Failure to Employ Qualified Activity Director
Penalty
Summary
The facility failed to employ an Activity Director with the appropriate certification or qualifications as required by both facility policy and regulatory standards. Review of records showed that the Activity Director accepted the position with the understanding that they would enroll in a certification program, but as of the time of the survey, they had not completed the certification nor could they specify the number of credits earned. The Activity Director reported only sporadic meetings with the Occupational Therapist who was temporarily assigned to oversee the department, and there was no documentation of these meetings. The Occupational Therapist confirmed that they had not met with the Activity Director regarding activities for at least a year and was unaware that oversight was still expected. Interviews with facility leadership confirmed that the Activity Director was not certified and had not met the alternative experience requirements at the time of hire. The facility policy required the Activity Director to be certified or have two years of relevant experience, but the individual in the role had not met these criteria upon assuming the position. There was also a lack of documentation and oversight regarding the activities program, as required by policy.