The typical reaction of nursing facility staff is to distrust technical assistance programs, particularly if they are run by the state survey agency or staffed by former or current surveyors. Many administrators want to avoid having surveyors in the facility any more frequently than is required by law. It takes time to educate facility staff about the potential benefits of technical assistance programs, and a major component of this educational process involves convincing facility staff that it is "safe" to have an open discussion with technical assistance staff and that results of technical assistance visits will not lead to survey deficiencies. Separating the technical assistance function from the survey process almost certainly helps achieve this purpose.
The degree of separation between technical assistance and survey staff varied across states. Missouri and Maryland has the greatest separation. In Missouri, there is little interaction between the state's technical assistance staff, who are employed by the University of Missouri, and the survey agency. This separation seems to facilitate the emphasis of these programs on providing consultation to facility staff, including reviewing care plans for individual residents and providing training to staff. Technical assistance staff in Missouri deliberately avoid enforcement and regulatory issues. LTC survey staff, in turn, avoid any consultative role. Acceptance of Missouri's program by nursing facilities was reportedly slowed because, when the program started, it was more closely linked to the survey process.
In Maryland, the state's technical assistance nurses report only the most extreme quality of care violations to the state survey agency. When technical assistance staff identifies routine violations, they bring such violations to the attention of the nursing home staff, require a plan of correction, and provide ongoing compliance monitoring. The state believes this level of separation is necessary in order to get providers to accept the technical assistance program.
In states like Washington, where the distinction between technical assistance staff and the survey agency is not clear, it is likely that this causes some distrust of the technical assistance staff by nursing home providers, resulting in a reluctance to have an open discussion with technical assistance staff about quality improvement issues. We were not able to evaluate whether this affects program effectiveness, but comments from providers suggest that this close association between TA and survey staff can present real problems.