Administration for Community Living/Administration on Aging- Office of Long-Term Care Ombudsman Programs 

National Ombudsman Reporting System (NORS) 

Table 1: NORS Parts 1 and 2 – Case/Complaint codes, values and definitions 

OMB Control Number 0985-XXXX 

Expiration Date: XX/XX/XXXX 

ACL Response to 60 Day Notice Comments 

Case Data Components 

Each case must contain a complainant, complaint code (s), a setting, verification, resolution, and information regarding whether a complaint was 

referred to another agency. Case and complaint data reported is only for those cases and complaints which were closed within the fiscal year. 

Element 

Number 

Data 

Element 

Definition Comment ACL Response 

C1 Date Case 

Opened 

Month, day, 

and year that 

the case was 

opened 

Element numbers 

Issue: C1 through C4 are also used in Table 2: Complaint 

codes and definitions 

Recommendation: Change Element Numbers in Table 1 

to CA1 through CA5 for case data and CO1 through CO7 

for complaint data. 

Table 1 Code number is now CA 01-CA-05 and 

Complaint Data Components are CD-01-CD-07 

C2 Date Case 

Closed 

Month, day, 

and year that 

the case was 

closed 

Recommends: Report only cases closed in the reporting 

year, regardless of whether they were opened in the 

reporting year or in a prior reporting year. 

Because case and complaint data will be 

submitted in an electronic file format, the 

business rules instruct that all cases and 

complaints must be closed in the fiscal year, 

regardless of date opened. We will clarify in 

the business rules 
 

 

 

 

 

 

Element 

Number 

Data 

Element 

Definition Comment ACL Response 

C3 Facility/ 

Setting Type 

Facility/setting 

type for the 

case 

13 commenters recommend changing the term 

͡Ά͊μΉ͆͊΢φΉ̮Λ C̮θ͊ CΩΡΡϡ΢Ήφϳ͢ ̻̮̼Θ φΩ φΆ͊ ̼ϡθθ͊΢φ 

Board and Care terminology as defined in the OAA and 

add the term ͡θ͊μΉ͆͊΢φΉ̮Λ ̼̮θ͊ ̼ΩΡΡϡ΢Ήφϳ͢ φΩ φΆ͊

definition. The concerns were best described as 

follows. 

Issue 1: CΆ̮΢ͼΉ΢ͼ ̻͡Ω̮θ͆ ̮΢͆ ̼̮θ͊͢ φΩ ͡θ͊μΉ͆͊΢φΉ̮Λ ̼̮θ͊ 

̼ΩΡΡϡ΢Ήφϳ͢ Ήμ ̮΢ ϡ΢΢̼͊͊μμ̮θϳ ̼Ά̮΢ͼ͊ Ή΢ ΢ΩΡ͊΢̼Λ̮φϡθ͊ 

that strays from the Older Americans Act language and 

would burden state programs and representatives of 

the Office. Adoption of this term would require change 

to state reporting systems and training to every 

representative of the Office, with no added value. A 

change to basic terminology is likely to cause confusion 

among states and representatives of the Office. 

Issue 2: The reference to licensed and unlicensed in the 

͔͆͊Ή΢ΉφΉΩ΢ Ω͔ ͡θ͊μΉ͆͊΢φΉ̮Λ ̼̮θ͊ ̼ΩΡΡϡ΢Ήφϳ͢ Ήμ ΡΉμΛ̮͊͆Ή΢ͼ

and inconsistent with the Older Americans Act (OAA) 

