THERAPEUTIC ACTIVITIES PROGRAM
Chapter 1
Stan Mucinic, LNHA
Chapter 1 – Therapeutic Activities Program
Introduction As the administrator-in-training or assistant administrator, your main duties
will be to visit and observe activities on a daily basis, identify compliance issues, and learn to
recognize “problems” in the same way as a surveyor would, and effectively address them with
staff.
1. The therapeutic activities program is responsible to provide therapeutic activities to residents which are critical to their quality of life, their independence and their dignity.
2. Unlike you or me, once an individual becomes a resident of a nursing home on a long term basis, there is simply nothing they ever have to do again.
3. Residents quickly loose what is the driving force of their lives, which is “purpose”. They have none. They do not have to worry about paying bills, preparing meals, writing checks or getting up for work.
4. There is no one who needs them or is depending on them for any thing. They are relieved of all of the everyday activities and chores that define our lives. And they quickly lose any sense of purpose or a need to be. Within 2 weeks of admission, you can observe an overall decrease in cognitive function. In some cases it can be quite dramatic.
5. A nursing home provides care in an institutionalized setting, and from the moment an individual is admitted into a facility, or the “institution”, the process of orientation begins. They must quickly learn they cannot do what they want, when they want to do it. And as a practical matter, that is because they have physical limitations that require assistance from staff to perform the activities of daily living.
6. Activities of daily living include transferring in and out of bed, showering, dressing, eating, and moving around the facility. Because of their physical and cognitive limitations, a major challenge of a facility is to meet the needs of these individual.
7. OBRA 1987 took a major step in addressing these critical quality of life challenges by requiring a therapeutic activities program to fill that void with something meaningful, and to provide activities that residents enjoy. And from a clinical standpoint, such activities must provide therapeutic exercise of their physical and cognitive capabilities which include tossing a ball, bowling, chair exercises and current events, to name a few.
8. Some basic therapeutic modalities employed by activities specialists include reality therapy which uses clocks and calendars and current events for residents with mild cognitive impairments, and are designed to orients them to time and place; milieu therapy uses the environment and involves having residents identify common objects in their environment and use cognitive skills that would otherwise be lost; and validation and music therapy that are used for residents with severe cognitive impairments.
9. Federal regulations require nursing homes to organize a varied and vibrant program that meets the needs of all residents. The therapeutic program must provide distinct activities for oriented residents, residents with mild cognitive impairments, and for residents with advanced or severe impairment or dementia.
10. Such varied programming requires space and staff to provide activities throughout the day, 7 days per week.
11. A resident’s therapeutic activity program is based on their MDS and the care plan (which identifies their hobbies, interests, social history, clinical and cognitive needs and goals). The care plan is developed from the MDS and is updated as the MDS is updated. The care plan details what specific steps staff will take on a daily basis to assist the resident to meet their highest level of functioning and their activities of daily living.
12. The MDS must be completed within 14 days of admission, and the care plan must be completed within 7 days of the completion of the MDS.
13. Because therapeutic activities is such an important aspect in maintaining the highest mental, physical, and psycho-social well being of residents, the CMS and state surveyors are devoting increasing scrutiny to assess the over effectiveness of the activities program and the specific outcomes achieved.
14. Each of the groups mentioned above needs separate and distinct programming and activities. To accurately assess a resident to determine which activities they would benefit from most. Therefore It is critical that the resident and resident’s family members be interviewed to elicit detailed information about the resident’s social history, cognitive abilities, hobbies, interests and former occupation. This information will then form of the basis of determining which group the individual should be placed in, and then which activities they would enjoy and benefit from most.
15. If a facility is marketing a specialized Alzheimer’s care program, then the facility needs to document specifically what that program entails and the special services provided to residents. Those services must go beyond those provided to all residents in the regular activities program such activities that emphasize tactile and auditory stimuli such as music, lighting and stuffed animals and other objects with different textures. Although these individuals may only possess very basic neurological capabilities in some cases, music, touch, the shape and feel of a doll or the soft fur of a stuffed animal, can evoke powerful and comforting sensations and emotions.
16. For the most part, the CMS and state survey agencies would ike a facility therapeutic program to consist of more than bingo and television.
17. Television watching is not a recognized therapeutic activity. And although bingo is very popular and a source of enjoyment for most residents, the CMS and state surveyors would like the focus to be on exercising their minds and their bodies. Providing activities that require moving the arms, legs, torso, hands, head and feet are essential in maintaining these abilities.
18. The activity program must be organized and directed by an individual who is a therapeutic activity professional or has consultation with one. An occupational therapist or occupational assistant is qualified to be the director of a facility activities program under federal and most state laws.
19. For obvious reasons, employing an experienced and knowledgeable activities director is very important. Since the activities director and staff are responsible to document each residents r interests, and also the individual services provided to them in their rooms, if they cannot or choose not to attend group activities. As the administrator, you need to check that this documentation is being properly maintained on a monthly basis and that resident progress notes are being documented. Special emphasis should be placed on residents who are bed bound or receiving activities in their rooms.
20. During survey, these residents will receive extra scrutiny and it is important to make sure their therapeutic records are current. If the administrator does not stay on top of these documentation requirements, and hold staff accountable throughout the year, department staff usually end up hastily assembling this documentation in the final days leading up to the actual survey.
