1. National Ombudsman Reporting System (NORS) Consistency
Welcome everyone. This is Carol Scott, Ombudsman Specialist for the National Ombudsman Resource Center. This webinar, NORS Consistency, is being recorded and therefore everyone’s phone line is muted. If you wish to ask a question, please type the question in the box on the right side of your screen. We will address those questions following the presentations. If time permits, we will open the phone lines for more conversation.
New State Ombudsman Orientation
February 9, 2017

2. Today We Will…
Look at definitions for Case, Complaint, and Consultation
Check out the NORS FAQs
Hear from:
Louise Ryan, Ombudsman Program Specialist, Administration for Community Living (ACL)
Mark Miller, Washington, DC State Ombudsman
Look at Resources
Hear from you: Questions and Answers
Closing
We'll be discussing some challenges which all states face: 
• Understanding the importance and value of the data, and sharing that with representatives,
• Getting representatives of the Office (staff and volunteers) to report their work 
• Ensuring consistency and quality of the data reported

3. Poll Question #1
As part of your homework, you were asked to review the definitions of Case, Complaint and Consultation.
Your state requires that all allegations of abuse be reported to the Adult Protective Services agency or the police and that the ombudsman program be notified. You receive a routine notification from APS, which is investigating the allegation.
a. Is it a case?
b. A consultation?
c. Both a and b
d. None of the above

4. Poll Question #2
Case: Mrs. Oliver asks you to help her obtain the medical records for her mother, who recently died in a nursing home; she is the executor of her mother’s will and was her health care durable power of attorney. She is planning to use the records in a private action lawsuit against the facility.
a. Is it a case?
b. A consultation?
c. Both a and b
d. None of the above

5. Poll Question #3
Can we count Ombudsman articles in the AAA newsletters or Senior Center newsletters as media?
a. Yes, you are using the AAA to get information out
b. No, this activity is not “work with media“

6. NORS 101 Consistency Counts!
Louise Ryan, MPA
Ombudsman Program Specialist, ACL/AoA
February 9, 2017

7. Agenda Overview the National Ombudsman Reporting System (NORS)
Tips to achieve consistency & basic definitions
Reporting Tips and Resources
How ACL uses NORS data or why consistency matters
Question & Answer

8. National Ombudsman Reporting System (NORS)
Data elements that LTC Ombudsmen are required to collect Sec 712(h) (1)-(3)(b)
Cases, Complaints
Types of Complaints and outcome (resolution)
Consultation
Funds Expended and sources
Staff FTE
Numbers of Volunteers and hours
Activities: Training, non-complaint visits, resident and family councils
Narratives:
Systems issues-required
case example & legal -optional
*REPORTING SYSTEM.—The State agency shall establish a statewide uniform reporting system to—
(1) collect and analyze data relating to complaints and conditions in long-term care facilities and to residents for the purpose of identifying and resolving significant problems; and
(2) submit the data, on a regular basis, to—
(A) the agency of the State responsible for licensing or certifying long-term care facilities in the State;
(B) other State and Federal entities that the Ombudsman determines to be appropriate;
(C) the Assistant Secretary; and
(D) the National Ombudsman Resource Center established in section 202(a)(21).
ADMINISTRATION.—The State agency shall require the Office to—
(1) prepare an annual report—
(A) describing the activities carried out by the Office in the year for which the report is prepared;
(B) containing and analyzing the data collected under subsection (c);
(C) evaluating the problems experienced by, and the complaints made by or on behalf of, residents;
(D) containing recommendations for—
(i) improving quality of the care and life of the residents; and
(ii) protecting the health, safety, welfare, and rights of the residents;
(E)(i) analyzing the success of the program including success in providing services to residents of board and care facilities and other similar adult care facilities; and
(ii) identifying barriers that prevent the optimal operation of the program; and
(F) providing policy, regulatory, and legislative recommendations to solve identified problems, to resolve the complaints, to improve the quality of care and life of residents, to protect the health, safety, welfare, and rights of residents, and to remove the barriers;
(2) analyze, comment on, and monitor the development and implementation of Federal, State, and local laws, regulations, and other government policies and actions that pertain to long-term care facilities and services, and to the health, safety, welfare, and rights of residents, in the State, and recommend any changes in such laws, regulations, and policies as the Office determines to be appropriate;
(3)(A) provide such information as the Office determines

9. Ombudsman Data
NORS data tells the big picture of the LTC Ombudsman Program.
What is required at the federal level is sometimes different than what is needed at the state level
State level can be used to promote the program, to evaluate the level of activity, to look at complaint trends to inform systems advocacy.
State- details on ombudsman activity, i.e. training.

