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

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.
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.
Subscribe to Kimberly's Newsletter
See Kim's You-Tube videos (Click Here)
A Closer Look at the MDS 3.0:
News and Overview for Activity and Recreation
By Kimberly Grandal, CTRS, ACC/EDU

The MDS 3.0 implementation date is scheduled for October 1, 2010. CMS highly
recommends that everyone should hold back from training until after the "Train-the-
Trainer" sessions have been completed. The Train-The-Trainer sessions are
scheduled for the spring of 2010.Although it’s still too early to start training the staff on
how to complete the MDS 3.0, it’s important to keep abreast of any MDS 3.0 news. The
RAI User Manual is available for download. It’s not too early to start reviewing these
materials and familiarize yourself with the new terminology, form design and layout, and
the process.  This way you will be more prepared to ask questions when you are
presented with specific training opportunities. I’ve begun reading various components
of the RAI Version 3.0 Manual. The following is a summary of what I have gathered to
Advantages of the MDS 3.0
A 5-year CMS Nursing Home MDS 3.0 Validation Study suggests that the MDS 3.0 has
many advantages such as:
•        Increased  resident’s voice
•        Increased clinical relevance for assessment
•        Increased accuracy, both validity and reliability
•        Increased clarity and efficiency
•        45% reduction in the average time for completion
•        Supports the movement of items toward future electronic formats

•        The CMS website has the MDS 3.0 materials, forms, timetables, RAI User Manual,
etc. available for download. Visit
To download the MDS 3.0 RAI user manual scroll down the page and click on MDS 3.0
RAI Manual Jan 2010. The section for Customary Routine and Activities is called
section F and is located in the Chapter 3 file folder. The section which refers to
Recreation Therapy can be found in section 0, Special Treatments and Procedures.
•        You can also download sections F and O at
•        Other items to download on the CMS website include:
o        MDS 3.0 Item Subsets  – A file that contains the various subsets of the  MDS 3.0
assessment and tracking document such as admission, quarterly, annual, significant
change, discharge, etc.
o        MDS 3.0 Item Matrix  - This document identifies the items required for each type of
assessment along with how the item is used (e.g. QMs, QIs, CATs, RUG-IV, or RUG-III).
o        MDS 3.0 Data Submission Specifications - Detailed data submission
specifications for MDS 3.0.
o        MDS 3.0 CATs Specifications - This document provides Care Area Trigger (CAT)
specifications for the MDS 3.0 items used in triggering the Care Area, the conditions for
triggering, and Visual Basic code for triggering.
CMS provided a webcast, entitled, MDS 3.0: Part 1- An Introduction, on December 17,
2009. You can view this archived webcast for free at http://surveyortraining.cms.hhs.
•        This webcast was the first of a three part series focused on providing information
about the MDS 3.0. The other webcasts in the series include:
o        2nd Part: Coding the MDS 3.0 (late spring/early summer, 2010)
o        3rd Part: CMS Programs impacted by the MDS 3.0 (summer, 2010

Resident Assessment Instrument Overview
The Resident Assessment Instrument (RAI) version 3.0 is no different than the 2.0
version in that it is a structured, standardized approach for applying a problem
identification process in nursing homes. Completion of the RAI includes: assessment,
decision making, care planning, care plan implementation and evaluation.

Care Area Assessment
The Care Area Assessment (CAA) process provides guidance on how to focus on
problems, concerns or important issues that are identified in the comprehensive and
MDS assessment. There are 20 CAA-s which include:

01.        Delirium
02.        Cognitive Loss/Dementia
03.        Visual Function
04.        Communication
05.        ADL Function/Rehabilitation Potential
06.        Urinary Incontinence and Indwelling Catheter
07.        Psychosocial well-being
08.        Mood State
09.        Behavioral Symptoms
10.        Activities        11.        Falls
12.        Nutritional Status
13.        Feeding Tube
14.        Dehydration/Fluid Maintenance
15.        Dental Care
16.        Pressure Ulcer
17.        Psychotropic Drug Use
18.        Physical Restraints
19.        Pain
20.        Return to Community Referral

The MDS 3.0 identifies the actual or potential problem areas and the CAA process
provides for further assessment. Care Area Triggers (CATs) replaced the MDS 2.0
Resident Assessment Protocol (RAPs). The triggers identify those who have or are at
risk for developing various functional problems in any of the 20 CAAs and directs staff to
evaluate further.  The Care Area Resources is a list of resources that may be helpful in
performing the assessment of a triggered care area. The Care Area Summary (Section
V of the MDS 3.0), provides a location for documentation of the care areas that have
triggered from the MDS and the decisions made during the CAA process regarding
whether or not to proceed with care planning.

Just as with the MDS 2.0, further documentation for each triggered CAA is required.
Documentation for each triggered CAA should describe:
•        The nature of the issue, concern or condition
•        Causes and contributing factors
•        Complications related to the specific care area
•        Risk factors
•        Need for referral or further evaluation by appropriate health care professionals
•        What research, resources or assessment tools were utilized

There are four types of triggers which can change how the CAA is reviewed:
•        Potential Problems
•        Broad Screening Triggers
•        Prevention of Problems
•        Rehabilitation Potential

In terms of activities, the purpose of the CAA is to identify strategies to assist the
resident in increasing their involvement in meaningful activities that have been of
interest to them in the past and to help them find new or adapted activities of interest to
accommodate their current level of functioning. The CAA for activities is triggered when
there are indications that the resident may have a decrease in involvement in social
activities. The information from the assessment should be used to identify residents
who may be uneasy in social relationships and activities. In addition, assessment
information is to identify resident interests and identify possible causes or risk factors.

