Table 1 ACL Response to Comments

Administration for Community Living/Administration on Aging- Office of Long-Term Care Ombudsman Programs
National Ombudsman Reporting System (NORS)
Table 1: NORS Parts 1 and 2 – Case/Complaint codes, values and definitions

OMB Control Number 0985-XXXX

Expiration Date: XX/XX/XXXX

ACL Response to 60 Day Notice Comments
Case Data Components
Each case must contain a complainant, complaint code (s), a setting, verification, resolution, and information regarding whether a complaint was
referred to another agency. Case and complaint data reported is only for those cases and complaints which were closed within the fiscal year.
Element Data
Number Element
C1

Date Case
Opened

Definition

Comment

ACL Response

Month, day,
and year that
the case was
opened

Element numbers

Table 1 Code number is now CA 01-CA-05 and
Complaint Data Components are CD-01-CD-07

Issue: C1 through C4 are also used in Table 2: Complaint
codes and definitions
Recommendation: Change Element Numbers in Table 1
to CA1 through CA5 for case data and CO1 through CO7
for complaint data.

C2

Date Case
Closed

Month, day,
and year that
the case was
closed

Recommends: Report only cases closed in the reporting
year, regardless of whether they were opened in the
reporting year or in a prior reporting year.

Because case and complaint data will be
submitted in an electronic file format, the
business rules instruct that all cases and
complaints must be closed in the fiscal year,
regardless of date opened. We will clarify in
the business rules

Element Data
Number Element
C3

Facility/
Setting Type

Definition

Comment

ACL Response

Facility/setting
type for the
case

13 commenters recommend changing the term
“Residential Care Community” back to the current
Board and Care terminology as defined in the OAA and
add the term “residential care community” to the
definition. The concerns were best described as
follows.

There is general concern that the proposed
definition somehow expands they type of
settings that LTC Ombudsmen have jurisdiction
over. This is not ACL’s intent and the definition
has been revised; the term Residential Care
Community remains unchanged.

Issue 1: Changing “board and care” to “residential care
community” is an unnecessary change in nomenclature
that strays from the Older Americans Act language and
would burden state programs and representatives of
the Office. Adoption of this term would require change
to state reporting systems and training to every
representative of the Office, with no added value. A
change to basic terminology is likely to cause confusion
among states and representatives of the Office.

ACL believes the term Residential Care
Community reflects current nomenclature. The
Assistant Secretary for Planning & Evaluation
(ASPE) Compendium of Residential Care and
Assisted Living Regulations and Policy: 2015
Edition notes that until the mid-1990s, the
most frequently used terms were board and
care or residential care. However the
popularity of the new assisted living model led
many residential care settings to change their
name to assisted living. Currently 23 states
have more than one licensure category. Most
states (44) use the term assisted living as a
licensing or certification category. The word
that follows "assisted living" varies, and
includes facility, residence, program, home, and
community. The next most commonly used
licensure term is residential care, used by 20
states.

Issue 2: The reference to licensed and unlicensed in the
definition of “residential care community” is misleading
and inconsistent with the Older Americans Act (OAA)
definitions of “long-term care facility” and “board and
care”. The OAA definition for “board and care” refers to
the Social Security Act definition and describes state
authority to regulate. The Social Security Act describes
institutions on which state and local authorities enforce
standards. Referring to an unlicensed facility in this
definition implies the State Long-Term Care
Ombudsman Program has a responsibility to cover

ACL does not believe that a change in definition
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Element Data
Number Element

Definition

Comment

ACL Response

unlicensed homes, which would create more strain on
an underfunded program and could result in an
unfunded mandate.

and title will cause confusion at the state and
local level because there will not be a change in
state level practice. Currently, state
Ombudsman programs use their state licensing
terms (i.e. assisted living, adult foster home,
and personal care home, etc.) States’ data
collection software allows for their residential
care data to be entered by state license type
which is then combined and reported in NORS
as one facility type, currently called board &
care.

By changing the definition of board and care to
residential care community, is it the implications that
ombudsmen should go into all settings that apply to
that definition or will ombudsman continue to serve the
residents in the same types of facilities that they have
been serving? If this is the case, why change the
definition. If states are expected to expand serves, how
will this be paid for?
Another area is in defining the types of facilities our
residents reside in we focus on NH’s, ALF’s and Adult
Family Care Homes. While AOA gives us the ability to
expand we could not do so without reducing services to
those we already serve.
One commenter Does not agree, and the program
offers complaint resolution services in these settings.

