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

National Ombudsman Reporting System (NORS) OMB Control Number 0985-0005

Table 3: State Program Information Expiration Date: 04/30/2021

State Program Data Elements

States will submit a wide range of elements describing their statewide Ombudsman program grouped into a range of categories. Each of these sets of elements 

is presented in the subsections below.

Part A-Complaint Example

States will submit complaint example data that provide narrative description and disposition information regarding two to three closed complaints during the 

reporting period.

Composite 

Data Element

Element Description Quantifier Type Codes and Values Examples and Reporting Tips

Complaint

Example

Provides information regarding 

two to three complaints during 

the reporting period.

Multiple Composite 

data element 

subsuming 

element 

numbers 

S01-S06

Not Applicable (NA) 

(not a coded 

element)

Selection of complaint examples is at the 

State Ombudsman’s discretion.

Elements included for each case example:

Element Number Data 

Element

Element 

Definition

Quantifier Type Codes and Values Examples and Reporting Tips

S-01 Facility or 

Setting 

Type of Facility

or setting for the 

complaint.

Single per 

complaint 

example

Alphanumeric See Table 1, CA-04 Select one example from a nursing facility, 

and one from a residential care 

community facility. A third example is 

optional. 

S-02 Description Narrative of the 

problem.

Single per 

complaint 

example

Alphanumeric NA (not a coded 

element)

Maximum length of 3,400 characters 

(about 500 words).

S-03 Complaint 

code

See Table 1, CD 

03 for complaint 

definition.

Single per 

complaint 

example

Alphanumeric See Table 1, CD 04

and Table 2

Select the complaint code associated with 

each complaint example.
2

Element Number Data 

Element

Element 

Definition

Quantifier Type Codes and Values Examples and Reporting Tips

S-04 Verification See Table 1, CD

06 for verified

definition.

Single per 

complaint

example

Numeric See Table 1, CD 07. Select the verification code associated 

with each complaint example.

S-05 Disposition See Table 1, CD

07 for 

definitions of:

Partially or fully 

resolved;

Withdrawn; or

No action 

needed.

Single per 

complaint 

example

Numeric See Table 1, CD 08. Select the disposition code associated 

with each complaint example.

S-06 Description Narrative of the 

resolution.

Single per 

complaint 

example

Alphanumeric 

string

NA (not a coded 

element)

Maximum length of 3,400 characters 

(about 500 words).
3

Part B: Systems Issues Data Elements

Describe up to three priority long-term care, services or supports issues identified by the Ombudsman and the leadership and advocacy activities the Office 

employed to address these priority issues.

Composite 

Data Element

Element Description Quantifier Type Codes and 

Values

Examples and Reporting Tips

Systems Issue Provides information on priority 

long-term care systemic issues 

the program identified and 

addressed during the reporting 

period.

Multiple 

(1 to 3)

Composite data 

including element 

numbers 

S-07 to S-13

NA (not a 

coded 

element)

Describe at least two and up to three 

priority long-term care systems issues 

identified by the Ombudsman. Describe 

the leadership and advocacy activities the 

Office used to address these systems

issues.
4

Elements included for each systems issue:

Element 

Number

Data Element Element 

Definition

Quantifier Type Codes and Values Examples and Reporting 

Tips

S-07 Systems Issue Provides 

information on 

priority long-term 

care issues the 

program identified 

and addressed 

during the 

reporting period.

Single per 

systems 

issue

Alphanumeric 

code

A- Abuse, Gross Neglect, 

Exploitation

B-Access to Information

C-Admission, Transfer, 

Discharge, Eviction

D-Autonomy, Choice, Rights

E-Financial, Property

F-Care

G-Activities, Community 

Integration and Social Services

H- Dietary

I-Environment

J-Facility Policies, Procedures 

and Practices

K-Complaints about an Outside 

Agency (non-facility)

L-System: Others (non-facility)

O-Other issue not identified in 

A-L
5

Element 

Number

Data Element Element 

Definition

Quantifier Type Codes and Values Examples and Reporting 

Tips

S-07.1 Systems issue 

not associated 

with codes A-L

Provides 

information on a 

priority long-term 

care issue the 

program identified 

and addressed 

during the 

reporting period

not associated 

with categories AL.

Single per 

systems 

issue

NA Provide a brief description of

the issue not associated with 

codes A-L (500 characters.)

S-08 Problem 

description

Description of the 

issue or problem.

Single per 

System 

Issue

Alphanumeric 

String

NA (not a coded element) Maximum length of 3,400 

characters (about 500 words).

S-09 Barriers 

description

Description of the 

barriers for the 

issue.

Single per 

System 

Issue

Alphanumeric 

String

NA (not a coded element) Maximum length of 3,400 

characters (about 500 words).

S-10 Status Status of the 

issue.

Single per 

System 

Issue

Numeric 

Code

01-Newly identified in this 

reporting year and not fully 

resolved. 

02-Ongoing issue from last 

fiscal year.

