RECAPTURING OUR CULTURE
THROUGH ACTIVITIES
Back to the Future
Susana Cruz R.N. MHA/MBA
CMS Dallas Regional Office
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CHANGE
2
The Past
Nursing Home
Resident
3
Change in the Activity Guidelines

A Guide to Recapturing Our Past
4
No Change at the regulation at F248
483.15(f) Activities

The facility must provide for an ongoing
program of activities designed to meet, in
accordance with the comprehensive
assessment, the interests and the
physical, mental, and psychosocial
well-being of each resident.
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CHANGE IN THE GUIDANCE
The Past
Activities
as
Busywork
Purposeful
Activities
Now & The Future
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CHANGE
The Past
Age
Appropriate
Activities
Person
Appropriate
Now & The Future
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Paradigm Shift
The Past
Nursing Home
Medical Model
Resident-directed
Culture
Now & The Future
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No more treating Residents as if they were cut from the same mold.
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Change (Recapture) How We Look at
Senior Citizens
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Nursing Home Residents
Come in different sizes, colors, and have different interests11
WHO AM I?
85 Years Old
Her past is part of her future
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Change: Meaningful Activities
Purpose
 Relevant
 Socialization
 Community events
 Physically Active
 Skills
 Abilities
 Life Roles
 New Interests

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Change: Outcome Oriented
Affect on the Resident
 Multidisciplinary Involvement
 Goals

 Measurable
 Realistic
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Change: Person Appropriate
Medical Illness
 Functional Impairments
 Needs
 Interests
 Culture
 Background

15
Activities Directors Can Lead The
Culture Change
New Guidance Supports it
 Activities Significant Part of Daily Life
 Activities Can Be Used to Address Medical
Issues

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Example


72 year old Hispanic female
Isolation Precautions for Chicken Pox
 Door
Closed
 Not allowed to leave room




Speaks only Spanish
Confused
Husband Visits Daily
Care Plan
 Problem
Identified: Disrupts Activities
 Goals: How to prevent disruption
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Example Continued





Care Plan not revised to consider Isolation Precautions
Resident’s activities (Music and Aroma Therapy) were
passive
Resident needed activities to counter the social isolation
Nursing along with Activities should have identified social
isolation as a consequence of the physical isolation to
treat chicken pox
Nursing needed to determine how much of the isolation
procedure was really needed to balance


Health needs
Social needs
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Change In The Survey Process




Review Activities for Every Resident on the
Sample
Emphasis on Outcomes
Observations
More Interviews
 Activities
Staff
 Social Worker
 Nurses
 CNAs
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Change in Guidelines Help to
Determine Compliance at F248
Recognized & assessed for individual
needs, preferences,
 Implemented activities which are “person
appropriate”
 Monitored and evaluated resident’s
response
 Revised approaches as needed

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Severity Determination

Use Psychosocial Outcomes
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Psychosocial Outcome Severity
Guide
Use in conjunction with Current Scope and
Severity Guidance in Appendix P and
Appendix PP, Appendix Q
 What is resident’s reaction (or outcome)?
 Non-verbal cues
 If resident is unable to communicate use

 Reasonable
person concept
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Psychosocial Outcome Severity
Guide

Reasonable Person Concept
 How
would a “reasonable person” react if
he/she were in resident’s situation?

Use this concept in two situations
The resident’s psychosocial outcome may
not be readily determined. For Level 2, 3, &
4 citations
 The resident’s reactions are incongruent
with the deficient practice (i.e. the resident
does not mind the deficient practice). For
Level 2 & 4.

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Level 4 – Immediate Jeopardy
Has caused or is likely to cause serious
injury, harm, impairment, or death to
resident
 Examples:

 Suicidal
ideation with a plan or attempt
 Sustained and intense crying
 Self-injurious behavior
 Debilitating fear
 Anger at an intense and sustained level
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Level 3 – Actual Harm that is
not IJ
Clinical compromise, decline, or the
resident’s inability to maintain and/or reach
his/her highest practicable well-being
 Examples:

 Significant
decline in former social patterns
 Persistent depressed mood
 Persistent pain or physical distress that has
compromised the resident’s functioning
 Diminished Activities of Daily Living
 Chronic or recurrent fear/anxiety that has
compromised the resident’s well-being
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Level 2 – No Actual Harm, Potential
for More Than Minimal Harm


No more than minimal discomfort or
Potential to compromise the resident’s ability to
maintain or reach highest practicable level of well
being. Examples
 Intermittent
sadness reflected in facial expression or
demeanor
 Discomfort or moderate pain (expressed or implied
by irritation)
 Fear/anxiety
 Feeling of shame or embarrassment without loss of
interest in self or environment
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Level 1 – No Actual Harm, Potential
for More than Minimal Harm

Not an option when citing the Activity
Program at F248
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No changes in the regulation at F249
483.15(f)(2) Activities Director

The activities program must be directed by a
qualified professional who(i) Is a qualified therapeutic recreation specialist
or an activities professional who
(A) Is licensed or registered, if applicable, by
the State in which practicing; and
(B) Is eligible for certification as a therapeutic
recreation specialist or as an activities
professional by a recognized accrediting
body on or after October 1, 1990; or
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483.15(f)(2) Activities Director
(ii) Has 2 years of experience in a social or
recreational program within the last 5 years,
1 of which was full-time in a patient activities
program in a health care setting; or
(iii) Is a qualified occupational therapist or
occupational therapy assistant; or
(iv) Has completed a training course
approved by the State.
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F249 Activities Director

