NORS Frequently Asked Questions (FAQs)

A - No. Receiving a copy of alleged abuse or incident report does not automatically count as a complaint. Examples include, but are not limited to, a state requiring long-term care facilities to send copies of incident reports to the Ombudsman program and/or a state requiring Adult Protective Services (APS) to send copies of their reports or referrals to the Ombudsman program.

In these examples, the facilities and/or APS are complying with a state requirement to send copies of these reports to your program. They are not acting as a complainant and reporting a complaint on behalf of a resident seeking Ombudsman program assistance, rather they are sharing information with your program per state requirements. 

As the head of the Office of the State Long-Term Care Ombudsman, the State Long-Term Care Ombudsman (Ombudsman) is responsible for developing policies and procedures for the statewide program. 

The State Long-Term Care Ombudsman Programs Final Rule (Final Rule) contains provisions related to complaint processing responsibilities, including developing policies and procedures that establish “standards to assure prompt response to complaints by the Office and/or local Ombudsman entities which prioritize abuse, neglect, exploitation and time-sensitive complaints.” The Final Rule states when establishing standards to consider the severity of the risk to the resident, the imminence of the threat of harm to the resident, and the opportunity for mitigating harm to the resident by providing services of the Ombudsman program in response to a complaint [§1324.11 (e)(1)(v)]. 

Therefore, the Ombudsman determines program priorities and how and when to respond to these reports. 

If your program responds to facility incident reports or APS reports, to ensure your work is resident-directed, do not determine how to document your work related to the incident report unless and until you speak with the involved resident (or their representative, when appropriate). 

For example:

• If you follow-up with the resident identified in the report and provide information about residents’ rights and options, but the resident does not have a complaint or want further assistance, you would document that interaction as an instance of information and assistance. 
• If you follow-up with the resident identified in the report and the resident wants your assistance with a complaint, you would open a case with a complaint (or complaints) and document your work related to that case accordingly. 

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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. 

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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. 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.  

See the FAQ regarding the Ombudsman as the complainant as an exception.

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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. 

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A - Document these meetings as community education (S-68). Count each meeting as once instance. Community education is defined as “Total number of instances of community education outreach sessions by Ombudsman program.” Review NORS Table 3, Community Education (S-68) for examples and reporting tips.

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A - None of these activities count as community education or information and assistance. There is not a way to verify that recipients received and reviewed the information, so newsletters, blogs, and other forms of media do not count as community education. NORS defines information and assistance as providing individual instances of information to individuals or facility staff, so emailing an e-newsletter and posting information would not be documented as information and assistance. Review NORS Training Parts I and IV and NORS Tables 1 and 3 for additional information about information and assistance and community education.

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A - No. Receiving copies of discharge notices (or notices of transfer) do not automatically count as a complaint. 

The nursing facilities are complying with the federal requirement to send copies of these notices to the Ombudsman program. The nursing facilities are not acting as a complainant and reporting a complaint on behalf of a resident seeking Ombudsman program assistance, rather they are passing along a copy of a notice to your program per federal requirements. 

Per your state program policies and procedures, if your program responds to notices of discharge or transfer, to ensure your work is resident-directed, do not determine how to document your work related to the notice until you speak with the involved resident (or their representative, when appropriate).

• If you follow-up with the resident identified in the notice (and/or their representative, when appropriate) and provide information about residents’ rights, facility responsibilities, and their right to appeal the discharge, but the resident (or their representative) does not want your assistance to address it as a complaint, you would document that interaction as an instance of information and assistance. 
• If you follow-up with the resident identified in the notice (and/or their representative, when appropriate) and the resident (or their representative) wants your assistance to address the discharge and proceed with complaint investigation, you would open a case with a complaint and document your work related to that case accordingly. 

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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.  

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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.”

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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.  

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A - You would select complaint disposition code “02 – no action needed or withdrawn by the resident, resident representative, or complainant” since the resident did not want your assistance with the complaint. Then you would document the visit according to what you did during the visit.

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.

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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.

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A - If you have an Information and Assistance (I&A) conversation with both a resident and a nursing facility staff member at the same time, record the conversation as one I&A activity with whichever person (resident or staff) requested the I&A.

If you have I&A conversations separately even if it's the same topic, one with a resident and one with a nursing facility staff person, record the activities as one instance of I&A with a resident and one instance of I&A with nursing facility staff. 

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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. 

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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. 

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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.

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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. 

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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.

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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

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A - Not all residents participate in resident council meetings. However, all residents are automatically considered part of a resident council [or “resident group” per federal nursing facility requirements, §483.10(f)(5)] just by residing in the long-term care facility.