Chapter 4 of the CMS RAI Version Manual also addresses care planning.  Tips for care
planning are provided. The manual indicates six general care planning areas:
•        Functional status
•        Rehabilitation/Restorative Nursing
•        Health Maintenance
•        Discharge Potential
•        Medications Daily Care Needed

When residents trigger for activities, the CMS RAI Version 3.0 manual states that the
focus of the care plan should be to address the underlying cause(s) and the
development of the inclusion of activity programs customized to the resident’s interests
and his or her abilities. Activities should focus on helping the resident fulfill his/her
wishes, use cognitive skills and provide enjoyment as well opportunities for
socialization with others.

Preferences for Customary Routine and Activities (Section F)
A section with significant revisions is the “Preferences for Customary Routine and
Activities”. The customary routine staff assessment is replaced by the MDS 3.0
Preference Assessment Tool. Residents are to be interviewed for their activity interests
and routine preferences. The RAI Version 3.0 Manual suggests various ways for the
interviewer to phrase the questions, probe for clarification of residents’ responses and
to utilize adaptive techniques such as cue cards, an interpreter, opportunity to write out
answers, etc.  The residents are to rate the level of importance by using the following
1. Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can’t do or no choice (meaning the resident finds it important but feel
he/she cannot do that at this time because of health or because of nursing home
resources or scheduling.
9. No response or non-responsive (resident, family or significant other refuses to
answer or doesn’t know, if the resident does not respond to the question, or provides a
nonsensical response. A nonsensical response is defined as, “any unrelated,
incomprehensible or incoherent response that is not informative with respect to the
item being rated”.
When coding the activity preferences interview, no look back is provided. The resident is
to respond to their current preferences while in the facility. Family members and
significant others may be the primary respondent to the interview questions if the
resident is unable to do so. In this case, the family member or significant other may
have to consider past preferences if they are unsure of current preferences and the
resident is unable to communicate.
There is a series of questions that relates to the resident’s preferences for daily routine
such as bathing, bedtime, clothing, etc. The questions relating to activities include:
•        How important is it to you to have books, newspapers, and magazines to read?
•        How important is it to you to listen to music you like?
•        How important is it to you to be around animals such as pets?
•        How important is it to you to keep up with the news?
•        How important is it to you to do things with groups of people?
•        How important is it to you to do your favorite activities?
•        How important is it to you to go outside to get fresh air when the weather is good?
•        How important is it to you to participate in religious services or practices?
For residents who cannot answer the questions and a family member or significant
other is not available to answer on behalf of the resident, a staff assessment of
activities and daily preferences is conducted. Staff is instructed to observe the resident’
s response during activity programs. A variety of routine and activity preferences are
listed and staff is to check off each item as it applies in the last 7 days. The items listed
are as follows:
A.        Choosing clothes to wear
B.        Caring for personal belongings
C.        Receiving tub bath
D.        Receiving shower
E.        Receiving bed bath
F.        Receiving sponge bath
G.        Snacks between meals
H.        Staying up past 8:00 p.m.
I.        Family of significant other involvement in care discussions
J.        Use of phone in private
K.        Place to lock personal belongings        L.        Reading books, newspapers, or
M.         Listening to music
N.        Being around animals such as pets
O.         Keeping up with the news
P.        Doing things with groups of people
Q.         Participating in favorite activities
R.         Spending time away from the nursing home
S.         Spending time outdoors
T.         Participating in religious activities or practices
Z.  None of the above

In a sample of individuals that completed the revised Preferences for Customary
Routine and Activities (Section F), findings indicated that:
•        81% rated the interview items as more useful for care planning
•        80% found that the interview changed their impression of resident’s wants
•        1% felt that some residents who responded didn’t really understand the items
•        More likely to report that post-acute residents appreciated being asked
Special Treatments and Therapies (Section O)
The RAI Version 3.0 Manual states that recreational therapy is not a skilled service
according to the Social Security Act however, for purposes of the MDS, providers should
record services for recreational therapy when the conditions for the provision of
recreation therapy are as follows:
•        The physician orders recreation therapy that provides therapeutic stimulation
beyond the general activity program;
•        The physicians order must include a statement of frequency, duration and scope
of treatment;
•        The services must be directly and specifically related to an active written treatment
plan that is based on an initial evaluation performed by a therapeutic recreation
•        The services are required and provided by a state licensed or nationally certified
therapeutic recreation specialist or therapeutic recreation assistant who is under the
direct supervision of a therapeutic recreation specialist; and
•        The services must be reasonable and necessary for the resident’s condition.
The assessor records the number of days and the minutes that recreation therapy was
administered over the 7 day look back period. Sessions must be at least 15 minutes in
length. The RAI Version 3.0 Manual states that therapy logs are not a MDS requirement
but is standard of good clinical practice by all therapy professionals.
It’s also important to note that when two clinicians work together, which may be
common with a recreational therapist and an occupational therapist, the clinicians must
split the time between the two disciplines.
Music Therapy is included under Recreational Therapy as well.
•        Visit the CMS website regularly using the link I provided above.
•        Download and print the items that are available on the CMS website and put it in a
•        Read the RAI User Manual and review all MDS 3.0 materials.
•        Write down your questions as you read the manual. Have these questions
available during formal training sessions.
•        Please share what you have learned with others. You can email me and I will post
news and information at as I receive it.
I will also address MDS 3.0 issues on my Facebook group page at