Quality Monitoring Program Provider Manual

Section 1000, QMPPM, Introduction

Revision 16-1; Effective February 3, 2016

 

The Quality Monitoring Program Provider Manual provides information about the activities of the Quality Monitoring Program (QMP), nursing facility quality review process, early warning system (EWS), contact information and additional resources.

QMP Purpose

 

The purpose of the QMP is to detect, through the EWS, conditions inside Texas nursing facilities that could be detrimental to the health, safety and welfare of facility residents. Quality monitors (QMs) are nurses, pharmacists and dietitians who may:

 

Vision

 

Long-term care facilities will use on-going quality improvement activities to ensure they are doing the right thing, in the right way and at the right time, for the right person to achieve the best possible resident outcomes.

 

Mission

 

The mission is to achieve optimal resident outcomes through the consistent application of evidence-based resident care planning and care practices.

 

Confidentiality

 

The information gathered through this process by the Texas Department of Aging and Disability Services (DADS) QMP staff is kept strictly confidential.

 

QMP History

 

In 2001, the 77th Texas Legislature, Regular Session, passed the Texas Long-Term Care Facility Quality Improvement Act, Senate Bill (SB) 1839. This bill had several components, one of which was to establish the QMP. 

 

Collaborative Relationships Promote Quality Improvement

 

The QMP function is intended to provide technical assistance to nursing facility providers, in a collaborative relationship that would promote quality improvement beyond minimal compliance with state and federal standards. SB 1839 requirements for the QM function include the development of a risk assessment tool called the EWS, which is used to alert DADS program staff to the need for comprehensive technical assistance in high-risk facilities. Facilities with a history of patient care deficiencies or that are identified as medium risk based on the facility’s EWS scores are given priority for quality monitoring visits. Rapid Response Team (RRT) visits are scheduled for those facilities identified as high risk through the EWS or facilities that have had three violations in a 24-month period that constitute an immediate threat to the health and safety of a resident due to abuse or neglect. Nursing facilities are also able to request quality monitoring or RRT visits.

The QM function consists of routine technical assistance (monitoring) visits, as well as more intensive assistance focused on those facilities identified by the EWS (RRT visits). During those visits, QMP staff assess the overall quality of life in the facility, as well as specific conditions related to quality of care. As required by statute, all QMs are nurses, dietitians or pharmacists. QMs are located in DADS regional offices throughout Texas, with each monitor assigned to specific areas of the state and specific nursing facilities within those areas. The QMs assigned to a specific facility are the ones a provider should contact:

 

Not a Regulatory Function

 

The QMP is not a regulatory program. QMs do not cite deficient practices. The QMP goal is to establish a partnership with nursing facilities and to work with facility staff to implement care approaches that can improve resident outcomes.

There are significant differences between QM visits, and the visits conducted by staff from DADS Regulatory Services Division. The QMP focuses on evidence-based best practices while surveyors focus on compliance with minimum standards. Best practice emphasizes achieving the best resident outcomes, with the goal of helping Texas facilities achieve more than the minimum standard required by state and federal regulations. The QMP is committed to working with facility staff to identify opportunities for improving resident care through the use of evidence-based best practices.

QMs are required to immediately report any condition observed that creates an immediate threat to the health or safety of a resident. If such a condition is identified by a QM, notification will be made to the facility administrator, the QM’s supervisor and to law enforcement, adult protective services, other agencies or another program within DADS, as appropriate, or as required by law.

Section 2000, QMPPM, Evidence-based Best Practices and Technical Assistance

Revision 16-1; Effective February 3, 2016

 

Evidence-based best practices are based on the best available studies, clinical trials and research that show which practices produce the best results. This is the standard of the Quality Monitoring Program (QMP). The goal is to help facilities to use evidence-based best practices to improve care systems and resident outcomes. The information that quality monitors (QMs) provide on evidence-based best practices is based on clinical science.

Through the provision of technical assistance during the visits, QMP staff focuses on specific, statewide quality improvement priorities for which evidence-based best practices can be identified from published clinical research. DADS encourages the use of evidence-based best practices to promote the highest-quality care to Texas nursing facility residents.

