Question: I don’t understand how and when I should use Section T on the MDS. I am a CTRS and work in a nursing home with a mix of residents, including some residents on Medicaid. Can you tell me more about Section T?

The short (and probably totally inadequate) answer to your question: If you are a CTRS (Certified Therapeutic Recreation Specialist) working in a nursing home, you should always fill in Section T of the MDS. Most of the time you will be entering a "zero" to indicate that special treatments or procedures were not ordered by a physician and were not delivered. When you do provide special treatments or procedures, the appropriate totals should be placed within the appropriate boxes. It is important not only for the government to know how often the recreational therapist’s special treatments or procedures are provided in the nursing home setting, but it is also important information for our field as a whole to know. Now, read on for a more adequate answer.

I want to begin this discussion by pointing out that this area is not well defined by the Health Care Finance Administration. My answer draws from my experience as both a CTRS and as a past OBRA surveyor.

Many of the questions on the MDS (the standardized, multi-disciplinary assessment required for every resident admitted to a nursing home in the United States) are used as information only items and do not directly affect reimbursement. This information assists the federal government in its future planning for health care coverage and help track illness and disability trends. Currently Section T falls into the category of information only.

Section T’s purpose is to gather information about the amount and types of recreational therapy services provided by a CTRS to residents of nursing homes which are outside the definition of expected and required activities. In this case, expected and required means expected and required by the federal government and not by the recreational therapist’s standards of practice or scope of practice. Section T measures only the number of days and the total minutes of special treatments or procedures recreational therapy administered during a specific time period. It is listed as "special treatments and procedures" just as splinting for occupational therapy or gait training for physical therapy would be considered a special treatment or procedure. So the question is, what types of special treatments or procedures fall within the scope of recreational therapy practice which are not already considered to be part of expected and required activities listed under Tag F248? (Tag F248 is the section of the Federal OBRA nursing home law which outlines the type of services required by the recreational therapist/activity professional/occupational therapist/certified occupational therapy assistant who is in charge of ensuring that each resident’s needs related to activities are being met.) To understand what falls outside of the expected and required activities, it is best to understand what types of activities are expected and required. These can be found at Tag F248 under both the regulation and the guidelines for surveyors. Tag F248 states:

Tag F248

(Regulation) The facility must provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental and psychosocial well-being of each resident.

(Guideline) Because the activities program should occur within the context of each resident’s comprehensive assessment and care plan, it should be multi-faceted and reflect each individual resident’s needs. Therefore, the activities program should provide stimulation or solace; promote physical, cognitive and/or emotional health; enhance, to the extent practicable, each resident’s physical and mental status; and promote each resident’s self-respect by providing, for example, activities that support self-expression and choice. Activities can occur at any time and are not limited to formal activities being provided by activity staff. Others involved may be any facility staff, volunteers and visitors.

(Probes to Surveyors) Observe individual group and bedside activities. Are residents who are confined or choose to remain in their rooms provided with in room activities in keeping with life-long interests (e.g., music, reading, visits with individuals who share their interests or reasonable attempts to connect the resident with such individuals) and in-room projects they can work on independently? Do any facility staff members assist the resident with activities he or she can pursue independently? If residents sit for long periods of time with no apparently meaningful activities, is the cause: resident choice, failure of any staff or volunteers either to inform residents when activities are occurring or to encourage resident involvement in activities; lack of assistance with ambulation; lack of sufficient supplies and/or staff to facilitate attendance and participation in the activity programs or program design that fails to reflect the interests or ability levels of residents, such as activities that are too complex?

Some of the key words and phrases found under expected and required activities are 1. interests and well-being of each resident, 2. provide stimulation/solace, 3. promote health, 4. enhance status and 5. promote self-respect. For the recreational therapist it is often very difficult to decide if the treatment provided is enhancing and providing well-being and health or if it is a treatment intervention which goes beyond that requirement. Most of the treatment provided which allows the resident to maintain his/her status (or to slow decline) and which allows the resident to engage in leisure/free time activities is considered to be part of the required and expected services. Required and expected activities include reality orientation; exercise group; almost all adaptation of supplies and activities to allow the resident to engage in activity; modifying activities/providing activities which are culturally, age or gender appropriate; cognitive stimulation; reminiscing; remotivation; resocializing; solace; generalized relaxation techniques; most in-room activities; range of motion through activity; activities to increase self-esteem/self-respect; teaching new leisure skills; and providing structure to modify behavior. Other activities, generally outside what is traditionally thought of as the activity professional’s job, relate to general resident safety and well-being. These activities include infection control; ensuring that residents have adequate skin protection including pressure releases, changing positions and appropriate padding; maintaining a safe environment; and ensuring a respectful environment.

