Table 3 ACL Response to Comments

Administration for Community Living – Response to comments on proposed revisions of the National Ombudsman Reporting System (NORS)
Table 3 - State Program Data Elements
States will submit a wide range of elements describing their statewide Ombudsman program grouped into a range of categories:
Public comments to table 3 primarily focused on proposed editorial changes to the examples and reporting tips; many of those were amended
into the final table. This review focuses on recommended additions or deletions to the proposed data collection.
Element
Number
S-01-S-06

Data Element

Comment

ACL Response

Case (now called complaint )
example
Provide 2-3 complaint
examples.

Change word from case to complaint

Recommendation accepted

Limit the requirements in this section to two case complaint
examples, one example from a nursing facility and one from a
board and care facility.

S-10

Systems Issue Status

S-12

Strategies applied to resolve
the reported systems issue.

Issue: It is unclear which code or value to choose if a systems
issue is both newly identified in the reporting year and fully
resolved as the Quantifier states “Single per Systems Issue”. No
Examples and Reporting Tips are provided.
Recommendation: Change code options to “1 = Newly
identified in this reporting year” and not yet resolved and “3 =
Fully or Partially Resolved” including issues that are newly
reported or an ongoing issue from last year. Under Examples
and Reporting Tips for code 3, include language that the Office
completed all work on this issue; otherwise, code 2 should be
selected.
Issue: This section does not include Examples and Reporting
Tips. Recommendation: Provide examples of when a situation
would be considered a case verses when it could be considered
a systems issue.

No change. Many states provide
more than 2 complaint
examples. Offering a third
optional example does not add
burden.
Recommendation accepted

Partial acceptance. A systems
issue may come from a specific
case. One does not exclude the
other. Systems issues reporting
will be addressed in NORS

Element
Number

Data Element

Comment

ACL Response
consistency training.

S-15

Local Ombudsman Entity

Issue 1: This section is required, but not all states have local
ombudsman entities.
Recommendations: Include a “not applicable” element for
states reporting no local ombudsman entities.
Issue 2: Clarification and a change are needed for 5 under
Codes and Values. It is written as a “regional representative of
State Ombudsman program – an employee of the State
Ombudsman program serving a specific geographic region.”
Recommendations: Given this coding category is titled “Local
Ombudsman Entity”, XX recommends that ACL collect
information about regional representatives of a State
Ombudsman program in a separate reporting category because
staff in these regional offices are not local ombudsman entities.
While it is reasonable for ACL to collect this information, it
should strive to collect information in such a way that does not
lead to confusion about the definition of a local ombudsman
entity.

Issue 1 – Accepted
Issue 2 – Accepted, code
number 5 removed. No separate
reporting category is necessary.

S-21/ S-26

Other volunteers, not
representatives of the Office
(State & Local)

S23

Total FTE in local
Ombudsman entity

Issue: Clarification is needed regarding S21 and S26. ACL has
raised questions regarding state practices with volunteers who
are not representatives of the Office.
Recommendation: Delete the collection of data on “Other
Volunteers, not representatives of the Office.” If this is not
deleted, XX recommends that ACL provide examples and
reporting tips to explain elements S21 and S26 and set clear
boundaries on volunteer activities that are allowable and
reportable in NORS.
1.) - Many local Ombudsman programs are able to supplement
State and Federal Ombudsman funds with locally raised funds

No Change. Many states have
volunteers who support the
program in advisory, fundraising
or in other programmatic
capacities. This provides an
opportunity to fully reflect all
volunteer support to a state
program. Reporting tips were
added.
1.) No change, this would be too
burdensome. States will report
2

Element
Number

Data Element

Comment

ACL Response

(grants, fundraising, donations, etc.). The use of these locally
raised funds to pay for Staff Ombudsman or FTEs can cause
over-reporting of FTEs provided by State and Federal dollars.
When comparing Ombudsman programs or looking at the total
number of FTEs provided nationwide with State and Federal
dollars, the inclusion of FTEs provided with local/non-Federal
and State funds creates an unfair imbalance and gives credit for
FTEs that are not creditable to Federal or State resources.
We recommend that the State report contain one Element for
FTE Local Ombudsman Staff funded with State and Federal
Ombudsman funds and another Element for FTE Local
Ombudsman Staff funded with Local Funding.

on all funds expended to
accurately reflect the statewide
program, including sources at
the local level. Likewise States
will report on all FTE’s regardless
of source of funds. The LTCOP
Rule defines the Ombudsman
program to include all
representatives of the Office and
any local entities; separating out
FTE reporting could cause
confusion.

