Unqualified Staff Directing the Activities Program
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the activities program was directed by a qualified professional as required. During an interview, the Activities Director (AD) reported she had been in the role since December 2025 and stated she was not certified but was currently taking a class. In a follow-up interview, she explained that the previous administrator had offered her the Activities Director position and that she believed she met the job description qualifications because she was eligible for certification. She further reported that she was responsible for scheduling activities, implementing or delegating implementation of programs, monitoring residents’ responses to the programs, reviewing and evaluating whether activities met residents’ assessed needs, and making revisions as necessary. A review of the facility’s Activities Director job description showed that the position required the activities program to be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who is licensed or registered if applicable, and who either is eligible for certification by a recognized accrediting body on or after October 1, 1990, has 2 years of experience in a social or recreational program within the last 5 years (with one year full-time in a therapeutic activities program), is a qualified occupational therapist or occupational therapy assistant, or has completed a state-approved training course. In an interview with the Nursing Home Administrator (NHA), after reviewing the job description, the NHA stated that based on the job description and her understanding of the regulation, the current AD was not qualified for the position.
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