Group Activities Implementation Checklist

F679

“(Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17)

§483.24(c) Activities

§483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.

INTENT §483.24(c)

To ensure that facilities implement an ongoing resident centered activities program that incorporates the resident’s interests, hobbies and cultural preferences which is integral to maintaining and/or improving a resident’s physical, mental, and psychosocial wellbeing and independence. To create opportunities for each resident to have a meaningful life by supporting his/her domains of wellness (security, autonomy, growth, connectedness, identity, joy and meaning).

DEFINITIONS §483.24(c)

“Activities” refer to any endeavor, other than routine ADLs, in which a resident participates that is intended to enhance her/his sense of well-being and to promote or enhance physical, cognitive, and emotional health. These include, but are not limited to, activities that promote self-esteem, pleasure, comfort, education, creativity, success, and independence.

NOTE: ADL-related activities, such as manicures/pedicures, hair styling, and makeovers, may be considered part of the activities program.

GUIDANCE §483.24(c)

Research findings and the observations of positive resident outcomes confirm that activities are an integral component of residents’ lives. Residents have indicated that daily life and involvement should be meaningful. Activities are meaningful when they reflect a person’s interests and lifestyle, are enjoyable to the person, help the person to feel useful, and provide a sense of belonging. Maintaining contact and interaction with the community is an important aspect of a person’s well-being and facilitates feelings of connectedness and self- esteem. Involvement in community includes interactions such as assisting the resident to maintain his/her ability to independently shop, attend the community theater, local concerts, library, and participate in community groups. Activity Approaches for Residents with Dementia All residents have a need for engagement in meaningful activities. For residents with dementia, the lack of engaging activities can cause boredom, loneliness and frustration, resulting in distress and agitation. Activities must be individualized and customized based on the resident’s previous lifestyle (occupation, family, hobbies), preferences and comforts. https://www.caringkindnyc.org/_pdf/CaringKind-PalliativeCareGuidelines.pdf

NOTE: References to non-CMS/HHS sources or sites on the Internet included above or later in this document are provided as a services and do not constitute or imply endorsement of these organizations or their programs by CMS or the U.S. Department of Health and Human Services. CMS is not responsible for the content of pages found at these sites. URL addresses were current at the date of this publication.

The facility may have identified a resident’s pattern of behavioral symptoms and may offer activity interventions, whenever possible, prior to the behavior occurring. Once a behavior escalates, activities may be less effective or may even cause further stress to the resident (some behaviors may be appropriate reactions to feelings of discomfort, pain, or embarrassment, such as aggressive behaviors exhibited by some residents with dementia during bathing16).

Examples of activities-related interventions that a facility may provide to try to minimize distressed behavior may include, but are not limited, to the following:

For the resident who exhibits unusual amounts of energy or walking without purpose:

• Providing a space and environmental cues that encourages physical exercise, decreases exit-seeking behavior and reduces extraneous stimulation (such as seating areas spaced along a walking path or garden; a setting in which the resident may manipulate objects; or a room with a calming atmosphere, for example, using music, light, and rocking chairs);

• Providing aroma(s)/aromatherapy that is/are pleasing and calming to the resident; and

• Validating the resident’s feelings and words; engaging the resident in conversation about who or what they are seeking; and using one-to-one activities, such as reading to the resident or looking at familiar pictures and photo albums.

For the resident who engages in behaviors not conducive with a therapeutic home like environment:

• Providing a calm, non-rushed environment, with structured, familiar activities such as folding, sorting, and matching; using one-to-one activities or small group activities that comfort the resident, such as their preferred music, walking quietly with the staff, a family member, or a friend; eating a favorite snack; looking at familiar pictures;

• Engaging in exercise and movement activities; and

• Exchanging self-stimulatory activity for a more socially-appropriate activity that uses the hands, if in a public space.

