Annals of Long Term Care

Introduction

The importance of redesigning nursing homes to better emulate living in one’s own home has driven regulation reform for decades. The early focus of addressing residents’ rights in the Nursing Home Reform Act1 has slowly expanded to a broader vision of creating “a culture of aging that is life affirming, satisfying, humane and meaningful.”2 Commonly called “culture change,” the movement to improve quality of life among older adults in nursing facilities and other long-term care (LTC) settings has gained considerable momentum. The primary advocacy group, the Pioneer Network, emphasizes values such as knowing the person, putting the person before the task, emphasizing self-determination, promoting growth and development, and using the environment to its best potential.2

Many of these values are exemplified in the revisions of activities regulations set forth by the Centers for Medicare & Medicaid Services (CMS) in 2006. According to 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.”3 This seemingly simple requirement is strengthened and expanded by definitions that characterize activities as enhancing well-being and promoting physical, cognitive, and emotional health, such as self-esteem, pleasure, comfort, creativity, success, and independence. An additional emphasis is placed on “person-appropriate” activities that are relevant to the specific needs, interests, culture, and background of individual residents, including those with dementia. “One-to-one programming” requires that caregivers provide assistance for those who cannot plan their own activity pursuits, or need special assistance, such as those with dementia. Finally, the program of activities is defined as being a combination of large- and small-group, one-to-one, and self-directed activities that occur throughout the day, every day of the week.

The investigative protocol that accompanies the rule reinforces the need for activities to be an ongoing program that is implemented throughout the day, one that is composed of activities that are compatible with the resident’s known interests, needs, abilities, and preferences, and that is implemented in an environment that promotes success.3 To determine compliance with the rule, residents, activity staff, nurses, nursing assistants, and social workers are all interviewed to determine whether the individual resident’s preferences and choices are assessed, activities are implemented in accordance with needs and goals, resident-specific outcomes are monitored and evaluated, and approaches are revised as appropriate.3

The proverbial “bottom line” in the activity revision is that the large-group programs that dominate activity calendars on a Monday-through-Friday basis are insufficient. The rule simultaneously calls for activities that are person-directed and for collaboration among team members to assure that meaningful activities are continuously available to residents. Language specific to persons with dementia emphasizes the important role that staff may need to play in identifying enjoyable activities that are consistent with the person’s level of current functioning, as well as implementing, monitoring, evaluating, and revising plans of care to ensure that needs and preferences are best met.

Training to Promote Activity Involvement

For many “pioneers” of culture change, the rule is an exciting opportunity. For others, the requirement is greeted with the same unenthusiastic response that has echoed throughout Nursing Home Reform: “More rules without any additional funding to make needed changes.” No matter which viewpoint one takes, the rule is in effect and will likely be a focus of compliance in future reviews.