In response to concerns expressed that the
definition expanded the service jurisdiction the
definition has been revised.
The new definition is:
Residential Care Community - A type of longterm care facility as described in the Older
Americans Act that, regardless of setting,
provides at a minimum, room and board,
around-the-clock on-site supervision, and help
with personal care such as bathing and dressing
or health-related services such as medication
management.
Facility types include but are not limited to:

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Element Data
Number Element

Definition

Comment

ACL Response

assisted living; board and care home;
congregate care; enriched housing programs;
homes for the aged; personal care homes; adult
foster/ family homes and shared housing
establishments that are licensed, registered,
listed, certified, or otherwise regulated by a
state.
Issue 3: Ombudsmen are increasingly receiving
complaints that have an element of managed care
involved and clarification would be helpful.
Recommendation: Add to Examples and Reporting Tips,
“If the consumer is a member of a managed long-term
services and supports plan, select the setting where the
consumer resides at the time of the complaint

Did not accept. Not all states have managed
care programs and the focus of the LTCOP is
persons in long-term care facilities. One state
One commenter – specifically did not agree
with the recommendation.

Issue 3: Clarify what types of settings are acceptable
under “99 = Other”. Recommendation: Add examples
under Examples and Reporting Tips for “Other” such as
hospital, psychiatric facilities, etc.

Accepted

“Helpful to have rudimentary breakdown of other
settings so that additional individual reading and
tabulation of cases will not be required to gather
needed data on other settings.”

The “Other setting” code is an optional code for
those states that have expanded their
Ombudsman services to settings outside of
long-term care facility settings. ACL does not
need that level of detail on services for which
the OAA has not authorized.
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Element Data
Number Element
C4

Definition

Complainant Complainant an individual
Type
(i.e., resident,
resident
representative,
family) who
requests
Ombudsman
program
complaint
investigation
services
regarding one
or more
complaints
made by, or on
behalf of,
residents.

Comment

ACL Response

Recommendation: Add to Codes and Values, 06 = Other
and add to Definition, “Other” includes individuals who
do not have a relationship with the resident such as a
neighbor to the facility, family member of another
resident, visiting pastor and change 06 to 07 =
Unknown.

Accepted

Recommendation: Change Definition of 05 =
Representative as follows. Representative of other
agency or (individual delete) program: Any entity or
(individual delete) that refers a complaint to the
Ombudsman program regarding one or more residents.

Based on recommendations a new code 06“Other” was added:
Other: a neighbor to the facility, family member
of another resident, visiting clergy, bank teller,
etc.

Recommendation: Under Code and Values for C4 add a
new code “Other” and in Examples and Reporting Tips
add “Select other when the complainant does not work
for an agency and has no personal relationship with the
resident such as community member, or family member
of another resident”. Also clarify under Examples and
Reporting Tips that “Resident Representative, Friend,
Family” refers to a complainant that has a personal
relationship with the resident. Also change “Unknown”
to 07.
Element #C4: 05-Representative of other agency or
program. A resident’s neighbor is frequently a friend
and would not be considered a representative of other

Based on recommendations a new code 06“Other” was added:
Other: a neighbor to the facility, family member

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Element Data
Number Element

Definition

Comment

ACL Response

agency or program.

of another resident, visiting clergy, bank teller,
etc.

Recommendation: Remove the term “neighbor” from
the examples given for 05=Representative of other
agency or program, and either remove “neighbor” from
all descriptions or add it to C02, Resident
Representative Friend, Family.
Anonymous should be included since many of the
complaints we receive are anonymous.

Anonymous and unknown have basically the
same meaning. If the Ombudsman program
receives a complaint and they do not know the
source of the complainant that would be
considered “unknown.” If a resident is a
complainant but says that she wants to be
“anonymous” to the facility staff or others; that
is considered direction from the resident on
how to conduct the complaint investigation.

C4 needs further explanation on allowing only one
selection of complainant as it relates to C5 when there
is more than one complainant per case.

Complainant Group was eliminated.

Omits value of “other medical staff,” which is useful to
LTCOP’s. Rather than unknown we prefer anonymous
which encompasses additional aspects…When

Nationwide, less than 3400 (2.5%) of
complaints per year are referred by “other
medical staff” to the Ombudsman program.
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Element Data
Number Element

Definition

Comment

ACL Response

complainant requests anonymity should not be
documented under role of …current use of
unknown/anonymous also is better than merely
“unknown” Do not agree and the current numbers do
not support

This has been consistent for the past five years.
We are seeking to simplify data collection by
merging codes that are not highly used and
have similar overlap (i.e. current code of Other
medical: physician/ staff with Representative
of other health or social service agency or
program.)
As noted above, the definition of unknown and
anonymous is similar. Over the past 5 years,
“unknown/anonymous” complaints averaged
around 3.5% of all complaints. The
complainant role should be accurately
identified so that we have a true picture of the
complainant concerns via the complaint
resolution process. Indicating the type of
complainant in a data system does not violate
disclosure requirements of the OAA or the
Ombudsman federal rule. Both the OAA and
the federal rule (see 1324. 11(e) (3) Disclosure
and 1324.19 Duties of the representatives of
the Office. (b) Complaint processing. Describe
when a resident or complainant’s identifying
information can be disclosed.

