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New activities guidelines for longterm care
place emphasis on personalized activities;
corrective benefits

(Reprinted from ElderCare Activities Guide, May/June 06, and Geriatric Nursing, May/June 06)

Strict enforcement could mean big changes for some activities programs

The Centers for Medicare & Medicaid Services (CMS) has issued new guidance for surveyors of
longterm care facilities relative to their activities programming.

There’s potentially a large amount of major new responsibilities for AD’s detailed in the new
guidelines, and they should be read in detail by staffers in every nursing home.

Depending upon how strictly the CMS enforces them, they could require major changes in many
activities programs out there.

There are three areas of very strong emphasis in the new guidelines:
• Activities will be required to be person-centered, and specifically developed for each and every
elder, according to each person’s own interests and health conditions. Large group activities, in
fact, are discouraged under this new “person-centered” emphasis.
•In addition, activities are also required to be developed as “interventions” for various health-
oriented problems, including improvement of cognitive function, improvement of various
behavioral problems such as aggressiveness, wandering, sleep deprivation and so on.
•Activity directors are also directed by the CMS to ensure that nursing home staffers have
supplied their elders with adequate equipment aids such as proper eyeglasses, hearing aids,
good lighting, required equipment for any disabilities, and so on.

Large group activities are discouraged

Now… it must be personal
Throughout the document, repeated strong emphasis is given to developing personalized
activities that are attuned toward each resident’s own likes and dislikes, hobbies, preferences
and previous life history.

Even for those residents “with no discernable response” the CMS requires such things as “one-
to-one activities such as talking to the resident, reading to the resident about prior interests, or
applying lotion while stroking the resident’s hands or feet.”

Specifically, the new guidelines advise surveyors, when they visit a facility,
“to determine if the
facility has provided an ongoing program of activities designed to accommodate the
individual resident’s interests and help enhance her/his physical, mental, and psychosocial
well-being, according to her/his comprehensive resident assessment.”  

The CMS advises the surveyors to be on the lookout to make sure that “person-appropriate”
activities dominate the activities program. And the CMS provides this definition:
“Person appropriate” refers to the idea that each resident has a personal identity and history
that includes much more than just their medical illnesses or functional impairments, and that
activities should be relevant—as much as possible—to the specific needs, interests, culture,
background, etc. of the individual for whom they are developed.”

Institute of Medicine study

The CMS further instructs surveyors to keep in mind a “landmark 1986 study conducted by the
Institute of Medicine” where it was determined that residents wanted an activities “choice” which
“Those that produce or teach something; activities using skills from residents’ former work;
religious activities; and activities that contribute to the nursing home.
“Residents in the study wanted activities to be “not childish,” to use their minds, that include
something for men, that relate to past work, that get them out of the facility, that allow for
socializing with people from outside the facility; and include active activities (such as
exercise class.)”

Activities “interventions” are required to help with various
healthcare/medically-related problems

Healthcare “interventions”

Relative to the area of activities to help various healthcare and medically-related situations, the
guidelines state that special activities, for each resident …which the CMS calls  “activities
interventions”… should be developed according to each elder’s specific needs.

These include activities that are effective in helping those residents in various stages of
cognitive impairment, plus those with behavioral problems… such as aggression, constant
walking, bathing problems, disruptive problems, uncontrolled crying or anger, and hallucinations.

A sign of the times? AD’s are sometimes called “activity therapists” in the CMS webcast of
instructions to surveyors

An AD responsibility: Checking for proper equipment

Also, the CMS now advises AD’s that they have a responsibility to check to make sure that other
nursing home staffers have provided elders with proper “adaptations.”
The list of things the AD is to check for is extensive, and could… if strictly enforced… add a
significant, and important, layer of responsibilities for AD’s.

On that topic, the new guidelines state: “When evaluating the provision of activities, it is important
for the surveyor to identify whether the resident has conditions and/or issues for which staff
should have provided adaptations.”

And the list includes: better lighting, proper eyeware according to the visual needs of each
resident, large print items, audio books, many items involving hearing impairments, closed
captioning TV, special earphones, proper adaptive equipment for those with disabilities.  And

Helping with pain

The new guidelines also specify that AD’s should provide corrective procedures and activities for
those residents who are in pain, including spiritual support, relaxation programs, music,
massage, aromatherapy, pet therapy, and touch therapy.

