State Nursing Home Quality Improvement Programs: Site Visit and Synthesis Report. Focus of TA Visits


The focus of TA visits varied across states.

  • The focus of Florida's quality monitoring visits includes both improving care practices and risk management. During visits, monitors seek to identify, at an early stage, any conditions that are potentially detrimental to the health, safety, and welfare of nursing home residents. These conditions are identified based on quality indicators or based on issues that the facility has identified as a problem. Since May 2002, quality monitors have also been given the responsibility to assess the operations of state-required internal quality improvement, risk management programs and adverse incident reports. They also coordinate with the state's Field Office Managers in visiting facilities that are being financially monitored, closing, or in immediate jeopardy, to ensure the health and safety of residents.

  • The Maine TA program has a narrow focus, targeting only residents with behavior problems. Facilities request the assistance of the state's TA nurse to assist staff in dealing more effectively with difficult behaviors by giving them a better understanding of the resident, why the behaviors are occurring, and making recommendations regarding the care of the resident.

  • In Maryland, the TA visit (i.e., the Second Survey) includes quality assurance, technical assistance, and sharing of best practices. A standardized tool has been developed for the Second Survey that examines the facility's ability to internally monitor falls, malnutrition and dehydration, pressure ulcers, medication administration, accidents and injuries, changes in physical/mental status, quality indicators, and other important aspects of care. A TA visit in Maryland requires two days, with about six hours spent in resident medical record review to reconcile what the staff is saying with what has been recorded in the charts. The remaining time is spent reviewing the facility's quality assurance plan, and interviewing residents and key staff.

  • The focus of Missouri QIPMO visits is often based on information from the facility's "Show-Me" Quality Indicator Reports, which show facility performance over the past five quarters for each CHSRA quality indicator in comparison to other facilities in the state.14 TA nurses review the Show-Me reports to identify potential problem areas at the facility, and also use the reports as the basis for a review of MDS coding errors, specific clinical conditions, current practice guidelines and standards or care. In-service education on a variety of MDS-and clinical care-related topics is the focus of some visits.

  • A core feature of the Texas Quality Monitoring program is a set of highly structured protocols and assessment instruments that Quality Monitors use during their visits to determine if care is being provided in accordance with evidence-based best practices. TA visits may include observations of and interviews with nursing facility residents. Quality Monitors provide information regarding best practices and how to achieve them, give feedback to facilities regarding the degree to which the facility is providing care consistent with best practice protocols, and help the facility identify system changes that could result in greater use of best practices.

  • In Washington, the focus of technical assistance visits is issues identified by the state's Quality Assurance Nurses (QANs) in advance of their visit. These issues are identified based on a review of casemix audit information, quality indicators, survey results, complaints, and/or discharge issues. For example, a review of casemix audit information might identify a facility with a high rate of pressure ulcers. Based on this information, the QAN visit may include a review of resident records, observation of the skin care provided to residents, and interview with staff and residents that focus on the facility's skin integrity protocol.

14. See Appendix B for an example of the Missouri Show-Me QI report.

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