Since all residents of a long-term care facility are automatically considered Resident Council members and you provided training to a group of residents, not “information and assistance” to an individual resident, you would document this training as “resident council participation: nursing facility” (S-64).

“Resident council participation” in nursing facilities (S-64) and residential care communities (S-65) is defined in NORS Table 3 as “total number of instances of attendance, at resident councils, including meeting with council leadership, and training of resident councils at [nursing facilities/residential care communities] by representatives of the Office.”

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A - Document your attendance during virtual council meetings in the appropriate category of resident council (S-64, S-65) or family council (S-66, S-67) participation. Count each meeting as one instance. Similarly, if you meet with council leadership or provide training to a resident or family council virtually, document those activities in the appropriate category of resident or family council participation.

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A – No. The definition of “facility survey participation” (S-62, S-63) in NORS Table 3 is “total number of instances of survey activity by representatives of the Office.” Discussing a specific complaint (after receiving consent) is part of the complaint investigation and/or resolution process and would be documented in the case record, not documented as survey participation.

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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.”

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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. 

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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.

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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.

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A – No. The definition and examples and reporting tips for “other state level volunteers” (S-21) and “other local level volunteers” (S-26) in NORS Table 3 are the same for state and local levels. The definition is “total number of other volunteers who are not representatives of the Office” and the examples and reporting tips state “examples of other volunteers may include: volunteers who serve on a program advisory or governing board; assist with fundraising; provide other in-kind services such as accounting or strategic planning, etc. This must be a whole number.” The volunteers participating in initial certification training are training to be representatives of the Office and tasks during training are related to their role as a trainee, not serving as an “other volunteer" (see NORS Table 3, Part D, for more details).

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NOTE: The archived information below is from the NORS data collection prior to October 1, 2019 and is no longer active.

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.

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).

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.

NOTE:  The term "ombudsman" is used throughout the FAQs as a generic term that may mean the state Ombudsman, a representative of the Office, or the Ombudsman program.

Revised NORS Reporting

Q - When are states required to begin using the updated NORS data collection?

A - Ombudsman programs will start using the revised NORS data collection  on October 1, 2019. Links to an introduction to the NORS revisions, tables, and crosswalks are below and on the NORC and ACL websites.

• Introduction: NORS Revisions
• Table 1: Case Levels
• Table 2: Complaint Codes
• Table 3: Program Information
• Crosswalk A: NORS Overview
• Crosswalk B: Complaint Codes (Old NORS to Revised NORS)

Q - Can states begin training on the revised  NORS definitions (Tables 1, 2 & 3) and start using the new codes, definitions, and activities in their current NORS reporting?

A -  No, states are to continue to use the current approved NORS form and instructions  to ensure consistent reporting. NORC is in the process of creating new training materials for the revised NORS data tables  in coordination with an advisory group and ACL.  NORC will update the current training materials, create PowerPoints for each training section, and develop a new on-demand training course (part of the new Consumer Voice/NORC Training Center) and make  this available to your programs. Prior to implementation of the updated NORS reporting system (October 1, 2019), please review your current data for trends, errors, and areas for improvement; discuss the importance of accurate and timely reporting; inform your program about upcoming changes; and use the current training materials and NORS FAQs to improve consistency in NORS reporting.

If you have questions about transition of your software from current NORS to new please contact Louise Ryan at ACL.

Training for LTCO Staff and Volunteers

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

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.

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).

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.

Training for Facility Staff

Q -  When an ombudsman is preparing for community education, facility training, or volunteer training does the preparation time for the presenter (e.g., copying, developing the PowerPoint, creating materials) count in the total number of hours in the activity category?

For example, an ombudsman provided a 1 hour training for facility staff regarding elder abuse and had 2 hours of preparation prior to the training for a total of 3 hours. Can the 2 hours of preparation for the training be counted as “Training for Facility Staff” or another activity such as “Technical Assistance?”

A -  NORS does not ask for hours associated to community education; just the instance (or event).  There is the NORS requirement to report an estimated percent of  technical assistance to local programs and volunteers but it is an estimated percent. As far as reporting technical assistance, an educated guess is acceptable. For NORS you don’t have to track this time, but your state program may have additional requirements for tracking this time. 

The 2 hours would not count as technical assistance to Ombudsman program staff/volunteers.  However, you can count the extra two hours toward training facility staff. It is not a NORS requirement to report the hours, so you would have one instance and 3 hours, but NORS only collects the