 

Focus Areas

 

The term “focus area” is used to refer to the specific clinical areas in which QMs provide technical assistance. These include:

Focus areas are identified for the development of evidence-based best practice frameworks in a variety of ways, including:

 

Focus Area Selection during QM Visits

 

Currently, all QM visits include a review of the use of antipsychotic medications in individuals with dementia, as well as the PASRR process. The selection of additional focus areas during a QM visit will be data driven, and will be prioritized based on the impact to residents' health and safety, and on quality of care. Data resources used to determine the selection of focus area include:

 

Technical Assistance

 

The QM reviews resident care in each selected focus area, looking at the appropriateness of assessments, care planning and outcomes. The technical assistance that QMs provide during monitoring and rapid response team visits is intended to help providers improve these three aspects of the care process. QMP staff use structured evaluation tools to help determine whether improvements in a nursing facility's clinical systems are needed. These tools incorporate the key elements of best practice for each focus area.

An assessment gives providers important information about the specific needs of the resident and identifies not only potential problems, but also the resident's strength, abilities and preferences. Care planning incorporates the information identified during assessment, using that information to develop person-centered interventions to meet the resident's needs. Interventions are periodically evaluated to determine whether or not they are effective. Based on the evaluation, the plan of care may be updated.

After each visit, facilities receive a summary of the QM's findings. The report is organized according to the focus areas addressed during the visit. Each focus area includes the QM's findings on resident assessment, care planning and care. These reports give providers a written record of the visit, and serve as a reference for providers as they undertake changes in care practices to address the improvement opportunities identified during a visit.

Note: These reports are not shared with DADS Regulatory Services Division.

Section 3000, QMPPM, Introductory Visits to Start a Partnership

Revision 15-0; Effective April 1, 2015

 

Introductory visits began in April 2002, and continue to be provided when new facilities open. These visits introduce the nursing facility to Quality Monitoring Program (QMP) activities and help facilities understand the goals of the QMP. The introductory visits are used to promote positive partnerships with providers, with an emphasis on improving the quality of care and quality of life for residents through evidence-based best practices.

Section 4000, QMPPM, Quality Monitoring Visits

Revision 16-1; Effective February 3, 2016

 

Quality monitoring visits are conducted by individual quality monitors (QMs), and are coordinated by a scheduling system that uses the early warning system (EWS) to ensure facilities that are identified as medium risk, or those that have a history of resident care deficiencies, are given priority for visits. A follow-up visit will be scheduled within 45 calendar days of the initial QM visit. The initial QM visit is the first time a nursing facility is scheduled for and receives a QM visit after being identified as medium risk through the EWS. The process of identifying a QM visit as an initial visit will start again once 12 months have passed with no QM visits to the facility. Nursing facilities may also request a quality monitoring visit by contacting QM staff.

Before conducting a quality monitoring visit, the QM reviews the facility's data, including the quality measure reports in the Certification and Survey Provider Enhanced Reports (CASPER) system, and identifies areas that may represent opportunities for improvement.

After reviewing the available data, the QM will contact a facility representative to provide the date of the visit and the QM's anticipated time of arrival. The QM gives advance notice so the nursing facility can plan to involve key staff related to the specific focus areas that will be evaluated during the visit, and to invite the facility's medical director to participate, if possible. The QMs are aware that, at times, there may be other events that prevent key staff from participating in the visit. In those situations, the QMs will work with available staff members, providing technical assistance to the extent possible.

 

Entrance Conference

 

Each visit begins with an entrance conference. This is the QM's opportunity to inform facility staff of the focus areas that will be addressed during the visit and give staff an opportunity to describe the progress the facility has made in implementing best practices since the last visit. The entrance conference is also an opportunity for the facility to mention other issues about which the QM should be aware. The QM will request a copy of the current resident roster to assist in the selection of the resident sample, and will provide facility staff with an estimated time for the exit conference time.

 

QM Visit Activity

 

During the monitoring visit, the QM will assess the overall quality of life in the facility, as well as specific conditions that are directly related to resident care.

Each QM visit consists of:

 

Visit Wrap-up

 

Each QM visit ends with a wrap-up meeting. During the wrap-up meeting, the QM will provide information regarding the focus areas that were reviewed. Findings will include identified best practices, as well as opportunities for improvement.

The QM will encourage facility staff to develop a plan for implementing evidence-based best practice systems to improve resident care. The purpose of this step is to help facilities determine how to make improvements; however, the QMs do not direct facilities to use any specific best practice. QMs will offer resources that can be used by facility staff to decide what may work best in their facility.

During the exit conference, the QM will also remind facility staff to expect a report summarizing the findings made during the visit and the technical assistance provided. The report will also include any steps the facility plans to take toward specific improvements in the areas identified by the QM. If the facility was not able to develop a specific plan for improvement at the time of the exit conference, that will be reflected in the report.