For the resident who exhibits behavior that require a less stimulating environment to discontinue behaviors not welcomed by others sharing their social space:

• Offering activities in which the resident can succeed, that are broken into simple steps, that involve small groups or are one-to-one activities such as using the computer, that are short and repetitive, and that are stopped if the resident becomes overwhelmed (reducing excessive noise such as from the television);

• Involving in familiar occupation-related activities. (A resident, if they desire, can do paid or volunteer work and the type of work would be included in the resident’s plan of care, such as working outside the facility, sorting supplies, delivering resident mail, passing juice and snacks, refer to §483.10(e)(8) Resident Right to Work);

• Involving in physical activities such as walking, exercise or dancing, games or projects requiring strategy, planning, and concentration, such as model building, and creative programs such as music, art, dance or physically resistive activities, such as kneading clay, hammering, scrubbing, sanding, using a punching bag, using stretch bands, or lifting weights; and

• Slow exercises (e.g., slow tapping, clapping or drumming); rocking or swinging motions (including a rocking chair).

For the resident who goes through others’ belongings:

• Using normalizing life activities such as stacking canned food onto shelves, folding laundry; offering sorting activities (e.g., sorting socks, ties or buttons); involving in organizing tasks (e.g., putting activity supplies away); providing rummage areas in plain sight, such as a dresser; and

• Using non-entry cues, such as “Do not disturb” signs or removable sashes, at the doors of other residents’ rooms; providing locks to secure other resident’s belongings (if requested).

For the resident who has withdrawn from previous activity interests/customary routines and isolates self in room/bed most of the day:

• Providing activities just before or after meal time and where the meal is being served (out of the room);

• Providing in-room volunteer visits, music or videos of choice;

• Encouraging volunteer-type work that begins in the room and needs to be completed outside of the room, or a small group activity in the resident’s room, if the resident agrees; working on failure-free activities, such as simple structured crafts or other activity with a friend; having the resident assist another person;

• Inviting to special events with a trusted peer or family/friend;

• Engaging in activities that give the resident a sense of value (e.g., intergenerational activities that emphasize the resident's oral history knowledge);

• Inviting resident to participate on facility committees;

• Inviting the resident outdoors; and

• Involving in gross motor exercises (e.g., aerobics, light weight training) to increase energy and uplift mood.

For the resident who excessively seeks attention from staff and/or peers: Including in social programs, small group activities, service projects, with opportunities for leadership.

For the resident who lacks awareness of personal safety, such as putting foreign objects in her/his mouth or who is self-destructive and tries to harm self by cutting or hitting self, head banging, or causing other injuries to self:

• Observing closely during activities, taking precautions with materials (e.g., avoiding sharp objects and small items that can be put into the mouth);

• Involving in smaller groups or one-to-one activities that use the hands (e.g., folding towels, putting together PVC tubing);

• Focusing attention on activities that are emotionally soothing, such as listening to music or talking about personal strengths and skills, followed by participation in related activities; and

• Focusing attention on physical activities, such as exercise. For the resident who has delusional and hallucinatory behavior that is stressful to her/him:

• Focusing the resident on activities that decrease stress and increase awareness of actual surroundings, such as familiar activities and physical activities; offering verbal reassurance, especially in terms of keeping the resident safe; and acknowledging that the resident’s experience is real to her/him.

The outcome for the resident, the decrease or elimination of the behavior, either validates the activity intervention or suggests the need for a new approach. The facility may use, but need not duplicate, information from other sources, such as the RAI/MDS assessment, including the CAAs, assessments by other disciplines, observation, and resident and family interviews. Other sources of relevant information include the resident’s lifelong interests, spirituality, life roles, goals, strengths, needs and activity pursuit patterns and preferences. This assessment should be completed by or under the supervision of a qualified professional.

NOTE: Some residents may be independently capable of pursuing their own activities without intervention from the facility. This information should be noted in the assessment and identified in the plan of care.

Surveyors need to be aware that some facilities may take a non-traditional approach to activities.

In nursing homes where culture change philosophy has been adopted, all staff may be trained as nurse aides or “universal workers,” (workers with primary role but multiple duties outside of primary role) and may be responsible to provide activities, which may resemble those of a private home. The provision of activities should not be confined to a department, but rather may involve all staff interacting with residents.

Residents, staff, and families should interact in ways that reflect daily life, instead of in formal activities programs. Residents may be more involved in the ongoing activities in their living area, such as care-planned approaches including chores, preparing foods, meeting with other residents to choose spontaneous activities, and leading an activity. It has been reported that, “some culture changed homes might not have a traditional activities calendar, and instead focus on community life to include activities.” Instead of an “activities director,” some homes have a Community Life Coordinator, a Community Developer, or other title for the individual directing the activities program.

