Re-Creative Resources
By Kimberly Grandal, BA, CTRS, ACC, Executive Director
Kimberly Grandal,

Kimberly Grandal, Founder
and Executive Director of Re-
Creative Resources, Inc., is a
strong advocate for the field
of Therapeutic Recreation
and Activities, with over fifteen
years of experience working
with the elderly in numerous
management and consultant
positions.  She is an Activity
Consultant Certified and a
Certified Therapeutic
Recreation Specialist. Kim is
a member of the New Jersey
Activity Professionals
Association and the New
Jersey/Eastern Pennsylvania
Therapeutic Recreation

In 1990, Kim graduated from
William Paterson University
with a BA in Sociology and
later studied gerontology
courses at Union County
College and Therapeutic
Recreation courses at Kean
University. Throughout her
career, Kim has been the
Director of Therapeutic
Recreation for several long-
term care facilities, including
one of NJ’s largest.

In 2006, Kim founded Re-
Creative Resources Inc. She
is a speaker for various state
and local activity associations
such as NJAPA, MOCAP, and
NJACA, as well as the Society
of Licensed Nursing Home
Administrators of NJ. She
also offers lectures for Re-
Creative Resources Inc.,
local colleges, and
community groups, and
provides consultation and
support to numerous
facilities in the state.

Kim is the editor and writer
for the “The Rec-Room", a
monthly newsletter published
by her company. In addition,
she writes monthly articles
for the Activity Directors Office
newsletter, and has
contributed articles to
Creative Forecasting
Magazine, and The
Continuing Care Insite

Kim is a recipient of the
Kessler Institute of
Rehabilitation 1997 Triumph
of the Human Spirit Award.  
Her passion is to promote
the field of Therapeutic
Recreation and Activities and
to unite Recreation
Therapists and Activity
Professionals. Kim currently
serves on the NJAPA board
as the Chairperson for the
Legislation Committee.
Providing Internet Resources
for Activity Professionals
in Long Term Care Settings

Copyright 2004-Present
The Activity Director's Office
All Rights Reserved

Resources Inc.

Re-Creative Resources, Inc.
is committed to enhancing
the lives of long-term care
residents through the use of
Therapeutic Recreation. We
provide a variety of services
such as Therapeutic
Recreation seminars,
in-services, resources, form
development, program
analysis and development,
consultation, and support for
activity professionals and
recreational therapists. A
selection of downloadable
training materials and forms
are available for your
convenience as well as a free
job posting site.
You need Java to see this applet.
The Ensuring Medicare Access to
Recreational Therapy Act of 2007:     
An Overview for Activity Professionals
K. Grandal, 2/08

H.R. 4248
A Recreational Therapy Bill  entitled "Ensuring Medicare   Access to Recreational
Therapy  Act of 2007”  This bill was initiated by ATRA (American Therapeutic Recreation
Association)  March 2007- ATRA posted the Medicare Project Position Statement

Why ATRA Initiated H.R. 4248
Currently, Medicare uses the Prospective Payment System (PPS) which does include the cost of
Recreational Therapy. However, the regulatory language is unclear.

The introduction of H.R. 4248 is a result of CMS’ reluctance to provide clarifying language in the

Congress has repeatedly requested CMS to clarify its RT policy to providers.
CMS has responded to congressional inquiries stating that RT is covered and included in existing
payment systems.

CMS has not communicated this same message to fiscal intermediaries, facility administrators,
treating physicians in these settings, etc.

Summary of H.R. 4248
Directs the Secretary of Health and Human Services, acting through the Administrator of the
Centers for Medicare and Medicaid Services, to issue a notice of proposed rulemaking, or a
transmittal amending the Medicare Benefits Policy Manual, or both, specifying that:
(1) recreational therapy is a covered service under title XVIII (Medicare) of the Social Security Act
in inpatient rehabilitation facilities, inpatient psychiatric facilities, and skilled nursing facilities

(2) recreational therapy is a skilled rehabilitative modality included in the bundle of services as
part of the payment rates for such facilities under Medicare's respective prospective payment
systems (PPS) for these inpatient settings.

Any recreational therapy that is provided to a Medicare beneficiary in such a facility prescribed
by a physician as part of the facility's plan of care for the patient must be provided by a qualified
recreational therapist.

Simply stated…..
To mandate CMS to clarify regulatory language regarding RT service coverage provided in the
Inpatient Rehab Facilities, Inpatient Psychiatric Facilities and Skilled Nursing Facilities.
It will direct CMS to issue notification in the Medicare Benefits Policy Manual (or by regulation)
that RT is a covered Medicare service under title XVIII of the Social Security Act in IRFs, IPFs,
and SNFs ,when such services are prescribed by their doctors, warranted by their health
condition and provided by a qualified recreational therapist.