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Element Data
Number Element
C5

Definition

Complainant Whether there
is more than
Group
one
complainant as
part of the
case.

Comment

ACL Response

Issue: This would be difficult to code and collect
consistent data from ombudsmen, as well as add an
additional burden to reporting. Recommendation:
Delete C5.

This data element was eliminated. In order to
capture some information on group complaints
a complainant code of “resident or family
council” was added to the complainant type.

Issue: This is a new data element and it is not clear if it
is to be used for group complaints by resident or family
councils or if it is to be used when several individuals
file complaints about the same incident.
Recommendation: Clarify language under the definition
and give examples in the Examples and Reporting Tips.
It is also important to ensure the system allows for
several complaints to be recorded for the same
incident.
Requires additional explanation regarding how it relates
to C4. In addition if one documents “yes” where does
one document (and collect data on) the additional
information regarding the role and type of complainant.

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Complaint Data Components
Element
Number

Data
Element

Definition

Comments

ACL Response

CD4

Allegedly
Responsible
Person

The type of person(s)
allegedly responsible for the
abuse/neglect or exploitation
(i.e. perpetrator).

Use of the term “allegedly responsible
person” is confusing. Responsible person may
be confused with a power of attorney or the
nursing facility terms “responsible party” and
“responsible person.” Other commenters
agree.

After much deliberation the data element
label was changed to “perpetrator.” This
is the most frequently used and
understood word to describe a person
who has been accused of causing abuse,
neglect or exploitation.

Recommendation: Change the Data Element
to Person Complaint is Against.
Issue 2: Codes and Values options are not
inclusive of outside providers of services.
Recommendation: Add to Codes and Values,
4 = Outside Providers of Services and add to
Examples and Reporting Tips, Use 4 for
Outside Providers of Services, for individuals
or entities such as laboratory staff, social
workers not employed by the facility, and
financial advisors. Also change 04 05 = Other.
Recommendation: Under Codes and Values
change number 4 to “Outside Providers of
Services” and change “Other” to number 5.
Under Examples and Reporting Tips add
examples for the new code recommended
above as well as for “Other”. Clarify that

No change, outside providers of services,
not associated with the facility fit in the
“other”

No change- the terms are self-explanatory.

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Element
Number

Data
Element

Definition

Comments

ACL Response

“Family, Residents Representative, and
Friend” are individuals that the resident has a
relationship with.

CD5

Referral
Agency Type

The type of agency/agencies
to which a complaint was
referred to as part of the
Ombudsman program’s plan
of action for complaint
resolution.

The addition of CD4-Allegedly Responsible
Person in ombudsman reporting, coupled
with the CD6 Complaint Verification Data
Element would appear to verify (or not)
whether the allegedly responsible person did,
in fact, cause the abuse, neglect, or
exploitation. This may confuse the public
who reviews Ombudsman program data and
confuse Ombudsmen about their role in
responding to a complaint involving abuse,
neglect, and exploitation.

The Ombudsman program rule at
1324.19(b) Complaint processing along
with states policies and procedures on
complaint processing should support
credible and effective complaint
resolution. The ability to analyze
disaggregated data and associate the
types of complaints, the perpetrator (for
abuse related complaints) and other
variables will inform ACL and states on
complaint outcomes. ACL and the
National Ombudsman Resource Center
will assist states in their interpretation of
their data and how to educate the public
on the data.

Several commenters: Issue: Ombudsmen
often refer complaints to the state Medicaid
Fraud Control Unit and to the Home and
Community Based Waiver Quality Assurance
agency. There does not appear to be an
option for these agencies.

Medicaid Fraud Control Unit is a law
enforcement agency and is included in law
enforcement definition.

Recommendation: Add under Examples and

Not all states have similar processes for
“Home and Community Based Waiver
Quality Assurance agency.” The definition
is broad enough to capture all types of
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Element
Number

Data
Element

Definition

Comments

ACL Response

Reporting Tips, Use 1 for Licensing,
Regulatory, Certification Agency, and for
referrals to the state Medicaid Fraud Control
Unit and to the Home and Community Based
Waiver Quality Assurance agency.

government entities that have a quality
oversight responsibility.

