Table 2 ACL Response to Comments

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

OMB Control Number 0985-XXXX
Expiration Date: XX/XX/XXXX

ACL response to 60 day Public Comment




No complaint codes were removed. Two additional complaint codes were added: I05-“Housekeeping, laundry and pest abatement;”
and L03-“Request to transition to community setting.”
Complaint code numbering was reformatted to a 2 digit number, i.e. A01
Complaint code labels were revised in accordance with comments. Most complaint code definitions and reporting tips were revised in
response to comments.

Complaint: 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.

Label
Abuse, Gross Neglect,
Exploitation

Code

Comments

ACL Response

A

Throughout Table 2, use language that is clear and does not contain See comments below
negative labels. For example, change labels to read…
Code labels changed as requested.
We recommend ensuring that all definitions for each type of abuse
The abuse complaint codes are consistent with
include the federal elder abuse definitions and include a statement
other federal definitions such as those found
that allows for States to use their own definitions for abuse, such
in National Adult Maltreatment Reporting
as, “and includes the state definition for this type of abuse.”
System (NAMRS) ; the Center for Disease
Control Elder Abuse Surveillance: Uniform
Definitions and Recommended Core Data
Elements; and the definitions found in the
revised nursing home regulations 42 CFR
§483.5 Definitions.

Label

Code

Comments

ACL Response

All sections should state if they are directly related to the facility or A - Complaint codes require the selection of a
not, i.e. A, K, L are not, B –D, I, J are related to the facility, E- is not perpetrator, which includes facility staff as one
clear, F-H does not state but should.
option.
B-J complaint codes are for complaints against
the facility.
K complaint codes are for complaints about an
Outside Agency (non-facility)
L complaint codes are for “System/Others
(non-facility)”
Additional coding questions can be addressed
in training and technical assistance provided
by the Ombudsman Resource Center.
Abuse, physical

A1

Several commenters agreed with above comments.
Code A1 and A3 – Abuse, physical and Abuse, Verbal/psychological

Agree. Revised “Examples and Reporting
Tips.”

Issue: Many residents are experiencing bullying both from staff and
other residents.
Recommendation: Add to Examples and Reporting Tips an addition
of bullying to the descriptions provided.
Abuse, Sexual

A2

Issue: includes language in the Examples and Reporting Tips about No change in definition made. Revised
“sexually explicit photographing.”
“Examples and Reporting Tips.”
Recommendation: In the Examples and Reporting Tips, add
language based on the recent guidance from CMS on posting
pictures to social media

A2

From what I could tell, the proposed changes do not appear to
State Ombudsman programs will be required
address “resident-to-resident physical or sexual abuse” (complaint to select a type of perpetrator for each abuse,
2

Label

Code

Comments

ACL Response

code A.6) as well as in “resident conflict (including roommates) and neglect and exploitation complaint.
inappropriate behaviors that impact other resident’s quality of life”
See Table 1.
(complaint code I.66).
Recent studies have shown that distressing and harmful residentto-resident interactions (DHRRI) in nursing homes are prevalent
(Lachs et al. 2016) and injurious (Shinoda-Tagawa et al. 2004

Abuse,
verbal/psychological

A2

We recommend adding “verbal” to the definition and the examples. Revised “Examples and Reporting Tips.”
We also recommend changing the examples to more clearly define
the three types of sexual abuse. Hands on offenses, hands off
offenses (ex. taking naked photos of an elder and distributing them
on social media, requiring a resident to watch another masturbate),
and harmful genital practices (those offenses that can occur during
peri-care)

A2

Additional instruction and guidance is needed as to how to code
complaints of sexual activity between individuals with cognitive
impairment or involving an individual who is unable to consent

This issue lends itself to complaint
investigation training.

Abuse, verbal or psychological. Move “including punishment and
seclusion” to Examples and Reporting Tips.

Revised “Examples and Reporting Tips.”

A3

Concern noted and will be shared with the
National Ombudsman Resource Center; they
are developing training on the new NORS
codes.

