Minnesota’s Call to Action
Quality of Life Initiative for
Activities F248/249:
An Interdisciplinary
Approach
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Minnesota’s Call to Action
Sponsors:
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MN Department of Health
Care Providers of Minnesota
ElderCare Rights Alliance
MN Directors of Nursing Association
Minnesota Health & Housing Alliance
The Office of Ombudsman for Older
Minnesotans
• Empira
• Stratis Health
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Minnesota’s Call to Action
Activity Services in Minnesota
• Perfect survey-ready activity
programs?
• Developing community
• Encompassing capacity,
cultures, leisure needs &
patterns
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Minnesota’s Call To Action
• Quality Of Life Alliance
• CMS Work group focus
• Excellent definition of the
Activity/Recreation Profession
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Minnesota’s Call To Action
Learning Objectives:
• Identify the major
components of the revised
guidance for activity
services as a Quality of Life
Initiative
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Minnesota’s Call to Action
History of Activity Regulation:
• 1958 – “Activities should be
provided”
• 2006 – “Revised Guidance for
Activities Requirements in
Long-term care (tags F248
and F249)”
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Minnesota’s Call To Action
Learning Objectives:
• Understand how to
successfully comply with
FTags 248 and 249 and the
role of the interdisciplinary
team.
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Minnesota’s Call to Action
Learning Objectives:
• Know how to assess and
document activity practices
and standards
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Minnesota’s Call to Action
Learning Objectives:
• Describe how quality
improvement programs are
related to activity/recreation
services
• Analyze program and
development skills for
activity/recreation services
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Minnesota’s Call to Action
Learning Objectives:
• Identify key components of potential
staff inin-services related to the new
guidance
• Understand how the new survey
guidance is a compliment to culture
change, residentresident-centered care and
other innovations and improvements in
longlong-term care services
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Minnesota’s Call to Action
Interpretive Guidelines:
• Activities F248
• (f) Activities
• (1) 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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Minnesota’s Call to Action
Interpretive Guidelines:
• Intent
• The facility identifies each resident’s interests
and needs; and
• The facility involves the resident in an ongoing
program of activities that is designed to appeal
to his or her interests and to enhance the
resident’s highest practicable level of physical,
mental, and psychosocial wellwell-being
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Minnesota’s Call to Action
Interpretative Guidelines
• Definitions
–Activities
–Person appropriate
–One-to-one programming
–Program of activities
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Minnesota’s Call to Action
Definitions:
• Activities
–Any endeavor
–Tales of the smoking lounge
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Minnesota’s Call to Action
Definitions:
• Person Appropriate
–Not age-appropriate
–Person versus Program
Approach
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Minnesota’s Call to Action
Definitions:
• One-to-one programming
–Defines
• Who, type, duration
• Categories
• Support of self-directed
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Minnesota’s Call to Action
Definitions:
• Program of Activities
–Quality over quantity factor
–Person-integrated
–Specifying content
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Minnesota’s Call to Action
Interpretative Guidelines
• Overview
–Resident’s Views on
Activities
–Alternative Approaches
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Minnesota’s Call to Action
Interpretive Guidelines:
• Assessment / Care planning
• Individualized care plans
– Assessment criteria tool
• Participation & Participation Level
– Assessment
• Before & After Example
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Minnesota’s Call to Action
Interpretative Guidelines:
• Assessment
–Activity RAP
–Determining “At Risk”
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Minnesota’s Call to Action
At Risk Audit:
• Actual behaviors / conditions
that could create at risk status
• Examples of risk factors /
underlying reasons for at risk
status
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Minnesota’s Call to Action
Interpretative Guidelines:
• Interventions
– When evaluating the provision
of activities, it is important to
identify whether the resident
has issues for which staff
should have provided
adaptations.
