State Nursing Home Quality Improvement Programs: Site Visit and Synthesis Report. Quality Assurance Plan (COMAR


The QA plan must include procedures for concurrent review of resident status, ongoing monitoring of resident status, handling and reporting of patient complaints, procedures for accidents and incidents, and procedures for implementing abuse and neglect regulations (e.g., family notification).

  • Concurrent review consists of daily rounds by a licensed nurse to determine any changes in each resident's physical or mental status. The facility's QA plan must include the procedure for conducting the review, criteria used to determine a change in condition, methods for documenting the review, and identification of the nurse conducting the review. It must also include a procedure to evaluate clinical data for any resident with a change in status, as well as procedures outlining what action to take when there is a change of condition noted. The clinical data to be evaluated must include at least medications, laboratory values, intake and output, skin breakdown, weights, appetite, injuries and any other parameter that may affect the patient's physical or mental status. Additionally, the QA plan must describe a process for the referral of data to the QA committee when appropriate.
  • Ongoing monitoring is required for all aspects of resident care and must be accompanied by measurable criteria for evaluating patient status in the following areas:
    • medication administration;
    • prevention of pressure ulcers;
    • dehydration and malnutrition;
    • nutritional status and weight loss/gain;
    • accidents and injuries;
    • unexpected death; and
    • changes in physical and mental status.

The QA plan must also include methodology for data collection and evaluation in these patient care areas, analysis of data to determine trends, description of the thresholds and performance parameters, timeframes for follow-up, and description of documentation.

Essentially, the "concurrent review" component of the QA Plan requirement prescribes to the facility that resident status must be evaluated daily and must be evaluated in specific aspects of resident functioning (e.g., appetite, skin). The ongoing monitoring component of the QA Plan prescribes particular quality indicators for which the facility will be held accountable. For example, all Maryland facilities must monitor patient outcomes in the seven specified areas (e.g., medication administration, pressure ulcers) listed above.

  • Patient complaints--The QA plan must include a description of a complaint process that effectively addresses resident or family concerns. It must identify the designated person(s) and phone numbers to receive complaints or concerns, the method to be used to acknowledge complaints received, and the time frames for investigating complaints dependent upon the nature or seriousness of the complaint. The QA plan must also include a description of a logging system that will be used including the name of the complainant, the date that the complaint was received, the nature of the complaint, and the date that the complainant was notified of the disposition or resolution of the complaint. The QA plan shall also include procedures for notifying residents of their right to file a complaint with OHCQ, informing residents, families or guardians of the complaint process upon admission and posting the complaint process or making it available without the need to request it.

  • Accidents and incidents--The QA plan must include a definition of accident and injury that is appropriate to the type of resident served by the nursing home. It must describe the procedure for reporting accidents and injuries including who shall report incidents, the time frame for reporting incidents, and the procedure for reporting incidents. A description of how internal investigations of accidents and injuries will be handled including time frames for conducting the investigation, methods for assessment of any injury, interview of the resident, staff, and witness, and review of any relevant records including the resident's medical records, discharge summary, hospital records, etc. and how information will be referred to the QA committee. It must describe the process for notifying family or guardian about the incident, the process of notifying the QA committee and the process for ongoing evaluation to identify trends. It must also contain a policy statement saying that reporting incidents can be done without fear of reprisal.

  • Abuse and neglect--The QA plan must include a description of the process for implementing abuse regulations, including the family notification process, the evaluative process for identifying trends and patterns, and a description of how information will be shared with the QA committee.

Though the QA Plans are submitted to the state, all of the described components of the QA Plan requirement are not reviewed until the technical assistance, or "second", survey (described later in this document). Each component of the plan, as well as the status of the implementation of the plan, is reviewed and discussed with each facility by the State Quality Assurance Nurses.

The following requirements were also enacted through the Maryland Nursing Home Reform legislation.

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