03-Fully or Partially Resolved

including issues that are newly 

reported or an ongoing issue 

from last year.

Use code 02, if the Office is 

still working to resolve this 

issue.
6

Element 

Number

Data Element Element 

Definition

Quantifier Type Codes and Values Examples and Reporting 

Tips

S-11 Setting Setting affected by 

the issue.

Multiple List of 

Numeric 

Codes

01- Nursing Facility

02-Residential Care Community

03-Not specific to a setting

Select codes for every facility 

or setting type that is 

associated with this systems

issue. 

Examples of systems issues 

not specific to a setting may 

include: legislative budget; 

emergency preparation and 

response; advance care 

planning that is not facility 

specific; guardianship; etc. 
7

Element 

Number

Data Element Element 

Definition

Quantifier Type Codes and Values Examples and Reporting 

Tips

S-12 Resolution 

Strategies

Strategies applied 

to resolve the 

reported systems 

issues.

Multiple List of 

Numeric 

Codes

Alphanumeric 

String

01-Provided information to

public or private agency

02-Provided Information to

legislator or legislative staff

03-Recommended changes to

laws, regulations, policies or

actions through written or oral

testimony.

04-Provided leadership or

participated on a task force

05-Provided information to the

media.

06-Provided educational

forums; facilitated public

comment on laws, regulations,

policies or actions

07-Developed and

disseminated information.

08-Legal action where an

Ombudsman program initiates

legal action

09- Engaged in LTC facility

corporate wide strategy

including providing information

or recommendations to

corporate leadership

A systems issue may have 

multiple Resolution Strategy 

codes. 

Use 03 for providing written or 

oral testimony to a legislative 

committee or providing 

testimony at a public hearing 

or during a comment period.

Use 05 for interviews with 

media, editorial opinions,

press releases, press 

conferences, etc.

Use 07 for reports or issue 

briefs, social media, 

newsletters, and other 

educational material.

S-12.1 Other resolution 

strategy 

description

Strategy employed 

but not included in

codes 01-09.

99-Other Provide a brief description of 

the strategy (500 characters).
8

Element 

Number

Data Element Element 

Definition

Quantifier Type Codes and Values Examples and Reporting 

Tips

S-13 Resolution 

description

Narrative 

description of 

resolution 

strategies used 

during fiscal year. 

Single per 

System 

Issue

Alphanumeric 

String

NA (not a coded element) Maximum length of 3,400 

characters (about 500 words).

Include any policy, regulatory, 

legislative or other outcomes 

that were achieved.
9

Part C: Organization Structure Data Elements

Element 

Number

Data Element Element 

Description

Quantifier Type Codes and Values Examples and Reporting tips

S-14 Organizational 

structure

Organizational 

location of Office 

of the State 

Long-Term Care 

Ombudsman.

Single Numeric Code 01-State Unit on

Aging

02-Inside state

government

03-Stand-alone

agency inside state

government

04-Within a private, 

non-profit agency 

05-Stand-alone

private, non-profit

agency.

Use the location as of last day of federal 

fiscal year (September 30.)

01-State Unit on Aging, means the

agency designated under section

305(a)(1) of the OAA

02-Inside state government, not in State

Unit on Aging, such as Housing

Department, Commerce, Treasury, etc.

03-Inside state government, in a standalone agency where the only program is

the Office of Long-Term Care

Ombudsman.

04-Outside state government within a

private, non-profit agency with 501(c)(3)

status

05-Outside state government in a

stand-alone private, non-profit agency

with 501(c)(3) status where the only

program is the Long-Term Care

Ombudsman Program.
10

Local Ombudsman Entity Data Elements

For states choosing to operate a decentralized model using local Ombudsman entities, specify the type of agency and the number of local Ombudsman entities 

located in each type.

Composite 

Data Element

Element 

Definition

Quantifier Type Codes and Values Examples and Reporting Tips

Organizational 

structure

Organizational location of local 

Ombudsman entities.

Multiple Composite 

data element 

including 

element 

numbers 

S15, S16

NA (not a coded 

element)

A local ombudsman entity is an entity 

designated under section 712(a)(5)(A)

to carry out the duties described in 

section 712(a)(5)(B) with respect to a 

planning and service area or other 

sub-state area. 

Elements included for each Local Ombudsman Entity:

Element 

Number

Data Element Element 

Definition

Quantifier Type Codes and Values Examples and Reporting Tips

S-15 Organizational 

location of 

local 

Ombudsman 

entities

Identifies the 

agency in which a 

local Ombudsman 

entity is located.

One per 

local 

Ombudsman entity 

group

Numeric 

Code 

Alphanumeric 

String

01-Area agency on aging

(AAA)

02-Non-profit agency, with

501(c)(3) status

03-Legal services provider

04-Stand-alone non-profit

agency

98-There are no local

Ombudsman entities

99-Other

Use 01 for an entity located in an 

area agency on aging designated 

under section 305(a)(2)(A) of the 

Older Americans Act or a State 

agency performing the functions of 

an area agency on aging under 

section 305(b)(5) of the OAA. 