Guidance
 Responsible
for
Directing,
 Implementing,
 Supervising, and
 Ongoing evaluation of the Activities Program

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Determining Compliance


Facility has employed a qualified professional
The director has completed or delegated
 Comprehensive
assessment
 Contribution to care plan
 Monitored and evaluated resident’s response
 Revised the approaches
 Developed, implemented, supervised, and evaluated
the activities program
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Change in Determining
Noncompliance

Cite F249 even if there has not been any
negative outcomes to residents if
 Lack
of Activities Director or
 Lack of providing direction by AD
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F248 Change in Determining
Severity

Depends on
 Presence
of harm or potential negative
outcomes
 Degree of harm
 Need for immediate correction
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Change
Level 3 – Actual Harm that is not IJ

Must have both
 (1)
Outcome:
 Resident(s)
inability to maintain and/or
reach highest practicable well-being.
 Relationship between F248 outcome
and F249
 (2)
No Activity Director or AD did not
direct, develop, implement or revised
individualized program or the activity
program
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Change Level 2 – No Actual Harm,
Potential for More than Minimal Harm

Must have both

(1) Outcome:



Resident outcomes of no more than minimal discomfort or
Potential to compromise resident’s ability to maintain or
reach highest practicable level of well-being inability to
maintain and/or reach highest practicable well-being.
Relationship between F248 outcome and F249
(2) No Activity Director or facility failed to involve the
AD in the assessment, development, implementation
and/or revision of an individualized program or the
activity program
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Change Level 1- No Actual Harm
with Potential for Minimal Harm

Must have
 No Activity
Director or the activity director is
not qualified, however
 F248 was not cited;
 Activity system is in place;
 Relatively short duration without AD; and
 Facility is actively seeking a qualified AD
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Good Use of Activities Program

To potentially lower
 Behaviors
 Restraints
 Abuse
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Activities

Identify Behaviors Amenable to Activities
 Repetitive
motions
 Wanderers
Identify Activities Beneficial to Resident
 Monitor Effect of Activities on Behaviors
 Ongoing Revision and Adaptation of
Activities

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Government Performance and
Improvement Act 1993

Requires Centers for Medicare and
Medicaid Services to set outcome goals
 So
far CMS has set outcome goals for nursing
homes in the areas of
Immunization Rates
 Pressure Sores
 Restraints

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Oklahoma Restraints GPRA Data
14.0%
12.0%
OK
10.0%
REGION 6
8.1% Region 6 Restraint Goal
8.0%
6.0%
NATION
4.0%
2.0%
0.0%
Y2003 Y2003 Y2004 Y2004 Y2004 Y2004 Y2005 Y2005 Y2005 Y2005 Y2006 Y2006 Y2006 Y2006 Y2007 Y2007 Y2007
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
7.1%
6.9%
6.7%
6.6%
6.4%
6.2%
6.1%
6.0%
5.8%
5.5%
5.2%
5.0%
Region VI 12.8% 12.1% 11.3% 11.0% 10.7% 10.3%
9.9%
9.5%
9.2%
8.8%
8.4%
8.2%
8.1%
7.9%
7.5%
7.2%
6.8%
11.4% 11.7% 11.7% 12.3% 12.8% 12.7% 12.7% 12.6% 12.7% 12.6% 12.0% 11.4% 11.7% 11.4% 10.2%
9.6%
9.1%
Nation
OK
7.8%
7.7%
7.4%
7.3%
7.3%
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Restraints in Oklahoma

Current Data (FY 2007 Quarter 3)
 325
Facilities in OK
 193 (59%) of facilities have an average of
residents in restraints above the current
Regional Average of 6.8%
 220 (67.7%) facilities above the
National Average of 5.5%
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Change in Guidance for Restraints

Clarification
 Survey
and Certification Letter 07-20 Issued June 22,
2007
 Effective July 22, 2002Restraints for short-term use
(acute conditions)
 Restraints only for Medical Symptom which


Cannot be addressed by less restrictive intervention AND
Restraint is required to treat the medical symptom


To protect the resident’s safety
Help attain/maintain highest level of physical/psychological wellbeing
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Restraints
There must be a link between restraint
use and benefits
 Must document ongoing assessments,
and care plans
 Systematic and gradual process of
reduction
 Includes those admitted with restraints
 Identify cause of medical symptom

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Restraints

New Clarifications
 Cannot
use restraints for Falls
 Need to identify cause (the medical symptom)
that leads to falls (e.g., postural hypotension,
syncope, urinary frequency from diuretics,
etc)
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Limited Use of Restraints

May be used when immediately necessary
to
 Prevent
resident from injuring self or others
and/or
 To prevent interference with life-sustaining
treatment and/or
 No other less restrictive OR less risky
interventions exist
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Advancing Excellence Campaign
Work with Local Area Network of
Excellence
 www.nhqualitycampaign.org

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QUESTIONS
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Susana Cruz
CMS
Dallas Regional Office
214-767-4415
susana.cruz@cms.hhs.gov
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