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Minnesota’s Call to Action
Interpretative Guidelines:
• Interventions
– Facilities should take into account
resident’s pattern of behavioral
symptoms
– Activities should be presented prior to
when symptoms usually present
themselves
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Minnesota’s Call to Action
Interpretative Guidelines
• Interventions:
–Addressing behavioral
symptoms
–Examples of interventions
for dealing with behaviors
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Minnesota’s Call to Action
Interpretative Guidelines:
• Addressing Behavioral
Symptoms
– Desired Outcome:
• The decrease or elimination
of the behavior/s
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Minnesota Call to Action
Interpretative Guidelines
• F249 - Intent
–The intent is to ensure that
the activities program is
directed by a qualified
professional.
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Minnesota’s Call to Action
Interpretative Guidelines:
• F (249)
The activities program must be directed by a
qualified professional whowho• Is a qualified therapeutic recreation specialist or an
activities professional whowho– (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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Minnesota’s Call to Action
Interpretative Guidelines:
– (ii) has 2 years of experience in a social or
recreational program within the last 5
years, 1 of which was fullfull-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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Minnesota’s Call to Action
Understanding Qualified Director:
• NCCAP (ACC , ADC)
• NCTRC (CTRS)
• NBCOT (OTR, COTA)
• BC MT
• MEPAP
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Minnesota’s Call to Action
Activity Director Responsibilities:
• Development
• Implementation
• Supervision
• Evaluation
• Completion/Delegation
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Minnesota’s Call to Action
Determination of Compliance:
• Noncompliance may look like:
– Facility does not have an activity
program and does not offer activities to
the resident.
– A resident with special needs does not
receive accommodations needed to
participate in individualized activities.
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Minnesota’s Call to Action
Determination of Compliance:
• The facility does not offer
activities on Saturday and
Sundays and only occasional
activities
• Planned activities were not
conducted or designed to meet
the resident’s care plan
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Minnesota’s Call to Action
Determination of Compliance:
• The always asked questions??
– What is sufficient staffing in
activity/recreation
departments?
– What is a sufficient level of
programming?
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Activities
Investigative Protocol
October, 2005
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Investigative Protocol
Objectives
To determine if:
Ongoing program of activities designed to
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October, 2005
accommodate the individual resident’s
interests and
help enhance her/his physical, mental, and
psychosocial well-being,
according to her/his comprehensive resident
assessment.
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Investigative Protocol
Procedure
Investigation involves:
• Observations
• Interviews
• Record review
To determine whether the facility is in compliance,
use this procedure for each resident sampled
October, 2005
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Investigative Protocol
Procedure: Observations
What to look for…
Is the staff:
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Taking preferences and needs into account?
Using adaptive equipment?
Providing timely transportation?
Providing activities that are compatible with
residents interests, needs, and abilities?
October, 2005
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Investigative Protocol
Procedure: Interviews
Interviews are an important facet of the
investigation of compliance for F248.
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Start with the resident (or their
representative, if applicable).
Their opinion of their activities
participation is important for determining
if activities are individualized according to
the resident’s preferences.
October, 2005
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Investigative Protocol
Procedure: Interviews
Which staff should be interviewed?
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Activity Staff
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Certified Nursing Aides (CNAs)
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Social Services Staff
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Nurses
October, 2005
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Investigative Protocol
Procedure: Nurse interviews
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October, 2005
Nursing staff support
Coordination of schedules
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Investigative Protocol
Procedure: Interviews
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October, 2005
Similar questions may be asked
of different staff
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Investigative Protocol
Procedure: Record Review - Assessment
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October, 2005
Has the facility found out about the
resident’s past life activities choices,
preferences,
needs for adaptations?
What do the records indicate?