Use 02 for an entity located within 

a private, non-profit with 501(c)(3) 

status, other than AAA

Use 03 for an entity located in a 

Legal services provider

Use 04 for a stand-alone private,

non-profit agency with 501(c)(3) 

status, where the only program is 
11

Element 

Number

Data Element Element 

Definition

Quantifier Type Codes and Values Examples and Reporting Tips

the local Ombudsman entity. 

S-15.1 Description of 

other type

Entity description

not identified in 

01-04.

Provide a brief description (500 

characters) of the type of agency 

or organization in which the local 

ombudsman entity is located.

S-16 Number of 

Entities

Number of local 

Ombudsman 

entities for the 

location.

One per 

local 

Ombudsma

n entity 

group

Numeric NA (not a coded element) For the location specified (S15), 

provide the associated number of 

local Ombudsman entities as of 

last day of federal fiscal year

(September 30.)
12

Part D: Staff and Volunteer Data Elements 

This is a total count of all staff and volunteers. Staff count includes those who work full-time and part-time for the Ombudsman program as of the last day of 

the fiscal year (September 30.) Each staff person who works full-time on the program is counted as one full-time equivalent (FTE.) If, however, an employee 

works only part-time, the FTE for that employee would reflect the percent of time dedicated to the Ombudsman program up to two decimal places 

– .25, .50, .75, for example. Each program can determine what constitutes full time, i.e. 40 hours per week, 37.5 hours, etc. All counts are as of September 30.

Element 

Number

Data Element Element Definition Quantifier Type Codes and Values Examples and Reporting Tips

S-17 Staff in Office of 

State LTCO 

Total number of 

Office of State 

Ombudsman 

employees.

Single Numeric NA (not a coded element) The number of employees (both 

full-time and part-time) of the 

Office of the State Ombudsman 

who are representatives of the 

Office, trained to investigate and 

resolve complaints and perform 

other functions of the State LongTerm Care Ombudsman Program.

Whole number

S-18 Full-time 

equivalent in 

Office of state 

LTCO

Total number of 

FTE’s of the Office of

state LTCO.

Single Numeric NA (not a coded element) FTEs are calculated by converting 

the weekly work hours of 

employees into a ratio. For 

example, a person who works fulltime and 100% of the time with the

Ombudsman Program counts as 1 

FTE. A person who works full-time, 

but only 50% of the time with the 

Ombudsman Program counts as .5 

FTE, and similarly, a person who 

works 10 hours a week and 100% 

of the time with the Ombudsman 

Program counts as .25 FTE.

May not be a whole number. For 

example: 2.5, 5.75,etc.is 

acceptable

Do not include overtime or holiday 

hours.
13

Element 

Number

Data Element Element Definition Quantifier Type Codes and Values Examples and Reporting Tips

S-19 State level 

volunteer 

representatives

Total number of state 

level volunteers 

designated as

representatives of the 

Office.

Single Numeric NA (not a coded element) Report the number of volunteers 

who serve in the capacity as 

representatives of the Office, 

trained to investigate and resolve 

complaints and perform other 

functions of the State Long-Term 

Care Ombudsman Program as 

described in 45 CFR 1324.19. 

It must be a whole number

S-20 Hours donated 

by state level 

volunteer

representatives 

Total number of 

volunteer hours 

donated by volunteer 

representatives of the 

Office.

Single Numeric N/A (not a coded element) Report hours for those volunteers 

who report directly to the state 

Office.

Includes all time donated, such as,

training, travel, phone calls and 

documentation.

May not be a whole number. For 

example: 52.5, 60.75, etc. is 

acceptable.

S-21 Other state level 

volunteers

Total number of other 

type of volunteers 

who are not 

representatives of the 

Office.

Single Numeric N/A (not a coded element) Examples of other volunteers may 

include: volunteers who serve on a 

program advisory or governing 

board; assist with fund raising; 

provide other in-kind services such 

as accounting or strategic 

planning, etc.

It must be a whole number.
14

Element 

Number

Data Element Element Definition Quantifier Type Codes and Values Examples and Reporting Tips

S-22 Staff in local 

Ombudsman 

entity 

Total number of local 

Ombudsman entity 

employees

designated as

representatives of the 

Office.

Single Numeric NA (not a coded element) The number of employees (both 

full-time and part-time) of local 

ombudsman entities who are 

representatives of the Office, 

trained to investigate and resolve 

complaints and perform other 

functions of the State Long-Term 

Care Ombudsman Program as 

described in 45 CFR 1324.19.

If no staff select – “no staff” or 

enter zero.

It must be a whole number

S-23 Full-time 

equivalent in

local 

Ombudsman 

entity 

Total number of

FTE’s at the local

Ombudsman entity.