21. In addition to documenting the residents’ progress and the specific services provided to them, activities staff is responsible to communicate with other disciplines any issues they identify while working with residents. For instance a cognitive decline, behavioral problems, depression or diminished range of motion or affective disorders observed during activities sessions.
22. The clinical stand up meeting in the morning is the main forum for communication of observations and other information that needs to be shared with the interdisciplinary team.
23. A good activities program should have a robust volunteer program capable of providing a varied schedule of activities for each cognitive level throughout the day. Volunteers are essential in staffing and implementing the wide ranges of activities that need to conducted from early morning and well into the evening.
24. A resident’s cognitive abilities will change rather quickly, and activities staff need to monitor those changes and adjust their therapeutic program accordingly.
25. Many activities are geared to helping residents retain what cognitive abilities they have, and to essentially exercise them to retain them as long as possible and prevent decline.
26. Music programs are an essential part of an activity program and has the power to reach cognitively impaired residents, especially severely impaired individuals.
27. Memory loss is not a normal part of aging. Senility is normal and having trouble remembering where you placed your keys or short term memory difficulties are to be expected. Forgetting your spouses name or your children’s names are or what the car keys are for is not a normal part of aging.
28. The average age of nursing home residents is about 85 years old, and the percentage of residents with moderate to severe cognitive impairments and Alzheimer’s is startling. This quickly growing population presents tremendous challenges to long term care administrators and staff to meet the needs of these individuals with the limited labor and resources afforded through Medicare, Medicaid and insurance reimbursements.
29. Spirituality is an important dimension of quality of life, and bringing ministers, pastors and rabbis into the facility to conduct services and offer spiritual counseling is critical to quality of life.
30. The types of tags that the activities program typically receives involve residents observed by surveyors asleep in their wheelchairs in the hallways or in the activities room, or residents lying in bed and watching television. If the overall program is lacking in varied activities that meet all cognitive levels, and residents seem for the most part to just be sitting around bored, the facility will be cited because yher activities program is not meeting the needs of its residents.
31. Determine how many beds are in the facility and the number of full time activities personnel and volunteers providing services to residents. Are there sufficient staff? Are activities available from early morning, during the day and are activities scheduled in the evening?
32. Ask the activities director to show you the various types of forms and documentation staff completes for each resident, and note how often the documentation should be filled out and filed in the chart or resident files maintained by the activities program
33. Ask the MDS Coordinator to identify 5 residents with behavioral problems or are bedridden or severely demented. Review the records in the activities department for those 5 residents to verify that staff documented the specific services and activities provided to those residents.
34. Where those activities appropriate for the special needs of those 5 residents? Was the documentation completed timely? These are the residents that the surveyors will focus on during survey.
35. Since the social service notes are very similar to the activities notes, cross check the progress notes from the social services department to verify they match.
36. Ask the activities director if the documentation for all residents are current and up to date. Check the documentation of individual visits to residents in their rooms.
37. I suggest you review these records on a quarterly basis to ensure they are maintained timely. What you want to avoid, is a common situation where the department falls behind, and staff must hastily complete hundreds of progress notes just weeks or days before the survey.
38. Attend and audit planned activities for the different cognitive groups, and determine if they seem adequate and meet the residents’ needs. Do the participants in those activities appear engaged and enjoying themselves?
39. Talk to the residents about their personal experience with the activities program and any recommendations for improvements.
40. Ask to see the schedule of individual visits by activities staff and whether those visits were timely.
41. Review the annual and monthly budget for activities.
42. Federal law requires the facility to post the activity schedule for 1 month in advance. Is the activities schedule posted? Is it large enough for residents to read? The facility is required to post in resident rooms and other public and resident areas in the facility a full schedule of the activities for the month. The main activities calendar is usually oversized and easy to read.
43. Is a copy posted in each resident room?
44. Is the schedule posted in more than one place in the facility?
45. Are activities scheduled 7 days a week, including evening hours?
46. Observe activities on the weekend. How does it differ from the weekday? Did you feel the energy level in the building is tremendously diminished in the facility on the weekends with so many key staff off?
47. Did you observe residents watching television or asleep, or lined up in the hallway in their wheelchairs, looking bored or nodding off? This is a tag if surveyors see residents in their chairs asleep.
48. Did you observe residents looking bored or nodding off while participating in an activity?
49. The Administrator and staff need to be alert to these visual cues because that is what the surveyors will be looking for during their observations.
50. Attend activities and observe the number of participants in each activity. Are the activities appropriate to the interests of the residents attending, and do they meet their cognitive needs?
51. As you walk through the building, be aware of the types of programs on the television that residents are watching. If they are watching cartoons or children’s programming, or a sports game or a soap opera that the nursing staff is watching with one eye while working, these are all tags. Or is the television program in a language none of the residents speak?
52. The television in the residents lounge is for the residents benefit during the day and evening.
53. If you have an activity that is focused on Alzheimer’s residents, then the program needs to address the needs of people with Alzheimer’s or severe cognitive limitations. These programs would use special lights, soft furry objects and music to stimulate their cognitive abilities.
54. It is important that highly cognitive individuals are not grouped into activities with mildly or severely cognitively impaired individuals.