͔͆͊Ή΢ΉφΉΩ΢μ Ω͔ ͡ΛΩ΢ͼ-term care ͔̮̼ΉΛΉφϳ͢ ̮΢͆ ̻͡Ω̮θ͆ ̮΢͆

̼̮θ͊͢ ́ ΐΆ͊ ͷ!! ͔͆͊Ή΢ΉφΉΩ΢ ͔Ωθ ̻͡Ω̮θ͆ ̮΢͆ ̼̮θ͊͢ θ͔͊͊θμ φΩ

the Social Security Act definition and describes state 

authority to regulate. The Social Security Act describes 

institutions on which state and local authorities enforce 

standards. Referring to an unlicensed facility in this 

definition implies the State Long-Term Care 

Ombudsman Program has a responsibility to cover 

There is general concern that the proposed 

definition somehow expands they type of 

settings that LTC Ombudsmen have jurisdiction 

over. This is not !Cͪ͞μ Ή΢φ͊΢φ and the definition 

has been revised; the term Residential Care 

Community remains unchanged. 

ACL believes the term Residential Care 

Community reflects current nomenclature. The 

Assistant Secretary for Planning & Evaluation 

(ASPE) Compendium of Residential Care and 

Assisted Living Regulations and Policy: 2015 

Edition notes that until the mid-1990s, the 

most frequently used terms were board and 

care or residential care. However the 

popularity of the new assisted living model led 

many residential care settings to change their 

name to assisted living. Currently 23 states 

have more than one licensure category. Most 

states (44) use the term assisted living as a 

licensing or certification category. The word 

that follows "assisted living" varies, and 

includes facility, residence, program, home, and 

community. The next most commonly used 

licensure term is residential care, used by 20 

states. 

ACL does not believe that a change in definition 

2 
 

 

Element 

Number 

Data 

Element 

Definition Comment ACL Response 

unlicensed homes, which would create more strain on 

an underfunded program and could result in an 

unfunded mandate. 

By changing the definition of board and care to 

residential care community, is it the implications that 

ombudsmen should go into all settings that apply to 

that definition or will ombudsman continue to serve the 

residents in the same types of facilities that they have 

been serving? If this is the case, why change the 

definition. If states are expected to expand serves, how 

will this be paid for? 

Another area is in defining the types of facilities our 

residents reside in we focϡμ Ω΢ ͱH͞μ΁ !ͪF͞μ ̮΢͆ !͆ϡΛφ

Family Care Homes. While AOA gives us the ability to 

expand we could not do so without reducing services to 

those we already serve. 

One commenter Does not agree, and the program 

offers complaint resolution services in these settings. 

and title will cause confusion at the state and 

local level because there will not be a change in 

state level practice. Currently, state 

Ombudsman programs use their state licensing 

terms (i.e. assisted living, adult foster home, 

̮΢͆ ε͊θμΩ΢̮Λ ̼̮θ͊ ΆΩΡ͊΁ ͊φ̼ ́) Ίφ̮φ͊μ͞ data 

collection software allows for their residential 

care data to be entered by state license type 

which is then combined and reported in NORS 

as one facility type, currently called board & 

care. 

In response to concerns expressed that the 

definition expanded the service jurisdiction the 

definition has been revised. 

The new definition is: 

Residential Care Community - A type of longterm care facility as described in the Older 

Americans Act that, regardless of setting, 

provides at a minimum, room and board, 

around-the-clock on-site supervision, and help 

with personal care such as bathing and dressing 

or health-related services such as medication 

management. 

Facility types include but are not limited to: 

3 
 

Element 

Number 

Data 

Element 

Definition Comment ACL Response 

assisted living; board and care home; 

congregate care; enriched housing programs; 

homes for the aged; personal care homes; adult 

foster/ family homes and shared housing 

establishments that are licensed, registered, 

listed, certified, or otherwise regulated by a 

state. 

Issue 3: Ombudsmen are increasingly receiving 

complaints that have an element of managed care 

involved and clarification would be helpful. 

Recommendation: Add to Examples and Reporting Tips, 

͔͛͡ φΆ͊ ̼Ω΢μϡΡ͊θ Ήμ ̮ Ρ͊Ρ̻͊θ Ω͔ ̮ Ρ̮΢̮ͼ͊͆ ΛΩ΢ͼ-term 

services and supports plan, select the setting where the 

consumer resides at the time of the complaint 

Did not accept. Not all states have managed 

care programs and the focus of the LTCOP is 

persons in long-term care facilities. One state 

One commenter – specifically did not agree 

with the recommendation. 