CD6

Complaint
Verification

Verified: A confirmation that
most or all facts alleged by
the complainant are likely to
be true. An ombudsman
conducts an investigation of
the complaint to determine
verification

Proposed changes in definition is less clear.
Use of word ‘fact’ does not seem appropriate
as a fact is something that is true.
Ombudsmen investigate to determine the
facts. We recommend that the current
definition of verified be unaltered. In
addition CD6 should note that Not Verified
has several meanings: not true, unable to
determine, etc.

The definition was slightly modified.
Verified: A confirmation that most or all
facts alleged by the complainant are likely
to be true.

CD7

Complaint
disposition

Final resolution or outcome
of the complaint

Several commenters - Issue: There is no
instruction regarding how to code the death
of a resident before there is an outcome of
the ombudsman resolution.

There are a number of variables that may
impact the final disposition of a complaint
if a resident dies before the complaint is
finally resolved. This will be addressed in
NORS consistency training.

Recommendation: Add to Examples and
Reporting Tips, Use 2 for Withdrawn when
the resident dies before a final outcome has
been obtained.

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Element
Number

Data
Element

Definition

Comments

ACL Response

Recommendation: Under Examples and
Reporting Tips add “When a resident dies
before a complaint is resolved use code 3.”
Add a reporting tip that lists an order of
preference for determining who to rely on to
determine disposition. For example, first
contact the resident if they are able to state
their satisfaction, then contact the resident
representative, then complainant, then
SLTCO.

There are a number of variables that may
impact the final disposition of a complaint
if a resident dies before the complaint is
finally resolved. This will be addressed in
NORS consistency training.

Element #CD7: Complaint Disposition, Item 2
(“Withdrawn or no action needed…”) There is
a distinct difference between a complaint
that is withdrawn and one where no action
was needed.

If a complaint is withdrawn by the resident
or complainant it means that no further
action shall be taken. Years of experience
of training on these two definitions
indicates that Ombudsman programs do
not have clear agreement on the
definitions and differences between these
two terms. Eliminating duplicative
definitions reduces the states’ reporting
burden.

Recommendation: Separate “Withdrawn”
and “No Action Needed” and continuing to
provide both options as a complaint
disposition in NORS.

Concerns about reducing the number of
dispositions primarily because of cost to
change software and re-training.

The new codes reflect the most commonly
used NORS disposition codes. The
simplification from 9 disposition codes to
3 reduces reporting burden. The NORC

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Element
Number

Data
Element

Definition

Comments

ACL Response

will provide a set of training materials
offering both live webinars and recorded
session’s available on-demand.
We are aware of state Ombudsman
programs’ cost concerns. NORS reporting
has not significantly changed over the past
20 years and we understand that this will
require states to modify their software
programs.
Issue 2: Codes and Values 1, 2, and 3 refer to
the resident, resident representative, or
complainant. It is unclear how an
ombudsman should report disposition when
a resident and complainant disagree about
satisfaction, such as how to report a situation
when a resident does not wish the
ombudsman to take any action and the
complainant is not satisfied. As a residentdirected advocate, ombudsmen are trained
to follow the resident’s direction. The
resident’s wishes should supersede the
complainant’s.

This is a helpful suggestion that lends itself
to training examples to be developed by
NORC.

Recommendation: Add to Examples and
Reporting Tips, “If the complainant is not the
resident, but is complaining on behalf of a
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Element
Number

Data
Element

Definition

Comments

ACL Response

resident who is able to state his or her
satisfaction or otherwise direct the
ombudsman, the resident’s direction
supersedes the complainant’s.
Concerns about removal of for which
government policy or regulatory change or
legislative action is required to resolve, and
referred to other agency – final disposition
not retained or failed to act may be useful to
retain.

The disposition code “for which
government policy or regulatory change or
legislative action is required to resolve,”
has not proven to be helpful at the federal
level with an average disposition of less
than 1%. It is our expectation that with
disaggregated data we will have the ability
to analyze the types of complaints that are
unresolved which may indicate that
resolution requires policy or systems level
changes. We also anticipate that with a
structured systems advocacy narrative this
will better inform of the types of
complaints that require policy,
government action, etc.
“Referred to other agency dispositions”
imply that the Ombudsman program is no
longer active in the complaint resolution.
The referral codes are also confusing to
many Ombudsman programs and have
created data inconsistences. Removing
referral codes clarifies that the
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Element
Number

Data
Element

Definition

Comments

ACL Response

Ombudsman program is to determine
whether the complaint is resolved to the
satisfaction of the resident (or resident
representative, where applicable).

15