Number range CHAPTER**Instructions for Completing the State**

**Long Term Care Ombudsman Program Reporting Form for**

**The National Ombudsman Reporting System (NORS)**

**Part I - Cases, Complainants and Complaints**

In the NORS system, a case is equivalent to a complainant or a specific
group of complainants.

> Definition of *case*: each inquiry brought to, or initiated by, the
> ombudsman on behalf of a resident or group of residents involving one
> or more complaints which requires opening a case and includes
> ombudsman investigation, strategy to resolve, and follow-up.

Calls reporting incidents or seeking advice but not requiring ombudsman
involvement to the degree specified in this definition should be counted
as consultations to individuals or facilities in Part III. D, or
recorded in some way specific to the state's needs but not included in
the NORS complaint system. For example, in those few states where state
law requires reporting instances of nursing home abuse to the ombudsman
program, the reports should not be counted as a case and as an abuse
complaint unless the ombudsman program investigates and is actively
involved in working out a resolution. Unless the ombudsman program is
actively engaged in investigating and working to resolve the problems
reported, the program should keep its own list of such reports and not
include them in the data submitted in the NORS system.

A.  **Cases Opened**

Provide the total number of *cases opened* during the reporting period.
Use definition of *case* provided on the form and above. (Note: This is
a free-standing number used to show the volume of cases on an annual
basis. The NORS system does not require reconciliation between the
number of cases opened and the number closed.)

B.  **Complainants/Cases Closed**

A case is equivalent to a complainant, and the number of complainants
will equal the number of cases filed.

For all *cases closed* during the reporting period, provide the number
of complainants, by type of facility/setting. Refer to discussion of
type of facility or other setting under D.1, below.

> Definition of *case closed*: *A case where none of the complaints
> within the case require any further action on the part of the
> ombudsman and every complaint has been assigned the appropriate
> disposition code.*

A case is closed when all complaints which are part of the case have
been resolved and/or no further ombudsman action can be taken for
reasons listed in Part I, E.2, "Complaint Disposition." (*A word about
the definition of closed cases*: Ombudsmen sometimes must refer
complaints to another agency for resolution. The ombudsman should follow
up on these complaints and record the outcome under the appropriate
category in Part I, E.2, "Complaint Disposition." Disposition categories
d.1), 2) and 3) in Part I, E.2 are for use only in those instances when
the agency to which the case was referred fails to act on a complaint or
provide a response to the ombudsman\'s attempts to follow up, or
follow-up is otherwise not possible. Since this outcome, although
undesirable, occasionally occurs with complaints, it is included in the
definition of closed case.)

> Definition *complainant*: an individual or a party (i.e., husband and
> wife; siblings) who files one or more complaints made by, or on behalf
> of, residents with the ombudsman program.

If more than one person or party **independently** file separate
complaints about the same situation in the same facility, or the same
problem outside of any facility, count as separate cases. If more than
one person **jointly** file complaint(s) about the same situation in the
same facility or outside the facility, count as one complainant and one
case.

A referring agency is not a complainant, but staff of another agency may
be aware of a situation and file a complaint about it, thus qualifying
as a complainant.

Clarification of selected categories of complainants (self-evident
categories are not repeated):

**2. *Relative/friend of resident*** includes relatives who are also
guardians or legal representatives but not friends who are also
guardians/legal representatives. For friends who are also guardians or
legal representatives, use category 3. Category 2 should be used for any
friend or acquaintance of the resident who does not more appropriately
fit into another category. Examples: church friends, hairdresser, etc.

**5. *Facility administrator/staff or former staff*** is for facility
representatives who register complaints ***on behalf of residents***. If
a facility administrator or staff person asks the ombudsman program for
assistance with a situation which is a problem for the administrator
and/or staff person, such as a resident with a behavior problem or
difficulties with a family, the problem should not be recorded as a case
but rather documented as "consultation to facilities" under III.D.4. in
the "Other Ombudsman Activities" section. The rationale for this is that
the ombudsman program is charged under the Older Americans Act with
identifying, investigating and resolving complaints that "***are made
by, or on behalf of, residents***" (Sec. 712\[a\]\[3\]\[A\]), not
complaints made by, or on behalf of, other parties.

**6. *Other medical: physician/ staff*** includes physicians and staff
of hospitals, hospices, clinics, visiting nurse programs and similar
programs which are primarily oriented toward providing medical/health
care.

