HospitalInspections.org
Bringing transparency to federal inspections
DECATUR HEALTH
PATIENT ACTIVITIES
Tag No.: C0385
Based on interview and facility policy review, the facility failed to ensure the activities program was directed by a qualified individual. This deficient practice had the potential to affect the activities of three of three current swing bed status patients admitted to the facility.
Findings Include:
Review of the facility policy and procedure titled, "Originator: [name] Licensed Baccalaureate Social Worker (LBSW)," titled "Subject: Swing Bed Activities," dated 02/20/18, showed: The Activities program must be directed by a qualified professional who -Is a qualified therapeutic recreation specialist or an activities professional who - *is licensed or registered, if applicable, by the State in which practicing and is eligible for certification as a therapeutic recreation specialist or as an activity professional by a recognized accrediting body on or after October 1, 1990 OR has 2 years of experience in a social or recreational program within the last 5 years, one of which was full-time in a patient activities program in a health care setting OR is a qualified occupation therapist or occupational therapy assistant OR has completed a training course approved by the State.
Interview on 02/19/19 at 12:09 PM, the LBSW brought in policies, that included swing bed activities. The LBSW stated she had been working at the facility as the Activity Director (AD) for three years and qualified for the position because she assisted in activities over the years. When asked about the job description and if she met the qualifications as listed in the policy, the LBSW/AD stated "No, I don't think so."
Interview on 02/20/19 at 9:36 AM, the Chief Operating Officer stated he was unaware of the requirements for the Activity Director.
Interview on 02/21/19 at 8:56 AM, LBSW/AD identified she had been working at the facility for 41 years and her primary duties were discharge planning, discharge assessments, and activity assessments. LBSW/AD said I try to do activities in the afternoon. When asked if she had written the swing bed activities policy, the LBSW/AD responded "I wrote the policy from the regulation - but I filled in for years. Guess I just never realized I didn't have the training."