This regulation requires nursing facilities to provide an ongoing, resident-centered activities program based on each resident's comprehensive assessment, care plan, and personal preferences, designed to support physical, mental, and psychosocial well-being. Facilities must offer both group and individual activities, as well as support for independent activities, including community engagement. Special guidance is provided for residents with dementia, addressing individualized activity interventions to minimize distressed behaviors. Surveyors are directed to use the Activities Critical Element pathway when investigating compliance concerns.
View official sourceF679 (Rev. 211; Issued: 02-03-23; Effective: 10-21-22; Implementation: 10-24-22) §483.24(c) Activities §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.