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F0680
C

Unqualified Activity Director Led Activities Program

Brownwood, Texas Survey Completed on 04-04-2025

Penalty

Fine: $20,400
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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 ensure that the activities program was directed by a qualified professional, as required. Record review showed that the Activity Director (AD) was hired without the necessary certification or qualifications as a therapeutic recreation specialist or activities professional meeting state licensing requirements. The AD began employment without prior experience or certification and only started the required training several months after hire, with completion projected to be nearly a year after starting the position. The delay in certification was attributed to a change in the course provider, which postponed the start of the training. Interviews with the AD, the administrator (ADMN), and HR revealed a lack of clear oversight and understanding regarding the certification requirements and timelines. The AD acknowledged not having the required certification upon hire, and the ADMN assumed certification could be obtained within the first year but was not aware of specific timeframes. HR did not have a checklist or awareness of the AD's certification status. Documentation in the AD's application and personnel file was incomplete, with unanswered fields regarding licensure and certification.

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