The report is sent by email within 15 working days of the visit. If the facility does not have internet access, a copy of the report will be mailed via the U.S. Postal Service. The QM who conducted the visit will request confirmation that the report was received by a facility representative.

 

Report Review

 

When the facility receives the report, the facility representative should read it to note those areas identified as needing improvement, and to review the plans that were decided upon at the time of the exit conference. If anything in the report is unclear or if additional information is needed, the facility representative should contact the QM who conducted the visit.

Note: This report is not shared with the Texas Department of Aging and Disability Services (DADS) Regulatory Services Division.

 

After the visit, the QM encourages facility staff to visit the Quality Monitoring Program website at http://www.dads.state.tx.us/providers/qmp/index.cfm for additional resources. The web address can also be found on the QM’s business card.

Anonymous Feedback Survey

 

Along with the report, the facility representative will receive a link to an anonymous feedback survey. The survey asks questions about the QM visit and conduct. This short survey is part of the Quality Monitoring Program's own quality improvement process, and facilities are encouraged to respond.

Section 5000, QMPPM, Rapid Response Team Visits

Revision 16-1; Effective February 3, 2016

 

40 Texas Administrative Code §19.911, Rapid Response Teams (RRT), permits the Texas Department of Aging and Disability Services (DADS) quality monitors (QMs) to conduct RRT visits, based on early warning system (EWS) scores; those facilities identified as high risk through the EWS receive RRT visits. In addition, a facility will receive an RRT visit if it has received three deficiency citations in a 24-month period and those citations were determined to constitute an immediate threat to health and safety, related to the abuse or neglect of a resident.

RRT visits are a comprehensive form of a QM visit. The main difference between RRT and QM visits is that there is usually more than one clinical discipline involved, which could be any combination of nursing, dietary or pharmacy monitors. This allows for flexibility so the RRT may address nursing issues, as well as pharmacy or nutrition issues, to provide a broader view of the resident care systems. The regional regulatory liaison may be part of the team, with Ombudsman staff and other professionals assisting the team, as needed.

Facilities are required, by statute, to cooperate with the RRT, in an effort to improve the quality of care provided to residents.

Purpose of RRT Visits

The purpose of the visit is to help nursing facilities improve services and supports. This includes:

The RRT visit includes a comprehensive review of nursing facility systems and is conducted in an atmosphere that encourages learning and team building, while promoting positive partnerships with providers.

RRT Visits

The RRT visit process begins with a letter from the QM to the facility's administrator announcing the purpose of the visit.  The visit process is similar to a standard QM visit involving the same steps. The goal is to provide comprehensive technical assistance in an effective way to address underlying issues that impact quality in multiple focus areas. The discussion of the systems issues that are identified during the visit is coordinated between the disciplines who are participating in the visit to avoid duplication.

Invited RRT Visits

A nursing facility may request a technical assistance visit at any time. QM staff make every effort to accommodate such requests when providers ask for help with any of the issues that the Quality Monitoring Program (QMP) addresses.

Through an invited RRT visit, the facility can request a nurse, pharmacist or dietitian monitor, or any combination of these. In an invited RRT visit, the facility can choose the focus areas from among those in which the monitors have technical assistance resources.

By law, some restrictions are placed on invited visits. They cannot be scheduled earlier than 60 days after the date of an exit interview following an annual or follow-up survey or inspection, and they cannot be used to prepare for a regular inspection or survey.

If a facility is interested in scheduling an RRT visit, a facility representative should contact a QMP staff member assigned to their facility for assistance.

Section 6000, QMPPM, In-service Visits

Revision 16-1; Effective February 3, 2016

 

Quality monitors (QMs) can provide facility staff with a variety of in-service education presentations. Each in-service presentation provides information that is evidence-based and that will provide greater understanding of how implementing evidence-based care can improve resident outcomes. The in-service visits are interactive and can be used to stimulate ideas for quality improvement.

The Quality Monitoring Program (QMP) cannot provide in-services as part of a facility's plan of correction nor are in-services intended to satisfy continuing education requirements. In-service education sessions can be provided during a QM visit or can be scheduled separately. To request an in-service for facility staff, providers may contact the QMs assigned to their facility. 

The following in-service education modules are available:

Nurses

Dietitians

Pharmacists

Multi-Disciplinary

Additional Training Opportunities

Section 7000, QMPPM, Early Warning System

Revision 15-0; Effective April 1, 2015

 

Legislation: Senate Bill 1839, relating to certain long-term care facilities; 77th Legislature, Regular session; signed June 15, 2001.

