CMS SOM App. PP, Tag F679

§483.24(c)(1) The facility must provide, based on the comprehensive assessment and

care plan and the preferences of each resident, an ongoing program to support

residents in their choice of activities, both facility-sponsored group and individual

activities and independent activities, designed to meet the interests of and support

the physical, mental, and psychosocial well-being of each resident, encouraging both

independence and interaction in the community.

INTENT §483.24(c)

To ensure that facilities implement an ongoing resident centered activities program that

incorporates the resident’s interests, hobbies and cultural preferences which is integral to

maintaining and/or improving a resident’s physical, mental, and psychosocial well-being

and independence. To create opportunities for each resident to have a meaningful life by

supporting his/her domains of wellness (security, autonomy, growth, connectedness,

identity, joy and meaning).

DEFINITIONS §483.24(c)

“Activities” refer to any endeavor, other than routine ADLs, in which a resident

participates that is intended to enhance her/his sense of well-being and to promote or

enhance physical, cognitive, and emotional health. These include, but are not limited to,

activities that promote self-esteem, pleasure, comfort, education, creativity, success, and

independence.

NOTE: ADL-related activities, such as manicures/pedicures, hair styling, and

makeovers, may be considered part of the activities program.

GUIDANCE §483.24(c)

Opportunities for each resident to have a meaningful life may be created by supporting

his/her domains of well-being (e.g., security, autonomy, growth, connectedness, identity,

joy and meaning) as identified by the Eden Alternative philosophy of care. More

information may be found at: https://www.edenalt.org/

.

Research findings and the observations of positive resident outcomes confirm that

activities are an integral component of residents’ lives. Residents have indicated that

daily life and involvement should be meaningful. Activities are meaningful when they

reflect a person’s interests and lifestyle, are enjoyable to the person, help the person to

feel useful, and provide a sense of belonging. Maintaining contact and interaction with

the community is an important aspect of a person’s well-being and facilitates feelings of

connectedness and self- esteem. Involvement in community includes interactions such as

assisting the resident to maintain his/her ability to independently shop, attend the

community theater, local concerts, library, and participate in community groups.

Activity Approaches for Residents with Dementia

All residents have a need for engagement in meaningful activities. For residents with

dementia, the lack of engaging activities can cause boredom, loneliness and frustration,

resulting in distress and agitation. Activities must be individualized and customized

based on the resident’s previous lifestyle (occupation, family, hobbies), preferences and

comforts. https://www.caringkindnyc.org/_pdf/CaringKind-PalliativeCareGuidelines.pdf

NOTE: References to non-CMS/HHS sources or sites on the Internet included above or

later in this document are provided as a service and do not constitute or imply

endorsement of these organizations or their programs by CMS or the U.S. Department of

Health and Human Services. CMS is not responsible for the content of pages found at

these sites. URL addresses were current at the date of this publication.

The facility may have identified a resident’s pattern of behavioral symptoms and may

offer activity interventions, whenever possible, prior to the behavior occurring. Once a

behavior escalates, activities may be less effective or may even cause further stress to the

resident (some behaviors may be appropriate reactions to feelings of discomfort, pain, or

embarrassment, such as aggressive behaviors exhibited by some residents with dementia

during bathing

16).

Examples of activities-related interventions that a facility may provide to try to minimize

distressed behavior may include, but are not limited, to the following:

For the resident who exhibits unusual amounts of energy or walking without purpose:

• Providing a space and environmental cues that encourages physical exercise,

decreases exit-seeking behavior and reduces extraneous stimulation (such as

seating areas spaced along a walking path or garden; a setting in which the

resident may manipulate objects; or a room with a calming atmosphere, for

example, using music, light, and rocking chairs);

• Providing aroma(s)/aromatherapy that is/are pleasing and calming to the resident;

and

• Validating the resident’s feelings and words; engaging the resident in

conversation about who or what they are seeking; and using one-to-one activities,

such as reading to the resident or looking at familiar pictures and photo albums.

For the resident who engages in behaviors not conducive with a therapeutic home like

environment:

• Providing a calm, non-rushed environment, with structured, familiar activities

such as folding, sorting, and matching; using one-to-one activities or small group

activities that comfort the resident, such as their preferred music, walking quietly

with the staff, a family member, or a friend; eating a favorite snack; looking at

familiar pictures;

• Engaging in exercise and movement activities; and

• Exchanging self-stimulatory activity for a more socially-appropriate activity that

uses the hands, if in a public space.

