Crosswalk A Overview

Crosswalk A: NORS Overview

This Crosswalk identifies changes that the new National Ombudsman Reporting System (NORS) guidance makes to each Part in the current NORS. It:

• Identifies in red font data that no longer is required in the Ombudsman program ’s annual report to ACL;

• Identifies and highlights in green data required under the new NORS guidance that Ombudsman programs must include in the Older American’s Act Performance System (OAAPS) ;

• Identifies existing NORS Parts that have been modified; and

• Explains the changes and modifications and tells Ombudsmen where to look for additional guidance.

NORS –Current	Status in New NORS OAAPS,	Explanation/ Guidance
Part 1-A. Cases Opened	Discontinued	The date a case is opened and the case number will be included in the case record data that you report to ACL. ACL will no longer require that you report the total number of cases opened during the reporting period. See Table 1: Part A, CA-01 See Table 1: Part A, CA-02
Part 1-B. Complainants/Cases closed	Modified	The date a case is closed will be included in the case record data that you report to ACL. Some complainant types are redefined. Some are combined, reducing the number of types from nine to eight. See Table 1: Part A, CA-03 See Table 1: Part A, CA-05
Part 1-C. Total Complaints for all cases closed during reporting year by facility type	Modified	The complaint number, the date the complaint is opened and the date the complaint is closed will be included in the case record data that you report to ACL. Definition of Board & Care is revised and renamed “Residential Care Community. “ “Other Settings” complaints can now be associated to a specific complaint code. See Table 1: Part A, CD-01 See Table 1: Part A, CD-02 See Table 1: Part A, CD-03 See Table 1: Part A, CD-04 See Table 1: Part C, CA-04 (99)
Part 1-D.Types of complaints	Modified	The number of complaint codes is reduced from A-Q to A-L. See Table 2
Part 1-D. A: Abuse, Gross Neglect, Exploitation	Modified and replaced with New Elements	Ombudsmen must identify the perpetrator: (1) Facility staff, (2) another resident (3) resident representative, family, friend or (4) other. Associating the perpetrator with the specific abuse complaint neglect reduces duplicate codes and eliminates coding confusion. Three codes are eliminated: A6-resident to resident abuse, P117 (abuse by non-facility person) and P121 (financial exploitation not affiliated with facility.) See Table1: Part B, CD-05 See Table 2: Category A, A01-A05
Part 1-D. B: Access to information	Modified	Codes are combined, reducing the number from seven to three. See Table 2: Category B, B01-B03
Part 1-D. C: Admission, transfer, discharge, eviction	Modified	Codes are combined, reducing the number from seven to four. See Table 2: Category B, B01-B02.
Part 1-D. D: Autonomy, choice	Modified	Codes are combined, reducing the number of codes from 11 to nine. See Table 2: Category D, D01-D09
Part 1-D. E: Financial, property	Modified	Codes are combined, reducing the number from three to two. See Table 2: Category E, E01, E02.
Part 1-D. F: Care	Modified	Current complaint categories G (Rehabilitation) and H (Restraints) are now included in the Care category. Other Care codes have combined reducing the number from 12 to 11. See Table 2: Parts F, F01-F12.
Part 1-D. G: Rehabilitation	Discontinued	The seven NORS Rehabilitation codes are subsumed in the Care category. See Table 2: Category F, F01-F12.
Part 1-D. H: Restraints	Discontinued	The two NORS Restraint codes are subsumed in the Care category. See Tables 2: Category F, F01-F12.
Part 1-D. I: Activities and Social Services	Modified	Now is category G in OAAPS. See Table 2: Parts G, G-01-G03.
Part 1-D. J: Dietary	Modified	Now is category H in OAAPS. Codes are combined, reducing the number from seven to three. See Table 2: Category H, H-01-H-03.