Issue 3: Clarify what types of settings are acceptable 

ϡ΢͆͊θ ͡99 = ͷφΆ͊θ͢ ́ Ά̼͊ΩΡΡ͊΢̮͆φΉΩ΢΃ !͆͆ ͊ς̮ΡεΛ͊μ 

ϡ΢͆͊θ Eς̮ΡεΛ͊μ ̮΢͆ Ά͊εΩθφΉ΢ͼ ΐΉεμ ͔Ωθ ͡ͷφΆ͊θ͢ μϡ̼Ά ̮μ 

hospital, psychiatric facilities, etc. 

Accepted 

͡Helpful to have rudimentary breakdown of other 

settings so that additional individual reading and 

tabulation of cases will not be required to gather 

΢͊͊͆͊͆ ̮͆φ̮ Ω΢ ΩφΆ͊θ μ͊φφΉ΢ͼμ ́͢

ΐΆ͊ ͡Other setting͢ ̼Ω͆͊ Ήμ an optional code for 

those states that have expanded their 

Ombudsman services to settings outside of 

long-term care facility settings. ACL does not 

need that level of detail on services for which 

the OAA has not authorized. 

4 
 

 

 

Element 

Number 

Data 

Element 

Definition Comment ACL Response 

C4 Complainant 

Type 

Complainant -

an individual 

(i.e., resident, 

resident 

representative, 

family) who 

requests 

Ombudsman 

program 

complaint 

investigation 

services 

regarding one 

or more 

complaints 

made by, or on 

behalf of, 

residents. 

Recommendation: Add to Codes and Values, 06 = Other 

̮΢͆ ̮͆͆ φΩ D͔͊Ή΢ΉφΉΩ΢΁ ͡ͷφΆ͊θ͢ Ή΢̼Λϡ͆͊μ Ή΢͆ΉϬΉ͆ϡ̮Λμ ϭΆΩ

do not have a relationship with the resident such as a 

neighbor to the facility, family member of another 

resident, visiting pastor and change 06 to 07 = 

Unknown. 

Recommendation: Change Definition of 05 = 

Representative as follows. Representative of other 

agency or (individual delete) program: Any entity or 

(individual delete) that refers a complaint to the 

Ombudsman program regarding one or more residents. 

Recommendation: Under Code and Values for C4 add a 

΢͊ϭ ̼Ω͆͊ ͡ͷφΆ͊θ͢ ̮΢͆ Ή΢ Eς̮ΡεΛ͊μ ̮΢͆ Ά͊εΩθφΉ΢ͼ ΐΉεμ 

̮͆͆ ͡Ί͊Λ̼͊t other when the complainant does not work 

for an agency and has no personal relationship with the 

resident such as community member, or family member 

Ω͔ ̮΢ΩφΆ͊θ θ͊μΉ͆͊΢φ͢ ́ !ΛμΩ ̼Λ̮θΉ͔ϳ ϡ΢͆͊θ Eς̮ΡεΛ͊μ ̮΢͆

Ά͊εΩθφΉ΢ͼ ΐΉεμ φΆ̮φ ͡Ά͊μΉ͆͊΢φ Ά͊εθ͊μ͊΢φ̮φΉϬ͊΁ FθΉ͊΢d, 

F̮ΡΉΛϳ͢ θ͔͊͊θμ φΩ ̮ ̼ΩΡεΛ̮Ή΢̮΢φ φΆ̮φ Ά̮μ ̮ ε͊θμΩ΢̮Λ 

θ͊Λ̮φΉΩ΢μΆΉε ϭΉφΆ φΆ͊ θ͊μΉ͆͊΢φ ́ !ΛμΩ ̼Ά̮΢ͼ͊ ͡Δ΢Θ΢Ωϭ΢͢

to 07. 

