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F0680
D

Failure to Provide Qualified Activities Director

Pittsburgh, Pennsylvania Survey Completed on 04-18-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a qualified professional to direct the activities program for a period of one month, from March 3, 2025, through April 14, 2025. This deficiency was identified based on staff interviews and a review of facility-provided documentation. The job description for the Activities Director required an Activity Director certificate, which was not met during the specified period. The Nursing Home Administrator confirmed this lapse during an interview conducted on April 16, 2025.

Plan Of Correction

The facility will ensure that all activity assessments are reviewed and signed off by a licensed Occupational Therapist (OT) under the supervision of the Director of Rehabilitation. This temporary oversight measure will remain in place until our current Activities director has completed her licensure for the state. The Director of Rehab and RDCS will also provide guidance and ensure compliance with all regulatory standards for activity assessments and care planning. Staff involved in activity programming will be educated on the interim procedure and documentation expectations. Weekly reviews will be conducted by the Director of Rehab to confirm that all assessments are completed and signed appropriately.

See complete original report
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