Single Numeric NA (not a coded element) FTEs are calculated by converting 

the weekly work hours of 

employees into a ratio. For 

example, a person who works fulltime and 100% of the time with the 

Ombudsman Program counts as 1 

FTE. A person who works full-time, 

but only 50% of the time with the 

Ombudsman Program counts as .5 

FTE, and similarly, a person who 

works 10 hours a week and 100% 

of the time with the Ombudsman 

Program counts as .25 FTE.

May not be a whole number. For 

example: 2.5, 5.75, etc.is 

acceptable.
15

Element 

Number

Data Element Element Definition Quantifier Type Codes and Values Examples and Reporting Tips

S-24 Local level 

volunteer 

representatives

of the Office

Total number of local 

level volunteers

designated as

representatives of the 

Office.

Single Numeric NA (not a coded element) Report the number of volunteers 

who serve in the capacity as 

representatives of the Office, 

trained to investigate and resolve 

complaints and perform other 

functions of the State Long-Term 

Care Ombudsman Program as 

described in 45 CFR 1324.19. 

It must be a whole number

S-25 Hours donated 

by local 

volunteer 

representatives 

Total number of 

volunteer hours 

donated by 

designated volunteer

representatives of the 

Office.

Single Numeric NA (not a coded element) Report hours for those volunteers 

who report directly to the local 

Ombudsman entity.

Includes all time donated, such as,

training, travel, phone calls and 

documentation.

May not be a whole number For 

example: 42.5, 65.75, etc. is 

acceptable.

S-26 Other local 

volunteers 

Total number of other 

volunteers who are 

not representatives of 

the Office. 

Single Numeric NA (not a coded element) Examples of other volunteers may 

include: volunteers who serve on a 

program advisory or governing 

board; assist with fund raising; 

provide other in-kind services such 

as accounting or strategic 

planning, etc.

This must be a whole number.
16

Part E: Conflict of Interest Data Elements

Composite 

Data 

Element

Element Description Quantifier Type Codes and 

Values

Examples and Reporting Tips

Conflict of 

Interest

Organizational conflicts of 

interest include, but are not 

limited to, placement of the 

Office, or local entity, or 

requiring that an Ombudsman 

or representative of the Office 

perform conflicting activities, in 

an organization that provides 

services and supports as 

described in codes and values 

01-15 and 99 (other conflict

that may impact the

effectiveness and credibility of

the work of the program.)

Multiple Composite 

data 

element 

subsuming 

element 

numbers S27, S-28 

and S-29

NA (not a 

coded element)

If the same conflicts exist among several entities and the 

same remedy was used to address the conflicts then

describe the remedy and type of entity once. For 

example: State Ombudsman program X has 15 local 

Ombudsman entities that are housed at Area Agencies 

on Aging that provide Medicaid assessment and case 

management on behalf of the State Medicaid agency. 

The Ombudsman can describe the steps and remedy 

one time and indicate that it applies to all 15 AAA’s. 
17

Elements included for each conflict of interest:

Element 

Number

Data 

Element

Element 

Description

Quantifier Type Codes and Values Examples and Reporting Tips

S-27 Conflict 

of 

Interest 

Type

Type of 

conflict that 

exists as 

described in 

45 CFR 

1324.21(a).

Single per 

Conflict of 

Interest

Numeric 

Code

Alphanu

meric 

String

01-Licenses, surveys or Certifies LTC facilities

02-Licenses, surveys or certifies LTC services

03- An association (or an affiliate) of LTC facilities

04-Has ownership, investment interest, receives

grants or donations from LTC facility

05-Has governing board, ownership, investment or

employment interest in LTC facility

06-Provides LTC to residents

07-Provides LTC coordination or case

management for residents

08-Provides LTC services, including

Medicaid/waivers

09-Sets reimbursement rates for LTC facilities

10-Sets reimbursement rates for LTC services

11-Provides adult protective services

12-Responsible for eligibility determinations for

Medicaid or public benefits

13-Conducts preadmission screening

14-Makes decisions on admissions or discharges

15-Provides guardianship, fiduciary, or surrogate

decision making services

98-None

99-Other

If 98 (None) is specified, no 

other Conflict of Interest data 

should be specified.

Indicate which, if any conflicts 

of interest were identified; the 

organizational location of the 

conflict and a narrative

description of the remedy. 
18

Element 

Number

Data 

Element

Element 

Description

Quantifier Type Codes and Values Examples and Reporting Tips

S-27.1 Other Narrative of 

other type of 

conflict not 

identified in 

items 1-15.

Provide a description of the 

conflict (500 characters).

S-28 Conflict 

of 

Interest 

Location

Organizational location of 

the conflict 

of interest.

Single per 

Conflict of 

Interest

Numeric 

Code

01-State

02-Local

03- Both State and Local

S-29 Conflict 

of 

Interest 

Remedy

Description 

of remedy 

used to 

remove the 

conflict of 

interest.

Single per 

Conflict of 

Interest

Alphanu

meric 

String

NA (not a coded element) Maximum length of 3,400 

characters (about 500 words).