For more information on activities in homes changing to a resident-directed culture, the following websites are available as resources: www.pioneernetwork.net; www.qualitypartnersri.org; and www.edenalt.org.

INVESTIGATIVE SUMMARY

Use the Activities Critical Element pathway and the guidance above to investigate concerns related to activities which are based on the resident’s comprehensive assessment and care plan, and meet the resident’s interests and preferences, and support his or her physical, mental, and psychosocial well-being.”1

•       Review individual resident activity assessments to identify potential alternatives in group, in-room, and independent activity preferences and needs

•       Interview residents to identify activity preferences within facility COVID-19 protocols and status

•       Identify adaptations needed to activity programming to remain within the facility COVID-19 protocols and status

•       Communicate alternate programming with Administrator and other departments

•       Provide education to activity and non- activity staff and residents

•       Access needed supplies for in-room, independent, and small group programming, following Core COVID-19 Infection Prevention and facility guidelines

•       Following facility, local, state, and federal guidelines, small group activities may be scheduled

•       Prior to beginning a small group activity program assist residents to perform hand hygiene, and monitor that participant are socially distanced six feet apart and wearing facial covers that cover their nose and mouth

•       Activity area is disinfected and sanitized prior to beginning and after completing small group programming

•       Activity staff consult with other staff members to ensure that residents unable to leave their room receive assistance with self-directed recreational programming as desired

•       1:1 in-room programming is completed by Activity staff based on resident interest and need

•       For residents with known behavioral issues or those with cognitive impairment activity programming based on physical and cognitive ability is identified and provided by staff

•       Collaborate among staff to identify ways to maintain involvement with the community while following COVID-19 prevention restrictions and implement within socially distanced programming

F680

(Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17)

“Activities Professional

§483.24(c)(2) The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who—

(i)             Is licensed or registered, if applicable, by the State in which practicing; and

(ii)            Is:

(A) Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990; or

(B) Has 2 years of experience in a social or recreational program within the last 5 years, one of which was full-time in a therapeutic activities program; or

(C) Is a qualified occupational therapist or occupational therapy assistant; or

(D) Has completed a training course approved by the State.

INTENT §483.24(c)(2)

The intent of this regulation is to ensure that the activities program is directed by a qualified professional.

DEFINITIONS §483.24(c)(2)

“Recognized accrediting body” refers to those organizations that certify, register, or license therapeutic recreation specialists, activity professionals, or occupational therapists.

Activities Director Responsibilities

An activity director is responsible for directing the development, implementation, supervision and ongoing evaluation of the activities program. This includes the completion and/or directing/delegating the completion of the activities component of the comprehensive assessment; and contributing to and/or directing/delegating the contribution to the comprehensive care plan goals and approaches that are individualized to match the skills, abilities, and interests/preferences of each resident.

Directing the activity program includes scheduling of activities, both individual and groups, implementing and/or delegating the implementation of the programs, monitoring the response and/or reviewing/evaluating the response to the programs to determine if the activities meet the assessed needs of the resident, and making revisions as necessary.

NOTE: Review the qualifications of the activities director if there are concerns with the facility’s compliance with the activities requirement at §483.24(c)(1), F679, or if there are concerns with the direction of the activity programs.

A person is a qualified professional under this regulatory tag if they meet the qualifications (if applicable) of §483.24(c)(2)(i), and one (or more) of the qualifications of §483.24(c)(2)(ii).

KEY ELEMENTS OF NONCOMPLIANCE §483.24(c)(2) To cite deficient practice at F680, the surveyor's investigation will generally show that the facility failed to ensure the activities program is directed by a qualified professional, who:

• Is licensed or registered, (if applicable); and

o Is eligible for certification as a therapeutic recreation specialist, or as an activities professional by a recognized accrediting body on or after October 1, 1990; or

o Has 2 years of experience in a social or recreational program with the last 5 years, one of which was full-time in a therapeutic activities program; or

o Is a qualified occupational therapist or occupational therapy assistant; or

o Has completed a training course approved by the state.