2) The proposed elements have omitted requesting number of
local ombudsman working full-time on the ombudsman
program. This element is important because it portrays a more
accurate picture of the Program and is helpful in advocating for
additional resources. Also omitted is ‘Paid clerical staff’ at both
the state and local level.

2.) No change. A clear count of
the number of people and FTE’s
will provide an estimate of the
number of people working fulltime and give a clear picture of
the staffing resources. Currently
there is confusion as to what
constitutes full-time.
Reporting of “paid clerical staff”
is unclear to many programs;
often paid clerical staff is
designated as a representative
of the Office and fulfill that role
but also have clerical
responsibilities. This has
resulted in undercounting those
individuals who serve a direct
program purpose.
3

Element
Number
S-27-S-29

Data Element

Comment

ACL Response

Conflicts of interest
reporting

Comments had various suggestions and requested further
technical assistance and reporting tips.

S-37

Identification of Other
Federal Sources

Various suggestions to add other federal sources, and questions
about the titles, i.e. “Community Service Block Grant” versus
“Community Development Block Grant.”

S-37

Funds expended – state
level

Issue 1: The Data Element – Identify other sources at the state
level, is not clear regarding who raises the money versus who
expends the funds. How is that reported? For example, the
State Ombudsman may do the work to secure a new funding
source for local ombudsman entities. The State Ombudsman
does not receive funding from this new funding source. Only
local entities benefit from it.
Recommendation: XX requests clarification on this issue.

Conflict of interest reporting was
approved in NORS under OMB
NO.: 0985-0005. ACL has
provided technical assistance
and worked with the National
Ombudsman Resource Center
(NORC) to develop further
clarifications and technical
assistance tools. The software in
development will allow for
states to choose their conflicts
from the previous year and to
edit if necessary.
No additional sources were
added. One was modified to
read “Social Services Block Grant
or Community Services Block
Grant.”
No change. ACL will provide
further guidance in NORS
consistency training.

S-45-S-47

Residential Care Community
name and definition

1. Issue: Names, types, and definitions of types of residential
care communities will not change significantly from year to
year. Entering each year when there is no change will be
unnecessarily time-consuming.
Recommendation: ACL should develop a reporting tool to carry

1. Agree. The reporting tool will
allow for previous year’s
information to roll over to the
current reporting year.

4

Element
Number

Data Element

Comment

ACL Response

responses over from year to year. Add a statement attesting
that there has been no change from the prior year or require
that updates be made.

2. The business rules were
revised, however many states do
provide Ombudsman services to
unlicensed homes and we want
to provide the option to include
those homes in their facility
count; this is not a change in
practice. The revised reporting
tips make it clear that it is
optional. “Reporting the
number of unregulated or
unlicensed Residential Care
Communities is optional (not
required.) “

2. Issue: Under Business Rules, states are given the option to
not report on unlicensed homes. XX believes this will create
inconsistency in the data.
Recommendation: Delete the Business Rules comments for this
element.

S-49

Number of Training Hours
Required to Maintain
Certification (now called
Continuing education)

S-53-S-55

Information & Assistance to
individuals

Issue: States may have various levels of required hours based
on volunteer or paid status. It is unclear how or whether these
levels can be reported, and if only one level can be reported,
which one.
Recommendation: Add under Business Rules, If a state has
various levels of training based on volunteer or paid status,
select the minimum number of annual training hours required
to maintain certification status.
Page twenty-two indicates a ‘language’ change in Activities
terms of ‘Information and Consultation’. The term
‘Consultation’ (in current and past use) is proposed to change
to ‘assistance’ whereby the activities types in the proposed
language would be ‘Information and Assistance’, ‘Information
and Assistance to Nursing Facility Staff’ and ‘Information and
Assistance to Residential Care Community Staff’. The change of
‘consultation’ to ‘assistance’ is an unnecessary change and it
lessens the substance and depth of the activity. We

Agree, included in reporting tips.