10. How AoA/ACL uses NORS Data:
Budget Justification – See following outputs & outcomes table
To inform policy – examples – revised nursing home regulations:
Long-Term Care Ombudsman complaints
“By way of background, we note that the ACL-funded Long-Term Care Ombudsman Programs processed complaints for “Discharge/Eviction” as the most frequent nursing facility complaint category nationally in FY 2013 (8,478 complaints) and the complaint category has been in the top one or two place since 2006.
“Failure to respond to requests for assistance” = Second most frequent nursing facility complaint category nationally in FY 2013 (7,220 complaints) and in top one or two place for past decade.

11. How AoA/ACL uses NORS Data: (continued)
With media inquiries –
NPR on nursing home staffing shortages
Excerpts: “. . . Long-term-care ombudsmen report frequent complaints of “dumping”: A nursing home sends a resident, often someone whose dementia causes problematic behavior, to a hospital. Then, after she is discharged, the home won’t readmit her…
NPR on improper transfers and evictions “This is not just a California issue. Nationwide, between 8,000 and 9,000 people complain to the government about nursing home evictions every year. It's the leading category of all nursing home complaints, according to the federal Administration for Community Living.”

12. Other Media Examples: Epoch Times Washington Post
In 2014, 14,258 complaints involving abuse, gross neglect, or exploitation at nursing homes were reported to the federal government’s Administration for Community Living ombudsman programs.
Washington Post
Example of using NORS Data:
“Bennett works as an advocate for county residents in the elderly care system. Every time a skilled nursing facility issues a notice of discharge for a resident, she receives a copy of the notice. Between July and December 2015, she received 161 notices of involuntary discharge from NMS Silver Spring and NMS Springbrook. She received only 71 of these notices from the 32 other county nursing homes for the entire calendar year.”

13. Budget Justification example
Federal level – very broad outcome and output measures, this helps to inform & justify HHS/President’s budget and Congressional budget

14. Three C’s Basic Principles
CASE
is an Inquiry brought to, or initiated by the LTCO, on behalf of a resident or group of residents,
involving ≥ 1 complaints which requires opening a case and
includes LTCO investigation, strategy to resolve, and follow-up.
The number of cases is equal to the number of complainants.
Case = One or more people jointly filing complaint count as one complainant.

15. Three C’s Basic Principles
COMPLAINT:
Concern brought to, or initiated by, LTCO for investigation and action: On behalf of 1 or more residents
Relating to the health, safety, welfare or rights of a resident.
Tips: One or more complaints constitute a case.
You cannot have a case without a complaint.

16. Three C’s Basic Principles
CONSULTATION: Providing information and assistance to an individual or a facility.
It does not involve investigating and working to resolve complaints. (≠ case)
If LTCO refers someone with a concern to another agency and is not actively involved in investigating and working to resolve the problem, it is not LTCO case or complaint.

17. Complaint versus Consultation
LTCOP Rule § (b) Complaint Processing
The Ombudsman or representative of the Office shall investigate a complaint, including but not limited to a complaint related to abuse, neglect, or exploitation, for the purposes of resolving the complaint to the resident’s satisfaction and of protecting the health, welfare, and rights of the resident. The Ombudsman or representative of the Office may identify, investigate and resolve a complaint impacting multiple residents or all residents of a facility.
Personally Discuss with Resident
Privacy
Resident communicates informed consent to take action on the complaint
Determine the wishes of the resident
Determine /obtain consent to disclose resident identifying information
Information and Consult Practice
Resident/staff/Family, etc. has a question about rights, care, etc. LTCO provides answer, resources, referral information. The LTCO may or may not follow up to see if more assistance is needed (i.e. when someone calls the program - there may not be a call back).
May or may not discuss with the resident (depending on who called)
Privacy may or may not be a factor, i.e. may be a phone call that the resident makes from a public phone
Work is not done to determine the inquirer’s perspective other than to understand the question/concern and provide accurate information
There is no informed consent because no further action is needed
However, the conversation cannot be disclosed without consent per disclosure requirements of the rule.

