F248, (Rev.) §483.15(f) Activities 

§483.15(f)(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.

Summary of Changes

The interpretive guidelines clarify areas such as assessment, care planning, interventions, and activity approaches for residents with behavioral symptoms. 

This new guidance becomes effective June 1, 2006. On that date, a final copy of the new guidance will be available at: www.cms.hhs.gov/Transmittals

INTENT: §483.15(f)(1) Activities 

The intent of this requirement is that: 

• 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 well-being.

 ASSESSMENT 

The information gathered through the assessment process should be used to develop the activities component of the comprehensive care plan. The ongoing program of activities should match the skills, abilities, needs, and preferences of each resident with the demands of the activity and the characteristics of the physical, social and cultural environments.⁵   

In order to develop individualized care planning goals and approaches, the facility should obtain sufficient, detailed information (even if the Activities RAP is not triggered) to determine what activities the resident prefers and what adaptations, if any, are needed.⁶  The facility may use, but need not duplicate, information from other sources, such as the RAI, including the RAPs, assessments by other disciplines, observation, and resident and family interviews.  Other sources of relevant information include the resident’s lifelong interests, spirituality, life roles, goals, strengths, needs and activity pursuit patterns and preferences.⁷  This assessment should be completed by or under the supervision of a qualified professional (see F249 for definition of qualified professional).

NOTE:  Some residents may be independently capable of pursuing their own activities without intervention from the facility.  This information should be noted in the assessment and identified in the plan of care.   

CARE PLANNING  

Care planning involves identification of the resident’s interests, preferences, and abilities; and any issues, concerns, problems, or needs affecting the resident’s involvement/engagement in activities.⁸   In addition to the activities component of the comprehensive care plan, information may also be found in a separate activity plan, on a CNA flow sheet, in a progress note, etc.

Activity goals related to the comprehensive care plan should be based on measurable objectives and focused on desired outcomes (e.g., engagement in an activity that matches the resident’s ability, maintaining attention to the activity for a specified period of time, expressing satisfaction with the activity verbally or non-verbally), not merely on attendance at a certain number of activities per week.  

NOTE:  For residents with no discernable response, service provision is still expected and may include one-to-one activities such as talking to the resident, reading to the resident about prior interests, or applying lotion while stroking the resident’s hands or feet. 

Activities can occur at any time, are not limited to formal activities being provided only by activities staff, and can include activities provided by other facility staff, volunteers, visitors, residents, and family members.  All relevant departments should collaborate to develop and implement an individualized activities program for each resident.   

Some medications, such as diuretics, or conditions such as pain, incontinence, etc. may affect the resident’s participation in activities.  Therefore, additional steps may be needed to facilitate the resident’s participation in activities, such as:   

If not contraindicated, timing the administration of medications, to the extent possible,

to avoid interfering with the resident’s ability to participate or to remain at a scheduled activity; or 

If not contraindicated, modifying the administration time of pain medication to allow the medication to take effect prior to an activity the resident enjoys. 

The care plan should also identify the discipline(s) that will carry out the approaches.  For example: 

      Notifying residents of preferred activities; 

Transporting residents who need assistance to and from activities (including indoor, outdoor, and outings); 

                          Providing needed functional assistance (such as toileting and eating assistance); and 

Providing needed supplies or adaptations, such as obtaining and returning audio books, setting up adaptive equipment, etc.  

INTERVENTIONS 

The concept of individualized intervention has evolved over the years.  Many activity professionals have abandoned generic interventions such as “reality orientation” and large-group activities that include residents with different levels of strengths and needs.  In their place, individualized interventions have been developed based upon the assessment of the resident’s history, preferences, strengths, and needs.  These interventions have changed from the idea of “age-appropriate” activities to promoting “person-appropriate” activities.  For example, one person may care for a doll or stroke a stuffed animal, another person may be inclined to reminisce about dolls or stuffed animals they once had, while someone else may enjoy petting a dog but will not be interested in inanimate objects.  The surveyor observing these interventions should determine if the facility selected them in response to the resident’s history and preferences.  Many activities can be adapted in various ways to accommodate the resident’s change in functioning due to physical or cognitive limitations.  

Synopsis of Regulation (F248)

This requirement stipulates that the facility’s program of activities should accommodate the interests and well-being of each resident.  In order to fulfill this requirement, it is necessary for the facility to gain awareness of each resident’s activity preferences as well as any current limitations that require adaptation in order to accommodate these preferences.   

Criteria for Compliance 

The facility is in compliance with this requirement if they:  

• 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; and
• Revised the approaches as appropriate. 

DEFINITIONS 

“Recognized accrediting body” refers to those organizations that certify, register, or license therapeutic recreation specialists, activity professionals, or occupational therapists. 

ACTIVITIES DIRECTOR RESPONSIBILITIES  

An activity director is responsible for directing the development, implementation, supervision and ongoing evaluation of the activities program.  This includes the completion and/or directing/delegating the completion of the activities component of the comprehensive assessment; and contributing to and/or directing/delegating the contribution to the comprehensive care plan goals and approaches that are individualized to match the skills, abilities, and interests/preferences of each resident.   

Directing the activity program includes scheduling of activities, both individual and groups, implementing and/or delegating the implementation of the programs, monitoring the response and/or reviewing/evaluating the response to the programs to determine if the activities meet the assessed needs of the resident, and making revisions as necessary. 

Criteria for Compliance 

The facility is in compliance with this requirement if they:  

• Have employed a qualified professional to provide direction in the development and implementation of activities in accordance with resident needs and goals, and the director: 

o       Has completed or delegated the completion of the activities component of the comprehensive assessment; 

o       Contributed or directed the contribution to the comprehensive care plan of activity goals and approaches that are individualized to match the skills, abilities, and interests/preferences of each resident;  

o       Has monitored and evaluated the resident’s response to activities and revised the approaches as appropriate; and  

o       Has developed, implemented, supervised and evaluated the activities program.

More information about Activities care plans for specific needs can be found in the book:

Activities Care Plans for Long Term Care