Provide a remedy description 

for each conflict of interest.
19

Part F: Funds Expended Data Elements

Element 

Number

Data 

Element

Element 

Definition

Quantifier Type Codes and Values Examples and Reporting Tips

Funds 

Expended

Expenditure 

means charges 

made by a nonFederal entity to a 

project or 

program for which 

a Federal award 

was received.

Only include funds which were expended on 

Ombudsman program activities authorized 

under Section 712. 

Do not include amounts which were 

budgeted or obligated but not expended. 

Do not include “in-kind” resources. These 

are not “funds expended.”

S-30 Older 

Americans 

Act (OAA) -

Title VII, 

Chapter 2 

Dollar amount 

expended from 

Older American’s 

Act (OAA) Title 

VII, Chapter 2 

(Ombudsman.)

Single Numeric 

(decimal)

NA (not a coded 

element)

In dollars ($) and cents.

S-31 OAA -Title 

VII, Chapter 

3

Dollar amount 

expended OAA 

Title VII, Chapter 

3 (Elder Abuse 

Prevention.)

Single Numeric 

(decimal)

NA (not a coded 

element)

In dollars ($) and cents.

S-32 OAA Title III 

state level

Dollar amount 

expended OAA 

Title III – State 

level.

Single Numeric 

(decimal)

NA (not a coded 

element)

In dollars ($) and cents.
20

Element 

Number

Data 

Element

Element 

Definition

Quantifier Type Codes and Values Examples and Reporting Tips

S-33 OAA Title III 

local level

Dollar amount of

OAA Title III, 

funds expended 

to support the 

Ombudsman 

program at the 

local level. 

Single Numeric 

(decimal)

NA (not a coded 

element)

In dollars ($) and cents.

Report funds expended by a local 

Ombudsman entity. Report funds expended

for purposes of providing local Ombudsman 

services (not by a local Ombudsman entity.) 

For example the state Office provides local 

services directly to a tri-county region of the 

state, the Tri-County AAA provides OAA 

Title III funds to the state Office for purposes 

of supporting Ombudsman services at the 

tri-county planning and service area.

S-34 Other 

Federal 

Total dollar 

amount expended 

from all other 

federal sources, 

not OAA.

Single Numeric 

(decimal)

NA (not a coded 

element)

In dollars ($) and cents.

S-35 Identification 

of Other 

Federal 

Sources

Indicate the types 

of federal sources 

not from the OAA.

Multiple Numeric 

Code

01-Medicaid 

Administrative 

Claiming

02-Other Medicaid

03-Social Services 

Block Grant or 

Community Services 

Block Grant

04-Community 

Development Block 

Grant 

05-Senior Medicare 

Patrol

06-Victims of Crime 

Act Funds

Identify all federal sources.
21

Element 

Number

Data 

Element

Element 

Definition

Quantifier Type Codes and Values Examples and Reporting Tips

S-35.1 Other 

Federal 

Sources, 

Other 

Description

Other source not 

described in 01-

06.

Single, per

other 

sources

99-Other federal

sources of funds

Provide a brief description (up to 500 

characters) of a federal funding source 

expended but not identified in codes 01-06.

S-36 State funds Total funds 

expended from 

state government 

sources or from 

grants, donations, 

etc. at the state 

level.

Single Numeric 

(decimal)

NA (not a coded 

element)

In dollars ($) and cents.

S-37 Identification 

of other 

sources -

state level

Specification of 

other state funds 

expended.

Multiple Numeric 

Code;; 

Alphanumeric 

String

01-State general

funds (appropriated by

the legislature)

02-State fee or tax

03-Civil Monetary

Penalties

04-Private funds –

foundation grants, etc.

Select all sources that apply.

S-37.1 Other state 

level 

sources

Other source not 

described in 01-

04.

Single, per 

other 

sources

99-Other state

sources of funds

(Text)

Provide a brief description (up to 500 

characters) of a state funding source 

expended but not identified in codes 01-04.

S-38 Local funds 

expended

Total funds 

expended by 

local programs

Single Numeric 

(decimal)

NA (not a coded 

element)

In dollars ($) and cents. 
22

Element 

Number

Data 

Element

Element 

Definition

Quantifier Type Codes and Values Examples and Reporting Tips

S-39 Identification 

of funds 

expended at 

the local 

level

Total funds 

expended from 

local sources 

from grants, 

donations, etc. at 

the local level.

Multiple Numeric 

Code; 

Alphanumeric 

String

01-Local government 

02-Private 

grants/funds 

03-Other state funds

expended at local (but 

not statewide) level 

04-Other federal 

funding obtained at 

local (but not 

statewide) level 

Select all sources that apply.

S-39.1 Other local 

funds 

expended

Other source not 

described in 01-

04.

99-Other (Text) If 99 other is used, write a brief description

(500 characters).

S-40 All Funds 

Expended

Grand total 

dollars expended 

from all sources.

