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 

Data Element Comment ACL Response 

S-01-S-06 Case (now called complaint ) 

example

Change word from case to complaint Recommendation accepted

Provide 2-3 complaint 

examples.

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.

No change. Many states provide 

more than 2 complaint 

examples. Offering a third 

optional example does not add 

burden.

S-10 Systems Issue Status 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.

Recommendation accepted

S-12 Strategies applied to resolve 

the reported systems issue.

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.

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 
2 

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)

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.

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.

S23 Total FTE in local 

Ombudsman entity

1.) - Many local Ombudsman programs are able to supplement 

State and Federal Ombudsman funds with locally raised funds 

1.) No change, this would be too 

burdensome. States will report 
3 

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.

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. 

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.) 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. 
4 

Element 

Number 

Data Element Comment ACL Response 

S-27-S-29 Conflicts of interest 

reporting

Comments had various suggestions and requested further 

technical assistance and reporting tips. 

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. 

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.” 

No additional sources were 

added. One was modified to 

read “Social Services Block Grant 

or Community Services 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. 

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.
5 

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. 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.

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.) “

S-49 Number of Training Hours 

Required to Maintain 

Certification (now called 

Continuing education)

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.

Agree, included in reporting tips.

S-53-S-55 Information & Assistance to 

individuals 

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 

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. 
6 

Element 

Number 

Data Element Comment ACL Response 

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.

S-56-S61 Facility visits, number of 

facilities visited and routine 

access

1. While this is a big change to the way facility visit data is 

currently collected, XX 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.”

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 
7 

Element 

Number 

Data Element Comment ACL Response 

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”

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.

presence in facilities. Further 

guidance will be provided in 

NORS consistency training. 

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 
8 

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.