ACTIVITIES IN THE LONG TERM CARE SETTING PART II

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ACTIVITIES IN THE LONG TERM CARE SETTING PART II

• HCFA Satellite Broadcast Highlights
• September 2000
• Surveyor Red Flags

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Offsite Survey Preparation

• History of the facility/OSCAR and 2567 Reports
  re past activity deficiencies
• Ombudsman report re activity concerns
• Facility Quality Indicator Profile

• Percentile rank of Quality Indicator 23
• Prevalence of little or no activity
• Resident Level Summary Resident triggers for
  this Quality Indicator
• Complaint Reports re activity issues

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Initial Tour

• Interviews with residents/family re satisfaction
  with activities program
• If dissatisfied, why?
• How does dissatisfaction affect the resident?
• What activities are desired/suggested?
• If the resident could do anything, what would it
  be?
• Are adaptations made to accommodate needs and
  schedules?

• Observations
• Are scheduled activities occurring?
• At occurring activities, are residents engaged?
• Are residents sitting around or wandering with no
  interaction or engagement?
• Are activities age-appropriate
• Is adaptive equipment used?

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Trigger Considerations for Sample Inclusion

• Group activities not being conducted at all or as
  planned according to the activities calendar
• Residents sitting around or wandering with no
  interaction or engagement for lengths of time
• Concerns/dissatisfaction from residents, family,
  staff, or ombudsman
• Social isolation, residents observed in rooms
  without stimulation provided
• Residents not invited to activities by any staff
  and unable to create their own activity
  stimulation
• Activities do not meet resident needs

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Observation/Record Review /Interviews Regarding
Sample Residents

• Resident/family interviews per interview form
• Care planned activities taking pace/offered?
  Groups? 11?
• Are residents invited to activities identified on
  the care plan?
• Documentation to reflect residents
  invited/attending care planned activities?
• Are activities attended appropriate to functional
  level?

• When attending an activity, are residents
  engaged, involved and encouraged to participate?
• For residents who spend most of their time in
  their rooms, are there activities, projects, or
  items for stimulation?
• When residents are not interested in, or refuse
  activities, have alternatives been explored?
• If problems triggered, what information do
  activity staff offer?

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Resident Review

• Assessment for Activities Potential for Sample
  Residents (F272)
• MDS triggered Section N
• N1 Morning time awake AND N20 Most time
  involved in activities
• N2 Little time involved in activities
• N3 None- time involved in activities
• N5 Slight or major change in
• Type of activities currently involved with
• Extent of resident involvement in activities

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Resident Review

• RAP utilized appropriately
• If proceed is there a care plan?
• Are all RAP considerations reviewed as to their
  effect on residents activity participation?

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Resident Review

• Comprehensive assessment
• Potential interests and needs, including past and
  current interests
• Social History may include additional information

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Resident Review

• Assess MDS identified preferences
• Identify the specific type of preference, not
  just the general category
• Identify how that interest was enjoyed actively
  or passively
• Follow up re activity concerns, even if not MDS
  triggered

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Resident Review

• Assessment information matches interview
  information
• Has resident expressed interests not included in
  the assessment or care plan?
• Did staff know of these interests?
• Assessment accurately reflects residents
  needs/interests and current ability to
  participate
• Assessment drives how activities will assist
  residents attainment of highest level of
  physical, mental and psychosocial well-being

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Care Plan (F 279)

• Interest-based, not necessarily problem-based,
  activities
• Care plans are individualized to both resident
  activity interests and needsbeyond just
  extending an invitation to participate
• Appropriate activities based on comprehensive
  assessment
• Provide services that meet highest practicable
  level of functioning
• Written with resident/family input

• Activity plan reflects past and present
  interests, not just the generic calendar
• Care planned activities are reflected in the
  activities schedule
• Appropriate goals
• Quantity and quality
• Individualized and meaningful to the resident
• Measurable beyond just the number attended each
  week
• Goal for 11 states expected outcome

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Documentation

• Activity attendance records may help determine
  the types of activities attended, including care
  planned activities
• Determine what activities the resident is really
  engaged in and if they match the care plan
• For activity codes that indicate non-attendance
  (sleeping, ill, refused, bed rest, etc.) the
  activity plan has been changed accordingly

• Care plan goals are met and if not, rationale is
  provided
• 11 records
• Content of visit is indicated
• Residents response is indicated
• Evidence the goal is being pursued

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Progress Notes

• Reflect outcomes to goals
• Reflect responses to care planned activity
  interventions
• Reflect progress, not just a summary
• Indicate goals are met and if not, new ones are
  developed
• Reflect plan changes related to condition changes
• Reflect alternatives offered when resident
  refuses activities
• Reflect the residents right to participate in
  activities

