Following the completion of the literature review, discussions with stakeholders and the meeting of the Technical Advisory Group, Maryland was identified as one of seven states meeting the project criteria for states with state-initiated quality improvement programs. These criteria include (1) having state-initiated programs in place, (2) having programs that were not reimbursement or payment related, and which (3) included aspects of technical assistance and/or quality improvement. In response to concerns from within the state and the nation at large, Maryland had enacted a number of measures aimed at improving the quality of care in nursing homes. Some (e.g., the quality improvement plan, the "Second Survey") were regulatory measures, while others ranged from educational services to research endeavors that were voluntary programs. Maryland was identified as the initial site visit because their technical assistance and quality improvement programs had been underway for approximately one year and the state is in close geographic proximity to Massachusetts and Washington, D.C. where members of the research team are located.