Accepted 

Based on recommendations a new code 06-

͡Other͢ ϭ̮μ ̮͆͆͊͆΃ 

Other: a neighbor to the facility, family member 

of another resident, visiting clergy, bank teller, 

etc. 

Element #C4: 05-Representative of other agency or 

εθΩͼθ̮Ρ ́ ! θ͊μΉ͆͊΢φ͞μ ΢͊ΉͼΆ̻Ωθ Ήμ ͔θ͊ηϡ͊΢φΛϳ ̮ ͔θΉ͊΢͆

and would not be considered a representative of other 

Based on recommendations a new code 06-

͡Other͢ ϭ̮μ ̮͆͆͊͆: 

Other: a neighbor to the facility, family member 

5 
 

 

 

 

Element 

Number 

Data 

Element 

Definition Comment ACL Response 

agency or program. 

Ά̼͊ΩΡΡ͊΢̮͆φΉΩ΢΃ Ά͊ΡΩϬ͊ φΆ͊ φ͊θΡ ͡΢͊ΉͼΆ̻Ωθ͢ ͔θΩΡ

the examples given for 05=Representative of other 

̮ͼ͊΢̼ϳ Ωθ εθΩͼθ̮Ρ΁ ̮΢͆ ͊ΉφΆ͊θ θ͊ΡΩϬ͊ ͡΢͊ΉͼΆ̻Ωθ͢ ͔θΩΡ

all descriptions or add it to C02, Resident 

Representative Friend, Family. 

of another resident, visiting clergy, bank teller, 

etc. 

Anonymous should be included since many of the 

complaints we receive are anonymous. 

Anonymous and unknown have basically the 

same meaning. If the Ombudsman program 

receives a complaint and they do not know the 

source of the complainant that would be 

̼Ω΢μΉ͆͊θ͊͆ ͡ϡ΢Θ΢Ωϭ΢ ́͢ ͔͛ ̮ θ͊μΉ͆͊΢φ Ήμ ̮ 

complainant but says that she wants to be 

̮͡΢Ω΢ϳΡΩϡμ͢ φΩ φΆ͊ ͔̮̼ΉΛΉty staff or others; that 

is considered direction from the resident on 

how to conduct the complaint investigation. 

C4 needs further explanation on allowing only one 

selection of complainant as it relates to C5 when there 

is more than one complainant per case. 

Complainant Group was eliminated. 

ͷΡΉφμ Ϭ̮Λϡ͊ Ω͔ ͡ΩφΆ͊θ Ρ͊͆Ή̼̮Λ μφ̮͔͔΁͢ ϭΆΉ̼Ά Ήμ ϡμ͔͊ϡΛ φΩ

ͪΐCͷ΃͞μ ́ Ά̮φΆ͊θ φΆ̮΢ ϡ΢Θ΢Ωϭ΢ ϭ͊ εθ͔͊͊θ ̮΢Ω΢ϳΡΩϡμ 

ϭΆΉ̼Ά ͊΢̼ΩΡε̮μμ͊μ ̮͆͆ΉφΉΩ΢̮Λ ̮με̼͊φμ ̈́ΠΆ͊΢

Nationwide, less than 3400 (2.5%) of 

̼ΩΡεΛ̮Ή΢φμ ε͊θ ϳ̮͊θ ̮θ͊ θ͔͊͊θθ͊͆ ̻ϳ ͡ΩφΆ͊θ

Ρ͊͆Ή̼̮Λ μφ̮͔͔͢ φΩ φΆ͊ ͷΡ̻ϡ͆μΡ̮΢ εθΩͼθ̮Ρ ́ 

6 
 

 

 

 

 

 

 

Element 

Number 

Data 

Element 

Definition Comment ACL Response 

complainant requests anonymity should not be 

͆Ω̼ϡΡ͊΢φ͊͆ ϡ΢͆͊θ θΩΛ͊ Ω͔  ̼̈́ϡθθ͊΢φ ϡμ͊ of 

unknown/anonymous also is better than merely 

͡ϡ΢Θ΢Ωϭ΢͢ DΩ ΢Ωφ ̮ͼθ͊͊ ̮΢͆ φΆ͊ ̼ϡθθ͊΢φ ΢ϡΡ̻͊θμ ͆Ω

not support 

This has been consistent for the past five years. 

