Unqualified Staff Directing Activities Program
Penalty
Summary
The facility failed to ensure that its activities program was directed by a qualified professional, as required by its own job description and regulatory standards. Review of the personnel file for the current Activity Director (AD) showed no evidence of appropriate qualifications or certification for the position. The AD was initially hired as an activity assistant and promoted to Activity Director after the previous director left, despite having no prior experience in an activity position and not being enrolled in a certification program at the time of promotion. The AD had attended a 13.5-hour training called Activity Director Bootcamp, but this did not count toward the required certification. The job description for the Activity Director position specified that certification through an accredited source was required. Interviews with the AD, the Administrator, and the Director of Clinical Services/Registered Nurse (DCS/RN) confirmed that neither the AD nor the DCS/RN held the necessary activity director certification. The DCS/RN, who had been overseeing the activities program since 2021, also lacked certification and only had limited experience in activity positions. Documentation showed that the AD was only enrolled in a certification program after surveyor inquiry, with enrollment confirmed on the day of the interview. This deficiency had the potential to affect all 56 residents in the facility.