State Nursing Home Quality Improvement Programs: Site Visit and Synthesis Report. 9.0 Conclusions


The backbone of the nation's system for monitoring nursing home quality of care is the LTC survey and certification process, which focuses on facility compliance with the regulations governing Medicare and Medicaid certification. This regulatory focus sharply limits the amount and types of consultative advice LTC surveyors can provide, as reflected in Section 4018 of the State Operations Manual:

"It is not the surveyor's job to examine the facility's policies and procedures to determine or speculate on the root cause of deficiencies, or to sift through various alternatives to prescribe one acceptable remedy."33

Survey and certification staff are directed not to assist facilities with in-depth problem solving on ways of improving the quality of care delivered. They are allowed to disseminate information that may be of assistance to the facility in meeting long-term care requirements, but they do not provide training to nursing home staff on quality-related issues.34

This limited focus, combined with continuing concerns about nursing home quality, has led some states to supplement their quality assurance standards with consultative, collaborative programs that directly address quality improvement. The goal of the study reported here is to examine these state-initiated quality improvement efforts and, more specifically, to identify their characteristics and look for information that might be helpful to other states considering such initiatives.

We focused on seven states with quality improvement programs: Florida, Iowa, Maryland, Maine, Missouri, Texas, and Washington. For each of these states, we collected detailed information on their quality improvement programs through both in-person and telephone discussions with stakeholders.

  1. Source: CMS (

  2. Further clarification on the role of surveyors regarding consultation, technical assistance, and sharing best practice information can be found in a CMS memorandum dated 12/12/02, available on-line at

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