For the resident who exhibits behavior that require a less stimulating environment to

discontinue behaviors not welcomed by others sharing their social space:

• Offering activities in which the resident can succeed, that are broken into simple

steps, that involve small groups or are one-to-one activities such as using the

computer, that are short and repetitive, and that are stopped if the resident

becomes overwhelmed (reducing excessive noise such as from the television);

• Involving in familiar occupation-related activities. (A resident, if they desire, can

do paid or volunteer work and the type of work would be included in the

resident’s plan of care, such as working outside the facility, sorting supplies,

delivering resident mail, passing juice and snacks (refer to §483.10(f)(9) Right to

Perform Facility Services or Refuse

• Involving in physical activities such as walking, exercise or dancing, games or

projects requiring strategy, planning, and concentration, such as model building,

and creative programs such as music, art, dance or physically resistive activities,

such as kneading clay, hammering, scrubbing, sanding, using a punching bag,

using stretch bands, or lifting weights; and

• Slow exercises (e.g., slow tapping, clapping or drumming); rocking or swinging

motions (including a rocking chair).

For the resident who goes through others’ belongings:

• Using normalizing life activities such as stacking canned food onto shelves,

folding laundry; offering sorting activities (e.g., sorting socks, ties or buttons);

involving in organizing tasks (e.g., putting activity supplies away); providing

rummage areas in plain sight, such as a dresser; and

• Using non-entry cues, such as “Do not disturb” signs or removable sashes, at the

doors of other residents’ rooms; providing locks to secure other resident’s

belongings (if requested).

For the resident who has withdrawn from previous activity interests/customary routines

and isolates self in room/bed most of the day:

• Providing activities just before or after meal time and where the meal is being

served (out of the room);

• Providing in-room volunteer visits, music or videos of choice;

• Encouraging volunteer-type work that begins in the room and needs to be

completed outside of the room, or a small group activity in the resident’s room, if

the resident agrees; working on failure-free activities, such as simple structured

crafts or other activity with a friend; having the resident assist another person;

• Inviting to special events with a trusted peer or family/friend;

• Engaging in activities that give the resident a sense of value (e.g.,

intergenerational activities that emphasize the resident's oral history knowledge);

• Inviting resident to participate on facility committees;

• Inviting the resident outdoors; and

• Involving in gross motor exercises (e.g., aerobics, light weight training) to

increase energy and uplift mood.

For the resident who excessively seeks attention from staff and/or peers: Including in

social programs, small group activities, service projects, with opportunities for

leadership.

For the resident who lacks awareness of personal safety, such as putting foreign objects

in her/his mouth or who is self-destructive and tries to harm self by cutting or hitting self,

head banging, or causing other injuries to self:

• Observing closely during activities, taking precautions with materials (e.g.,

avoiding sharp objects and small items that can be put into the mouth);

• Involving in smaller groups or one-to-one activities that use the hands (e.g.,

folding towels, putting together PVC tubing);

• Focusing attention on activities that are emotionally soothing, such as listening to

music or talking about personal strengths and skills, followed by participation in

related activities; and

• Focusing attention on physical activities, such as exercise.

For the resident who has delusional and hallucinatory behavior that is stressful to

her/him:

• Focusing the resident on activities that decrease stress and increase awareness of

actual surroundings, such as familiar activities and physical activities; offering

verbal reassurance, especially in terms of keeping the resident safe; and

acknowledging that the resident’s experience is real to her/him.

The outcome for the resident, the decrease or elimination of the behavior, either validates

the activity intervention or suggests the need for a new approach.

The facility may use, but need not duplicate, information from other sources, such as the

RAI/MDS assessment, including the CAAs, 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. This assessment should be completed by or

under the supervision of a 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.

Surveyors need to be aware that some facilities may take a non-traditional approach to

activities. In nursing homes where culture change philosophy has been adopted, all staff

may be trained as nurse aides or “universal workers,” (workers with primary role but

multiple duties outside of primary role) and may be responsible to provide activities,

which may resemble those of a private home. The provision of activities should not be

confined to a department, but rather may involve all staff interacting with residents.

Residents, staff, and families should interact in ways that reflect daily life, instead of in

formal activities programs. Residents may be more involved in the ongoing activities in

their living area, such as care-planned approaches including chores, preparing foods,

meeting with other residents to choose spontaneous activities, and leading an activity.

Some nursing homes may not have a traditional activities calendar, but instead focus on

community life to include activities. Instead of an “activities director,” some homes have

a Community Life Coordinator, a Community Developer, or other title for the individual

directing the activities program

For more information on activities in homes changing to a resident-directed culture, the

following websites are available as resources: www.pioneernetwork.net

;

www.qualitypartnersri.org; and www.edenalt.org.

INVESTIGATIVE SUMMARY

Use the Activities Critical Element pathway and the guidance above to investigate

concerns related to activities which are based on the resident’s comprehensive assessment

and care plan, and meet the resident’s interests and preferences, and support his or her

physical, mental, and psychosocial well-being.