Unqualified Activities Director and Inconsistent Program Management
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, as required by regulations. The Activities Director (AD) had only been in the position for two weeks and previously worked as a unit clerk for several years. The AD was unfamiliar with key aspects of the role, such as the process for delivering a daily newspaper to a resident and the documentation of resident activity participation. Additionally, the AD had not attended any Quality Assurance or resident care plan meetings, indicating a lack of experience and training for the position. The facility had not had a consistent Activity Director since July, and the current AD was not qualified according to the job description, which required a Bachelor's degree in a relevant field and 2-3 years of experience. The Staffing Coordinator/Lead Certified Nursing Aide (SC/LCNA) was identified as the new AD, but she had not yet completed the necessary training or attended relevant meetings. This lack of a qualified and consistent Activities Director had the potential to affect all residents in the facility, as evidenced by the issues observed during the survey.
Plan Of Correction
1: The facility was successful in hiring a full-time certified U.S. FOIA (b) (6) with a start date of NU Exec Order 26.4b1. 2: All residents had the potential to be affected by the deficient practice. 3: The non-certified U.S. FOIA (b) (6) who is now a U.S. FOIA (b) (6) and the other activity staff were made aware of the hiring and were also educated that the certified AD will be responsible for completing the assessments. 4: The Administrator / designee will audit the new director's performance in general and specifically with completing the assessments accurately and timely. Results will be reported to the QAPI committee for review and action as necessary. 5: 3-3-2025. Element One: Corrective Actions The facility hired a full-time U.S. FOIA (b) (6) who started employment on NJ Ex Order 26.4(b)(1). The facility had sister facility Certified Activity Directors review, revise as needed, and sign the most recent APR for each resident and then review and update the care plan as appropriate to ensure the assessment and care plan met the current interests, abilities, and preferences of each resident. Element Two: Identification of at-risk Residents All residents had the potential to be affected by this practice. Element Three: Systemic Change All residents and facility staff were informed of the hiring of a Certified Activity Director and all activity staff were re-educated about their role and that of the CAD for completing the assessment and updating care plans. Element Four: QAPI A sister facility CAD/designee will monitor the new certified activity director's performance through audits of 10% of APR assessments weekly for two weeks, then monthly for two months to ensure they are properly completed and signed, and the care plan has been updated. Results will be reported to the QAPI committee for review and action as necessary. Completion Date: 3-5-2025.