Statute: Texas Health and Safety Code, Chapter 255, Quality Assurance Early Warning System for Long-Term Care Facilities; Rapid Response Teams

40 Texas Administrative Code (TAC), Chapter 19, Subchapter J, §19.910, Quality Assurance Early Warning System

The above cited law and rule mandates the use of an early warning system (EWS) to prioritize the use of the Quality Monitoring Program's (QMP's) resources.

Identifying Potential Risk

The EWS calculates a score for each facility that helps identify facilities with a higher-than-average risk of being cited in future surveys for significant deficiencies. The EWS score is based on criteria that includes:

While QMP staff visit all nursing facilities across the state, the Texas Department of Aging and Disability Services (DADS) priority is to visit those facilities with the highest EWS scores first, and to provide the most comprehensive technical assistance to those facilities with the highest risk.

Statistical Risk Model

Criteria are reassessed annually by comparing EWS predictions to actual outcomes in the preceding year. Because EWS is a statistical risk model, more often than not it is accurate in its prediction of risk. However, some facilities that appear to be at low risk can subsequently show very poor survey results. Similarly, some facilities that appear to be at high risk can subsequently show excellent survey results.

Preventing Poor Outcomes

Rapid response team (RRT) visits are made to those facilities with the highest EWS scores. The purpose is to provide facilities with the most comprehensive assessment and technical assistance to identify systems issues that may adversely impact resident care. These visits help facilities to identify ways to make improvements that could prevent poor resident outcomes and poor survey results.

EWS Annual Report

This document is a report on the risk assessment tool that is used to identify those nursing facilities most likely to need the technical assistance that is available, as required by Senate Bill 1839, 77th Legislature, Regular Session, 2001.

2014: The Long Term Care Early Warning System, posted January 2015
2010: The Long Term Care Early Warning System, posted January 2011
2009: The Long Term Care Early Warning System, posted April 2010

Section 8000, QMPPM, Nursing Facility Quality Review

Revision 16-1; Effective February 3, 2016

 

The Nursing Facility Quality Review (NFQR) is a statewide survey of people residing in Medicaid-certified nursing facilities, assessing their satisfaction with quality of care and quality of life.

NFQR Methodology

The NFQR includes a valid random sample of individuals across the state living in Medicaid-certified nursing facilities that are assessed and interviewed by an independent contractor, using a structured survey tool. The NFQR data is analyzed by DADS using statistical software to test for linear trends across time. This analysis helps DADS track progress in quality improvement activities and formulate strategies to improve both the quality of long-term services and supports and clinical outcomes of individuals.

NFQR Report

A written report on the findings of the survey is prepared and submitted to the legislature, governor and Health and Human Services Commission executive commissioner each biennium.

2013: Report in PDF
2012: Report in PDF

Section 9000, QMPPM, Minimum Data Set (MDS) Clinical Coordinator

Revision 16-1; Effective February 3, 2016

 

The MDS Clinical Coordinator for Texas is housed within the Quality Monitoring Program. Federal language refers to this position as the State Resident Assessment Instrument (RAI) Coordinator.

The MDS Clinical Coordinator for Texas is responsible for assisting state staff, nursing facilities and swing-bed providers with questions regarding:

In addition, the MDS Clinical Coordinator conducts webinar and face-to-face trainings covering recent MDS and Quality Measure clarifications and changes, common MDS coding errors, MDS Outcome Reports, program specific requests for MDS-related information and planned future MDS and QM updates.

The MDS Clinical Coordinator is responsible for developing and publishing The MDS Mentor, a training tool for providers and state staff, as well as maintaining the DADS MDS Web page.

Section 10000, QMPPM, Resources

Revision 16-1; Effective February 3, 2016

 

The Quality Monitoring Program website contains evidence-based best practice frameworks compiled from systematic clinical literature reviews. Each framework has links to related resources. At each quality monitoring visit, the quality monitor (QM) will review the website with facility staff and will use the information to provide technical assistance. The Quality Monitoring Program (QMP) encourages facility staff to visit the website and become familiar with the wealth of information located there. The website was developed and is maintained by the QMP section of the Center for Policy and Innovation within the Texas Department of Aging and Disability Services (DADS). It contains information that can help providers implement best practices.

DADS offers information on the Long-term Care (LTC) Provider Search to help individuals and families evaluate the quality of long-term care services. The website can be used to obtain specific information about a particular long-term care provider or to compare providers in a particular area. Long-term Care (LTC) Provider Search provides information that can help identify providers that may meet a family member's needs, but it is not meant to serve as the only basis for choosing a particular provider. After using the Long-term Care (LTC) Provider Search to identify providers that are of possible interest, individuals and families are encouraged to visit those providers to evaluate the appropriateness as a residence for their loved ones.

