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By Sandra Stimson ADC, CALA, CDP
Executive Director,
Alternative Solutions in Long Term Care

Sandra Stimson has experience as a
corporate consultant, Corporate
Trainer and National Speaker. Her
experience is in long term care, as
Activity Director, Director of
Alzheimer's Units and Assistant
Administrator of a 550 bed long term
care county home.  She is
Co-founder of Pet Express Pet
Therapy Club, is a Life Replay
Specialist.  Sandra implements
dementia units nationwide.  Sandra
has written several books, Volunteer
Management Essentials for Long
Term Care and Pet Express Pet
Therapy Program. Sandra has been a
facilitator for Alzheimer's support
groups and is the Awards Chair for the
NJ Association of Activity
Professionals.  Sandra is the
Executive Director of
Council of Certified Dementia

Alternative Solutions in Long Term
Care offers resources for health care
professionals in many areas of
dementia care, care plans,
Snoezelen products, dementia
activity calendars, adult day care
calendars, sensory calendars,
reminisce videos for dementia,
activity books, and dates to
remember, party supplies,
resources and links.

To prepare for the new changes to CMS Surveyor Guidelines for long term care and the activity
department, it is recommended that you purchase Population Analysis and Calendar Analysis Tools
available at web site. As we move towards Resident Centered Activities Vs
Mathematical Models (staffing), you will need to conduct Population Analysis to determine the types of
populations in your facility and current staffing levels in the activity department. The Calendar Analysis
once completed will tell you what activities you currently offer.

Once you have determined the populations you serve, the needs of each of these groups, current staffing,
locations of programs, types of programs and times of programs, the Activity Director will than implement
changes to how the activity department is providing services. This will include increased staffing, other
staff assisting with programs (CNA's) and other staff assisting with transporting to programs, adaptive
devices, shorter or longer programming times, additional programming, in-room programs,
documentation, environmental changes, etc.

The Calendar Analysis tool will help you calculate how many programs you have, what you have too much
of and what you don't have enough of for each population. For example, a high functioning calendar may
not offer enough empowerment, wellness, educational, community programs and spiritual programs.

A dementia calendar may be non existent or lack in areas of wellness, spiritual, reminisce, music and
exercise programs. Dementia programs should be offered 7 days a week and change on the half hour.
Please note that some programs may run longer. See for sample dementia

A sub acute calendar may be offering programs at a time that is not convenient to the resident's therapy
schedules. Typically, we see programs for Sub Acute in the morning when they should be offered in the
afternoon, evening and weekends as to not conflict with therapy times. Additionally, activity staff should be
bringing activities to their room, such as games, computers, crafts, word games and reading materials.
Activity Directors should be coordinating these programs with the Rehabilitation Director.

A low functioning program may be too difficult and not be success oriented and failure free. Typically
these programs are not offered enough or may have programs scheduled that are too difficult for this
population. This type of programming should be heavy in sensory and tactile programs, such as a
sensory room, sensory programs, Wake Up, Sensory Stimulation Programs, Aroma Therapy, Pet
Therapy, etc. We have many products available at such as Wake Up, Sensory
Enrichment, Low Functioning calendars, relaxation videos, Pet Express and reminisce videos.

Additionally, there may not be programs for the room bound and bed bound. Many directors make the
mistake of counting a visit such as delivering mail or just “popping in.” There has to be evidence of room
visits. The room bound program should be tailored to their care plan interventions and the initial
assessment that states their preferences. The in - room program should be a "real activity program." For
example, you may have a resident who is room bound and has stated their interest is gardening. For a
high functioning client, it may be potting a plant. For a dementia client it might be a flower press book. For
a low functioning resident it may be soft music and pictures of flowers. All room visits must be
documented and follow the care plan... Just dropping in and delivering the mail or a short conversation is
not enough stimulation.

Population and Calendar Analysis Tools should be completed together and at a minimum once as year
as a Q/A.

Be sure to add a resident right to every calendar. We are now selling Resident Right Prints that are
gorgeous. Each right is paired with a Norman Rockwell print. They can be purchased as a set or

Now is the time to start beefing up your volunteer program. We have an excellent book, Volunteer
Management Essentials for Long Term Care that has all the information you will need to implement a
volunteer program. Volunteers can help with programming, transporting, walking programs, pet therapy
and intergenerational programs.

For more information about the draft for Ftag 248 and Ftag 249, we recommend that you contact Cat
Selman (HealthCare Communications (601 899 9250) or Rita Spak (see for a list
of speaking engagements or attend any seminars that you see advertised dealing with CMS changes to
come that specifically address Activities as a part of the seminar.

Additionally, contact Karen Schoeneman ( senior policy analyst and project
officer for the CMS Division of Nursing Homes for dates or booking her for speaking on The New CMS
Surveyor Guidelines... If, you are in New Jersey she is scheduled to speak at Alex Aidekman Family
Jewish Community Campus on February 17th 2006. To register for this engagement contact Barbara
Bridges Quinlan at Daughters of Israel and click on Franzblau Institute as seating is

As we have consulted for many long term care facilities and implemented the Calendar Analysis and
Population Analysis tools for many years, it has shown to be an important tool in developing staffing
levels and designing calendars and programs. We have written for many years in our newsletters about
the need to have more than one calendar. You should have low functioning (sensory calendars) High
Functioning calendars, Short Term Stay calendars and Alzheimer's and Dementia Calendars.

