The impetus for the enactment of the Maryland quality improvement programs in 2000 as explained by the provider associations and the survey agency appears to have been based on a series of events and activities that occurred both within and outside the state in the preceding ten years. Beginning in 1989, deplorable conditions existing in a Maryland facility were reported in the media, which led (over the next three years) to multiple nursing facility closures. In 1997, findings from the California study of death certificates were published in Time Magazine. This led to a U.S. General Accounting Office (GAO) investigation in 1998 on California nursing homes (USGAO, 1998) and in 1999 on federal and state complaint and enforcement practices (USGAO, 1999). The 1999 GAO study noted problems with Maryland's complaint investigations, stating that the process was too slow. That same year, negative personal experiences by several influential state senators in Maryland nursing homes, along with damaging testimony before the legislature by OHCQ staff on the issue of complaints, pressed the legislature to tie the passage of a nursing home funding bill to the creation of a Nursing Home Task Force to study quality and oversight in Maryland. The for-profit provider association explained to the project team that their primary concern at that time was the restoration of full Medicaid funding that was promised in the bill. Although both provider associations indicated that they did not agree with the proposed member composition of the Task Force, specifically that stakeholders were included only on subcommittees, they were compelled to support the bill to ensure funding.
The Task Force began meeting during the summer of 1999 and presented their recommendations in January 2000. The Task Force identified the following:
- Nursing home care in Maryland is deficient;
- The regulatory system needs to be strengthened; and
- Serious staffing issues exist requiring development of the workforce in Maryland nursing homes.
In May 2000 a broad Nursing Home Reform Package was introduced containing six bills covering the following areas:
- Continued legislative oversight through the Quality Task Force;
- Addition of a second annual survey for each nursing home;
- Licensure standards that included mandated internal Quality Assurance Programs, qualifications for medical directors, standards for physician accountability, and mandated posting of staff within each home;
- Strengthened state sanctions and penalties;
- Additional Medicaid funding to the nursing homes to hire more nursing staff, improve benefits to stabilize the work force;
- Increases in Ombudsman staff.
Carol Benner explained that the six bills, which she wrote, represented a "six prong approach to improve quality." She stated that the general approach in the past had been to strengthen regulations and sanctions to weed out the bad providers, but that there had been no provisions to address quality. According to Benner, at the heart of the bills was the quality improvement program. HFAM reported that the key aspect of the legislation had to do with Medicaid funding for additional staffing and benefits.
Within each specific bill, there were components that the various stakeholders pushed to modify; however, no bill was defeated in its entirety. One provider explained that members of the Task Force agreed on the principles of the reform but differed on the operationalization of reforms and the timing for implementation. For example, Benner had proposed that the quality improvement programs in each facility be lead by a full-time nurse. Due to opposition by HFAM, this was modified to remove the requirement of a nurse. The legislature had initially promoted four surveys per year while the survey agency and provider groups were satisfied with two surveys. The final bill passed called for two nursing home surveys per year.