**7. *Representative of other health or social service agency or
program*** includes individuals other than ombudsmen or ombudsman
volunteers who file complaints (not merely refer other complainants) and
are affiliated with such agencies as: area agencies on aging, facility
licensure and certification, homemaker agencies and similar agencies
which are primarily oriented toward health or social services. (If other
agency requests consultation, in contrast to filing a complaint, record
under \"Other Ombudsman Activities," Part III, D., item 4.)

**9. *Other*** includes any complainant whose identity is known but who
does not fit easily into a listed category. Examples: bankers, clergy,
law enforcement, public officials. For complainants in this category,
specify in the space provided the types included in the numeric count.

**C. Total Complaints:**

For all *cases closed* during the reporting period, provide the total
number of complaints received. This will be the same number as the
combined total from Part I, D, *Types of Complaints*, including
complaints from nursing facilities; board and care and similar types of
facilities and other settings. (Do not report complaints for cases which
are still open at the end of the reporting period. Save those for the
next reporting period, after the case is closed.)

**D. Types of Complaints**

*General Instructions for Complaint Categories*

For all *cases closed* during the reporting period, provide the total
number of complaints received by the statewide ombudsman program in each
of the complaint categories listed. Use the following definition of
*complaint*, which is also provided in Part I, C, page 1 on the hard
copy of the reporting form.

> *complaint*: a concern brought to, or initiated by, the ombudsman for
> investigation and action by or on behalf of one or more residents of a
> long-term care facility relating to health, safety, welfare or rights
> of a resident. **One or more complaints constitute a case.**

As stated in the definitions of *case* and *complaint*, each case may
have more than one complaint. However, each problem, or complaint, will
have only one code. Use only one category for each type of problem
(i.e., do not check both A.3 and D.26 for the same staff behavior ---
determine which category is most appropriate to the particular problem).

*Type of Facility*: For each type of complainant, place in the first
column the number received involving a skilled nursing facility as
defined in section 1819 of the Social Security Act or a nursing facility
as defined in section 1919(a) of the Social Security Act (Older
Americans Act Section 102(32)(A) and (B)).

Place in the second column totals of complaints received involving
problems of residents in facilities, *whether licensed or unlicensed,*
which the ombudsman program is authorized to serve under Section
102(32)(C) and (D) of the Older Americans Act, including the following:
board and care homes, residential care facilities, adult congregate
living facilities, assisted living facilities, foster care homes, and
other adult care homes similar to a nursing facility or board and care
home which provides room, board and personal care services to a
primarily older residential population.

Add totals in both columns, sections A through P, to total for Section
Q. Place grand total at **Total Complaints** on page 7 and in box at C
on page 1.

***Specific Instructions for Complaint Categories***

See the attachment to these instructions for examples of what types of
problems to code in the specific complaint categories. (State and local
ombudsman programs may wish to reproduce the attachment for staff and
volunteers to use in documenting complaints.)

The first four major headings -- Residents' Rights, Resident Care,
Quality of Life and Administration -- are for complaints involving acts
of commission or omission by staff or management of the facility, or
problems which staff or management has the responsibility to resolve.

The fifth major heading is for complaints against individuals or
agencies outside the facility, or problems which can be resolved only by
outside agencies or individuals. **Use P. 128 "Request for less
restrictive placement" for requests for less restrictive setting and
describe in the narrative section for this category.** (Use Part III. D.
5, "Information and Consultation to Individuals" for general information
on alternative care options, with no substantial ombudsman involvement
in counseling about or locating possible alternatives.)

The last section, Q, is for complaints involving settings other than
nursing or board and care or similar facilities, such as home care,
hospitals, hospices, or congregate housing where personal care to
residents is not provided. (The categories in Section Q are provided for
documenting numbers of complaints only; the form does not include types
of complaints for these settings, as such settings are not included
within the purview of the ombudsman program in the Older Americans Act.)

**Use Q.132 for complaints about services from an outside provider for a
resident in a long-term care facility.** (Example: outside home health
care for an assisted living facility resident; personal and homemaking
services in an assisted living facility, therapies, non-Medicaid
transportation, psychosocial services and other services provided to a
facility resident by an outside provider.)

Since ombudsmen are authorized to cover unregulated or unlicensed board
and care, assisted living and similar adult care facilities, code
complaints involving residents of these facilities in the right-hand
column for one of the first 128 codes in sections A-P.

See the attachment for other specific instructions on how to code
complaints.

