State Nursing Home Quality Improvement Programs: Site Visit and Synthesis Report. Relationship Between the Survey and TA Programs


Close Ties

In two of our study states we found close relationship between the TA program and the state survey agency.

  • Washington's TA staff work within the LTC survey agency, and share findings with surveyors. The TA staff conduct LTC surveys as well as complaint investigations, and monitor facilities that are in compliance trouble. TA staff may also write deficiency citations during a quality monitoring visit, although this is rare.

  • In Florida, the Quality Monitoring staff work within the survey agency. While they report to the State Survey Agency central office rather than the local field survey office as the LTC surveyors do, TA staff attend survey field office staff meetings and coordinate with the field office when performing surveyor functions. While Florida's TA staff do not conduct annual certification surveys, they are required to perform surveyor functions such as monitoring facilities that are closing or in immediate jeopardy. TA staff also provides on-site training for new survey staff. Because of their multiple roles, Florida TA staff must make clear upon arrival to facilities as to which of their functions they are performing that day. On occasion, TA staff find it necessary to caution facility staff that information shared with them on a particular visit is in effect being shared with a surveyor.

"Relative" Independence

In some of the study states there was relatively more independence or separation between the TA program and the state survey agency.

  • In Maryland, the TA staff work within the LTC survey agency, but are separate from and independent of the survey team.

  • Maine's TA nurse technically works within the survey agency but physically works from her home office. A copy of her reports, which goes to her supervisor in the survey agency, is available to LTC surveyors.

  • In Texas, legislation specifically mandates that the TA program be separate from the survey process. However, surveyors do access TA site visit reports on the Intranet prior to their survey visit.

Total Separation

In our study states, Missouri was the only one state in which there was total separation between the TA program and the State Survey Agency.

  • Missouri's QIPMO staff work completely outside the LTC survey agency. The QIPMO staff are not surveyors, not survey trained, and not currently or in the past affiliated with the survey agency. The state agency responsible for the LTC survey provides only broad oversight and has virtually nothing to do with the day-to-day operation of the TA program. The survey agency receives summary reports of TA activity, which give numbers of facilities visited but no facility names. Survey agency staff take a strong stance in maintaining their role as monitors and regulators and distancing themselves from any consultative role. Surveyors appear to defer to the TA nurses on clinical issues, and the TA nurses do not get involved in enforcement/regulatory issues.

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