If you have not implemented sensory rooms, this would be the time to look at where you can open a
sensory room for your low functioning residents as the sensory rooms provide programming at levels
that allow this challenging population to succeed. The sensory room product line is extensive and
available at We can also provide downloaded products such as Sensory Room
In-services, Sensory Room Care Plans and Sensory Room Policy and Procedures. These products
should be implemented as part of the sensory room programs. All staff should be in-serviced and
educated about the benefits and uses that sensory rooms can offer your clients.

The most important advice we can pass on to you to is to increase programming and implement the
programs, add more staff if the analysis proves that, (including CNA's), complete Population Analysis and
Calendar Analysis and implement the findings from the analysis. Have this information ready to present
to a surveyor and you will be well ahead of the surveyor’s questions. These analysis tools will be the
written proof to show your administrator what your needs are.

The second piece of advice we can offer to pass survey (every day is survey day) is to document group
attendance. Complete this for every single program. Simply, take your census document, at the top of the
census form; write the name of program, program time, and date and activity assistants’ name. Take a
highlighter and highlight each resident’s name who attended the activity program. Keep group
attendance as well for all room visits conducted on a daily basis.

The third suggestion would be to begin documenting individual participation. There are many tools out
there but the one that takes the least time for your staff is to simply take the activity calendar, place a
resident's name on the calendar and highlight each activity they attend. This is your proof that residents
are attending programs. If it's a room visit, simply write 1-1 across the block for that date. On the back of
the calendar, write the date and specifically what you implemented or completed with the client. You
should be documenting how they participated, active or passive. If passive, you should note why? This
simple way of documenting allows the surveyor to look at a monthly calendar and quickly see the activity
patterns of a resident.

Make sure that the program a resident is attending is a program that the resident can be successful at. If
they can not successfully complete the program, than they are in the wrong type of program. Use these
four words to determine if a program is successful for a resident, Success Oriented, Failure Free,
Purposeful and Meaningful. These four words should apply to every single program a resident is

Lastly, the activity discipline should be noted the care plans. If, you don't have the Care Plan Cookbook,
please see our site. This will help you in care planning appropriate interventions. Most of the care plans
should have activity interventions. For example, you may have a client care planned for weight loss. If, for
example, the care plan notes that snacks will be offered through out the day than the Activity Department
would play a vital role in insuring the client receives the snack during activities or room visits. Additionally,
there are other interventions that the Activity Department could add to this type of problem.

Conduct an inventory of all your products. You may not have enough supplies based on the calendar
audit and population analysis. For example, your analysis shows you have 30 low functioning residents.
Based on the inventory quality assurance, you may note that you do not have enough adaptive devices,
sensory items or props for programs. Now would be the time to begin ordering supplies for your
programs as you are required to have enough supplies for all those attending programs. You are
required to accommodate their needs.

Know your current federal regulations and interpretive guidelines. It is not just FTAG 248 and 249 for
nursing homes. Know your state regulations (nursing homes, assisted living and adult day care) and
request new ones when they expire. Go to the CMS site and sign up for updates and newsletters. Stay
involved in your state and local activity groups. conventions. Take the time to visit, The
NAAP and ATRA web sites for information and changes to the regulations. We also recommend that you
sign up for newsletters with those associations. Have current subscriptions to Creative Forecasting, www., and Elder Care Activity Guides. Take the time to read thoroughly
through these publications and advise your staff in weekly meetings of any changes that will affect
residents and the activity departments. Another great source is and read the
articles by Reta Underwood ADC.

Activity Professionals should download or obtain these documents titled:
State Operations Manual Appendix PP "Guidance to Surveyors for Long Term Care Facilities" November
05 or type in the search box SOM at the CMS web site. Additionally, request the draft copy from your
regional CMS site. The draft is called Draft Copy Intent F248 & F249 Activities and is 25 pages long. Also
request from the regional office, Psychosocial Outcome Severity Guide and Revised Long-Term Care
Facility Resident Assessment Instrument User’s Manual January 2006. Don’t wait for the draft to be
approved, begin implementing the changes now! Ask your administrator to review the draft and assist you
in making changes to your activity department, for without his / her help, the process will be a lot harder to
complete... We have not been advised when these draft interpretive guideline changes will go into effect,
only that the document is awaiting final approval.

Know F154 Resident Rights,F156 Notice of Rights and Services, F164 Privacy and Confidentiality, F172
Access and Visitation Rights, F242 Self Determination and Participation, F246 Accommodation of Needs,
F249 Qualifications of the Activity Director, F250, F252 Personal Property, Social Service, F272
Comprehensive Assessment, F279 Comprehensive Care Plan, F280 Care Plan Revision, F353
Sufficient Staff, F464 Dining and Activities Rooms, F499 Staff Qualifications and of course F248 and F249
for Nursing Homes.


Sandra Stimson CALA, ADC, CDP
Executive Director

Lisa Reidinger LNHA, CSW, CTRS, ADC
Executive Director
Alternative Solutions in Long Term Care
Copyright 2004-2006
The Activity Director's Office
All rights reserved
Music: "Peg of My Heart" furnished by Heart and Soul Music "Providing Quality Music for Nursing Homes"