Abuse, verbal/psychological (including punishment, seclusion)
Issue: Code A3 – Examples and Reporting Tips includes oral, written
or gestured language that willfully includes disparaging and
derogatory terms used against residents but does not specifically
3

Label

Code

Comments

ACL Response

address the misuse of social media.
Recommendation: Add language to Examples and Reporting Tips for
A3 about postings to social media that includes disparaging and
derogatory terms used against residents.
A3

Under examples and tips, recommend adding ‘actions’ to broaden Revised “Examples and Reporting Tips.”
the scope as psychological abuse may take many forms. Add at end
“Actions that confuse, disrupt, ignore the resident.

A3

Abuse, verbal/psychological (including punishment, seclusion) A3

Definition was not changed.

We recommend adding abduction to the Definition and including
abduction in the examples and reporting tips.

Revised “Examples and Reporting Tips.”

Helpful to add ‘involuntary seclusion’ is not considered abuse when
it is medically directed for infection control.
Financial Exploitation

A4

Delete ‘trusting relationship to the resident.” Abuse is abuse
Agree – the definition was changed to be
whether it is from a person in a ‘trusted relationship’ or not and one consistent with the National Adult
is left wondering how a ‘trust relationship’ is involved.
Maltreatment Reporting System (NAMRS).

Gross Neglect

A5

Delete “in a trust relationship”

Access to Information/
Communication
Access to information,
including records

B
B1

Agree

Issue: The Definition and Examples and Reporting Tips need clarity Revised “Examples and Reporting Tips.”
and alignment with the Older Americans Act.
Recommendation: Use language from §712(b) of the reauthorized
OAA.

B1

There is a significant difference between access to a resident’s own No additional definitions were added in this
medical/personal records at a facility and records that are not
category. Past complaint history indicates that
the numbers are too small. Total access
4

Label

Code

Comments
specific to a particular resident, such as the licensing survey.
We recommend creating a second category for this code to clarify
the difference between complaints about resident access to their
own records (medical), and access to other records such as survey,
etc. that are not resident specific.

ACL Response
complaints are less than 3% with no current
category rising above 1% of all complaints.

Language/
communication barrier

B2

Under Examples and Reporting Tips, add examples.

Revised “Examples and Reporting Tips.”

Willful interference with
Ombudsman duties

B3

Issue: The definition for willful interference with ombudsman duties
Cod Agree. Revised “Examples and Reporting Tips.”
does not include examples that fully address an ombudsman’s
immediate, private, and unimpeded access to facilities, residents,
and records.
Recommendation: Revise the Examples and Reporting Tips to state,
“Includes when an employee or other representative of a facility
interferes with the Ombudsman program having immediate access
to the facility, access to records, or to meet with a resident in
person, in private, or by phone.”

B3

Willful interference is frequently a corporate decision or upper
No additional definitions were added to this
management decision as opposed to a decision made by an
category. The total number retaliation
individual who works in a care facility. We recommend adding the
complaints are .35% (less than 700 annually)
term “entity” to the definition of who may be responsible for willful and while an important matter it does not
interference. “Willful interference means actions or inactions taken need to be singled out in a separate
by an individual or entity in an attempt…”
complaint code.
We also recommend including access to facility or resident records
to the definition and the description to clarify that interference can
include those items.
Complaints regarding Interference with Ombudsman duties would
generally be a complaint made by the Ombudsman as opposed a
5

Label

Code

Comments

ACL Response

complaint made by the resident.
Recommendation:
Create a separate complaint code section for ‘Interference with
Ombudsman duties’ with sub-categories encompassing retaliation
against the resident or the complainant, retaliation against staff
cooperating with the investigation / resolution; interfering with the
Ombudsman’s duties by refusing access to the building, refusing
private space for interviewing or ease-dropping, refusing access to
records, verbal threats to the ombudsman, other actions impeding
the investigation and false accusations against the ombudsman etc.

Issue: The definition for willful interference with ombudsman
duties does not include examples that fully address an
ombudsman’s immediate, private, and unimpeded access to
facilities, residents, and records.

See above comments.

Recommendation: Revise the examples and reporting tips to
state, “Includes when an employee or other representative of a
facility interferes with Inability to access the
Ombudsman/representative having immediate access to the
facility, access to electronic and paper records, or to meet with
a resident in person, in private, or by phone.”

Add example for threats to residents after meeting with LTC
ombudsman.

Admission, Transfer,
Discharge, Eviction

C

6

Label
Admission

Code
C1

Comments
Issue: Examples in Definition do not address admission to facility
without legal authority.

