Unqualified Activity Director
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, as required by regulation. The deficiency was identified through interviews, facility documents, and employee record reviews. Staff #21, who was promoted to the Director of Activity position in 2013, did not meet the necessary qualifications. Although staff #21 had two years of experience in a social or recreational program within the last five years, she did not meet the requirement of being licensed or registered by the State in which she was practicing. The Human Resources Director and Business Office Director, staff #52, was responsible for verifying licenses and certifications but was unaware of the specific policy on licenses and certifications. Staff #21 had been in the Activity Director role for ten years and had a total of thirteen years with the company. Her responsibilities included organizing monthly activity calendars and staff schedules, ensuring activities were available seven days a week, including holidays and evenings. Despite her experience and involvement in activity professional group meetings, she had not taken any courses or training approved by the State. This lack of state-approved training contributed to her not meeting the qualifications required for her role as the Director of Activity, leading to the identified deficiency.
Penalty
Resources
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The facility failed to ensure its activities program was directed by a qualified professional. An Activities Director, who had been in the role for several months and was not yet certified, reported being responsible for scheduling, implementing, and evaluating resident activities. She stated she believed she met the job requirements because she was eligible for certification and was taking a class. Review of the facility’s job description showed specific qualification requirements, including licensure/registration if applicable and defined experience, certification eligibility, or completion of a state-approved course. The NHA acknowledged that, based on these requirements and her understanding of the regulation, the current Activities Director did not meet the qualifications for the position.
The facility’s activities program was directed by an Activity Director (AD) who did not meet required qualifications. The AD had been in the role for several months without being enrolled in an activities director course and was not certified, despite the facility’s job description requiring a certified AD with appropriate state-required credentials. Interviews with the AD and the Administrator, along with personnel record review, confirmed that the AD lacked the necessary certification and training, potentially affecting the provision of individualized activities for residents.
Surveyors found that the facility’s activities program was being directed by an individual who lacked required qualifications, including prior activities experience, therapeutic services education, social work or OT training, or a recreational services background. The Activities Director confirmed this lack of relevant education and experience. The facility’s OT reported having no oversight or involvement with the activities program, and the COTA/rehab director stated her role was limited to completing the mobility portion of the activities assessment without further involvement in activities programming or supervision. The NHA acknowledged that the facility did not have a qualified professional overseeing the activities department.
Surveyors found that the facility did not have a qualified activity director in place for a census of 74 residents, despite posted schedules for group activities such as coffee and conversations, bible study, and stretching. Residents were observed playing bingo with an automated bingo machine while a CMA sat at the table, rather than a qualified activities professional directing the program. A social worker reported that they or other staff assisted with activities and were unsure how long the facility had been without an activity director, and the administrator confirmed there had been no full-time activity director for several weeks, even though resident rights materials stated that a program of activities would be provided to meet residents’ needs and interests.
Surveyors found that the facility’s activities program was being directed by an Activity Director who lacked the required certification or qualifying credentials. The Activity Director had been hired and functioning in the role for several months without meeting federal criteria for an activities professional or therapeutic recreation specialist, and she could not describe the risks to residents from her lack of qualification. The Administrator confirmed he had only recently learned she was not certified and acknowledged that this could affect her ability to recognize and address resident isolation, contrary to facility policy and regulatory requirements for a qualified individual to direct the activities program.
The facility did not ensure its Activities Program was overseen by a qualified Activities Director, as the staff member in the role lacked required certification or training and was originally hired for social services. Resident Council meetings were facilitated by an Activities Aid, and management was not kept informed of resident concerns from these meetings.
Unqualified Staff Directing the Activities Program
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the activities program was directed by a qualified professional as required. During an interview, the Activities Director (AD) reported she had been in the role since December 2025 and stated she was not certified but was currently taking a class. In a follow-up interview, she explained that the previous administrator had offered her the Activities Director position and that she believed she met the job description qualifications because she was eligible for certification. She further reported that she was responsible for scheduling activities, implementing or delegating implementation of programs, monitoring residents’ responses to the programs, reviewing and evaluating whether activities met residents’ assessed needs, and making revisions as necessary. A review of the facility’s Activities Director job description showed that the position required the activities program to be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who is licensed or registered if applicable, and who either is eligible for certification by a recognized accrediting body on or after October 1, 1990, has 2 years of experience in a social or recreational program within the last 5 years (with one year full-time in a therapeutic activities program), is a qualified occupational therapist or occupational therapy assistant, or has completed a state-approved training course. In an interview with the Nursing Home Administrator (NHA), after reviewing the job description, the NHA stated that based on the job description and her understanding of the regulation, the current AD was not qualified for the position.