Part 1-D. K: Environment/Safety	Modified	Now is category I in OAAPS. Codes are combined, reducing the number from 10 to five. See Table 2: Category I, I01-I05.
Part 1-D. L: Policies, procedures	Modified	Now is category J in OAAPS. Renamed: Facility Policies, Procedures and Practices. Includes NORS codes M (Staffing) category. NORS Codes are combined and simplified, reducing the number from eight to three. See Table 2: Category J, J01-J02.
Part 1-D. M: Staffing	Discontinued	This category is eliminated and subsumed in category J (Facility Policies, Procedures and Practices). See Table 2: Category J, J-03.
Part 1-D. Complaints about Outside Agency (non-facility)	Modified	This is now a specific complaint category, category K. Includes six codes Includes codes in NORS N (Regulatory System) and O (Medicaid) categories. See Table 2: Category K, K-01-K-06
Part 1-D. N: Certification/Licensing agency	Discontinued	The seven NORS codes in this category are subsumed in new category K. See Table 2: Category K, K01-K-06.
Part 1-D. O: State Medicaid agency	Discontinued	The five NORS codes in this category are subsumed in the new category K. See Table 2: Category K, K-01-K-06.
Part 1-D. P: System/Others	Modified	Now is category L in OAAPS. Renamed: System: Others (non-facility). Some codes were discontinued because of lack of use, such as P118 (bed shortage) or were incorporated into other complaint definitions. The number of NORS codes is reduced from 12 to three. See Table 2: Category L, L-01-L-03
Part 1-D. Q: Services other than LTC facility settings	Discontinued	Ombudsman programs that respond to complaints in other settings (home care, hospital, etc.) may choose to report these complaints to ACL. They should select “other setting “ as the facility type and choose the appropriate complaint code. See Table 1: Part A, CA-04 (99)
Part 1 E. Action on Complaints
Part 1 E 1. Verification	No change	See Table 1: Part B CD-06.
Part 1 E 2. Disposition		The number of disposition codes is reduced from seven to three. See Table 1: Part B, CD-08
a. For which government policy or regulatory change or legislative action is required	Discontinued
b. Which were not resolved to satisfaction of resident or complainant	No Change
c. Which were withdrawn by the resident or complainant or resident died before final outcome of complaint investigation	Modified	Combined with code e. The new code is: Withdrawn or no action needed by the resident, resident representative or complainant. See Table 1: Part B, CD-08 (02).
d. Which were referred to other agency for resolution and: 1) report of final disposition was not obtained 2) other agency failed to act on complaint 3) agency did not substantiate complaint	Discontinued/ Replaced with New Element	Instead of using code d., Ombudsmen must indicate the type of agency or agencies to which a complaint was referred as part of the plan of action for complaint resolution. See Table 1: Part B, CD-06.
e. For which no action was needed or appropriate	Modified	Combined with code c. The new code is: Withdrawn or no action needed by the resident, resident representative or complainant. See Table 1: Part B, CD-08 (02).
f. Which were partially resolved but some problem remained	Modified	Combined with code g. The new code is: Partially or fully resolved to the satisfaction of the resident, resident representative or complainant. See Table 1: Part B, CD-08 (01).
g. Which were resolved to the satisfaction of resident or complainant	Modified	Combined with code f. The new code is: Partially or fully resolved to the satisfaction of the resident, resident representative or complainant See Table 1: Part B, CD-08 (01).
3. Discussion of Legal Assistance/ Remedies (Optional)	Discontinued
Part I F. Complaint Description (Optional)	Modified	Two examples are required. A third is optional. Ombudsmen must include specific complaint codes, verification and disposition with each example. See Table 3: Part A, S-01 – S-06.