So what types of services might be considered special treatments and procedures? I believe that they would generally fall into four categories of interventions: intensive community integration, aquatic therapy, adaptive computer equipment and very specialized patient training in specific techniques using cognitive therapy. Almost all of these special treatments and procedures are implemented during one-on-one treatment sessions. Just as with the treatments which are required and expected activities, the resident’s treatment plan includes the special treatments because they were determined, through the assessment process, to be necessary. The care plan would also have a stated goal and at least one measurable objective. The therapist must conduct a regular re-assessment to determine if the treatment goal and objective(s) need to be changed to better meet the resident's needs. For interventions considered to be special treatments and procedures the therapist also needs to have a written prescription from the resident’s physician listing the type of treatment (e.g., develop functional ability to use community transportation to attend outpatient services), duration of treatment (e.g., two weeks), and frequency of treatment (e.g., three times a week).

Community integration is more than taking a resident out into the community to enjoy community resources, even if this involves teaching the resident some new skills in the process. Using a pre-established set of community integration treatment protocols such as the Community Integration Program (CIP) (Armstrong and Lauzen, 1995) helps the therapist ensure that the treatment remains in the special treatments and procedures category and not the required and expected category. To cite an example of one of the CIP’s treatment protocols I will explain Module 1A: Environmental Safety protocol. The purpose of the protocol is to determine, first, how safe the resident will be in the community and, second, for areas where the resident has problems with community safety, to provide training which will allow the resident’s safe use of the community after discharge. This is important information for the entire treatment team to know as they plan the resident’s discharge. To run the module the therapist takes a 3 x 5 card with instructions written on one side of the card. The instructions take the resident from one of the doors of the facility and, using five turns along sidewalks, driveways and other areas, leads the resident to a spot where s/he can no longer see the door which s/he started from. At this point the therapist asks for the card back and then instructs the resident to return to the door from which s/he started. Module 1A provides the therapist with a series of questions related to resident knowledge, endurance, safety of ambulation/locomotion, speed of both gross motor and cognitive actions, problem solving, personal safety, awareness of his/her own needs for assistance, appropriateness of grooming and clothing for situation, and ability to tolerate stimulation in the environment.

Aquatic therapy is more than just exercising or playing in the water (although these activities are very beneficial in and of themselves). For recreational therapists who have specialized training in aquatic therapy, using techniques such as Bad Ragaz in pools with the appropriate water temperature for the resident’s diagnosis should clearly be seen as specialized treatment and procedures.

Adaptive computer equipment (assistive technology) may only be a specialized treatment and procedure if the recreational therapist is evaluating the resident for specialized computer devices which will be used exclusively by that resident to improve function. The following are considered conventional equipment and are not likely to be considered specialized devices: cable, CD-ROM drives, computer or central processing units (CPUs), disk drives, disk operating software (or system software), keyboards, microphones, modems, scanners, monitors, mice, printers. software programs (or application programs), and trackballs. Assistive technology usually includes the following equipment: abbreviation expansion and macro programs, access utilities, arm and wrist supports, Braille embossers, electronic pointing devices, interface devices, joysticks, keyboard additions, menu management programs, monitor additions, optical character recognition and scanners, pointing and typing aids, reading comprehension programs, refreshable Braille displays, screen enlargement programs, screen readers, speech synthesizers, switches and switch software, talking and large-print word processors, touch screens, voice recognition, and writing composition programs. Once the equipment is available, the recreational therapist provides treatment sessions to help the resident learn how to use the equipment.

Cognitive therapy is the therapist’s use of words to teach and counsel the resident to bring about the desired change. Of all four types of specialized treatment and procedures, this may be the most difficult to truly separate out from required and expected activities. The primary difference here is the scope (usually more limited in nature than reality orientation) and intensity (greater intensity). For example, interventions related to increasing executive functions (initiation; self-monitoring/awareness; planning and organization; problem solving; mental flexibility and abstraction; and generalization and transfer) using the assessment process and intervention strategies as presented in Vision, Perception, and Cognition, Third Edition (Zoltan, 1996) may well qualify as specialized treatment and procedures because of their scope and intensity.

Because Section T is an information gathering question, it should only be filled out by the CTRS and only filled out as providing recreational therapy treatment if the services are outside of the expected and required activities and inside the scope of practice for the recreational therapist. Section T in no way indicates that a CTRS has priority for the position of activity director. When filled out to indicate services provided, Section T clearly indicates that the services provided by the CTRS were outside the services normally provided by an activity director (no matter what professional qualifications the activity director may hold). Section T services are a totally different scope of service than what is expected and required of the activity director.