withdrawn or no action needed by the resident, resident representative or complainant.”
Even though it was withdrawn, it helps to build a picture of possible issues at the facility. Also, it is important to consider the first person that contacted the program with a complaint as the complainant because the Administration for Community Living (ACL) wants to analyze complaints and their dispositions based on the complainant.
If the resident is unable to communicate and provide guidance to the Ombudsman, the Ombudsman should investigate based on the complaint received from the complainant, following the program’s complaint investigation protocols.
Q - When a nursing facility sends the Ombudsman program copies of resident discharge notices, should the program open a case at the time of receipt of the notice?
A - No. The nursing facility is not asking the program to establish a case and investigate. Therefore, at the point of receipt of the notice there is no complainant for which to establish a case. The nursing facilities are meeting a federal requirement by sending copies of the notices to the Ombudsman program.
Skilled nursing facilities are required by the Centers for Medicare and Medicare Services (CMS) regulation, F622 (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) §483.15(c) Transfer and discharge- §483.15(c)(1) Facility requirements, to inform the resident, resident representative, and the Ombudsman program of resident discharge notices (see CMS S&C 17-27-NH for more information).
As a reminder, a case is comprised of a complainant; one or more complaints; documentation of a perpetrator for cases involving abuse, gross neglect, and exploitation; a setting; verification; resolution; and any referrals to another agency. A complaint is “an expression of dissatisfaction or concern brought to, or initiated by, the Ombudsman program which requires Ombudsman program investigation and resolution on behalf of one or more residents of a long-term care facility.”
In this situation, the Ombudsman program is not yet actively involved in investigating and working to resolve the discharges and no one has asked them to on behalf of a resident. Rather, the nursing facilities are sending the notices as part of routine compliance with one of their requirements.
The Training Tips for question #4 of the NORS Training Part I Case, Complaint, Complainant, and Information and Assistance Quiz Answer Sheet that addresses this situation are:
Q - For referral agency codes, how do I code referrals to the Office of Inspector General, Attorney General, and State Attorney or professional boards such as the Board of Nursing?
A - Use referral code 03, “law enforcement or prosecutor” for Office of Inspector General, Attorney General, and State Attorney.
Use referral code 01, “licensing, regulatory, or certification agency” for professional boards of licensing.
NORS Table 1, Referral Agency Codes are:
01 Licensing, regulatory, or certification agency
02 Adult protective services
03 Law enforcement or prosecutor
04 Protection and advocacy
05 Legal services
06 No referral was made
99 Other
Q - How do I count participation in facility surveys?
Answer
A - Report each distinct type of survey activity as one instance by facility type. You may have more than one survey participation activity associated with one survey in one facility. Refer to NORS Training Part IV Ombudsman Program Activities Basic Principles and quiz questions #14 and #15 for more information.
Review descriptions, examples, and reporting tips for reporting survey participation in the NORS Table III State Program Information, codes S62, and S63. The table states, “include participation in both standard surveys and complaint surveys. Survey participation includes but is not limited to pre-survey information to surveyors, sharing complaint summary reports, participation in exit conferences and informal dispute resolution.”
Q - Does reading a survey count as participation in a facility survey?
A - No, reading a survey does not count as participation in facility surveys. NORS does not ask that you report all activities and reading a survey, while important, is not reported in NORS. However, your state data system and policy may require that you collect additional activities not reported in NORS.
Q - What is the definition for verified? If the resident confirms the complaint, does that mean it is verified?
A - Per the NORS Table 1: Part A, B, and C – Case and complaint codes, values, and definitions the definition of verified is, “a confirmation that most or all facts alleged by the complainant are likely to be true.”
Review the NORS Training, Part III Complaint Verification, Coding Dispositions, Referrals, and Closing a Complaint and a Case for additional information about verification. When determining verification of complaints consider the following:
a) Your interview with the complainant or resident,
b) Your observations,
c) Assuming you have consent to disclose, facts can be gathered from interviews of staff or others in the know,
d) Review of records or other documents.
The who, what, when, where, why, and how of an investigation will help you determine whether the complaint is verified (i.e. likely to be true). For additional information on complaint investigation, see Module 4- The Problem Solving Process of the NORC Curriculum.
Q - If I visit a facility in response to a complaint, but I also visit with other residents and share information about the Ombudsman program, do I document this visit as a complaint visit or routine access visit (non-complaint visit)?
Answer
A - To determine whether to report your visit as a complaint visit or routine access visit focus on the activities you conducted during the visit rather than the initial reason for the visit and any program requirements.
Although the original reason for visiting the facility was to follow-up on a complaint, if you conduct activities that constitute a routine access visit (e.g., visit with multiple residents, share information about the Ombudsman program, walk around and observe activities in the facility) you may document this as a routine visit.
If you visited the facility in response to the complaint and only conducted activities related to the complaint investigation, then you would document the visit as a complaint visit.
Most importantly, document all your visits.
For additional information refer to the NORS Training Part IV – Ombudsman Program Activities and ACL Table 3 State Program Information for the definition of “routine access” and state reporting requirements for visits, available here.