Part II – A. Major Long-Term Care Issues

Modified

Ombudsmen must include specific systems issues topics, dispositions and strategies used in addition to narratives. See Table 3: Part B, S-07 – S-11.

Part III-A. Facilities and Beds	Modified	Term “Board & Care” replaced by “Residential Care Community” See Table 1: Part C, CA-04.
Total number of beds for which the facilities are licensed, certified or registered (when known)	Modified	Ombudsmen will have the option of selecting no maximum or minimum specified. See Table 3: Part G, S-41, S-42 See Table 3: Part G, S-47, S-47.1
Part III B. 1. Designated local entities hosted by:	Modified/ New Elements	Each type of location for local ombudsmen entities is assigned a specific code. The number of locations is reduced from five to six. Ombudsmen must indicate the number of ombudsmen entities in each location. See Table 3: Part C, S-15, S-16.
-Area agency on aging	No change
-Other local government entity	Discontinued
-Legal services provider	No change
-Social services non-profit agency	No change
-Free-standing ombudsman program	No change
-Regional office of State ombudsman program	Discontinued
-Other; specify:	No change
Part III B.2. Staff and volunteers- State & local	Modified/ New Elements	Ombudsmen will report the number of all paid staff, including clerical (full and part time) at the state and local level. See Table 3: Part D, S-17 - S-21 (State Office) See Table 3: Part D, S-22 - S-26 (local)
Full-time Equivalents (FTE’s) –	No change	See Table 3: Part C S-18 (State Office). See Table 3: Part C S-23 (local).
Number people working full-time on ombudsman program	Discontinued
Paid clerical staff	Discontinued
Number of volunteers certified (designated)	No change	See Table 3: Part C, S-19 (State Office). See Table 3: Part, S-24 (local).
Number of Volunteer hours donated	No change	See Table 3: Part C, S-20 (State) Office). See Table 3: Part C, S-25 (local)
Other volunteers	No Change	See Table 3: Part C, S-21 (State Office) See Table 3: Part C, S-26 (local)
Part III B.3. Organizational conflicts of interest	No change	OAAPS will offer drop down menu of conflicts, and text fields to describe remedies, and will allow rolling over entries from the previous year. See Table 3: Part E, S-27-S-29
Part III C. Program Funding	Modified	See Table 3: Part F, S-30 – S-40.
OAA Title VII, Ch. 2	No change	See Table 3: Part F, S-30
OAA Title VII, Ch. 3	No change	See Table 3: Part F, S-31
OAA Title III –State	No change	See Table 3: Part F, S-32
OAA Title III-AAA level	No change	See Table 3: Part F, S-33
Other federal	Modified	Ombudsmen will choose the federal funding source from a drop down menu. See Table 3: Part F, S-34. See Table 3: Part F, S-35.
State funds	Modified	Ombudsmen will choose the state funding source from a drop down menu. See Table 3: Part F, S-36 See Table 3: Part F, S-37
Local	Modified	Ombudsmen will choose the local funding source from a drop down menu. See Table 3: Part F, S-38 See Table 3: Part F, S-39
Total Program Funding		See Table 3: Part F, S-40
Part III D. Other Ombudsman Activities	Modified	See Table 3: Part H
Part III D.1. Training for staff/volunteers	Discontinued/Replaced with New Elements	Ombudsmen will report the minimum number of hours required for certification training for purposes of designation and continuing education training. Ombudsmen will report the minimum number of hours required for certification training for purposes of designation and continuing education training. See Table 3: Part G, S-48 & S-49 Ombudsmen will report the number of people who completed certification training. See Table 3: Part H, S-50
Number of sessions	Discontinued
Number of hours	Discontinued
Number of trainees	Discontinued
Part III D. 2. Technical assistance to local staff/volunteers -estimated percentage of total staff time	Discontinued
Part III D.3.Training for facility staff	Modified with New Element	Ombudsmen must indicate if training is provided to nursing facility or residential care community. See Table 3: Part H, S-51 & S-52.
Number of Sessions Provided	No change
Three Most Frequent Training Topics	Discontinued
Part III D. 4. Consultation to facilities	Modified with New element	Renamed Now “information and assistance.” Ombudsmen must indicate if consultation is provided to a nursing facility or residential care community. See Table 3: Part H, S-53 & S-54.
Number of consultations	No change	See Table 3: Part H, S-53 & S-54.
Three Most Frequent Training Topics	Discontinued
Part III D. 5. Information and consultation to individuals	Modified	See Table 3: Part H, S-55.
Number of consultations	No change
Three most frequent requests/needs	Discontinued
Part III D. 6. Facility Coverage Number of facilities (unduplicated count) covered on a regular basis, not in response to a complaint	No change	See Table 3: Part H, S-58 & S-61.
Number of facilities visited, both nursing facility and residential care community	New	This is a new element related to facility coverage See Table 3: Part H, S-56 & S-59
Number of visits, regardless of purpose, both nursing facility and residential care community	New	This is a new element related to facility coverage See Table 3: Part H, S-57 & S-60.
Part III D.7. Participation in Facility Surveys	Modified	Ombudsmen must include the facility type. See Table3: Part H, S-62 & S-63.
Part III D.8. Work with Resident Councils	Modified	Ombudsmen must include the facility type. See Table3: Part H, S-64 & S-65.
Part III D. 9. Work with family councils	Modified	Ombudsmen must include the facility type. See Table 3: Part H, S-66 & S-67.
10. Community Education	No change	See Table 3: Part H, S-68.
11. Work with media-# topics, # of interviews, # of press releases	Discontinued
12. Monitoring/work on laws, regulations, government policies and actions-estimated percentage of staff time	Discontinued
State and local level coordination activities	New	Ombudsmen will select from a drop down list the agencies or programs that have state or local level coordination activities led by the Ombudsman program. See Table 3: Part H, S-69.

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1/26/2018