Single Numeric 

(decimal)

NA (not a coded 

element)

In dollars ($) and cents.
23

Part G: Facility Data Elements 

Report for both nursing facilities and residential care communities, in the appropriate section, the number of facilities which were licensed, ( or 

registered, listed, certified, or otherwise regulated) by a state during the reporting period and the resident capacity (number of beds) of those facilities. 

Element 

Number

Data Element Element Definition Quantifier Type Codes and Values Examples and Reporting Tips

S-41 Number of 

nursing 

facilities 

Total number of 

nursing facilities 

within the state.

Single Numeric) NA (not a coded 

element)

Count on last day of federal fiscal year. It 

must be a whole number.

S-42 Total nursing 

facility 

resident 

capacity

Number of beds for 

which the facilities 

are licensed.

Single Numeric NA (not a coded 

element)

Count on last day of federal fiscal year. It 

must be a whole number.

S-43 Number of 

residential 

care 

communities 

Total number of 

residential care 

communities within 

the state.

Single Numeric NA (not a coded 

element)

Count on last day of federal fiscal year. It 

must be a whole number.

S-44 Total 

residential 

care 

community 

resident 

capacity

Number of beds for 

which the facilities 

are licensed, 

certified or 

registered.

Single Numeric NA (not a coded 

element)

Count on last day of federal fiscal year. It 

must be a whole number.
24

Composite 

Data 

Element 

Element Description Quantifier Type Codes and Values Examples and Reporting Tips

Residential 

Care 

Community 

Type

Provide information regarding each 

type of Residential Care Community.

Multiple Composite 

data 

element 

subsuming 

element 

numbers 

S45, S46, 

and S47

NA (not a coded 

element)

Indicate the name of each type of Residential 

Care Community that is licensed, registered, 

listed, certified, or otherwise regulated by the 

state and the state’s definition for each type.

Include the total number of beds licensed, 

registered, listed or certified using this 

definition. Indicate the minimum and 

maximum number of beds permitted by the 

license or other regulatory designation for 

each type of facility.

Element 

Number

Data 

Element

Element 

Description

Quantifier Type Codes and Values Examples and Reporting Tips

S-45 Residential

care

community

name 

License, registration 

or License, 

registration or 

certification name of

the residential care 

community.

Single per 

Residential 

Care 

Community 

Alphanumeric 

String

NA (not a coded 

element)

Reporting the number of unregulated or 

unlicensed Residential Care

Communities is optional (not required.) If 

the state chooses to report, write 

“unregulated” as the Residential Care 

Community name (500 characters).
25

Element 

Number

Data 

Element

Element 

Description

Quantifier Type Codes and Values Examples and Reporting Tips

S-46 Residential 

care 

community 

definition

State definition of a 

residential care 

community facility.

Single per 

Residential 

Care 

Community 

Type

Alphanumeric 

String

NA (not a coded 

element)

Provide a brief description of the state’s 

definition of residential care community.

Include a brief description of the 

unregulated Residential Care 

Community, if identified.

Maximum length of 3,400 characters 

(about 500 words).

S-47 Residential 

care 

community 

capacity 

range

Minimum number of 

beds permitted by 

the license or other 

regulatory 

designation.

Single per 

Residential 

Care 

Community 

Type

Alphanumeric 

String

NA (not a coded 

element)

If known, include the minimum capacity 

(minimum number of beds allowed by 

licensed type). If capacity is not known 

then select no minimum. If there is no 

maximum or no minimum select that 

option. 

S-47.1 Residential 

care 

community 

capacity 

range

Maximum number of 

beds permitted by 

the license or other 

regulatory 

designation.

Single per 

Residential 

Care 

Community 

Type

If known, include the maximum capacity

(maximum number of beds allowed by 

license type). If capacity is not known 

then select no maximum. If there is no 

maximum or no minimum select that 

option.
26

Part H: Ombudsman Program Activity Data Elements

Element 

Number

Data 

Element

Element Description Quantifier Type Codes and Values Examples and Reporting Tips

S-48 Certification 

training hours 

Total hours of training 

required for an 

individual (paid or 

volunteer) to achieve 

certification which 

allows an individual 

to be eligible for 

designation as a 

representative of the 

Office of State LTC 

Ombudsman. 

Single Numeric NA (not a coded 

element)

If a state has various levels of 

training based on volunteer or paid 

status, select the minimum number 

of training hours required to perform 

the duties as a representative of the 

Office.

It must be a whole number.

S-49 Continuing 

education

Annual number of 

hours of in-service 

training required for 

all representatives of 

the Office.

Single Numeric NA (not a coded 

element)

If a state has various levels of 

continuing education requirements

based on volunteer or paid status, 

select the minimum number of 

continuing education hours required 

to maintain ability to perform the 

duties as a representative of the 

Office.

It must be a whole number.

S-50 Number of 

individuals 

completing 

certification 

training

Total number of

individuals (paid or 

volunteer) completing 

certification training 

within the federal 

fiscal year.

Single Numeric NA (not a coded 

element)

Report number of individuals who 

completed training even if they have 

not started fulfilling the duties of a 

representative of the Office.