ACL Response
Did not accept recommendation to include the
term “without legal authority.”

Recommendation 1: Revise Definition to read: “Complaints related Revised “Examples and Reporting Tips.”
to admission to a facility.”
Recommendation 2: Move examples to Examples and Report Tips
and change to read: “Examples include: resident is admitted to a
facility or section of a facility against their wishes or without legal
authority, including admission to a secured or locked unit. Contract
is missing or contains illegal provisions, such as requiring or
requesting waivers of rights, or a violation of Medicaid rules other
improper or illegal provisions including discrimination in admission
determinations and similar problems.”

C1

Discharge appeal process
- absent or not followed

C2

Recommendation 2: Move examples to Examples and Report Tips
and change to read: “Examples include: resident is admitted to a
facility or section of a facility against their wishes, without legal
authority, or to an overly restrictive setting, including admission to
a secured or locked unit…”
Discharge appeal process - absent or not followed

“Overly restrictive" is too vague a term to
include.
Definition and “Examples and Reporting Tips”
revised.

Issue 1: Definition is incomplete and includes examples.

Revised “Examples and Reporting Tips.”

Definition revised.

Recommendation 1: Revise Definition to read: Complaints related
to the discharge appeal process or lack of appeal process.
Recommendation 2: Move examples to Examples and Reporting
Tips and change to read, Examples include: “the required number of
days to appeal a discharge was not followed; the facility failed to
follow appeal ruling; there was no appeal process in place; and
similar problems.” Use this code when facility fails to inform
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Label

Code

Comments

ACL Response

resident of appeal rights.
Issue 2: Examples and Reporting Tips section is incomplete.
Recommendation: Under Tips section, include when the facility fails
to inform residents of appeal rights under Medicaid, Medicare,
managed care or other.
C2

Issue 1: Appeal process is too similar to C3, Discharge and Eviction. Definition revised.
Appeal code may be confusing to the ombudsman reporting work
“Examples and Reporting Tips” revised.
and only fits if it is against the facility. Other parts of the appeal
process could be a problem with the system, state agency, or
Error corrected.
managed care organization.
Recommendation 1: Combine the two codes into one. In the
combined C2 and 3, add discharge planning to the definition.
Recommendation 2: Correct “behold” to “bed hold.”
Include a separate numeric for transfer to a different facility rather Did not accept this suggestion; it is too specific
than one that is a community or less restrictive setting (some
and would cause code confusion.
residents believe that a facility wants to retain them for payment or
other reasons and therefore do not advocate for a resident to
relocate to a different facility);

Discharge/Eviction

C3

No comments

Label changed to “Discharge or Eviction”

Room assignment/room
change/intra-facility
transfer

C4

Move “Use for issues with room assignments, forced room changes Accepted suggestion.
or intra-facility transfers” under Examples and Reporting Tips.

Autonomy, Choice, Rights

D

8

Label

Code

Comments

ACL Response

Exercise choice: care,
treatment, schedule,
health care provider

D1

Issue: Clarify definition and move examples to the correct section. Definition modified with part moved to
“Examples and Reporting Tips.”
Recommendation: Change the definition to read “Resident is denied
the right to choose or schedule their care, treatment or healthcare
provider.” Under Examples and Reporting Tips add the examples
listed in the definition.

Choice to live in less
restrictive setting

D2

Issue: Definition references “discharge planning”, which is confusing Definition revised.
with Code C2 and 3 about discharge.
“Examples and Reporting Tips” revised.
Recommendation: Delete reference to “discharge planning” in the
definition. Replace the beginning of the definition with, “Resident is
not offered choice of where they live, request to return to
community...”

D2

Issue: Examples and Reporting Tips section needs additional
examples to clarify.

Definition revised.
“Examples and Reporting Tips” revised.

Recommendation: Clarify Examples and Reporting Tips for those
not familiar with MDS Section Q. Add examples to clarify when to
use this code

Not being treated with
dignity, respect

D2

Change verbiage to “Resident is not offered discharge planning,
Definition revised.
request to return to community is denied; ignored; or inadequately
“Examples and Reporting Tips” revised.
addressed; corrected or the facility staff prevents the resident from
leaving facility and similar problems.