Interventions for skin diseases; eating problems
In addition to pain, and other healthcare-related items in the new guidelines, in an instructional
webcast CMS advised surveyors to be on the lookout for certain other medically-related activities
interventions, such as those to help correct skin diseases, weight loss, eating problems, and so
And, since the CMS does not expect the AD’s to be able to tackle this very wide-ranging list of
activities and interventions all alone, they specifically state that the entire staff is expected to
become involved. And that many other members of the staff will be interviewed by the surveyors
during compliance visits.

Activities are required even for residents “with no discernable response”

Educational requirements?

All of this, if strictly enforced, would seem to make the AD position one of increased
responsibility in nursing homes, with major… and accountable… responsibilities in many areas
of resident quality- of- life and healthcare issues.

So one question now of interest is this: What type of education will be required to appropriately
and effectively develop these types of sometimes-complex, evidence-based programs?
It’s long been the case that some AD’s have not wanted the word “therapeutics”, “therapy” or
even “effectiveness” to be part of their program description or vocabulary. But, at least some of
that may have changed with these new guidelines and instructions.
In fact, AD’s are called “activity therapists” several times in the CMS webcast of instructions to

Differing state requirements

But, as everyone knows, state educational requirements for activity directors vary astronomically,
from almost no specialized education, on up to special degrees in such areas as recreational
therapy, occupational therapy and social science.

Here’s part of what the CMS says about educational requirements in their new guidelines:
“The activities program must be directed by a qualified professional who is a qualified
therapeutic recreation specialist or an activities professional who is licensed or registered, if
applicable, by the state.”

For those states that don’t require specialized degrees, the regulations are unclear as to who
will be qualified to develop and supervise the more therapeutically-involved activities
interventions which are mandated in the guidelines for various health-related situations.

ElderCare Activities Guide queried the CMS on this, but has not received an answer.

How will effectiveness be measured?

Still another unknown is how surveyors will measure the effectiveness of the intervention
For those designed to help with cognition, how will improvements in cognition be determined?
For those activities designed to help with various behavioral problems, what standards of
improvement will the surveyors apply in determining compliance?

And so on. Improvements in some of these areas often are complex issues, which are being
researched by universities around the world. And many types of activities don’t work, while
others work very well.

Will AD’s be required to use evidence-based, research-proven activities for these health

Will AD’s be required to use evidence-based, research-proven activities for these health
conditions? How will surveyors determine if evidence-based, effective activities are being
Again, we queried the CMS with these questions, but has received no response.

The haves vs. the have-nots?

Also, there remains the unknown question about how smaller, lower-budget facilities can
comply with this new set of guidelines.

In one of their major examples of compliance in their webcast, CMS profiled a facility that had a
half-dozen activities directors, and a total staff of 20 involved in their activities programming.

They also gave an example of a “Snoezelen” type of sensory program (cost: up to $60,000) as
being highly effective and recommended for the treatment of various dementia-related problems.

But these examples involve very large investments in staff, materials and professional
programming that may be beyond the reach of many of the smaller nursing homes.

The differences that surveyors will see between the big and small residences could be startling
relative to compliance with these new, tough, performance-oriented guidelines… and how they
will react remains to be seen.

Just the issue of personnel requirements, alone, could be a major factor.
Providing person-centered, individual, activities to each and every resident every day will most
likely take a large activities staff.

If the AD, for example, is driving the van and taking shoppers to the mall, will the facility have
enough trained staffers to individually guide and monitor all those non-shoppers left back at the
facility... each with their own interests, levels of cognition, disabilities, and so on?

So very strict enforcement on the smaller facilities could be difficult in some cases; but is the
CMS permitted to develop two different compliance norms?

CMS enforcement will be a key factor

CMS enforcement is key

In the end, how these new guidelines, and new responsibilities for AD’s, will be implemented
depends significantly, on how strict the CMS will be in their enforcement.

It it’s strict, there will be big changes in the AD profession in years to come, with a major
increase in their responsibilities and programming... not to mention large increases in the
activities budget at come facilities.

If enforcement is not strict, then not much may change.

In any case, it’ll take months for these new guidelines to roll out into the nursing home industry,
be reacted to, and absorbed by the many different types of facilities, state requirements and
programs out there.

But the fact is: AD’s and their programs, are a very significant part of the lives of  nursing home
residents most days.

Their programs are critical to the quality of the lives (meaning: happiness) for these elders in
their remaining years.

And these new person-centered guidelines... if properly enforced... can be a major step forward
in improving the daily lives of our elders in nursing home environments.

At ElderCare Activities Guide, we’ll do our best to monitor activities surveys in the months ahead,
and keep readers informed about how the CMS surveyors are reacting to the new guidelines out
there. So stay tuned.  

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From the pages of
Kate Lynch, Editor