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Highest Practical Level of Functioning

• Observe/interview resident to establish highest
  level of functioning
• Interview family to establish residents highest
  level of functioning
• Residents are aware of planned approaches
• Observe approaches used
• Observe resident reaction to approaches
• Ask staff/resident re knowledge of approaches
• Indications of participation in planning

• Ask staff why care planned approaches are not
  known or not carried out
• Ask residents who are not attending activities if
  they were invited or interested in attending
  those activities
• Utilize the family interview protocol to
  establish interests
• Staff knowledge of past interests
• Pas t interests assessed, care planned, adapted
  to current level

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Highest Level of Functioning

• Consider the context of each residents day
• The residents day should be scheduled according
  to the residents preference of order
• F 242 Respect for resident choices
• Facility works together for the optimum of the
  resident

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Ongoing Activities Program (F248)

• Meets needs of each sample resident
• Activity probes using Group, Family, and
  Individual Resident Interview protocols
• Past/current favorite activities
• Favorite activities are available, including
  adapted
• Desired activities
• Ability to provide desired activities
• Activity brainstorming
• Staffing is adequate to meet an activities
  program based upon the interests of the residents

• Mechanisms are in place to keep the activities
  program operating during times of activity staff
  transition
• Activity and non-activity staff
• Knowledgeable about residents preferences
• Knowledgeable about residents care planned
  activities
• Invite and/or escort residents to activities of
  choice
• Responsible for providing ongoing program of
  activities, even when the activity staff are off
  duty

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Activity Calendar Probes

• Review calendar in relation to interests of
  sample residents and any comments from the Group
  Interview
• Reflect schedules, choices, and rights
• Available to residents
• Posted, easy to see, readable
• Multi-faceted
• Low and high functioning
• Cultural interests
• Religious interests
• Gender appeal
• Age appeal

• Evening activities based on interests of the
  residents
• Weekend activities based on interests of the
  residents
• Outings
• Community involvement
• Activity calendar matches residents, not simply
  fits them into an already established calendar

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Secured Unit Probes

• Activities are designed to meet resident needs
• Geared toward attention span
• Offered more frequently
• Expend energy for wanderers
• Supplies are available according to resident
  needs and wishes
• Activities are available outside of scheduled
  times
• Evenings
• Early morning
• During the night for those unable to sleep

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Transitional Care/ Extended Care/Sub Acute/
Swing Bed Unit Probes

• Staff are assigned to activities
• CENAs assigned to activities are able to conduct
  both activities and CENA duties
• Activities are observed being conducted/offered
• Activities calendar is developed
• In room activities are offered/provided for
  fatigued residents
• Rehabilitation residents are encouraged to
  participate in activities outside their rooms
• Eg. May choose to eat in the dining room instead
  of in room (F242)

• Residents knowledge
• Available activities
• Available supplies
• Activity calendar
• Activity room
• Residents in pain are offered activities at a
  time of diminished or absent pain
• Resident assessment includes
• Level of pain
• Level of fatigue
• Times of resident availability
• Televisions are in a comfortable viewing position
  (F 246)

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Activity Director Qualification (F 249)

• Often triggered if problems exist with activities
  program or during an initial certification survey
• Qualified therapeutic recreation therapist or an
  activities professional who is licensed,
  registered or certified
• Or 2 years experience in a social/recreational
  program within the past 5 years, 1 fulltime in
  activities
• Or qualified occupational therapist or
  occupational therapist assistant
• Or has completed a training course approved by
  the state

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Other Red Flags

• Group activity area is too noisy, too small, or
  does not exist
• Insufficient supplies to meet resident needs or
  no adaptive materials
• Long periods of time with no scheduled activities
• Residents appear bored, sleep through
  activities,or dont attend
• Resident choice?
• Failure of staff to inform or encourage
  involvement
• Lack of assistance to get to activity
• Lack of staff
• Program does not reflect interests or ability
  level
• Too complex
• Too simple
• Age inappropriate
• Beyond capabilities, mental or physical

• Resident interview/observation indicate
  activities insult the intelligence, age and
  dignity of the resident
• Activities are canceled on a regular
  basis/schedule not followed or there have been no
  changes in activities month after month
• Negative outcomes due to staff requirements away
  from activity program
• Incongruity between observations or documentation
  of implementation of care plan and statements
  from staff

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For more information please contact the Quality
Improvement Nurse Consultation Program

• Activities in the Long Term Care Setting Part II
  continues the highlights of the HCFA satellite
  program presented September, 2000. It focuses on
  the survey process related to activity
  programming.
• Activities in the Long Term Care Setting Part I
  is an overview of the highlights of this
  satellite program.