18. Complaint versus Consultation
LTCOP Rule § (b) Complaint Processing
Advise the resident (and resident representative, where applicable) of the resident’s rights;
Work with the resident (or resident representative, where applicable) to develop a plan of action for resolution of the complaint
Investigate the complaint to determine whether the complaint can be verified; and
Determine whether the complaint is resolved to the satisfaction of the resident (or resident representative, where applicable).
Case notes are documented within the case, not as a consultation activity.
May offer consultation related to the complaint but that is documented in the case notes.
Information and Consult Practice
Provide information on applicable rights, laws, etc. if appropriate
No action for complaint resolution requested so no plan to develop
No investigation
May or may not follow up with inquirer; there is no requirement to determine level of satisfaction
Consultations are documented as activities; document each instance and the topic(s)

19. Activities – Areas of Confusion
Training for ombudsman staff and volunteers
This activity is from the perspective of the trainer, reporting on training provided by or arranged by Ombudsman program staff.
The number of sessions is unduplicated. A session is a meeting/training, whether it lasts for three hours, all day, or all week.
The number of hours is the time the trainees spend receiving training.
It does not capture the time spent preparing for training.

20. Training Sessions Example: Example:
Certification training is offered 1 x per week for 8 hours at a time
total of 32 hours
10 trainees
Common errors
4 sessions
320 hours
Example:
Certification training is offered 1 x per week for 8 hours at a time
total of 32 hours
10 trainees
Actual
1 session
32 hours

21. Activities – Areas of Confusion
Facility Coverage
This is an unduplicated count of facilities visited no less frequently than quarterly based on the federal fiscal year. The number reported indicates the facility was covered on a regular basis, not in response to a complaint, by paid or volunteer representatives of the Office.
Quarterly visits are not an ACL/AoA requirement – it is a measure of the LTCOP providing “routine access” to residents.
From FAQ’s: Q – If a complaint arises during a regular/routine visit in a facility, can the representative of the Office open a case during that visit and still count the visit as a regular visit to that facility?
A – Yes, that would still be a routine visit because the purpose of the visit was to provide residents with access to ombudsman services. The visit was not initiated in response to a complaint, to provide further investigation on an existing complaint, or to provide follow-up.
A program is not prohibited from counting a visit as a “routine visit” when making a visit in response to a complaint IF there is a protocol for what is included in a routine visit; i.e. visit with a percentage of residents, spend a certain amount of time, etc. We understand the need to be efficient with travel time.

22. Activities – Areas of Confusion
Over counting activities:
Five program volunteers assist with one community education event
Is it 5 instances or 1?
The state Ombudsman and a representative of the Office both participate in a survey exit conference
Is it 2 instances or 1?

23. NORS Reporting Tips: Go through all NORS training I-IV
Learn NORS definitions, work cases to bring it to life
Go through all NORS training I-IV
Review and implement on-going training with staff/volunteers
Expect on-going documentation
If there is not consistent reporting build into requirements – make it routine
Use technology – if you have access to data use it as much as possible – run reports, random spot check, etc.
“Share from” your peers – lots of good tips & tools

24. Ombudsman Reporting Tool
The mechanism to deliver the NORS report
Must install on your computer
Access all information at AoA Data Community
Ability to run lots of reports
ORT is the mechanism to report NORS data

25. AoA Data Community https://aoadatacommunity.us/login/index.php
Use your address (all lower case) as user name and password
If no current account contact
Harmony Information Systems is the ACL contractor for both ORT and the State Reporting Tool (SRT)

26. We at ACL take data quality seriously
Review conducted by a Harmony/Mediware sub-contractor Marianne Follingstad
A template is available
Final Review by Ombudsman Program Specialist, (Louise) who certifies the report
Common concerns:
General drop in complaint numbers
Inconsistent quality of narratives & complaint resolution examples
We use your narrative information!!
Narrative info uses, CMS – proposed regulations, researchers, other federal agencies such as Asst. Sectary for Planning & Evaluation, Dept. of Justice, Office of Inspector General, Government Accounting Office

27. Resources NORS Training Materials
Aging Integrated Database – AGID – offers data at a glance and custom tables

28. National Ombudsman Reporting System Make Your Data Work for You
This presentation will amaze and may shock you.
It both confirms what we think we know intuitively and it raises questions (which require further analysis).
The information is actual and real because it is your data, taken from your reports.
The data tells a story about the program and the work it does. And it tells that story to the nation.
Your reports are essential and important --- and I hope to give you some insight into why by showing you where it goes, how it is used and the story it portrays to world.
Invite questions as we go.
NORC Presentation

