State Annual Long-Term Care Ombudsman Report

Forms and Documents

Document Name	Status
Form 1 State Annual Long-Term Care Ombudsman Report Form	Modified
Crosswalk B 01_25_18.FINAL_508.pdf Supplementary Document	2018-02-23
Crosswalk A_Overview 1_26_18 NOT 508.docx Supplementary Document	2018-02-23
Table 3 ACL Response to NORS Comments .pdf Supplementary Document	2018-02-23
Table 2 ACL Response to NORS Comments.pdf Supplementary Document	2018-02-23
Table 1 ACL response to NORS comments 01-26-18 .pdf Supplementary Document	2018-02-23
NORS Table_3 _Final_01-25-18.pdf Supplementary Document	2018-02-23
NORS Table_2_final_01_25_18.pdf Supplementary Document	2018-02-23
NORS Table_1_final_01-25-18.pdf Supplementary Document	2018-02-23
NORS Burden Estimates 01-08-2016.xlsx Supplementary Document	2016-01-22
Supporting Statement for NORS 02-14-18 rev.docx Supporting Statement A	2018-02-23

IC Document Collections

IC ID	Document Title	Status
10249	State Annual Long-Term Care Ombudsman Report Form	Modified

ICR Details

OMB Control No: 0985-0005	ICR Reference No: 201802-0985-003
Status: Active	Previous ICR Reference No: 201612-0985-001
Agency/Subagency: HHS/ACL	Agency Tracking No:
Title: State Annual Long-Term Care Ombudsman Report
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 04/10/2018
	Date Received in OIRA: 02/27/2018
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2021	36 Months From Approved	02/29/2020
Responses	52	0	52
Time Burden (Hours)	11,628	0	7,754
Cost Burden (Dollars)	0	0	0

---

Abstract: The State Annual Long Term Care Ombudsman Report is needed to: comply with state and Administration on Aging reporting requirements in the Older Americans Act; carry out recommendations made by the General Accounting Office, the Department of Health and Human Services' Office of the Inspector General, and the Institute of Medicine; advocate at the state and federal levels for changes needed to improve the quality of life and care in long-term care facilities; and effectively manage the Long-Term Care Ombudsman Program at the local, state and federal levels. The report form and instructions have been in continuous use, with minor modifications, since they were first approved by OMB for the FY 1995 reporting period.

---

Authorizing Statute(s): US Code: 42 USC chapter 35 Name of Law: Programs for Older Americans
   PL: Pub.L. 109 - 365 712 (c),(h)(1)-(3) Name of Law: Older Americans Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 52438	08/08/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 8086	02/23/2018
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
State Annual Long-Term Care Ombudsman Report	3, 1, 2, 3	NORS Table 1 ,   Table 2 Complaint Codes ,   NORS Table 3 Program Information ,   NORS Table 3 Program Information

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	52	52	0	0	0	0
Annual Time Burden (Hours)	11,628	7,754	0	3,874	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The Administration for Community Living (ACL) proposes to revise the existing data in order to: (1) simplify the form and clarify the instructions by reducing the number of data codes currently collected and to employ modern methodologies for data submission, which are efficient, effective, and improve data quality. This data collection will also support ACL in tracking performance outcomes and efficiency measures with respect to the annual and long-term performance targets established in compliance with the Government Performance Results Modernization Act (GPRMA).

---

Annual Cost to Federal Government: $403,712

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/27/2018

---