NOTE: F680 is a tag that is absolute, which means the facility must have a qualified activities professional to direct the provision of activities to the residents. Thus, it is cited if the facility is non-compliant with the regulation, whether or not there have been any negative outcomes to residents. In determining the Scope and Severity, surveyors must consider the extent to which non-compliance at F679 is attributed to the lack of an activity director or the lack of qualifications of the activity director.”1

•       Observe and assess the Activity programming and changes made to remain compliant with COVID-19 prevention policies.

•       Interview residents for satisfaction with alternate programming provided

•       Observe residents for meaningful independent and recreational involvement. Monitor for lack of involvement and statements of hopelessness, boredom, and loss- Intervene

•       Review that the Activities Professional maintains current licensure, registration, and certifications and that continuing education requirements are being met.

F880   Infection Control

§483.80 Infection Control:

“The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

(a) Infection Prevention and Control Program (IPCP)

    The facility must establish an infection prevention and control program that must include, at a minimum, the following:

(a)(1)     Prevent, identification, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and others providing services under contractual arrangements based upon the facility assessment and accepted national standards.

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:

(i)A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility;

(ii)When and to whom possible incidents of communicable disease or infections should be reported;

(iii)Standard and transmission-based precautions to be followed to prevent spread of infections;

(iv)When and how isolation should be used for a resident; including but not limited to:

(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and

(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.

(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and

(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.”1

·      Review for comprehensive and updated Infection Prevention and Control policies including COVID-19 guidelines and staff performance requirements

·      Review requirements for and develop plan for maintenance of resident cloth re-useable facial coverings

·      Educate staff regarding policies for infection prevention, hand hygiene and face mask use on an ongoing basis

·      Educate staff and residents regarding the importance for residents to wear cloth facial coverings when not in their room

·      Monitor employee performance at varied times to observe proper face mask use and maintenance and for assistance provided to residents in proper facial covering use

·      Observe the environment for proper social distancing of activity tables and residents in common areas

·      Interact with residents to determine understanding of the need to wear a cloth facial mask and maintain social distance

·      Complete record review to determine that residents are assessed for ability to apply and remove masks and receive assistance as needed

·      Monitor infection rates and trends. Follow national and state specific reporting guidelines

·      Evaluate staff adherence to universal source control measures and COVID-19 cases within the health center and community.

o   Number of events

o   Location and trends

o   Outcomes

o   Staff performance-based re-education

·      Present findings to QAPI Committee for discussion and follow up

F882 Infection Preventionist

“The facility must designate one or more individual(s) as the infection preventionist(s) (IP)(s) who are responsible for the facility’s IPCP. The IP must:

§483.80(b)(1) Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field;

§483.80(b)(2) Be qualified by education, training, experience or certification;

§483.80(b)(3) Work at least part-time at the facility; and

§483.80(b)(4) Have completed specialized training in infection prevention and control. §483.80 (c) IP participation on quality assessment and assurance committee. The individual designated as the IP, or at least one of the individuals if there is more than one IP, must be a member of the facility’s quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.”1

·       Ensure that the professional assigned responsibility as the Infection Preventionist meets all qualifications for the role and is a member of the QAPI/QAA committee

·       Is a member of the health center COVID-19 task force to plan and implement actions to prevent and mitigate spread

·       Collaborates with Activity Professional and others in development and implementation of Activity programming within the facility COVID-19 prevention program and to meet local, state, and federal guidelines

·       Update Infection Control policies with current COVID-19 recommendations by Federal, State, and Local Officials

·       Provides education on Infection Prevention and Control including COVID-19 to all department staff in the facility

·       Evaluate environment, infection control practices, and safety

·       Develop and implement COVID-19 Prevention Program and provide education to staff, residents, and others as required

·       Observe staff performance in proper PPE use

·       Monitor staff performance with hand hygiene

·       Complete tracking of COVID-19 cases within the facility and collaborate with health officials in assessing and evaluating of community case levels for risk

·       Complete reporting to local, state, and Federal officials as required

·       Maintain accurate and complete records of all infections within the health center and actions being taken to address potential issues

·       Present findings and improvement plans to QAPI/QAA Committee for discussion and follow up