D3

Move “Use when resident is not treated with dignity or respect.”
under Examples and Reporting Tips.

Definition modified with part moved to
“Examples and Reporting Tips.”

Issue: Examples and Reporting Tips section is incomplete.
Additional coding tips added with regards to
Recommendation: Clarify under Examples and Reporting Tips
social media.
section that posts on social media are related to abuse code under
A2 or A3.
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Label

Privacy

Code

D4

Comments

Issue: Examples and Reporting Tips section is incomplete.

ACL Response

“Examples and Reporting Tips” revised.

Recommendation: Clarify under Examples and Reporting Tips
section that if related to Ombudsman visits, the complaint should
be coded under B3 – Willful interference with Ombudsman duties.
D4

Add, “Social media posts that are made without a resident’s
permission and do not meet criteria for abuse.”

Did not include, this can be addressed in a
training example.

We recommend expanding the Examples and Reporting Tips to
“Examples and Reporting Tips” revised.
include failure to close doors/privacy curtains when giving personal
care.
Response to complaints,
grievance-process

D5

The Definition is unclear and removes helpful definitions for
current NORS complaint code L88 and L89.

No change in definition. “Examples and
Reporting Tips” added to include “Use if the
grievance procedure is not followed or made
Recommendation: End the Definition after the words, “…grievance known to residents.”
process.” Add to the definition, “Use if the grievance procedure is
not followed or made known to residents.”

Freedom from Retaliation

D6

Issue: The title, Definition, and Examples need clarification.
Title changed to “Retaliation.”
Recommendation 1: Change the title to “Retaliation.”
Definition revised as suggested.
Recommendation 2: In the Definition, strike “and similar problems”
and add “to the facility, ombudsman, or state survey agency.
“Examples and Reporting Tips” revised.
Includes retaliation in response to actions taken by a resident,
family, or another person acting on behalf of a resident.”
Recommendation 3: Revise the last sentence in Examples and
Reporting Tips to more clearly direct when the ombudsman should
report retaliation as abuse or neglect.

10

Label

Code

Visitors

D7

Resident or Family Council

D8

Exercise other rights and
preferences

D9

Financial, Property

E

Billing/charges

E1

Comments

ACL Response

Include removal of cigarettes as an example of retaliation rather
Do not include specific example, this can be
than in the list of possessions in E2.
included in a training example.
Issue: The definition does not address the resident’s right to have Revised definition based on suggested
visitors at the time of their choosing.
language.
Recommendation: Revise the definition to say, “Restrictions on a
resident’s ability to choose who to associate with, and when to visit,
either in the facility or in the community.”
D8: include "staff dominance over rather than support of" resident Definition modified.
or family council.
No comments

Accepted suggested label change to “Other
rights and preferences.”

Issue: The Definition needs clarity and contains examples.

Accepted.

Recommendation: Move examples to Examples and Reporting Tips, “Examples and Reporting Tips” revised.
and add “Billing for items or services which should be covered by
Medicaid.”

Personal property lost,
destroyed

E2

Issue: Clarifying language is needed in Definition and in Examples
and Reporting Tips.

Accepted. Definition modified with part
moved to “Examples and Reporting Tips.”

Recommendation: Revise the definition to read, “Resident property
lost or destroyed including resident money or trust fund
mismanaged. Move all the examples listed in the definition to the
Examples and Reporting Tips section and add failing to reimburse
resident for lost or damaged items.
E2

Move all the examples listed in the definition to the Examples and Accepted – See I05- Housekeeping, laundry
Reporting Tips section and add failing to reimburse resident for lost and pest abatement
or damaged items. Remove laundry from this section and include in
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Code

Comments

ACL Response

new I5 section on “Housekeeping and Pest Abatement”. Add tip
that laundry should be coded under this new section.

E2

Remove cigarettes from this list of items that are for resident
wellbeing.

See revised “Examples and Reporting Tips.”

