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Recreation therapy and MDS 3.0

August 16, 2011
by Linda Buettner, PhD, CTRS/LTR, FGSA and Timothy J. Legg, PhD, CNHA, GNP-BC, RAC-CT, FACHCA
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Reclaiming a lost opportunity
Linda buettner phd, ctrs/ltr, fgsa
Linda Buettner PhD, CTRS/LTR, FGSA

In the months leading up to the implementation of the Minimum Data Set (MDS) 3.0, and since the time of its implementation, the vast majority of trainings and information rolled out on MDS 3.0 and the Resource Utilization Groups version 4 (RUGs-IV) from the Centers for Medicare & Medicaid Services (CMS) have focused primarily on the MDS as a tool for reimbursement. What has been largely absent from the equation is the role of the MDS in terms of the survey process, which assesses two parameters essential to the well-being of the nursing home resident-quality of care and quality of life. In their final decisions as to which MDS 3.0 items would ultimately impact the RUGs score, CMS omitted recreational therapy (RT). This omission may result in facility owners/operators decreasing the use of RT in the LTC setting. This decision may be detrimental since RT has the potential to mitigate (if not avoid) deficiencies in several F-tags. In this article, we will reintroduce the role of the recreation therapist to the skilled nursing facility and describe how RT can improve both residents quality of care and quality of life.


The Omnibus Budget Reconciliation Act of 1987 (OBRA ′87) changed the landscape of long-term care. Among other things, it mandated the use of a Resident Assessment Instrument (RAI) to achieve a standardized comprehensive assessment of residents living in skilled nursing facilities. Implemented in 1991, revised in 1997, and again in October 2010, the MDS 3.0 has increased the resident's “voice” in the assessment process while improving the clinical relevance, accuracy, reliability and validity of the assessment. The initial purpose of the MDS was to ensure that residents received a comprehensive assessment, one that could be translated into an individualized plan of care to meet identified needs. This intent is embodied in §483.20 (F-272), which states that the facility “must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity.”1 Unfortunately, many facilities primarily embraced this instrument as a reimbursement mechanism, considering clinical applications to be secondary.

When the MDS 2.0 was introduced in 1997, RT did not impact the calculation of the RUGs-III groups, meaning the provision of RT did not increase the case-mix index (CMI) that established the fiscal reimbursement for resident care. Although CMS had the opportunity to include it as one of the services that would impact the RUGs-IV grouper, this did not happen. A major consequence of this decision can be to either not incorporate or discontinue the use of the recreation therapy in the LTC setting as it is incapable of generating revenue.

This decision can be detrimental to residents in terms of the benefits that residents could receive from recreational therapy services, and fiscally shortsighted in terms of the financial impact that recreation therapists could have on the facility.


When presented with the idea of RT, one of the most popular initial responses heard from administration is: “but we already have an activity director.” Much confusion between the two roles is perpetuated by the requirements at F-249, which describes who can serve as an activity director. The options include a certified activity director (ADC), occupational therapist (OT), certified occupational therapy assistant (COTA) or a certified therapeutic recreation specialist (CTRS). Although the CTRS can serve as an activity director, the discipline of recreational therapy goes beyond the activities offered in SNFs.

Activities are mandated in federal regulations (at §483.15(f), F-248), but not all residents are able to participate in general offerings because of mental, affective or physical barriers.2 Those residents should be targeted for time-limited RT to “restore, remediate and rehabilitate a level of functioning and independence in life activities, to promote health and wellness as well as reduce or eliminate the activity limitations and restrictions to participation in life situations caused by an illness or disabling condition.”3 The RAI User's Manual for MDS 3.0 acknowledges that recreational therapists “treat and help maintain the physical, mental and emotional well-being of their clients by seeking to reduce depression, stress and anxiety; recover basic motor functioning and reasoning abilities; build confidence; and socialize effectively.”4 The RAI manual even goes so far as to warn: “Recreational therapists should not be confused with recreational workers, who organize recreational activities primarily for enjoyment.”4 Moreover, CMS defines RT as “therapy ordered by a physician that provides therapeutic stimulation beyond the general activity program in a facility. The physician's order must include a statement of frequency, duration and scope of the treatment. Such therapy must be provided by a state licensed or nationally certified Therapeutic Recreational Specialist or Therapeutic Recreational Assistant. The Therapeutic Recreational Assistant must work under the direction of a Therapeutic Recreational Specialist.”5