We are seeking to simplify data collection by 

merging codes that are not highly used and 

have similar overlap (i.e. current code of Other 

medical: physician/ staff with Representative 

of other health or social service agency or 

program.) 

As noted above, the definition of unknown and 

anonymous is similar. Over the past 5 years, 

͡ϡ΢Θ΢Ωϭ΢/̮΢Ω΢ϳΡΩϡμ͢ ̼ΩΡεΛ̮Ή΢φμ ̮Ϭ͊θ̮ͼ͊͆ 

around 3.5% of all complaints. The 

complainant role should be accurately 

identified so that we have a true picture of the 

complainant concerns via the complaint 

resolution process. Indicating the type of 

complainant in a data system does not violate 

disclosure requirements of the OAA or the 

Ombudsman federal rule. Both the OAA and 

the federal rule (see 1324. 11(e) (3) Disclosure 

and 1324.19 Duties of the representatives of 

the Office. (b) Complaint processing. Describe 

ϭΆ͊΢ ̮ θ͊μΉ͆͊΢φ Ωθ ̼ΩΡεΛ̮Ή΢̮΢φ͞μ Ή͆͊΢φΉ͔ϳΉ΢ͼ

information can be disclosed. 

7 
 

Element 

Number 

Data 

Element 

Definition Comment ACL Response 

C5 Complainant 

Group 

Whether there 

is more than 

one 

complainant as 

part of the 

case. 

Issue: This would be difficult to code and collect 

consistent data from ombudsmen, as well as add an 

additional burden to reporting. Recommendation: 

Delete C5. 

Issue: This is a new data element and it is not clear if it 

is to be used for group complaints by resident or family 

councils or if it is to be used when several individuals 

file complaints about the same incident. 

Recommendation: Clarify language under the definition 

and give examples in the Examples and Reporting Tips. 

It is also important to ensure the system allows for 

several complaints to be recorded for the same 

incident. 

Requires additional explanation regarding how it relates 

φΩ C4 ́ ͛΢ ̮͆͆ΉφΉΩ΢ Ή͔ Ω΢͊ ͆Ω̼ϡΡ͊΢φμ ͡ϳ͊μ͢ ϭΆ͊θ͊ ͆Ω͊μ 

one document (and collect data on) the additional 

information regarding the role and type of complainant. 

This data element was eliminated. In order to 

capture some information on group complaints 

̮ ̼ΩΡεΛ̮Ή΢̮΢φ ̼Ω͆͊ Ω͔ ͡θ͊μΉ͆͊΢φ Ωθ ͔̮ΡΉΛϳ

̼Ωϡ΢̼ΉΛ͢ ϭ̮μ ̮͆͆͊͆ φΩ φΆ͊ ̼ΩΡεΛainant type. 

8 
 

Complaint Data Components 

 

 

 

 

 

 

Element 

Number 

Data 

Element 

Definition Comments ACL Response 

CD4 Allegedly 

Responsible 

Person 

The type of person(s) 

allegedly responsible for the 

abuse/neglect or exploitation 

(i.e. perpetrator). 