E2

The proposed E2 has combined the current E37 Personal funds –
The definition was revised but we did not add
mismanaged, access/information denied, deposits and other money “funds mismanaged code” as a separate code
not returned with the current E38 Personal property lost, stolen,
Funds mismanaged is 1.3% of all complaints
used by others, destroyed, withheld from resident; however the
and can be adequately identified within
concepts and issues encompassed in the current E37 and E38 are personal property.
not fully evident in the proposed E2.
Correct the title of E2 as ‘Personal Property Lost, Destroyed’ does
not convey funds mismanaged, withheld etc.. For example:
E2 Personal property including resident funds mismanaged, lost,
stolen, used by others, destroyed, withheld from resident

Care

F

Accidents, falls

F1

Issue: In the Examples and Reporting Tips, the use of “A selfpropelling resident” should be changed to use more personcentered language.

No change. “Self-propelling “ is a more active
description than “A resident using a
wheelchair.”

Recommendation: Under Examples and Reporting Tips change “A
self-propelling resident” to A resident using a wheelchair.
The definition does not match the ‘title’ of the code. The definition Label changed to “Accidents and Falls.”
needs to include ‘injury of unknown origin’ and not simply
Definition modified to include “injury of
unexpected or unintended incidents.
unknown origin.”
Recommendation: Include ‘injury of unknown origin’ in the
12

Label

Code

Comments

ACL Response

definition of F1 and not simply ‘unexpected or unintended
incidents’.
Failure to respond to
requests for assistance

F2

Failure to provide
adequate care planning

F3

Issue: Differentiate from D6-retaliation

“Examples and Reporting Tips” revised.

Recommendation: Add in Examples and Reporting Tips, “If lack of
response to request for assistance is in response to a resident
complaint or actions taken by the resident, family, or other person
involved in the resident’s care, use D6, (Retaliation).”

Issue: Does not include person-centered planning.
Recommendation: Add to Definition, “Facility does not create or
follow a person-centered care plan.”

Medications

F4

No comment

Personal hygiene

F5

Issue: Need examples to be expanded. Think it is clear enough
Recommendation: Add Example to include infection control issues
when related to poor hygiene.

Access to health-related
services

F6

Symptoms unattended

F7

Definition revised to be inclusive of “person centered care plan.”
“Examples and Reporting Tips” revised.

Added “Examples and Reporting Tips.” Did not
get as specific as suggested recommendation.

Issue: The Examples and Reporting Tips section needs to be
Definition revised.
expanded. I think it’s clear enough
“Examples and Reporting Tips” revised.
Recommendation: Under Examples and Reporting Tips add
including mental health services after psychosocial. Also add Use D1
if denied choice of medical provider.
Issue: Nothing addressing wandering behaviors
Definition revised.
“Examples and Reporting Tips” revised.
Recommendation: Under Examples and Reporting Tips under area
about lack of monitoring add “failure to redirect residents who
display wandering tendencies.”

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Label

Code

Comments

ACL Response

Toileting, incontinent
care, catheter care

F8

Issue: In the description section the use of “toileted” should be
Definition revised as suggested.
changed to use more person-centered language.
Recommendation: Under Definition change “toileted” to assisted in “Examples and Reporting Tips” revised.
going to the bathroom. Assisted to going to the bathroom has a
different connotation.

Assistive devices,
equipment, other
supports

F9

No comments

Rehabilitation Services

F10

Issue: Add a reference to A5 to clarify when to use F10 or A5.
Definition revised.
Recommendation: Under Examples and Reporting Tips, add Use A5 Revised “Examples and Reporting Tips.”
for contractures due to gross neglect. Contracture is a possible
The contracture complaint code has received
outcome of neglect or lack of care.
less than 100 complaints each year for the
past 5 years. Prefer to address this detailed
level of coding in training.

Label revised to “Assistive devices or
equipment.”

Issue 1: The title is inconsistent with the definition because it only Label revised to “Rehabilitation Services.”
reflects rehabilitation services to maintain function, instead of also
Definition revised.
including services to improve function.
“Examples and Reporting Tips” revised.
Recommendation: Change the title to “Rehabilitation Service” to
make it consistent with the definition that includes rehabilitation
services to improve and maintain a resident’s function.
Physical restraintassessment, use,
monitoring

F 11

The definition is unclear.
Definition revised.
Recommendation: Under Examples and Reporting Tips, add or any “Examples and Reporting Tips” revised.
other devices a resident is unable to get out of without assistance
including reclining chairs and bed rails. Also add Use this code for
issues involving the assessment, use and monitoring of physical
restraints.
Recommendation: Under definition add “Use this code for issues