**Part I, E.** **Action on Complaints**

> 1\. **Verification:** Provide, for *cases closed* during the reporting
> period, the total number of *complaints* which were verified, by type
> of facility. Use the following definition of *verified*:
>
> *verified*: it is determined after work (interviews, record
> inspection, observation, etc.) that the circumstances described in the
> complaint are generally accurate.
>
> Complaints included in the number of complaints received but not
> included in the verified total are considered unverified, but they are
> still counted in the disposition section below -- see following note.
>
> (Note: Some states investigate complaints which cannot be verified;
> other states do not. For this reason, the definition of \"case
> closed\" on page 1 of the form includes \"complaint cannot be
> verified\" as a reason for closing a case. However, the disposition
> categories in Part I, E. 2 do not include \"complaint unverified.\"
> States which do not investigate unverified complaints should use 2.e
> or another category which best describes the disposition of a
> particular unverified complaint.)
>
> 2\. **Disposition:** Provide, for *cases closed* during the reporting
> period, the total number of ***complaints** (not complainants/cases)*,
> by type of facility or setting, for each disposition category. Where
> there are two possible choices, the ombudsman must choose the *one*
> category which *best* describes the outcome of the complaint. See note
> above for documentation of unverified complaints.

If a complaint has been referred to another agency and that agency acts
on the complaint and reports the final outcome to the ombudsman program,
code in the appropriate disposition category: requires policy,
regulatory or legislative change to resolve; not resolved; withdrawn; no
action needed or appropriate; partially resolved; or resolved. If a
report on the referral is not obtained, code as E.2.d.1. If the other
agency fails to act on the complaint, code as E.2.d.2. If the other
agency did not substantiate the complaint, code as E.2.d.3.

> Definition of *resolved* complaint: The complaint/problem was
> addressed to the satisfaction of the resident or complainant.
>
> **The total for complaint disposition must be the same as total number
> of complaints received, by type of facility or other setting. The
> grand total, as provided on page 7 and in box at C on page 1, must be
> the same number.**

3\. **Discussion of Legal Assistance/Remedies** **(Optional)**:

For each facility type, list the number of legal assistance remedies
that were used in helping to resolve a complaint: a) legal consultation
was needed and/or used; b) regulatory endorsement action was needed
and/or used; c) an administrative appeal or adjudication was needed
and/or used; and d) civil legal action was needed and/or used.

**F. Complaint Description (Optional):** Provide on a one-page attached
sheet a concise description of the most interesting and/or significant
individual complaint your program handled during the reporting period.
State the problem, how the problem was resolved, and the outcome.

**Part II --- Major Long-Term Care Issues**:

A.  Describe in the section indicated the priority long-term care issues
    your program identified and/or worked on during the reporting
    period. For each issue, briefly state:

> a\) the problem and barriers to resolution, and b) recommendations for
> system-wide changes needed to resolve the issue, or a description of
> how the issue was resolved in your state. Examples of major long-term
> care issues may include facility closures, planning for alternatives
> to institutional care, transition of residents to less restrictive
> settings, etc.

***Note: Do not use attachments when entering this material on the data
input program provided for the report --- the material will be lost.
Enter the material in the box provided for this purpose in the data
input program.***

**Part III --- Program Information and Activities**

A.  **Facilities and Beds**

Provide, for both nursing facilities and board and care homes and
similar facilities (residential care facilities, adult congregate living
facilities, assisted living facilities, foster care homes, and other
adult care homes similar to a nursing facility or board and care home
which provide room, board and personal care services to a primarily
older residential population), at the places indicated, the number of
facilities which were regulated (licensed or registered) in the state
during the reporting period and the number of beds in those facilities.
(Note: Under the Older Americans Act, the ombudsman program covers all
such facilities, whether regulated or unregulated by the state, but it
would not be possible for the program to provide the total number of
unregulated facilities and beds. However, if the program receives and
opens cases involving unregulated facilities, it should document these
cases and complaints Part I in the same way cases and complaints from
regulated facilities are documented.

If there has been no change in the names and definitions of types of
board and care and similar facilities previously reported, type \"no
change\" at space indicated.

Per instructions from the U.S. Office of Management and Budget, the
State has the option of providing only the number of nursing facilities
which are **not** certified for Medicare and Medicaid, as numbers of
Medicare/Medicaid certified facilities are available to AoA from the
Centers for Medicare and Medicaid Services. If Medicare/Medicaid
certified homes are not included in the total, please indicate in a note
included with your submission.