Unqualified Activity Director Leading the Activities Program
Penalty
Summary
The facility failed to ensure its activities program was directed by a qualified professional, as the current Activity Director (AD) did not meet the required qualifications. During an interview, the AD reported she had been working in the role since April 2025 and was not registered for an activities director course. She stated that a previous administration had told her they would assist her with getting registered for an AD course, but after that administration left, she did not get enrolled. Record review confirmed the AD was neither enrolled in an activity course nor certified as an AD. The facility’s job description for the Activity Director, dated 2014, specified that the position required a high school graduate with certification where required by state regulations and that the individual must be a certified Activity Director. The report stated this failure could place residents at risk for reduced quality of life due to lack of individualized activities that matched their skills, abilities, and interests/preferences. The Administrator acknowledged in an interview that the AD was not yet enrolled in the required AD course and confirmed they were working on getting her enrolled, further supporting that the AD did not currently meet the stated qualification requirements.
Unqualified Individual Directing Activities Program
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the activities program was directed by a qualified professional. The Activities Director’s job description stated that the position’s primary purpose was to plan, organize, implement, evaluate, and direct activity programs in accordance with federal, state, and local standards, and as directed by the administrator, to meet residents’ emotional, recreational, and social needs on an individual basis. Review of the Activities Director’s (Employee E1) personnel record showed she was hired on 1/9/25, but there was no documentation of prior experience as an Activities Director, education in therapeutic services, education as a social worker or occupational therapist, or a background in recreational services. During interviews, the Activities Director (E1) confirmed she did not have education in therapeutic services, social work, occupational therapy, or recreational services. The facility’s Occupational Therapist (E3) confirmed she had no oversight or involvement with the activity program and that she was the only regularly scheduled OT for the facility. The Certified Occupational Therapy Assistant and Rehabilitation Services Director (E2) stated she only completed the mobility portion of the activities assessment in the clinical record and had no other involvement or oversight of the activities department programming or staff. The Nursing Home Administrator confirmed that the facility failed to ensure the Activities Department had a qualified director to oversee the activities program, in violation of 28 Pa Code 201.18(b)(3) and 201.189(e)(6).
Lack of Qualified Activity Director for Resident Activities Program
Penalty
Summary
The facility failed to ensure its activities program was directed by a qualified professional, resulting in the absence of a full-time activity director for a census of 74 residents. On multiple observations, residents were seen participating in bingo games in the dining area, with an automated bingo machine calling numbers and a CMA present at the table, rather than a qualified activity director leading or overseeing the program. The posted activity board listed scheduled group activities such as coffee and conversations, bible study, and stretch sessions, but there was no indication of a qualified activities professional coordinating or conducting these programs. A Resident Rights poster stated the facility would provide a program of activities designed to meet residents’ needs and interests, yet the social worker reported that either they or another staff member would assist with activities and did not know how long the facility had been without an activity director. The administrator confirmed that the facility did not currently have a full-time activity director and that it had been “some weeks” since one was in place, acknowledging they were in the process of hiring but leaving the activities program without a qualified director during that period. No specific resident medical histories or clinical conditions were described in relation to this deficiency, only that 74 residents resided in the facility at the time of the survey.
Unqualified Staff Directing the Activities Program
Penalty
Summary
The facility failed to ensure its activities program was directed by a qualified professional as required by regulation and facility policy. Record review showed the Activity Director was hired on 08/24/2024 and began performing activity duties on 10/18/2025. During an interview, the Activity Director reported she did not yet have her activity certification and stated that a previous administrator had agreed to pay for the certification, but it had not been obtained. When asked about the risk to residents from her lack of certification, she stated she did not have an answer. In a separate interview, the Administrator acknowledged he had just learned that the Activity Director was not certified. He stated that the risk to residents was that the Activity Director might not be able to identify if residents were isolating themselves or secluded and how to address that. Review of the facility’s “Therapeutic Activities Program” policy, dated 09/26/2025, showed it required that the activities program be directed by a qualified activities director responsible for directing the development, implementation, supervision, and ongoing evaluation of the activities program. Federal regulatory criteria cited in the report specify that the activities program must be directed by a qualified therapeutic recreation specialist or activities professional meeting defined licensure, certification, experience, or training requirements, which the current Activity Director did not meet at the time of the survey.
Unqualified Activities Director Oversight
Penalty
Summary
The facility failed to ensure that its Activities Program was directed by a qualified Activities Director (AD). Record review showed that the AD did not sign attendance forms for several Resident Council meetings, and these meetings were instead facilitated and signed by an Activities Aid (AA). Interviews revealed that the DON was unaware of any concerns from these meetings and did not know if the AD met the required qualifications. The AA stated she had only recently been informed of her responsibility to share meeting minutes with management. Personnel file review indicated that the individual serving as AD was originally hired as social services staff and lacked documentation of certification or appropriate training for the AD role. The AD confirmed in an interview that she did not meet the qualifications for the position and had not enrolled in the necessary program due to a change in facility ownership. This deficiency had the potential to affect 32 residents interested in or participating in activities.
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