“Examples and Reporting Tips” revised.
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Label

Code

Comments

ACL Response

involving the inappropriate assessment, use and monitoring of
physical restraints.” Under Examples and Reporting Tips, after
“easily” add “or any other devices a resident is unable to get out of
without assistance including reclining chairs and bed rails”.
Chemical Restraint

F-12

Activities/Community
Integration and Social
Services

G

Activities -choice and
appropriateness

G1

Issue: Clarify under the definition that is code is to be used for
inappropriate assessment, use, monitoring and reduction of
chemical restraints.
Recommendation: Under definition add “Use this code for issues
involving the inappropriate assessment, use, monitoring and
reduction of chemical restraints.”

Definition revised.
“Examples and Reporting Tips revised.”

Issue: Include choice and appropriateness in the definition of this
code.

Definition revised.
“Examples and Reporting Tips revised.”

Recommendation: Under definition, after “Lack of” add “choice
and”
Include individual use of e-readers, personal music devices, and
These are examples that can be used in
computers as essential components of activities that residents must training.
be able to access if desired.
Transportation

G2

Issue: Alternate code option is mislabeled.

Corrected

Recommendation: Revise Examples and Reporting Tips to read,
“Use L2 L3 if complaint is about a transportation service.”
Tip refers to L3 if complaint is about a service. Presumably L2 was
intended. However, while there are outside transportation
providers, there is also Medicaid Brokered transportation provision
which should be coded as a complaint against Medicaid services.
Some specificity in usage and differentiations is helpful with using

This complaint is about the failure of the
facility to assist the resident in obtaining
transportation, not about the payment source
or the transportation service. Agree that if the
complaint was about a Medicaid service it
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Label

Code

Comments

ACL Response

complaint codes to inform the ‘picture’ of long term care in locales, could be coded as K2 Medicaid. The NORS
and state. Specificity is also helpful to Programs in addressing
codes and reporting tips do not cover every
systems issues.
potential complaint variable.
Conflict resolution

G3

This complaint and the accompanying description do not seem
appropriate for Activities, Community Integration and Social
Services. It would be more appropriate as a new section L3 under
System/Others (non-facility). This section replaces “resident
conflict, including roommates” from the current complaint codes.

Definition revised.
“Examples and Reporting Tips” revised.

The code remains G03 within the “Activities,
Community Integration and Social Services”
category. The facility staff has a responsibility
Recommendation: Move to System/Others (non-facility). Create a
to assist residents to resolve conflicts.
new code L3 and add examples to clarify. Include a Definition to
read, “A complaint involving a disagreement between residents or
resident and another party where the assistance of the
Ombudsman is requested by the residents to achieve a resolution.”
Add Examples and Tips such as roommate disagreement over the
volume of the TV or visitors in the room.

G3

Add examples such as, “roommate disagreement over the volume “Examples and Reporting Tips” revised.
of the TV, visitors in the room, and conflict between residents about
a resident council.”
If the disagreement is between resident / or their legal decision
Conflict between a resident and their family or
maker where appropriate and the facility staff and the ombudsman legal decision maker is code L01 “Resident
is requested by either entity to assisted with conflict resolution /
representative or family conflict.”
mediation, where would one code this? The above definition only
applies G3 to an issue between residents.
Recommendation: Broaden the definition to include requests for
conflict resolution for issues between residents, resident and family
or resident and staff etc.

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Label
Social Services

Code
G4

Comments

ACL Response

: Need to define what is meant by social services and add examples “Examples and Reporting Tips” revised.
in the appropriate section.
Recommendation: Under Examples and Reporting Tips add, For
example, discharge planning, family support, and grief counseling.

G4

The term “social services” means different things in various
settings. Provide a description of social services in the Definition
section. Add examples in the appropriate section.

The definition did not change. This definition
is intended to apply to both nursing facilities
who have staff such as social workers and to
residential care communities who may not
Recommendation: Under the Definition add “Social Services means
have dedicated social work staff.
services typically provided by a social worker, counselor or
discharge planner.”
Under Examples and Reporting Tips add, “Examples include but are
not limited to: admission process, discharge planning, making
medical appointments, arranging for escorts to appointments,
family support, and grief counseling.”