B.  **Program Coverage**

Definition of *statewide coverage*: Residents of both nursing homes and
board and care homes (and similar adult care facilities) and their
friends and families throughout the state have access to knowledge of
the ombudsman program and how to contact it, and complaints received
from any part of the state are investigated and documented and steps are
taken to resolve problems in a timely manner, in accordance with federal
and state requirements.

**B. 1.** **Designated Local Entities**

Provide, for each type of host organization, the **number** of regional
or local ombudsman entities (programs) designated by the State Ombudsman
to participate in the statewide ombudsman program that are
geographically located outside of the State Office. There should be one
or more paid staff and/or volunteers designated by the state ombudsman
to investigate complaints and represent the state ombudsman program. As
indicated on the form, include regional offices of the state ombudsman
office.

**B. 2.** **Staff and Volunteers**

Provide the numbers of staff and volunteers, as specified at the state
and local levels.

**Staff**

Figures should be provided as a snapshot of actual staffing at the end
of the fiscal year at both the state and local level.

The Full-Time Equivalent (FTE) count includes both staff who work
full-time on the ombudsman program and those who work part-time on the
program. Each staff person who works full-time on the program is counted
as one FTE. If, however, an employee works only part-time or a full-time
employee works only a percentage of her time on the ombudsman program,
the FTE for that employee would reflect the percent of time in which
(s)he performed ombudsman work, up to two decimal places -- .25, .50,
.75, for example. Similarly, a full-time employee who splits her time
between state and local ombudsman work would be .5 FTE at each level.

**Volunteers**

Figures should be provided as a snapshot of actual volunteers (i.e., the
contingent of volunteers) serving at the end of the fiscal year at both
the state and local level. Include individuals serving the ombudsman
program **except** those who served only as members of advisory or
policy committees. Use the following definition for certified volunteer:

> *certified volunteer*: an individual who has completed a training
> course prescribed by the state ombudsman and is approved by the state
> ombudsman to participate in the statewide ombudsman program.

Include an estimate of the total number of hours donated by certified
volunteer ombudsmen during the reporting period on all activities --
training, regular visitation, complaint investigation and serving in the
ombudsman program in other ways.

C.  **Program Funding**:

Provide funds **expended** during the reporting period on the Ombudsman
Program as it is defined under Section 712 of the Older Americans Act,
regardless of the year for which it was allocated by AoA. (Expended
means when payment is made on incurred costs.) Do **not** include
amounts which were budgeted or obligated but not expended. **Do**
include amounts obligated in an earlier year but expended during the
reporting year.

Do **not** include Title VII, chapter 3 funds for abuse prevention
unless they were expended on ombudsman activities. Do **not** include
amounts which were expended on ombudsman activities not authorized under
Section 712 (i.e., ombudsman activity in settings other than long-term
care facilities, as defined in the Act).

Provide on the third line the Title III expenditures for State **or**
local ombudsman activity **made by the State** from Title III funding
made available under Section 304(d)(1)(B) of the Older Americans Act.
Provide on the fourth line Title III expenditures for local ombudsman
activity **made by area agencies on aging** from Title III funding
provided under Section 304(d)(1)(D) of the Act.

Provide other funding, by source, as specified on the form.

**D. Other Ombudsman Activities**

Provide the information requested in the appropriate column. Use the
State column for activities performed by the state office of the State
Long-Term Care Ombudsman. Use the local column for activities performed
by designated local or regional ombudsman programs, regional offices of
the state ombudsman program or individuals designated by the state
ombudsman to provide an ombudsman presence in a locality or region of
the state. These individuals may be paid or volunteer Ombudsmen. Provide
exact numbers wherever possible; where not possible, provide your *best
estimate* of the numbers requested. Please be sure to record each
activity only once, under the most appropriate heading.