It must be a whole number.
27

Element 

Number

Data 

Element

Element Description Quantifier Type Codes and Values Examples and Reporting Tips

S-51 Training 

sessions:

nursing 

facility staff

Number of sessions 

provided by 

representatives of the 

Office to nursing 

facility staff.

Single Numeric NA (not a coded 

element)

Training may be in person, or webbased and typically includes an 

agenda and learning outcome(s). 

If the Ombudsman program is 

presenting to a large group that 

includes multiple types of facility 

staff, decide which staff type to 

select based on majority in 

attendance. If training is webbased, on-line or on-demand the 

Ombudsman program must have a 

way to count the number of 

individuals who completed a training 

session in order to report in NORS.

It must be a whole number

S-52 Training 

sessions:

residential 

care 

community

staff

Number of sessions 

provided by 

representatives of the 

Office to residential 

care community staff. 

Single Numeric NA (not a coded 

element)

Training may be in person, or webbased and typically includes an 

agenda and learning outcome(s). 

If the Ombudsman program is 

presenting to a large group that 

includes multiple types of facility 

staff, decide which staff type to 

select based on majority in 

attendance. If training is webbased, on-line or on-demand the 

Ombudsman program must have a 

way to count the number of 

individuals who completed a training 

session in order to report in NORS.

It must be a whole number.
28

Element 

Number

Data 

Element

Element Description Quantifier Type Codes and Values Examples and Reporting Tips

Information 

and 

Assistance

Providing information 

about issues 

impacting residents 

(e.g., resident rights, 

care issues, services) 

and/or providing 

assistance to access 

services without 

opening a case and 

working to resolve a 

complaint. 

Information and assistance may be 

provided through various means, 

including but not limited to 

telephone, by written 

correspondence such as e-mail, or in 

person. 

S-53 Information 

and 

assistance: 

nursing 

facility staff

Number of instances 

provided by 

representatives of the 

Office.

Single Numeric NA (not a coded 

element)

It must be a whole number.

S-54 Information 

and 

assistance: 

residential 

care 

community 

staff

Number of instances 

provided by 

representatives of the 

Office.

Single Numeric NA (not a coded 

element)

It must be a whole number.

S-55 Information 

and 

assistance to 

Individuals

Total number of

information and 

assistance instances 

to individuals 

provided by 

representatives of the 

Office.

Single Numeric NA (not a coded 

element)

It must be a whole number.
29

Element 

Number

Data 

Element

Element Description Quantifier Type Codes and Values Examples and Reporting Tips

S-56 Facilities 

visited: 

nursing 

facility 

Total number of 

nursing facilities that 

received at least one 

visit by a

representative of the 

Office during the 

reporting year,

regardless of the 

purpose of the visit.

Single Numeric NA (not a coded 

element)

This is a count of the number of 

facilities that received a visit. For 

example 350 of the 350 nursing 

facilities in State A had at least one 

visit, regardless of purpose.

It must be a whole number.

S-57 Number of 

visits: nursing 

facility 

Total number of 

nursing facility visits 

no matter the 

purpose of visit 

(complaint or noncomplaint related) by 

representatives of the 

Office.

Single Numeric NA (not a coded 

element)

This is a count of the total number of 

visits; for example, there were 1500 

visits made to the 350 nursing 

facilities in State A (both complaint 

and non-complaint.)

It must be a whole number.

S-58 Routine 

access:

nursing 

facility

Total number of 

nursing facilities 

visited, not in 

response to a 

complaint, in all four 

quarters by 

representatives of the 

Office.

Single Numeric NA(not a coded 

element)

This count demonstrates routine 

access. For example, of the 350 

nursing facilities in State A, 150 had 

a visit each quarter, not in response 

to a complaint. 

It must be a whole number.
30

Element 

Number

Data 

Element

Element Description Quantifier Type Codes and Values Examples and Reporting Tips

S-59 Facilities 

visited: 

residential 

care 

community

Total number of 

residential care 

communities that 

received at least one 

visit by a 

representative of the 

Office during the 

reporting year, 

regardless of the 

purpose of the visit.

Single Numeric NA (not a coded 

element)

This is a count of the number of

facilities that received at least one

visit. For example 700 of the 2000 

residential care communities in State 

B had at least one visit during the 

reporting year, regardless of 

purpose.

It must be a whole number.

S-60 Number of 

visits: 

residential 

care 

community 

Total number of 

residential care 

community facility 

visits no matter the 

purpose of visit 

(complaint or noncomplaint related) by 

representatives of the 

Office.

Single Numeric NA (not a coded 

element)

This is a count of the total number of 

visits; for example, there were 1400

visits made to the 700 residential 

care communities in State B (both 

complaint and non-complaint.)

It must be a whole number.

S-61 Routine 

access: 

residential 

care 

community 

Total number of 

residential care 

community facilities 

visited, not in 

response to a 

complaint, in all four 

quarters by 

representatives of the 

Office.