Dietary
Food Services

H
H1

Issue: Need to add examples related to weight loss
Recommendation: Add an example that addresses weight loss
related to food issues.

If a resident is losing weight because the food
is not palatable it is still a problem with the
food service.
Weight loss for other reasons is more closely
related to care.

H1

Move examples to the appropriate section.

Definition revised.

Recommendation: Move “Examples include: the posted menu….and “Examples and Reporting Tips revised.”
similar complaints” from the Definition section to the Examples and
Reporting Tips section.

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Code

Comments

ACL Response

Assistance with Dining
and Hydration

H2

No comments.

Code renamed “Dining and Hydration.”

Therapeutic/ special diet

H3

No comments.

“Examples and Reporting Tips added.”

General comment: Proposed complaint code revisions in section ‘I’
have omitted Infection Control. Infection Control (current 81
complaint code) is a critical issue and needs to be added to the
proposed codes.

Infection control has not reached 1% of all
complaints over the past 5 years.
A new code I05 was added to address
housekeeping complaints.

No comments.

“Examples and Reporting Tips added.”

Environment

I

Environmenttemperature ventilation

I1

Equipment/Buildings

I2

Code renamed “Environment.”
This code combines the current 78 ‘Cleanliness, pests, general
Agree. A new code I05, “Housekeeping,
housekeeping’ with 79 ‘Equipment/Buildings – disrepair, hazard,
laundry and pest abatement,” was added to
poor lighting, fire safety, not secure’. These are two different
address housekeeping complaints.
categories of issues that are difficult to combine. A building in
disrepair with an elevator malfunctioning is very different from
housekeeping and/or pests. A state or local program needs some
specificity in complaint codes in order to differentiate issues to
apply data to systems change efforts. Some code combinations
proposed would end up requiring state and local ombudsmen to
have to read through numerous cases documentation to ascertain
the scope of a ‘pest’ problem or the scope of physical plant
disrepair in a particular chain provider that may for example have
declared bankruptcy.
Recommendation:
Re-examine the proposed complaint codes that have combined
current complaints codes with attention to the top complaint codes
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Label

Code

Comments

ACL Response

utilized and need for specificity / meaningful data to inform systems
advocacy efforts.
Inadequate Supplies and
furnishings

I3

The definition seems unrelated to the code title. The current
Agree.
definition would seem more appropriate under the previous code, I
Code label changed to “Supplies, Storage and
– 2, Buildings/Equipment, which deals with maintenance and
Furnishings.”
environment. The definition does not mention supplies.
“Examples and Reporting Tips” added.
Recommendation: Change label to Supplies, Storage and
Furnishings. Revise the definition to include lack of supplies such as Laundry complaints are now in I05.
bed linen, towels, toilet paper; lack of furnishings in resident rooms
or common areas; and inadequate dining supplies.
Laundry issues (lost or damaged items, frequency, and process)
remain a common complaint for many programs. There does do not
appear to be an appropriate code (or related definition) to report
these types of complaints.
Recommendation: Create a label code I – 5, Housekeeping and
Pests, and create a definition to include laundry issues, pests, and
cleanliness.

I3

I3 title indicates the complaint would be about supplies and/or
furnishings; however, the definition only addresses furnishings.

Definition now addressees shortage of
supplies.

Current code has 85 Supplies and Linens – not available, in poor
condition, shortage of supplies (soap, gloves, toilet paper,
incontinence products, nursing supplies which is a significant
complaint category.

“Examples and Reporting Tips” added.

Recommendation: Include supplies and linens issues in the
definition of the proposed code or have separate codes for supplies
and furnishings/ storage.

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Label

Code

Accessibility

I4

Facility Policies,
Procedures and Practices

J

Administrative
Oversight/leadership

J1

Comments

ACL Response

No comment

Current codes have a category for administrator being unresponsive Agree. Definition and “Examples and
which is a frequent issue. Tip section should include failure to
Reporting Tips” amended.
report incidents to the regulatory entity.
Recommend: Revise definition to include ‘unresponsive’:

Fiscal Management

J2

No comments

“Examples and Reporting Tips” revised.

Staffing – inadequate

J3

No comments

Code name revised to J03: “Staffing.”
“Examples and Reporting Tips” added.