Use of the φ͊θΡ ̮͡ΛΛ͊ͼ͊͆Λϳ θ͊μεΩ΢μΉ̻Λ͊ 

ε͊θμΩ΢͢ Ήμ ̼Ω΢͔ϡμΉ΢ͼ ́ Ά͊μεΩ΢μΉ̻Λ͊ ε͊θμΩ΢ Ρ̮ϳ

be confused with a power of attorney or the 

΢ϡθμΉ΢ͼ ͔̮̼ΉΛΉφϳ φ͊θΡμ ͡θ͊μεΩ΢μΉ̻Λ͊ ε̮θφϳ͢ ̮΢͆

͡θ͊μεΩ΢μΉ̻Λ͊ ε͊θμΩ΢.͢ Other commenters 

agree. 

Recommendation: Change the Data Element 

to Person Complaint is Against. 

After much deliberation the data element 

Λ̮̻͊Λ ϭ̮μ ̼Ά̮΢ͼ͊͆ φΩ ͡ε͊θε͊φθ̮φΩθ ́͢ ΐΆΉμ 

is the most frequently used and 

understood word to describe a person 

who has been accused of causing abuse, 

neglect or exploitation. 

Issue 2: Codes and Values options are not 

inclusive of outside providers of services. 

Recommendation: Add to Codes and Values, 

4 = Outside Providers of Services and add to 

Examples and Reporting Tips, Use 4 for 

Outside Providers of Services, for individuals 

or entities such as laboratory staff, social 

workers not employed by the facility, and 

financial advisors. Also change 04 05 = Other. 

No change, outside providers of services, 

not associated with the facility fit in the 

͡ΩφΆ͊θ͢

Recommendation: Under Codes and Values 

̼Ά̮΢ͼ͊ ΢ϡΡ̻͊θ 4 φΩ ͡ͷϡφμΉ͆͊ ΃θΩϬΉ͆͊θμ Ω͔ 

Ί͊θϬΉ̼͊μ͢ ̮΢͆ ̼Ά̮΢ͼ͊ ͡ͷφΆ͊θ͢ φΩ ΢ϡΡ̻͊θ 5 ́ 

Under Examples and Reporting Tips add 

examples for the new code recommended 

̮̻ΩϬ͊ ̮μ ϭ͊ΛΛ ̮μ ͔Ωθ ͡ͷφΆ͊θ͢ ́ CΛ̮θΉ͔ϳ φΆ̮φ

No change- the terms are self-explanatory. 

9 
 

 

 

Element 

Number 

Data 

Element 

Definition Comments ACL Response 

͡F̮ΡΉΛϳ΁ Ά͊μΉ͆ents Representative, and 

Friend͢ ̮θ͊ Ή΢͆ΉϬΉ͆ϡ̮Λμ φΆ̮φ φΆ͊ θ͊μΉ͆͊΢φ Ά̮μ ̮ 

relationship with. 

The addition of CD4-Allegedly Responsible 

Person in ombudsman reporting, coupled 

with the CD6 Complaint Verification Data 

Element would appear to verify (or not) 

whether the allegedly responsible person did, 

in fact, cause the abuse, neglect, or 

exploitation. This may confuse the public 

who reviews Ombudsman program data and 

confuse Ombudsmen about their role in 

responding to a complaint involving abuse, 

neglect, and exploitation. 

The Ombudsman program rule at 

1324.19(b) Complaint processing along 

with states policies and procedures on 

complaint processing should support 

credible and effective complaint 

resolution. The ability to analyze 

disaggregated data and associate the 

types of complaints, the perpetrator (for 

abuse related complaints) and other 

variables will inform ACL and states on 

complaint outcomes. ACL and the 

National Ombudsman Resource Center 

will assist states in their interpretation of 

their data and how to educate the public 

on the data. 

CD5 Referral 

Agency Type 

The type of agency/agencies 

to which a complaint was 

referred to as part of the 

ͷΡ̻ϡ͆μΡ̮΢ εθΩͼθ̮Ρ͞μ εΛ̮΢

of action for complaint 

resolution. 