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Investigative Protocol
Procedure: Record Review – Care Plan
Activities component of comprehensive care plan
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October, 2005
Resident participated in development
Plan matches the resident’s interests and
goals
Specifies who provides needed services
Periodically reviewed with resident input
and made needed changes
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Activities
Determination of
Compliance
October, 2005
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Activities
Determination of Compliance
NonNon-Traditional Approach
www.cms
www.cms..internetstreaming.com
internetstreaming.com
October, 2005
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Determination of Compliance
The facility is in compliance if they:
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October, 2005
Recognized and assessed for preferences, choices,
specific conditions, causes and/or problems, needs
and behaviors
Defined and implemented activities in accordance
with resident needs and goals
Monitored and evaluated the resident’s response
Revised the approaches as appropriate
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Determination of Compliance
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October, 2005
Compliance must be determined
separately for each resident sampled
Activity interventions must be
individualized to the resident’s needs
and preferences
The facility must have provided
necessary adaptations to facilitate the
resident’s participation
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Determination of Compliance
Noncompliance might look like:
! Facility does not have an activity program or
doesn’t offer any activities
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A resident with special needs doesn’t receive
adaptations needed to participate
Planned activities were not conducted to meet the
resident’s care plan
What else might noncompliance look like?
October, 2005
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Potential Tags for Additional
Investigation
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October, 2005
Additional concerns may be
identified with F248 Investigative
Protocol
Additional tags identified on pages
23 and 24 of Transmittal 19 Excerpt
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Deficiency Categorization
Deficiencies at F248 are most
likely to have psychosocial
outcomes.
October, 2005
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October, 2005
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The survey team will compare
their findings to the various
levels of severity on the
Psychosocial Outcome Severity
Guide at Appendix P, Part V.
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October, 2005
Follow-up Communication
Joint provider, consumer and MDH
Stakeholder Workgroup will
sponsor 4 phone conference calls
See Information Bulletin 06-03
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Minnesota’s Call to Action
Putting it all Together:
• Measurements for a residentcentered activities program
• Staff Development Model
• Implications for the future of
Long-term care.
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Minnesota’s Call to Action
Putting it all Together:
• Population Analysis
• Time Studies
• Program and Program
content Studies
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Minnesota’s Call to Action
Putting it all Together:
• Population Analysis
– Abilities/characteristics
Independent/Modified Independent
Modified Impaired
Severely Impaired
– Participation status
Group Participant
NonNon-Group Participant
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Minnesota’s Call to Action
Putting it all Together:
Participation
Poor – 0%
Fair – 20%
Good – 79%
Excellent – 1%
Participation Level
Unresponsive – 0%
Passive – 26%
Active – 74%
Very Active – 0%
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Minnesota’s Call to Action
Putting it all Together:
ExampleExample-32 Bed Dementia Unit
Participation
Participation Level
Poor – 3%
Unresponsive – 0%
Fair – 16%
Passive – 56%
Good – 39%
Active – 44%
Excellent – 42% Very Active – 0%
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Minnesota’s Call to Action
Putting it all Together:
• Evaluation of Time Awake Status (MDS)
– 8 categories of evaluation:
In Room – Active or Passive
In Unit Lounge – Active or Passive
In bed – Active or Passive
Asleep
Off Unit or involved in ADL’s
– 6 time periods
– 3 different days
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Minnesota’s call to Action
Putting it all Together:
• Group Program Time Study
– Categories
• Early AM
• Late AM
• Early PM
• Mid PM
• Late PM
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Minnesota’s Call to Action
Putting in all Together:
• Program / Program content studies
– Evening & Weekend Programs
– Attenders & NonNon-attenders
– Younger residents
– Exercise program
– Pet Therapy program
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Minnesota’s Call to Action
Putting it all Together:
• Changing the focus of the
facility a Quality of Life
Initiative
• Involving the
Interdisciplinary Team – Key
responsibilities
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Minnesota’s Call to Action
Putting it all Together
• Staff Development
–What’s your top 5?
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Minnesota’s Call to Action
Putting it all Together:
• How to prepare…
– Quantitative and Qualitative
Program Evaluation
– Review activity staffing
– Audit the comprehensive
assessment
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Minnesota’s Call to Action
Putting it all Together:
• Culture Change – Implementing the guidance
– Culture Change Now
– Pioneer Network
– Project Enhance Wellness
– U of M Vital Aging Network
– National Institute of Health Science
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