Presented by: Kimberly Smoak, MSH, QIDP Chief of Field Operations/State Survey Agency Director

1. Florida Health Care Activity Coordinators AssociationJuly 31, 2019- Daytona BeachWhat To Expect During Your State Survey Presented by: Kimberly Smoak, MSH, QIDP Chief of Field Operations/State Survey Agency Director Health Quality Assurance Agency for Health Care Administration

2. Questions What is expected for the activity program in ALF’s? What is the specific staffing requirement for activities in a 120 bed or larger nursing home? What is the time requirement for 1:1 activity programs? Where does the activity program fit into the new long term care regulations?

3. Questions How to provide an effective activity program on a limited budget and with limited resources? Are there plans in the future to add staffing ratios in the activity program like certified nursing assistants?

4. What are we finding? Lack of and/or limited activities for younger adults Failure to use the internet for social connections Limited outings or community involvement Lack of person-centered focus

5. Activity Program F679-Activities Deficiency Count • 59 times in CY 2018 • 27 times CY 2019

6. Findings • Findings Include: • CP failed to support resident choice regarding activities • Cognitively impaired residents not provided activities • Failure to provide a resident centered activities program • Failed to conduct an initial activity assessment

7. Findings, cont. • Activity program did not enhance the residents quality of life or provide mental stimulation • Failed to provide activities per resident preference • Failed to demonstrate a system for ensuring the residents activity program was monitored and re-evaluated for continued effectiveness

8. Residents Life in a NH Activities plays into so many aspects of the resident's life -- mood, behaviors, functional status, nutritional status, etc. They are key players. It is important to interview the resident-talk to the resident to learn directly from the resident as to what is important in their life.

9. Resident Assessment Reminders • Section F: Preferences for Customary Routine and Activities • The intent of items in this section is to obtain information regarding the resident’s preferences for his or her daily routine and activities. This is best accomplished when the information is obtained directly from the resident or through family or significant other, or staff interviews if the resident cannot report preferences. The information obtained during this interview is just a portion of the assessment. Nursing homes should use this as a guide to create an individualized plan based on the resident’s preferences, and is not meant to be all-inclusive.

10. Health-Related Quality of Life Most residents capable of communicating can answer questions about what they like. Obtaining information about preferences directly from the resident, sometimes called “hearing the resident’s voice,” is the most reliable and accurate way of identifying preferences. If a resident cannot communicate, then family or significant other who knows the resident well may be able to provide useful information about preferences.

11. Planning for Care Quality of life can be greatly enhanced when care respects the resident’s choice regarding anything that is important to the resident. Interviews allow the resident’s voice to be reflected in the care plan. Information about preferences that comes directly from the resident provides specific information for individualized daily care and activity planning.

12. 483.24 Quality of Life

13. 483.24 Quality of Life • Quality of Life Defined • An individuals sense of well-being, level of satisfaction with and feeling of self-worth and self-esteem. For nursing home residents, this includes a basic sense of satisfaction with oneself, the environment, the care received, the accomplishments of desired goals, and control over one’s life.

14. F675-Quality of Life • 483.24 Quality of life • Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the residents comprehensive assessment and plan of care.

15. Principles of Quality of Life Sense of well-being. Satisfaction with life. Feeling of self worth and self-esteem. Sense of satisfaction with oneself, environment, and control over one’s life.

16. F679-Activities 483.249(c)(1) The facility must provide: 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.

17. F679-Activities 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.

18. 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.

19. F680-Activities Director Qualifications 483.24(c)(2) The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professionalwho……

20. F680-Activities Director Qualifications • (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.

21. Activities Director Responsibilities 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.

22. Reminder 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.

23. Surveying for Activity Requirements • Observations • How does staff inform the resident of the activity program schedule? • How does the facility provide timely transportation, if needed, for the resident to attend in-facility activities, and help the resident access transportation for out-of-facility and community activities? • Are the activities compatible with the resident’s individual physical and mental capabilities? If not, describe.

24. Surveying for Activity Requirements • How are the activities compatible with known interest and preferences? • How are the activities adapted, as needed (such as large print, holders if resident lacks hand strength, task segmentation)? • Are the activities person-appropriate? If not, describe. • How has the facility provided any needed assistance, equipment, and supplies?

25. Surveying for Activity Requirements • Interviews with Resident, Resident Representative, or Family • How did the facility involve you in care plan development, including defining the approaches and goals? • Do the activities offered here reflect your (or the resident’s) preferences and choices? If not, please explain. • In what activities do you participate? If none, why don’t you participate?

26. Additional Interviews Activity Staff Interviews Nurse Interviews Social Service Interviews

27. Record Reviews Review activity documentation. Does the most recent RAI assessment accurately and comprehensively reflect the status of the resident? How does facility encourage and support development of interests, hobbies, and skills? For a resident with severely limited attention span or who is medically compromised, how does the facility ensure activities are time-limited or low-energy programs and address pertinent medical, nursing, dietary, or therapy recommendations or restrictions?

28. Other Tags to Consider Access and Visitation Rights F563 Admission Orders F635, Professional Standards F658, Social Services F745, Facility Assessment F838, Staff Qualifications F839, and Resident Records F842

29. Other Important Regulatory Requirements

30. Resident Rights-Self Determination • 483.10(f) F561-Self-Determination • The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section. • The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part.

31. Resident Rights-Self Determination • 483.10(f) F561-Self-Determination • The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident. • The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility. • The resident has a right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility.

32. Guidance Its important for residents to have a choice about which activities they participate in. Formal activities or self-directed. How the resident spends time, both inside and outside the facility.

33. Resident Rights-Resident Groups • 483.10(f)(5)-F565 • The resident has a right to organize and participate in resident groups in the facility. • The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner. • Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.

34. Resident Rights-Resident Groups • 483.10(f)(5)-F565 • The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings. • The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.

35. Behavioral Health Services • 483.40(b)(s)- F744 • A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. • The facility must provide dementia treatment and services which may include, meaningful activities.

36. Administration • 483.70(e)-F838-Facility Assessment • (1) The facility’s resident population • (2) The facility’s resource • (3) A facility-based and community-based risk assessment, utilizing an all-hazards approach.

37. Administration • The facility’s resident population, including, but not limited to, • Both the number of residents and the facility’s resident capacity; • The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population; • The staff competencies that are necessary to provide the level and types of care needed for the resident population; • The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and • Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services.

38. Resources • Nursing Home • https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html

39. Sign up for Email Health Alertshttp://ahca.myflorida.com/MCHQ/alerts/alerts.shtml

40. Contact Information ahca.myflorida.com (“contact us”) Kimberly Smoak 850-412-4516 Kimberly.Smoak@ahca.myflorida.com