F0680

E

Unqualified Individual Directing Activities Program

Jefferson Hills, Pennsylvania Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that the activities program was directed by a qualified professional. The Activities Director’s job description stated that the position’s primary purpose was to plan, organize, implement, evaluate, and direct activity programs in accordance with federal, state, and local standards, and as directed by the administrator, to meet residents’ emotional, recreational, and social needs on an individual basis. Review of the Activities Director’s (Employee E1) personnel record showed she was hired on 1/9/25, but there was no documentation of prior experience as an Activities Director, education in therapeutic services, education as a social worker or occupational therapist, or a background in recreational services.

During interviews, the Activities Director (E1) confirmed she did not have education in therapeutic services, social work, occupational therapy, or recreational services. The facility’s Occupational Therapist (E3) confirmed she had no oversight or involvement with the activity program and that she was the only regularly scheduled OT for the facility. The Certified Occupational Therapy Assistant and Rehabilitation Services Director (E2) stated she only completed the mobility portion of the activities assessment in the clinical record and had no other involvement or oversight of the activities department programming or staff. The Nursing Home Administrator confirmed that the facility failed to ensure the Activities Department had a qualified director to oversee the activities program, in violation of 28 Pa Code 201.18(b)(3) and 201.189(e)(6).