RECREATION AUDIT TOOL



INTERNAL QUALITY ASSURANCE

THERAPEUTIC RECREATION DEPARTMENT AUDIT

1. Must be completed quarterly

2. All items must be answered

3. Make copies of chart review page and perform 5 chart reviews per unit

4. An action plan is required for areas that have a score of less than 90% compliance

THERAPEUTIC RECREATION DEPARTMENT AUDIT TOOL

Facility: __________________________ Date: _______________________

Auditor:__________________________

|Criteria |Yes |No |COMMENT |

|Therapeutic Recreation Calendar | | | |

|1. Current Recreation calendar is posted & accessible | | | |

|to all residents, staff, & visitors | | | |

|2. Name, location, & time of activity is on the | | | |

|monthly calendar | | | |

|3. The Recreation calendar can be easily read by | | | |

|residents | | | |

|4. A copy of the calendar is placed in each residents | | | |

|room | | | |

|5. All Recreation calendars are retained for one year | | | |

|in the Recreation Department files | | | |

|Total – Therapeutic Recreation Calendar | | |#Yes____/5 = ____% |

|Programming | | | |

|1. Recreation programs are offered 7 days of the week | | | |

|2. At least 2 evening Recreation programs are offered | | | |

|per week | | | |

|3. Monthly programming reflects an inclusion of each | | | |

|of the following types of activities: | | | |

|a. Social | | | |

| b. Physical | | | |

| c. Cognitive | | | |

| d. Emotional | | | |

| e. Spiritual | | | |

| f. Creative | | | |

|4. Monthly programming includes a balance of Passive | | | |

|and Active activities | | | |

|5. Monthly programming includes Gender Specific | | | |

|activities | | | |

|6. Monthly programming includes age appropriate | | | |

|recreation opportunities for younger residents | | | |

|7. Group Program Design Tool is available and | | | |

|completed bi-annually | | | |

|8. Group Program Design Tool is directly linked to | | | |

|monthly programming which includes an equitable | | | |

|distribution of each of the following levels of | | | |

|functioning: | | | |

|a. Level I— Full Assist (high risk social isolation| | | |

|& sensory deprivation) | | | |

|Level II—Moderate Assist | | | |

|(requires social facilitation, cueing, and | | | |

|redirection) | | | |

|Level III—Minimal Assist | | | |

|(makes independent choices, may need some reminders) | | | |

|9. Programs are created on the basis of the | | | |

|resident-based interest survey which has been | | | |

|completed within the past year. | | | |

|10. At least two Recreation programs were observed | | | |

|and began on time, were posted, and facilitation was | | | |

|appropriate. | | | |

|11. Empowerment programs/ initiatives (resident | | | |

|planning committees, resident volunteers, fundraising | | | |

|committees) | | | |

|12. Residents are given the opportunity to vote, and | | | |

|there is a documented system in place. | | | |

|13. Transportation of residents to & from activities | | | |

|programs is provided in a safe, organized, and timely | | | |

|manner | | | |

|Total - Programming | | |#Yes____/20 = ____% |

|Resident Council | | | |

|1. Resident Council is established & active (meets at | | | |

|least monthly) | | | |

|2. The meeting is held with privacy | | | |

|3. Resident Council Minutes: | | | |

|a. reveal concern, timely follow-up, & resolutions are| | | |

|documented within QA minutes & signed by Administrator| | | |

|b. are signed by facilitator and approved by Resident | | | |

|Council President | | | |

|c. are easily accessible to residents (& staff or | | | |

|visitors with Council approval) | | | |

|Total - Resident Council | | |#Yes____/5 = _____% |

|Therapeutic Recreation Equipment, Supplies & Storage | | | |

|Space | | | |

|1. When appropriate, adaptive equipment is used for | | | |

|residents with sensory impairments (i.e. language | | | |

|board, picture board, writing implements, large print,| | | |

|one to one communicators) | | | |

|2. Sufficient space is provided in recreation area to | | | |

|accommodate scheduled activities without restricting | | | |

|movement &/or active participation of the residents | | | |

|3. Furnishings are in good repair, clean, & at proper | | | |

|height for activities | | | |

|4. Activity area is: | | | |

|a. clean & maintained | | | |

|b. is free from any electrical and other safety | | | |

|hazards | | | |

|c. has adequate lighting | | | |

|d. temperature regulated to resident’s comfort level | | | |

|e. has adequate ventilation | | | |

|5. Restroom is accessible to residents near the | | | |

|activity area | | | |

|6. There is adequate storage space for equipment with | | | |

|items 6 inches off the floor and 18 inches from the | | | |

|sprinkler heads | | | |

|7. There is evidence of continuous infection control | | | |

|precautions being observed for supplies (cleaning | | | |

|schedule, protocol, etc.) | | | |

|8. MSDS sheets are available in the Recreation office| | | |

|and in the facility MSDS book for all | | | |

|Recreation-specific potentially hazardous materials | | | |

|Total - Equip, Supp, Storage | | |#Yes____/12 = ____% |

|Management | | | |

|1. Involvement in CQI is evident | | | |

|2. Evidence of continued department specific staff | | | |

|development | | | |

|3. Recreation department staff meetings are held | | | |

|monthly and minutes are kept in the Recreation office | | | |

|4. Currently signed (within past yr.) Recreation | | | |

|policy & procedure manual is located in the recreation| | | |

|department. | | | |

|5. Physician’s order for activities is present | | | |

|6. Volunteer protocol in place | | | |

|7. Volunteer orientation in place | | | |

|8. Volunteer records are complete and kept in | | | |

|Recreation office | | | |

|Total - Management | | |#Yes_____/8 = _____% |

|Participation Record | | | |

|1. Recreation code list found in Participation Record | | | |

|2. Participation records are complete and reflect | | | |

|specific elder interests | | | |

|3. Directly linked to care plan goals and approaches | | | |

|4. Residents on Individual Program Plan are | | | |

|identified, and for each Individual Intervention | | | |

|provided, a corresponding note is on reverse side of | | | |

|Participation Record | | | |

|5. Reflects resident’s refusal of programs, | | | |

|independent recreation (TV, crosswords, cards, etc.), | | | |

|and/or family visits as appropriate | | | |

|6. Reflects participation in individual, independent, | | | |

|or structured Recreation programs at least 3 times per| | | |

|week. | | | |

|7. Past three months of Part. Records are readily | | | |

|available (previous three years are kept in Recreation| | | |

|office) | | | |

|Total - Participation Record | | |#Yes____/7 = ____% |

Audit Analysis

Documentation Review:

Total # Yes responses from all reviews = ______ = _____%

Total # Charts Reviewed multiplied by 8

Area Specific Results:

____% Therapeutic Recreation Calendar

____ % Programming

____ % Resident Council

____ % Recreation Equip. , Supplies

& Storage

____ % Management

____ % Participation Records

____ % Documentation Review

Total:

Total # Yes_(include total # Yes from chart audits) = _____ = _____%

(Total # Charts Reviewed multiplied by 8) + 57

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