Unqualified Staff Directing the Activities Program
Penalty
Summary
The facility failed to ensure its activities program was directed by a qualified professional as required by regulation and facility policy. Record review showed the Activity Director was hired on 08/24/2024 and began performing activity duties on 10/18/2025. During an interview, the Activity Director reported she did not yet have her activity certification and stated that a previous administrator had agreed to pay for the certification, but it had not been obtained. When asked about the risk to residents from her lack of certification, she stated she did not have an answer. In a separate interview, the Administrator acknowledged he had just learned that the Activity Director was not certified. He stated that the risk to residents was that the Activity Director might not be able to identify if residents were isolating themselves or secluded and how to address that. Review of the facility’s “Therapeutic Activities Program” policy, dated 09/26/2025, showed it required that the activities program be directed by a qualified activities director responsible for directing the development, implementation, supervision, and ongoing evaluation of the activities program. Federal regulatory criteria cited in the report specify that the activities program must be directed by a qualified therapeutic recreation specialist or activities professional meeting defined licensure, certification, experience, or training requirements, which the current Activity Director did not meet at the time of the survey.
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