5 Ways to Avoid Activities Related Nursing Home Survey Citations

Beginning June 1, 2006, CMS is implementing revised interpretive guidelines

for activity and behavior when performing the annual nursing home Medicare
certification survey. The changes to the interpretive guidelines for the Federal
regulations concerning activities (F248/249), and the intent and application of the new
scope and severity grid for psychosocial well being, present new challenges to nursing
home recreation therapy directors and administrators, and actually to the entire facility
staff. In the past, nursing home surveys of resident activity focused on whether or not
they were provided, and if they were provided as planned. The focus now is more on
the outcome of those activities on the resident. For instance, if a resident is appears sad
and depressed, the surveyor may investigate what his or her level of engagement in
activities has been and whether or not the team has addressed this mood. Additionally,
if a resident has a fall or develops a pressure ulcer, the surveyor may pursue whether or
not they were engaged in any diversionary activity to prevent unsupervised walking or
mobilizing activity to prevent pressure on bony prominences.

It is important that you take steps to prepare your facility for these new
guidelines, and here are some practical action steps to make that happen:
• Educate yourself and your staff on the new guidelines and what they mean for
resident life and care
• Have each care planning team make a list of residents who exhibit activity
levels or behavior that potentially could trigger inquiries as to their activities
(for example, those who appear sad and depressed, those who wander or who
get up with little or no warning, those who disrobe in the hallway, etc.)
• Each team should review the care plans of the residents they identify as at risk
for activity related issues, and revise them with practical strategies that they can
be cared for (e.g. diversionary games, large motor activities, sorting exercises,
etc.)
• Train the direct care staff on that unit about the new care plan and the rationale
for the interventions
• Monitor for sustained performance. As President Ronald Regan once said about
a related issue with the then Soviet Union, “Trust, but verify.” A revised care
plan that is implemented may not be sustained if no one is checking to make
certain it is done.

Just as is the case for the many other standards that nursing homes are measured
against, these guidelines are focused on residents being cared for in a way that
prevents harm, but the definition of harm is now broader. There is concern that
outcomes such as resident happiness may be quite subjective, and that citations may
be unfair. While there may be a great deal left to the subjectivity of the surveyor,
the key is to remain observant to manifestations of unhappiness, boredom,
inactivity, etc. and assess and care plan for them. If a resident’s life pattern is
documented as being a loner and not actively engaging in activities, then care plan
for that. If you can observe those behaviors, a surveyor may also, and they may ask
you why the behavior persists. If you are able to pull out documentation that shows
 that this is a lifelong pattern, and that the team has worked with the resident on
accepting perhaps a very few activities that he or she is willing to participate in, and
that materials to read or listen to are provided when he or she is alone, then the
surveyor will be hard pressed to find you deficient. Sensitize your staff to these
issues, personalize the resident care approaches and care plans, and monitor these
high risk residents on an ongoing basis.

Joseph Tomaino is a patient care executive, educator, and consultant. His business, The
Tomaino Group, provides consultative services and products that support the cost effective
provision of quality patient care in acute, sub-acute, long term care, and home care settings. Visit
www.continuingcareinsite.info to subscribe to free newsletter.

© Copyright, 2006 All rights reserved, Joseph J. Tomaino, The Tomaino Group, 834 Heritage
Court, Yorktown Heights, NY 10598 Email: jtomaino@continuingcareinsite.info.