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NORS Frequently Asked Questions (FAQs)

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. View the Asked and Answered: Frequently Asked Questions (FAQs) about the Revised NORS webinar recording which is based on the first round of FAQs.

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? 

Answer

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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Q - Why is there a perpetrator code for abuse, neglect, or exploitation complaints?

Answer

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. 

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Complainant

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.

Answer

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.

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Q - When should the Ombudsman program be the complainant?

Answer

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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Complaint Coding

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? 

Answer

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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Q - When a complainant has two complaints/issues that would fall under the same code do I only record the code once?

Answer

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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Q - If there is a case where the complaint could be documented under two different codes, do I choose one code?

Answer

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.

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Q - When is it appropriate to add another complaint to an existing case or establish a new case?

Answer

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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Disposition

Q - How do I determine the disposition code if the resident dies during the investigation? 

Answer

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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Information and Assistance

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. 

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Opening and Closing a Case

Q - When do you open a case? 

Answer

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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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.

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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? 

Answer

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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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?

Answer

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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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?

Answer

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:

  • If you follow-up with the residents who received the notices or if one of them or their representative contacts you, you may have a case or an information and assistance.  
  • If the resident or their representative asks you for information or suggestions on how to proceed with the discharge or with an appeal, this would be an information and assistance. 
  • If the resident or their representative asks you to investigate, identify options, and help them either stay in the facility or find another solution, it would be a case with one complaint. 

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Referral

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?

Answer

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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Survey Participation

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.”

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Q - Does reading a survey count as participation in a facility survey? 

Answer

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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Verification

Q - What is the definition for verified? If the resident confirms the complaint, does that mean it is verified?

Answer

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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Visits

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.

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Archive


View archive here

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.

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 youdon’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 youwould have one instance and 3 hours, but NORS only collects the one instance.

Facility Coverage

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

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

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?

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.

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?

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."

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? 

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.

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?

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.

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?

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

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?

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.

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

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. 

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)?

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. 

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? 

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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