Single Numeric NA (not a coded 

element)

This count demonstrates routine 

access. For example, of the 2000 

residential care communities in State

B, 200 had a visit each quarter, not 

in response to a complaint. 

It must be a whole number.
31

Element 

Number

Data 

Element

Element Description Quantifier Type Codes and Values Examples and Reporting Tips

S-62 Facility 

survey 

participation: 

nursing

facility

Total number of 

instances of survey 

activity by

representatives of the 

Office.

Single Numeric NA (not a coded 

element)

Include participation in both standard 

surveys and complaint surveys.

Survey participation includes but is 

not limited to pre-survey information 

to surveyors, sharing complaint 

summary reports, participation in exit 

conferences and informal dispute 

resolution.

It must be a whole number.

S-63 Facility 

survey

participation: 

residential

care 

community 

Total number of 

instances of survey 

activity by 

representatives of the

Office.

Single Numeric NA (not a coded 

element)

Include participation in both standard 

surveys and complaint surveys, (or 

similar state surveys or inspections 

conducted in Residential Care

Communities.) Survey participation 

includes but is not limited to presurvey information to surveyors, 

sharing complaint summary reports, 

participation in exit conferences and 

informal dispute resolution.

It must be a whole number.

S-64 Resident 

council 

participation:

nursing 

facility

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.

Single Numeric NA (not a coded 

element)

Use S-55 to count technical support, 

consultations and providing resource 

information, for information and 

assistance that was not offered 

during a council meeting.

It must be a whole number whole 

number.
32

Element 

Number

Data 

Element

Element Description Quantifier Type Codes and Values Examples and Reporting Tips

S-65 Resident 

council 

participation: 

residential 

care 

community

Total number of 

instances of 

attendance, at 

resident councils, 

including meeting 

with council 

leadership, and 

training of resident 

councils at residential 

care community 

facilities by 

representatives of the 

Office.

Single Numeric NA(not a coded 

element)

Use S-55 to count technical support, 

consultations and providing resource 

information, for information and 

assistance that was not offered 

during a council meeting. 

It must be a whole number.

S-66 Family 

council 

participation:

nursing

facilities

Total number of 

instances of 

attendance, at family

councils, including 

meeting with council 

leadership, and 

training of family

councils at nursing 

facilities by 

representatives of the 

Office.

Single Numeric NA (not a coded 

element)

Use S-55 to count technical support, 

consultations and providing resource 

information, for information and 

assistance that was not offered 

during a council meeting.

It must be a whole number.
33

Element 

Number

Data 

Element

Element Description Quantifier Type Codes and Values Examples and Reporting Tips

S-67 Family 

council 

participation:

residential 

care 

community 

Total number of 

instances of 

attendance, at family 

councils, including 

meeting with council 

leadership, and 

training of family 

councils at residential 

care community 

facilities by 

representatives of the 

Office.

Single Numeric NA (not a coded 

element)

Use S-55 to count technical support, 

consultations and providing resource 

information, for information and 

assistance that was not offered 

during a council meeting.

S-68 Community 

Education 

Total number of 

instances of 

community education 

outreach sessions by 

Ombudsman 

program.

Single Numeric N/A (not a coded 

element)

Use for attendance at health fairs, 

community events, general 

presentations, etc. If education is 

web-based or on-line/on-demand the 

Ombudsman program must have a 

way to count the number of 

individuals who completed the 

session in order to report in NORS. 

Newsletters, blogs and other forms 

of media do not count as community 

education.

It must be a whole number.
34

Element 

Number

Data 

Element

Element Description Quantifier Type Codes and Values Examples and Reporting Tips

S-69 State and 

local level 

coordination 

activities

Identifies the list of 

agencies/programs 

that have state or 

local level 

coordination activities 

led by the 

Ombudsman

program.

Multiple List of 

Numeric 

Codes

01-Area agency on

aging programs

02-Aging and

disability resource

centers

03-Adult protective

services programs

04-Protection and

advocacy systems

05-Facility and longterm care provider

licensure and

certification

programs

06-The State

Medicaid fraud

control unit

07-Victim assistance

programs

08-State and local

law enforcement

agencies

09-Courts of

competent

jurisdiction

10-The State legal

assistance

developer and legal

assistance programs

11-Centers for

Independent Living

98-None

Report any leadership activities 

and/or state/local-level coordination, 

where the State Ombudsman 

provides state-level coordination, 

and support for appropriate local 

Ombudsman entity coordination, 

between the Ombudsman program 

and other entities with 

responsibilities relevant to the health, 

safety, well-being or rights of 

residents of long-term care facilities 

Select one or more agency or 

program. 

Optional narrative up to 5000 words.
35

Element 

Number

Data 

Element

Element Description Quantifier Type Codes and Values Examples and Reporting Tips

S-69.1 Other state 

and local 

activities. 

Description of state 

and local level 

coordination 

organization not 

listed in 01-11.

99- Other (text) Provide a brief description of the 

organization (500 characters.)