Complaints about an
Outside Agency (nonfacility)

K

Certification/Licensing
agency and regulatory
system

K1

One commenter provided extensive comments regarding the
reduction of K topic codes.

These codes are not frequently used, for
example, all complaints related to “State
Medicaid agency “is less than 1%. If a state
•This proposed code section appears to replace the current N, O &
wishes to have a more granular code related
P sections without adequately covering the complaint categories
to Medicaid they can add these codes in their
currently covered. Essentially, the proposed code goes into
software system and crosswalk it to the NORS
specificity with various types of insurances but omits programs and
Medicaid code.
agencies (though the definition indicates it is for “…complaints
involving decisions, policies, actions or inactions by the programs ACL and their contractor have developed
and agencies”.
crosswalks to assist states in determining how
old codes are mapped to new codes.
•This proposed arrangement loses the specificity of common
Medicaid complaints of access to information, denial of eligibility, We believe that reducing and combining
non-covered services, Personal Needs Allowance and the quality or complaint codes and removing codes that are
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Label

Code

Comments

ACL Response

quantity of services or difficulty in obtaining services. Coding with rarely used will reduce states’ reporting
the proposed code of K2 Medicaid will only provide reporting
burden.
information that there were X number of complaints regarding
Medicaid with no indication of what the issue may be such of denial
of eligibility issues versus PNA. To have data to address any
systems issue regarding Medicaid, will require the Ombudsman to
read through each case with a K2 complaint to determine what the
issue with Medicaid may be.
•Current complaint code categories that appear to be omitted from
the proposed complaint codes include: bed shortage – placement;
facilities operating without an license; legal issues of guardianship,
conservatorship, powers of attorney; problems with resident’s
physician/assistant; Adult Protective Services; SSA, SSI or other
benefits (an example of ‘other benefits’ would be a state specific
program.).
•There appears to be an emphasis on insurance types in this section
at the loss of ‘programs’ and ‘agencies’ complaint codes.
Recommendation:
Reassess the purpose and use of ombudsman program data at local,
state and national levels and the degree of specificity of complaint
codes needed to address issues. While there is value in combining
some complaint code categories, there is loss and increased burden
of ‘research’ in omitting some current complaint categories.
Medicaid

K2

No comments.

“Examples and Reporting Tips” added.

Managed care

K3

The definition is vague and refers to eligibility that is not a function Agree. Definition and “Examples and Reporting
of managed care. Problems with eligibility are likely to relate to
Tips” amended.
Medicaid or Medicare.
21

Label

Code

Comments

ACL Response

Recommendation: Revise the definition to read, Problems with
managed care services, coverage areas, enrollment and disenrollment, and the grievance and appeals process.
Medicare

K4

No comments.

Veteran’s Administration

K5

No comments.

Private Insurance

K6

No comments.

Request to transition to
community setting

K7

It is unclear whether this category should be used when the
problem is not with the facility.
Recommendation: Amend definition to add at the end, “… , not
related to facility action or inaction.”
Code does not seem to be appropriate under the “Complaints
about an Outside Agency (non-facility)” category.

“Examples and Reporting Tips” added.

Agree K7 moved to L03 “Request to transition
to community setting” under “System: Other
(non-facility) category.
Definition and “Examples and Reporting Tips”
amended.

Recommendation: Consider moving to general category L,
“Systems/Others (non-facility)”.
System/Others (nonfacility)

L

Resident
Representative/Family
conflict; interference

L1

No comments.

Code name revised: “Resident Representative
or Family Conflict”

Services from outside
provider

L2

The title may be misleading.

Category K is for complaints involving
decisions, policies, actions or inactions by the
programs and agencies listed in K01-K06, i.e.
Medicaid and Medicare and other private and

Recommendation: Rename category to Non-facility persons,
representatives or providers.

22

Label

Code

Comments

ACL Response

Issue 2: Code does not seem to be appropriate under the “Systems” public benefits.
category.
L-System: Others (non-facility) is intended to
Recommendation: Consider moving to general category K,
capture those resident complaints that are not
“Complaints about an Outside Agency (non-facility).
about the facility or a public or private benefits
agency.
The definition and “Examples and Reporting
Tips” were amended.

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