Several commenters: Issue: Ombudsmen 

often refer complaints to the state Medicaid 

Fraud Control Unit and to the Home and 

Community Based Waiver Quality Assurance 

agency. There does not appear to be an 

option for these agencies. 

Recommendation: Add under Examples and 

Medicaid Fraud Control Unit is a law 

enforcement agency and is included in law 

enforcement definition. 

Not all states have similar processes for 

͡Home and Community Based Waiver 

Quality Assurance agency ́͢ ΐΆ͊ ͔͆͊Ή΢ΉφΉΩ΢

is broad enough to capture all types of 

10 
 

 

 

 

Element 

Number 

Data 

Element 

Definition Comments ACL Response 

Reporting Tips, Use 1 for Licensing, 

Regulatory, Certification Agency, and for 

referrals to the state Medicaid Fraud Control 

Unit and to the Home and Community Based 

Waiver Quality Assurance agency. 

government entities that have a quality 

oversight responsibility. 

CD6 Complaint 

Verification 

Verified: A confirmation that 

most or all facts alleged by 

the complainant are likely to 

be true. An ombudsman 

conducts an investigation of 

the complaint to determine 

verification 

Proposed changes in definition is less clear. 

Δμ͊ Ω͔ ϭΩθ͆ Ά͔̮̼φ͞ ͆Ω͊μ ΢Ωφ μ͊͊Ρ ̮εεθΩεθΉ̮φ͊

as a fact is something that is true. 

Ombudsmen investigate to determine the 

facts. We recommend that the current 

definition of verified be unaltered. In 

addition CD6 should note that Not Verified 

has several meanings: not true, unable to 

determine, etc. 

The definition was slightly modified. 

Verified: A confirmation that most or all 

facts alleged by the complainant are likely 

to be true. 

CD7 Complaint 

disposition 

Final resolution or outcome 

of the complaint 

Several commenters - Issue: There is no 

instruction regarding how to code the death 

of a resident before there is an outcome of 

the ombudsman resolution. 

Recommendation: Add to Examples and 

Reporting Tips, Use 2 for Withdrawn when 

the resident dies before a final outcome has 

been obtained. 

There are a number of variables that may 

impact the final disposition of a complaint 

if a resident dies before the complaint is 

finally resolved. This will be addressed in 

NORS consistency training. 

11 
 

 

 

 

 

 

Element 

Number 

Data 

Element 

Definition Comments ACL Response 

Recommendation: Under Examples and 

Reporting Tips ̮͆͆ ͡ΠΆ͊΢ ̮ θ͊μΉ͆͊΢φ ͆Ή͊μ 

̻͔͊Ωθ͊ ̮ ̼ΩΡεΛ̮Ή΢φ Ήμ θ͊μΩΛϬ͊͆ ϡμ͊ ̼Ω͆͊ 3 ́͢

Add a reporting tip that lists an order of 

preference for determining who to rely on to 

determine disposition. For example, first 

contact the resident if they are able to state 

their satisfaction, then contact the resident 

representative, then complainant, then 

SLTCO. 

There are a number of variables that may 

impact the final disposition of a complaint 

if a resident dies before the complaint is 

finally resolved. This will be addressed in 

NORS consistency training. 

Element #CD7: Complaint Disposition, Item 2 

(͡ΠΉφΆ͆θ̮ϭ΢ Ωθ ΢Ω ̮̼φΉΩ΢ ΢͊͊͆͊͆ ̈́͢) ΐΆ͊θ͊ Ήμ 

a distinct difference between a complaint 

that is withdrawn and one where no action 

was needed. 

Ά̼͊ΩΡΡ͊΢̮͆φΉΩ΢΃ Ί͊ε̮θ̮φ͊ ͡ΠΉφΆ͆θ̮ϭ΢͢

̮΢͆ ͡ͱΩ !̼φΉΩ΢ ͱ͊͊͆͊͆͢ ̮΢͆ ̼Ω΢φΉ΢ϡΉ΢ͼ φΩ

provide both options as a complaint 

disposition in NORS. 

