State Nursing Home Quality Improvement Programs: Site Visit and Synthesis Report. References


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General Accounting Office. California Nursing Homes: Care Problems Persist Despite Federal and State Oversight. GAO-HEHS-98-202. Washington, DC: GAO, 1998.

General Accounting Office. Nursing Homes: Complaint Investigation Processes Often Inadequate to Protect Residents. GAO-HEHS-99-80. Washington, DC: GAO, 1999.

General Accounting Office. Nursing Homes: Quality of Care More Related to Staffing than Spending. GAO/HEHS-02-431R Washington, DC: GAO, 2002.

General Accounting Office. Nursing Homes: Sustained Efforts Are Essential to Realize Potential of the Quality Initiatives. GAO/HEHS-00-197. Washington, DC: GAO, 2000.

Institute of Medicine. Takeuchi, J., Burke, R., and McGeary, M., eds. Improving the Quality of Care in Nursing Homes. Washington, DC: National Academy Press, 1986.

Massoud, MRF. 2001. Advances in Quality Improvement: Principles and Framework. QA Brief--The Quality Assurance Project's Information Outlet. Spring, 9:1.

Minority Staff, Special Investigations Division, Committee on Government Reform, U.S. House of Representatives. Abuse of Residents Is a Major Problem in U.S. Nursing Homes, July 2001.

Office of the Inspector General. Nursing Home Survey and Certification: Overall Capacity, OEI-02-98-00330. Washington, DC: OIG, 1999(a).

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Office of the Inspector General. Nursing Home Survey and Certification: Deficiency Trends, OEI-02-98-00331. Washington, DC: OIG, 1999(c).

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TABLE 1. Description of State-Initiated Technical Assistance Programs

State Program Administration Facility Involvement Funding Source(s) Program Staff Frequency of Visits* Year Established Evaluation (Informal vs. Formal) Relationship to LTC Survey
Florida Health Standards & Quality Unit, Division of Managed Care and Health Quality within the Florida Agency for Health Care Administration (AHCA) Mandatory visits for all facilities (approx 700 facilities). The Quality of Long-Term Care Facility Improvement Trust Fund which supports activities and programs directly related to the care of nursing home and assisted living facility residents, is funded through a combination of general revenues and 50 percent of any punitive damages awarded as part of a lawsuit against nursing homes or related health care facilities (Florida law 400.0238). 19 Quality Monitors in 8 geographic regions. Each monitor has a caseload of approx 30 facilities. Design is for all facilities to be visited at least quarterly, plus additional visits to facilities on the Watch List as well as those that have a history of non-compliance, those whose QI reports reflect potential weaknesses; and facilities that have either changed ownership, changed administrators or changed Director of Nursing Services recently; and all new facilities. 1999 Feedback forms are collected from facilities visited by Quality Monitors to assess the helpfulness of the visit and rate the performance of the TA staff. No formal analysis done to date. The QOC Monitor program is administered by the survey branch. QOC Monitors do not share findings of monitoring visits with LTC Survey, except when conditions threaten the health or safety of a resident. Monitors perform the following surveyor responsibilities: monitoring facilities' compliance with the internal risk management program and minimum staffing standards; and coordination with the Field Office Managers in visiting facilities that are being financially monitored, closing, or in immediate jeopardy.
Maine Maine Department of Human Services, Bureau of Medical Services, Division of Licensing and Certification Voluntary--no records kept of number of facilities visited. The cost of this program is the single TA staff member's salary and administrative support, which is part of the Licensing and Certification budget. The funding for the state's best practices program comes from CMP fines. 1 RN Long Term Care Behavior Management Consultant. Consultation upon request. 1994 Informal evaluation of perceived usefulness of visit conducted by the nurse. Reports to the Assistant Director of the Division of Licensing and Certification. Reports are available to surveyors.
Maryland Maryland Department of Health and Mental Hygiene/Office of Health Care Quality Mandatory for all facilities (approx 250). All State General Funds approx $400,000. 1 Manager, 5 RNs, 1 Dietician Annual visits. 2000 A standardized tool was developed to examine compliance with regulations requiring facilities to implement a Quality Assurance Plan, which includes internal monitoring of falls, malnutrition and dehydration, pressure ulcers, medication administration, accidents and injuries, changes in physical/mental status, QIs, and other important aspects of care. Internal measures are reviewed by surveyors during the Second Survey. At the time of our visit, all nursing homes had been surveyed once and baseline data had been collected and is being analyzed. The Second Survey program is administered by the survey branch. TA nurses do not share findings of monitoring visits with LTC Survey, although they do report egregious conditions that threaten patient safety.
Missouri Quality Improvement Program for MO Long-Term Care Facilities (QUIP-MO) administered by the University of Missouri-Columbia School of Nursing Available to all facilities on a voluntary basis. As of July 2002, 345 site visits in 163 different facilities had been conducted by MU QI nurses. Funding provided by: (1) Nursing facility QI fund derived from facility tax based on number of residents. (2) Annual nursing facility licensing fee. (3) Civil Money Penalty fines, and in 2001-2002, the University received a $625,947 grant for its quality improvement programs. In 2000-2001, they received $743,424 and in 1998-1999, $492,258. Director, Statistician, Research Nurse, 7 QIPMO Nurses Voluntary Program--visits scheduled based on facility request. Pilot in 1999, official start in mid-2000. An anonymous evaluation instrument is completed at the conclusion of each site visit. Comparison of the distribution os CHRSA QI scores for all nursing facilities prior to QUIPMO start with 2001 scores (2 years into the program) show improvement in scores in multiple QIs. No relationship to survey agency.
Texas Texas Department of Human Services Mandatory for all facilities (approx 1250). TA and other quality improvement programs are financed by a combination of state and federal matching funds and a facility licensing fee. The total budget for the first two years of the program is $2.7 million. 36 TA staff (RNs, pharmacists and dieticians); 14 liaisons with providers; 16 FTEs for joint training. It is the intention of the program to visit all facilities annually. Facilities are targeted for a visit based on priority as determined by indicators in a DHS Early Warning System that identifies the facility as being at-risk for a poor survey. Facilities can also solicit a site visit from the rapid response team. 2001 DHS anticipates evaluating the program in 2003, after it has been in place approx 12 months. The evaluation will be based on comparing measures such as number of pressure ulcers pre and post initiation of the Quality Monitoring Program. Results of TA visits are discussed with survey.
Washington Department of Social and Human Services, Division of Residential Care Services Mandatory visits for all facilities (approx 275). The state receives a 75 percent match on TA staff salary and benefit costs. Costs for the program are approx $2.8 million. 30 nurses, each with a caseload of 8-12 facilities. Quarterly visits. 1988 No formal evaluation of impact of program has been conducted. TA staff work within the LTC survey agency, and share findings with surveyors. TA staff conduct LTC surveys as well as complaint investigations and monitoring of facilities that are in compliance trouble. TA staff may also write deficiency citations during a quality monitoring visit.

TABLE 2. Non-TA Quality Improvement Programs, by State

  Florida Iowa Maine Maryland Missouri Texas Washington
Public Reporting X X   X   X X
Best Practice Dissemination   X X   X    
Facility Recognition Program X X          
Provider and/or Joint Provider/Surveyor Training X X X   X X  
Clinical Alerts Newsletter       X      
Consumer Satisfaction Survey     X        
Rapid Response Teams X         X  
Risk Management Program X     X      
Medical Director Requirements X     X      
Teaching Nursing Home Research and Training Program X            
Corporate Visit Program             X
Pet Therapy Program       X      
Wellspring Project       X      
Decubitus Ulcer       X      
Family Council Project       X      

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