29. Three Things for Certain
Death
Taxes
A Call from Marianne Follingstad

30. Recording Your Work is Important
Program activities
Case Information
Program Information
NORS Report

31. Do you think it’ll matter if I don’t submit this story on that Watergate thing?

32. Two Big Challenges
Getting volunteers (and local coordinators) to report their work
Ensuring consistency and quality of the data reported

33. Give local programs the facts about the importance of their data

34. Tell them where the data goes
Volunteer
Ombudsman Coordinator
State Ombudsman
Administration on Aging
Congress

35. … and how the data is used
Accountability
Program management
Information sharing
Identifying, tracking and analyzing trends
Systems advocacy

36. … and the difference it made for residents
Provided information and consultation to 400,000 persons
Investigated 199,000 complaints
Attended more than 21,000 resident council meetings and 2,400 family council meetings
Resolved 72% of resident complaints

37. Ombudsmen like to know how their data compares to other programs and where it fits in the bigger picture

38. Complaint Venue

39. Percentage of Facilities Visited on a Regular Basis

40. Most Frequent Nursing Home Complaints
Nationwide
District of Columbia
Discharge/eviction (planning, notice, process)
Billing/charges (notice, approval)
Medications –administration
Symptoms unattended, pain not managed, no notice to others of changes in condition
Food Service – quantity, quality, choice, etc.
Discharge/eviction (planning, notice, process)
Failure to respond to requests for assistance
Dignity/respect/staff attitudes
Medications –administration
Resident Conflict
NYS LTCOP

41. Nursing Home Complaints

42. Complaints versus consultations to individuals

43. Use your data to: Inform the public Direct your program
Motivate your staff
Tell your story
Make a difference

44. Resources NORS training modules (I - IV) NORC website
Aging Integrated Database (AGID)
AoA resources
AoA Regional Office data analysis

45. Case No. 1
A nursing home resident complains that the facility is keeping her money. “They’re ripping me off,” she states emphatically. You talk with the business office manager who tells you that the resident asked to have her own phone in her room. She agreed to pay for the phone out of her Personal Needs Allowance (PNA). She uses the balance of her PNA to have her hair done and purchase a few personal items. You report back to the resident. She forgot that she was paying for the phone out of her PNA. She’s glad you straightened things out. She really likes having the phone because she can keep in touch with her children and her friends.

46. Poll Question #4
 Poll Question #4
Is the complaint verified: Yes or No

47. Poll Question #5
What is the appropriate disposition?
Not resolved to satisfaction of resident or complainant
Referred to another agency
Withdrawn by resident or complainant
No action needed or appropriate
Partially resolved but some problem remained
Resolved to satisfaction of resident or complainant

48. Verifying Complaints
Ombudsmen always attempt to verify complaints, but they work to resolve a complaint, whether it is verified or not.  
Definition of verified:  It is determined after work (interviews, record inspection, observation, etc.) that the circumstances described in the complaint are generally accurate.

49. Disposition
The facts alleged in the complaint are not accurate therefore the complaint is not verified. But, even though the compliant is not verified, it still required action on the part of the ombudsman. After investigating the complaint, the ombudsman discovered that the facility is not keeping the resident’s money. They are paying for the phone that the resident requested. The case can be closed because there is nothing more for the ombudsman to do. You still must determine the outcome even though the complaint is not verified. The problem was resolved to the satisfaction of the resident. That is the outcome.

50. Disposition of Complaint
Not resolved to satisfaction of resident or complainant
Withdrawn by resident or complainant
No action needed or appropriate
Partially resolved but some problem remained
Resolved to satisfaction of resident or complainant

51. Questions?

52. resources

53. Resources NORS Training Materials and Data (public side)
NORS Training and Data (log-in side)
New State Ombudsman webpage (under “Understanding Your Program Data)

54. The National Long-Term Care Ombudsman Resource Center (NORC)
Carol Scott
Ombudsman Specialist
The National Long-Term Care
Ombudsman Resource Center (NORC)
This presentation was supported, in part, by a grant from the Administration on Aging, Administration for Community Living, U.S. Department of Health and
Human Services.