DADS seeks to assist healthcare facilities in emergency preparedness and emergency response. The Emergency Management Coordination Resource (EMResource) is a web-based solution from Intermedix. The EMResource is a system used statewide for tracking available hospital beds, hospital and emergency medical services resources, and other emergency response data. Users can access the EMResource from multiple sources, such as computers, smartphones, iPads or tablets.

While DADS does not maintain the EMResource, DADS worked with Intermedix, the Texas Department of State Health Services and the Texas Hospital Preparedness Program regional lead agencies to configure EMResource for assisted living facilities, intermediate care facilities for individuals with an intellectual or developmental disability or related conditions, in-patient hospice facilities, and nursing facilities. DADS strongly encourages these service providers to participate in the EMResource, as participation will incorporate non-hospital healthcare providers into the Texas Healthcare Coalition and enhance local emergency response efforts. Additional details can be found in the policy letter published on Dec. 16, 2014, IL 14-84, Discontinuation of the Facility Inventory, Vacancy, and Evacuation Status System. Facilities should note that they must establish a user account before they can log into the EMResource.

QMs cannot respond to questions regarding the Minimum Data Set (MDS) website. Any issues with MDS identified by QMs during the review of quality measures will be provided to nursing facility staff and referred to the MDS coordinator for assistance. Contact information for the MDS Clinical Coordinator and the MDS Automation Coordinator is also available on the MDS website.

The Top Ten Complaints, Program Deficiencies and Life Safety Code Violations website  information is updated annually, based on data collected in the most recent year.

The Texas Nursing Home Quality Initiative Coalition website consists of health care providers, government representatives and consumer advocates coming together as Local Area Networks for Excellence to improve the quality of life for the country's 1.5 million nursing home residents. The promotion of these national efforts in Texas is being organized by TMF Health Quality Institute, a leading nonprofit health care consulting company, and other partners in the Texas Nursing Home Quality Initiative Coalition.

Additional Resources

DADS Nursing Facility Provider Resources websit: http://www.dads.state.tx.us/providers/qmp/

QMP Contact Information

Telephone: QMP director at 512-438-4399

Email: For the following list of managers and coordinators, email questions to TQM@dads.state.tx.us. In the subject line or the first sentence of the message, indicate which manager or coordinator should respond.

Statewide Program Managers

Nurse program manager

Dietitian and pharmacist program manager

Regional Nurse Managers

Nurse manager for Regions 1, 2, 3 and 4

Nurse manager for Regions 5, 6, 7, 8, 9, 10 and 11

Revisions, QMPPM

Revision 16-1, QMPPM, Miscellaneous Changes

Revision Notice 16-1; Effective February 3, 2016

The following changes were made:

Section Title Change
1000 Introduction Clarifies the information under Collaborative Relationships Promote Quality Improvement, and adds a paragraph under Not a Regulatory Function.
2000 Evidence-based Best Practices and Technical Assistance Removes the Texas Department of Aging and Disability Services from the second sentence.
4000 Quality Monitoring Visits Clarifies the use of the early warning system to prioritize visits. Defines the terms "initial quality monitor visit" and "45 day follow-up visit." Updates a link to the Quality Monitoring Program website.
5000 Rapid Response Team Visits Adds a facility will receive a Rapid Response Team visit if it has received three deficiency citations in a 24-month period and those citations were determined to constitute an immediate threat to health and safety, related to the abuse or neglect of a resident.
6000 In-service Visits Adds additional training opportunities including Alzheimer’s Disease and Dementia Care Training and Virtual Dementia Tour.
8000 Nursing Facility Quality Review Clarifies the Nursing Facility Quality Review. Removes the 2008 and 2009 PDF Reports.
9000 Minimum Data Set (MDS) Clinical Coordinator Adds a new section to the handbook.
10000 Resources Moves the information previously in Section 9000 and updates a link to the Quality Monitoring Program website.

Revision 15-0, QMPPM New Provider Manual

Revision Notice 15-0; Effective April 1, 2015

The Quality Monitoring Program Provider Manual provides information about the activities of the Quality Monitoring Program, nursing facility quality review process, early warning system, contact information and additional resources.

QMPPM, Contact Us

For questions about the Quality Monitoring Program Provider Manual, email: QMP@hhsc.state.tx.us

For technical or accessibility issues with this handbook, email: Editorial_Services@hhsc.state.tx.us