If a complaint is withdrawn by the resident 

or complainant it means that no further 

action shall be taken. Years of experience 

of training on these two definitions 

indicates that Ombudsman programs do 

not have clear agreement on the 

definitions and differences between these 

two terms. Eliminating duplicative 

definitions reduces the μφ̮φ͊μ͞ θ͊εΩθφΉ΢ͼ

burden. 

Concerns about reducing the number of 

dispositions primarily because of cost to 

change software and re-training. 

The new codes reflect the most commonly 

used NORS disposition codes. The 

simplification from 9 disposition codes to 

3 reduces reporting burden. The NORC 

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Definition Comments ACL Response 

will provide a set of training materials 

offering both live webinars and recorded 

μ͊μμΉΩ΢͞μ ̮Ϭ̮ΉΛ̮̻Λ͊ Ω΢-demand. 

We are aware of state Ombudsman 

εθΩͼθ̮Ρμ͞ ̼Ωμφ ̼Ω΢̼͊θ΢μ ́ ͱͷΆΊ reporting 

has not significantly changed over the past 

20 years and we understand that this will 

require states to modify their software 

programs. 

Issue 2: Codes and Values 1, 2, and 3 refer to 

the resident, resident representative, or 

complainant. It is unclear how an 

ombudsman should report disposition when 

a resident and complainant disagree about 

satisfaction, such as how to report a situation 

when a resident does not wish the 

ombudsman to take any action and the 

complainant is not satisfied. As a residentdirected advocate, ombudsmen are trained 

φΩ ͔ΩΛΛΩϭ φΆ͊ θ͊μΉ͆͊΢φ͞μ ͆Ήθ̼͊φΉΩ΢ ́ ΐΆ͊ 

θ͊μΉ͆͊΢φ͞μ ϭΉμΆ͊μ μΆΩϡΛ͆ μϡε͊θμ͊͆͊ φΆ͊ 

̼ΩΡεΛ̮Ή΢̮΢φ͞μ ́

Recommendation: Add to Examples and 

Ά͊εΩθφΉ΢ͼ ΐΉεμ΁ ͔͛͡ φΆ͊ ̼ΩΡεΛ̮Ή΢̮΢φ Ήμ ΢Ωφ φΆ͊ 

resident, but is complaining on behalf of a 

This is a helpful suggestion that lends itself 

to training examples to be developed by 

NORC. 

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resident who is able to state his or her 

satisfaction or otherwise direct the 

ΩΡ̻ϡ͆μΡ̮΢΁ φΆ͊ θ͊μΉ͆͊΢φ͞μ ͆Ήθ̼͊φΉΩ΢

μϡε͊θμ͊͆͊μ φΆ͊ ̼ΩΡεΛ̮Ή΢̮΢φ͞μ. 

Concerns about removal of for which 

government policy or regulatory change or 

legislative action is required to resolve, and 

referred to other agency – final disposition 

not retained or failed to act may be useful to 

retain. 

The disposition code ͔͡Ωθ which 

government policy or regulatory change or 

legislative action is required to resolve΁͢

has not proven to be helpful at the federal 

level with an average disposition of less 

than 1%. It is our expectation that with 

disaggregated data we will have the ability 

to analyze the types of complaints that are 

unresolved which may indicate that 

resolution requires policy or systems level 

changes. We also anticipate that with a 

structured systems advocacy narrative this 

will better inform of the types of 

complaints that require policy, 

government action, etc. 

͡Referred to other agency dispositions͢

imply that the Ombudsman program is no 

longer active in the complaint resolution. 

The referral codes are also confusing to 

many Ombudsman programs and have 

created data inconsistences. Removing 

referral codes clarifies that the 

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Ombudsman program is to determine 

whether the complaint is resolved to the 

satisfaction of the resident (or resident 

representative, where applicable). 

15