Financial Implications
This is a budget neutral bill that does not add new services or additional  costs to the Medicare

What is happening with H.R. 4248
November 15 2007, H.R. 4248 was introduced in the US House of Representatives by
Representative Ellen Tauscher (D-CA) and Representative Phil English (R-PA).
They are seeking co-sponsors for the bi-partisan bill.

On 11/15/07 the bill was referred to the following committees:

  • House Ways and Means
  • House Energy and Commerce
  • Subcommittee on Health

H.R. 4248 Co-Sponsors as of 2/16/08
  • Rep English, Phil [PA-3] - 11/15/2007
  • Rep Gordon, Bart[TN-6] - 12/5/2007
  • Rep Etheridge, Bob[NC-2] - 12/5/2007
  • Rep Ros-Lehtinen, Ileana [FL-18] - 12/11/2007
  • Rep Rahall, Nick J., II [WV-3] - 12/11/2007
  • Rep Boucher, Rick [VA-9] - 12/12/2007
  • Rep Wamp, Zach [TN-3] - 12/12/2007
  • Rep Rehberg, Dennis R.[MT] - 12/12/2007
  • Rep Carnahan, Russ [MO-3] - 12/17/2007  
  • Rep Peterson, John E. [PA-5] - 12/17/2007
  • Rep Cohen, Steve [TN-9] - 12/17/2007
  • Rep Butterfield, G. K. [NC-1] - 1/16/2008
  • Rep Dent, Charles W. [PA-15] - 1/16/2008
  • Rep Shea-Porter, Carol [NH-1] - 1/16/2008
  • Rep Welch, Peter [VT] - 1/23/2008
  • Rep Farr, Sam [CA-17] - 2/12/2008
  • Rep Jones, Walter B., Jr. [NC-3] - 2/12/2008
  • Rep McIntyre, Mike [NC-7] - 2/12/2008
  • Rep Murphy, Patrick J. [PA-8] - 2/12/2008
  • Rep Hool, Darlene [OR-5] - 2/12/2008

Should Activity Professionals in SNF’s Be Concerned?
If the bill is passed as currently written, administrators and other health care leaders may
misinterpret that:

Only a CTRS is qualified to lead an Activity Department in a SNF
CTRS’s will generate more money for the facility

As reported by NAAP, there have been some Activity Professionals and Directors that have lost
their jobs or have been demoted because of this misconception.

National Activity Professionals Association (NAAP)
December, 2007- NAAP originated draft position statement.

January, 2008 – NAAP finalized position statement which will be posted on their website (

NAAP is providing guidance to individuals who are interested in the bill.

National Certification Council of Activity Professionals (NCCAP)
January, 2008 - NCCAP wrote position statement and sent it to congress. NCCAP statement
found on their website ( on the announcement page.

NCCAP met with Congressman Phil English on 2/20 to address the bill and discuss NCCAP, the
national standard and MEPAP.

NCCAP plans on meeting with additional congressmen as well.

What Should Activity Professionals Do?
Educate Administrators that the bill does not refer to federally mandated activity programming.
Contact NAAP or NCCAP for guidance.

Monitor the progress of the bill at  OR http:
// (type in bill # H.R. 4248)

Visit click on “Write my Representative”. This will give you contact information for
your LOCAL representative. Call or write asking your representative NOT to Co-Sponsor H.R.

What should Activity Professionals say to their local representatives?

Key Point # 1
While not directly opposed to the intent of H.R. Bill 4248, concern is with the exclusiveness of the
terminology r/t who is qualified to lead the activity programs in SNF’s facilities.

If the bill is passed as stated, many administrators in the SNF's facilities could mistakenly believe
that they must employ a recreation therapist to lead their programs which is not the case.

Key Point # 2
NCCAP is recognized by CMS in the federal regulations under F249 as being a nationally
credentialing body for activity professionals which enable a person to be considered qualified to
lead activity programming in SNF.

Key Point # 3
Recreation Therapy and Activity programming are different services:
Recreation Therapy is provided by a qualified Recreation Therapist as warranted  by the patient’
s condition and must be prescribed by a physician.

Activity programs offered in geriatric facilities are federally mandated under F248 and are
designed to promote quality of life for ALL residents, regardless of payment source and
functional abilities.

In Conclusion
Although the intent of  H.R. 4248 is to ensure that eligible Medicare patients receive prescribed
Recreation Therapy, the current wording of the bill is “perceived exclusive in nature and could
mistakenly be an assumed mandate that facilities discharge their qualified NCCAP certified
activity professionals, only to replace them with a recreation therapist that probably has not been
physician ordered.”   (NCCAP)