No change. Ombudsman
programs typically provide
information and assistance or
referrals to residents, their
families, facility staff and others.
We are using this term for
consistency purposes.

5

Element
Number

S-56-S61

Data Element

Facility visits, number of
facilities visited and routine
access

Comment
recommend that the use of ‘consultation’ remain and that it
not be replaced by ‘assistance’. By retaining ‘consultation’ (an
accurate description of what is provided) it further
differentiates and expands the activity from I & A or I & R.
1. While this is a big change to the way facility visit data is
currently collected, AK OLTCO appreciates being able to
show data for all types of facility visits.
2. We strongly support the inclusion of these types of visits
in the Stare report. It is very important for the
Ombudsman Programs to show the real number of visits
to facilities.
3. The new items would certainly provide a better ‘picture’
of the Program work. This proposed change is welcomed
with the caveat that time is sufficient prior to
implementation, to reconfigure electronic data collection
programs to capture these numbers without requiring
multiple entries from the ombudsman for one
documentation. For example, if an ombudsman visits a
nursing home in the course of working on a case, the case
documentation should automatically reflect visits in the
‘number of facility visits’ count.
4. Elements #S58 and S61: Routine Access
We do not believe there is any evidence that shows a quarterly
visit to a care facility (skilled nursing or residential) ensures
resident access to the Ombudsman program. We recommend
that quarterly visits are eliminated as a measure of success or
resident access from all Ombudsman requirements. If it is not
possible to eliminate quarterly visits, we recommend changing
the wording for “Total Number of nursing facilities that
received routine access” to “Total number of nursing facilities
that received a quarterly visit.”

ACL Response

1, 2 & 3. Thank you. We believe
that states reporting software
systems can accommodate this
change. The ACL contractor
developing new software will
work with vendors to support
transition to a new reporting
system.
3. The suggestion made that
“the case documentation should
automatically reflect visits in the
‘number of facility visits’ count”
is appropriate to request of the
state vendor.
4-6. No change, we anticipate
that we will learn more about
the effectiveness of routine
access visits from the findings of
the LTCOP process and
outcomes evaluations.
ACL would like to maintain a
measurement of the number of
facilities that have at least
quarterly visits, not in response
to a complaint. This provides
some measure of LTCOP
6

Element
Number

Data Element

Comment

5.

The definition of “routine access” is limiting and does not
give a thorough picture of visitation and access.
Recommend, eliminate “not in response to a complaint”

ACL Response
presence in facilities. Further
guidance will be provided in
NORS consistency training.

6. Issue: It is difficult for local ombudsman to visit facilities
for only one purpose. Even during a compliant visit, other
residents are visited and issues addressed. The opposite is
possible, local ombudsman make a facility visit that turns
into a complaint visit. It is a burden to collect visitation
data when it is very difficult to separate out the purpose
for the visit to a single reason.
Recommendation: to delete the S58 – and S61, allowing local
ombudsman to enter data for any type of visit and not separate
visitation by a complaint or non-complaint visit.

S64-S67

Resident and Family
Councils in Nursing Facilities
and Residential Care
Community Facilities

Issue: The OAA requires ombudsman programs to “provide
technical support for, actively encourage, and assist in the
development of resident and family councils to protect the
well-being and rights of residents”. Reporting only attendance
at council meeting or meeting with council leadership does not
capture the support and assistance provided by ombudsmen,
which is often of more value than attending a council meeting.
Recommendation: Expand Business Rules for S64, S65, S66, and
S67, to state, Including but not limited to meeting with council
leadership, providing training, consultation, and resources.

Accept part. New definition
reads: “Total number of
instances of attendance, at
resident councils, including
meeting with council leadership,
and training of resident councils
at nursing facilities by
representatives of the Office.”
Providing consultation and
resources outside of a meeting
can be documented as an
information and assistance
7

Element
Number

Data Element

Comment

ACL Response
activity.

S68

Community education

Issue: Not counting newsletters, blogs and other forms of
media in this element fails to capture important modern ways
in which ombudsman provide education and information to the
community.
Recommendation: Change the Business Rules so that
newsletters, blogs, and other forms of media be counted here
or add an element in order to give a full picture of ombudsman
work.

No change. ACL understands
that newsletters, blogs and
other forms of media are
important ways to educate the
public but we believe it would
be a reporting burden.

8