State Nursing Home Quality Improvement Programs: Site Visit and Synthesis Report. Facility Quality Assurance Program (COMAR 10.07.02.45)

05/15/2003

As of January 1, 2001, legislation mandated that each Maryland nursing facility establish an effective quality assurance program. The program was developed by the Nursing Home Task Force (described earlier) with the goal of changing the culture within the nursing home from one of living from survey to survey, to one focused on internal quality improvement. It contains guidance that exceeds the existing applicable federal regulations on nursing home quality assurance programs (42 CFR 483.75(o)).

Program requirements include the appointment of a qualified individual to manage quality assurance activities within the nursing facility, and the creation of a quality assurance (QA) committee. The regulation is silent with regard to the qualifications of the individual who must manage the QA activities, and OHCQ staff describe this position as being held by directors of nursing, administrators, QA nurses, and others. Membership of the QA committee must include at least the director of nursing, the administrator, the medical director, and a social worker, dietician, and geriatric nursing assistant. The committee must designate a chairperson to manage committee activities, must meet monthly to implement the QA plan, and must prepare monthly reports for the ombudsman, family council and resident's council. Quality assurance records must be available to the OHCQ for the purposes of ensuring implementation and effectiveness of the program.

The QA committee's primary responsibility is to assist in developing and approving the facility's initial quality assurance plan, and for assisting in the on-going implementation of that plan. They are responsible for submitting the QA plan to the OHCQ at the time of licensure or at the time of license renewal, and submitting any change in the QA plan to the OHCQ within 30 days of the change. They are also responsible for reviewing and approving the facility's QA plan at least yearly.

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