Recreation therapy and MDS 3.0

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

The scope of RT treatment includes social, physical, affective and cognitive domains with the ultimate goal of inclusion in general activities after discharge from treatment. These activities clearly go beyond the diversional activities offered in SNFs by the activities department.


Another major issue that often surfaces when considering RT implementation in a SNF is what can best be described as “turf wars” between occupational therapy (OT) and RT. Whereas the two professions are distinctly different, there is also some overlap in their functions and impact on the resident. The most immediate question that nursing home administrators ask is “what is the difference between what the occupational therapist can ‘do’ and what the recreational therapist can ‘do’?” The answer isn’t as clear as it might seem.

Many state licensure laws governing OT address entry into practice requirements, title protection for the occupational therapist, continuing education/competence requirements, licensure fees and disciplinary processes. State licensure laws can vary widely in terms of actually defining “tasks” that are the sole province of the occupational therapist. Therefore, treatment modalities implemented may have more to do with the scope of practice as defined by the respective professions (OT and RT) as well as whether the individual therapist possesses the necessary “competence” to engage in a given practice.

In long-term care there is no room for the so-called “turf wars.” When we keep the resident as our central focus, we quickly discover that there are a multiplicity of ways in which the RT can augment the therapy program of a given SNF. For example, RT can play a vital role in the “falls prevention team” by co-treating at-risk residents with walking, exercise and balance programs.

Another example of co-treatment involves neuropsychiatric disorders, in which RT has proven interventions and practice guidelines for depression and behavioral disturbances. In addition, recreational therapy can also be beneficial with a wide variety of diagnoses including residents with cerebrovascular accidents, chronic obstructive pulmonary disease, Alzheimer’s (and other forms of dementia), Parkinson’s disease and arthritis, just to name a few. RT can also augment restorative nursing programs by developing creative programming that will engage residents, increase interest and ultimately improve the residents’ overall quality of life.


Providing quality resident care under tight fiscal restraints is challenging. Expenses related to medication costs have increased faster than Medicare’s routine care per-diem rate.6 MDS 3.0 represents an even greater need to tighten the “financial belt.” Whereas it would not seem prudent to add another position to your facility’s payroll in an era which mandates controlled costs, research has demonstrated a significant return on investment (ROI) from hiring a recreational therapist. In one cost-benefit analysis of an RT falls prevention program alone, it was estimated a facility could save $70,000 per year by hiring a CTRS to focus on at-risk residents.7 Another study of neuropsychiatric behaviors estimated a savings of $30,000-50,000 per year by providing nonpharmacologic approaches through recreational therapy.8


The recreational therapist also increases value by being able to precept RT students, who are required to complete a practicum supervised by a CTRS. Students add more opportunities to provide psychosocial interventions for residents who otherwise would prefer not to attend to group activities. Students can also be used to provide meaningful one-on-one interventions with residents in their rooms.


Perhaps the most significant impact of the recreational therapist can be appreciated during the annual survey. Nationwide, approximately 94 percent of nursing homes received deficiencies during their annual survey receiving anywhere from 2.5 to 13.3 deficiencies per survey.9 The days of “deficiency-free” surveys are all but behind us. For facilities that do enjoy deficiency-free surveys, the risk of a federal follow-up survey is great. While we should always aim for a deficiency-free survey, the more practical goal should be to minimize number of deficiencies as well as scope and severity of deficiencies. To do this, use every advantage that can be leveraged, including RT. When the program is used appropriately, the recreational therapist can impact many of the tags found at §483.15 (Quality of Life).

Several studies have documented the positive effects of recreational therapy on the quality of a resident’s life. In addition to the quality-of-life tags, the RT can also impact other tags found in §483.25 (Quality of Care). These studies, regulations and the current state of available evidence can be found in the tables downloaded at In the examples listed, recreational therapy augments the services of occupational, physical and speech therapy.


It is not surprising that CMS omitted reimbursement for RT under MDS 3.0 skilled nursing facilities. The decision was clearly fiscally based and not related to the efficacy of the therapy. Despite CMS’s decision, long-term care administrators can impact both quality of care and quality of life for their residents by using the recreational therapist to his or her fullest potential in their organization. It is the resident who will ultimately benefit from your decision.

Linda L. Buettner, PhD, LRT, CTRS, is Professor of Recreation Therapy and Gerontology at the University of North Carolina at Greensboro and Co-coordinator of the Geriatric Treatment Network for the American Therapeutic Recreation Association.

Timothy J. Legg, PhD, CNHA, GNP-BC, FACHCA, is interim MSN academic chair at the Kaplan University School of Nursing.


  1. Centers for Medicare & Medicaid Services. State Operations Manual Appendix P-Survey Protocol for Long Term Care Facilities-Part I (Revision 42), 2009. Available at:
  2. Buettner L, Fitzsimmons S. Activity calendars for older adults with dementia: What you see is not what you get. American Journal of Alzheimer’s Disease 2003; 18 (4): 215-26.
  3. Definition Statement. American Therapeutic Recreational Association, 2009. Available at:
  4. RAI Version 3.0 manual. Centers for Medicare & Medicaid Services, 2010. Available at:
  5. Centers for Medicare & Medicaid Services.State Operations Manual, Appendix PP-Guidance to Surveyors for Long Term Care Facilities, 2009. Available at:
  6. Nowels DE, Kutner JS, Kassner C, Beehler C. Hospice pharmaceutical cost trends. American Journal of Hospice and Palliative care 2004; 21; 297-302.
  7. Buettner L. Research Monograph: Preventing falls in nursing home residents with dementia, Hattiesburg, MS:ATRA Publication, 2001.
  8. Buettner L, Fitzsimmons S, Atav S. (2006). Predicting outcomes: Therapeutic recreational for behaviors in dementia. Therapeutic Recreational Journal 2006; 40:33.
  9. Pear R.Violations reported at 94% of nursing homes. The New York Times. September 30, 2008. Available at

Long-Term Living 2011 August;60(8):38-41

Topics: Articles , MDS/RAI