Clarification of items listed on chart:

> **1. *Training for ombudsman staff and volunteers***
>
> The information is from the perspective of the trainer (not the
> trainee), reporting on training provided. Thus, sessions and hours are
> unduplicated. A session is a meeting, whether it lasts for three
> hours, all day or all week.
>
> In the state office column, give the number of training sessions and
> total hours provided or otherwise arranged by staff of the state
> office of the ombudsman for state or local program staff and
> volunteers, whether the meetings were held in the state capital or
> elsewhere in the state. In the local program column, give the total
> number of sessions and total hours provided or otherwise arranged by
> staff of local ombudsman entities or regional offices for staff and
> volunteers of the local program. When state staff provides all or part
> of the training, but the training is arranged by local program staff,
> the training is counted as local.
>
> For each level, provide the total number of trainees ([**not** an
> unduplicated count of individuals]{.underline}, but the total number
> people trained at each session) during the reporting year.
>
> List the three most frequent topics for training at the both the state
> and local levels.
>
> **2. *Technical assistance to local ombudsmen and/or volunteers***
>
> Record here *percentages of staff resources* devoted to the management
> and administration of local and volunteer programs as a whole. Provide
> in the state column an estimate of the percentage of total staff time
> which paid staff of the state office of the ombudsman (i.e., state
> ombudsman, plus other staff) devote to developing and assisting local
> programs, whether in person or by telephone. Provide in the local
> column an estimate of the percentage of total staff time which local
> program paid staff devote to developing volunteer programs and
> supporting other staff and volunteers. Include staff time spent
> developing and delivering training, passing along information from
> training sessions, conveying changes in procedures, reviewing others'
> cases records, and counseling and providing informal assistance to
> staff and volunteers.
>
> **3. *Training for facility staff***
>
> Give the number of sessions provided by state and local ombudsman
> staff and the three most frequent topics of training at each level.

**4. *Consultation to facilities***

> Ombudsmen often provide information and assistance to facility
> managers and staff. To capture the extent of this important activity,
> report the number of such consultations provided during the year. If
> there are repeated consultations to the same facility, count each
> consultation separately.
>
> Do not count training sessions, documented in F.3. Provide the three
> most frequent subject areas of consultation.
>
> **5. *Information and consultation to individuals***
>
> Provide the number of individuals assisted by telephone [or in person
> on a one-to-one basis]{.underline} on needs ranging from alternatives
> to institutional care, to how to select a nursing home, to residents\'
> rights, to understanding Medicaid. Count each separate request for
> information or assistance (but not each call related to the same
> request), whether made by someone who requested assistance earlier in
> the year or by a new caller. Do not include here participants in
> community education sessions documented in F.10. Document the three
> most frequent topics/areas of requests or needs.
>
> If the ombudsman has been involved in helping residents move into
> community-based settings (as part of the state's response to the
> Supreme Court's Olmstead Decision or as a general practice), please
> note this in the narrative section provided for this item and also in
> the major issues section, providing in both sections an estimate of
> the number of people the program assisted in moving from a facility to
> a residential setting of their choice. *Reminder: Use complaint code
> P. 128 for Olmstead related complaints.*
>
> **6. *Facility Coverage***
>
> Document the number of facilities (unduplicated count) covered on a
> *regular basis*, not in response to a complaint, by paid and volunteer
> Ombudsmen. ***Regular basis* means no less frequently than
> quarterly.** Note that the information requested is the unduplicated
> number of facilities visited, not the number of visits. If there is no
> visitation program, type N.A.

**7. *Participation in facility surveys***

> Provide the number of facility surveys in which the ombudsman or
> designated ombudsman representatives participated in any aspect of
> both regular surveys and surveys held in response to a complaint,
> including pre-survey briefing of surveyors and participation in exit
> interviews. (Note: This count is for any kind of survey participation,
> not actually going with the team on the survey. The count is of
> surveys in which there was some level of participation, not the number
> of contacts regarding a particular survey; for example, three calls
> regarding one survey would count as one.)
>
> **8/9. *Work with resident and family councils***
>
> Provide the total count of all resident and family council meetings
> attended by designated ombudsman representatives during the reporting
> period, for both state and local levels.
>
> **10. *Community Education***
>
> Provide the total number of presentations made to and or other
> meetings with community groups, students, churches, etc.
>
> **11. *Work with media***
>
> Provide the three most frequent topics discussed with the media, the
> number of interviews/discussions, and the number of press releases at
> both state and local levels.
>
> **12. *Monitoring/work on laws, regulations, government policies and
> actions***
>
> Provide, for both state and local levels, a *best estimate of the
> percentage of total paid staff time* spent working with other agencies
> and individuals, both inside and outside of government, on laws,
> regulations, policies and actions to improve the health, welfare,
> safety and rights of long-term care residents. (Note: percentage of
> time spent on this work and on item 2, providing technical assistance
> to staff and volunteers, cannot total more than 100 %.)