Organization of Therapeutic Recreation/Recreation Therapy Service

Question 1

Program design relative to population served

Answer 1

An important competency to have is an understanding of program design relative to the population served. As programs are designed, it is necessary to have a thorough understanding of the diverse needs of the clients to be served. We are accountable for out clients’ outcomes thus a program must focus on their needs. In order to do this, we must have knowledge and skills in selecting the correct intervention and using the appropriate facilitation skill that will help clients achieve their goals.
•All populations have different needs; for some we will focus on their cognitive needs, other social needs and others a combination. *Must have the knowledge and skills to determine what is important for the clients you are serving and the ability to develop and utilize diagnostic and program protocols is very important.

Question 2

Protocols/definition

Answer 2

documents that describe the best practice of a specific intervention as applied to a specific group of clients or client needs that have been standardized and result from recent research evidence, literature reviews or professional consensus. Protocols document the purposeful procedures used to deliver intervention to clients and provide a basis for evaluating the efficacy of those procedures. Either based on intervention/treatment or diagnostic groups/client problems. The cornerstone of evidence-based practice because they describe the best practice or standardization of specific interventions w/ specific clients.

Question 3

Types of service delivery systems

Answer 3

health, leisure services, education and human services

Question 4

Health Care

Answer 4

One of the major competencies covered within the subtopic of Service Delivery Systems is health care. Majority of TR Services are found in a health care agency, be it a rehabilitation hospital, community hospital, outpatient unit or pediatric unit, all are found in the healthcare service delivery system. *Important to understand what makes this service delivery health care. Is it how the services are offered? The types of services offered? Usually in health care services treatment is prescribed either by the physician or the treatment team. When TR is prescribed, the therapeutic recreation process (assess, plan, implement, and evaluate) becomes activated and specific programs and interventions are determined.

Question 5

Leisure services

Answer 5

Another part of the service delivery system. Usually the client is referred either through self-referral or by another TRS as part of the client’s discharge plan from health care. Leisure services are usually community based and may be segregated or the client may be participating in inclusive recreation. If the services are segregated, the TRS will follow the same therapeutic recreation process to determine the most appropriate program for the client. If the services are inclusive, then the client often can choose what recreation/leisure service they would like to be involved in.

Question 6

Education services/IEP

Answer 6

Another kind of service delivery system. Due to the inclusion recreation as a related service in the Individuals w/ Disabilities Education Act, TRSs can be found in school systems, specifically in special education services. All students eligible for special education services must have an individualized education plan (IEP). The IEP outlines the services that are necessary for the student to achieve his/her goals and objectives and the IEP can specify TR services. Within the IEP, depending on the age of the child, there may be a section labeled “transition.” The Individualized Transition Plan projects “post school” goals and methods to ensure those goals will become reality. This section may specifically address leisure goals and objectives. The TRS may assist in the development of the goals and objectives but will certainly provide the necessary programming to meet those goals and objectives, once again using the TR process.

Question 7

Understanding of the roles and functions of other health and human service professions and of interdisciplinary approaches

Answer 7

• TRS is expected to understand the roles of treatment team members, such as psychiatric social workers or psychiatrists and their roles in the rehabilitation process.
• Most TRSs will co-treat with other professionals on the treatment team and need to understand what each discipline can provide in the treatment process. Ex.- The physical therapist and the TRS may co-treat on a community re-integration program w/ the physical therapist working on car transfers or walking endurance, while the TRS is working on decision making, community resources or money management skills.

Question 8

Interdisciplinary Approaches

Answer 8

The team approach to caring for patients includes many professionals performing a variety of specialized functions designed to meet the physical, emotional and psychological needs of the patient. In the course of just one stay, a hospitalized patient may be cared for by an array of non-MD/DO providers. Integrated health care, often referred to as interdisciplinary health care, is an approach characterized by a high degree of collaboration and communication among health professionals. What makes integrated health care unique is the sharing of information among team members related to patient care and the establishment of a comprehensive treatment plan to address the biological, psychological, and social needs of the patient. The interdisciplinary health care team includes a diverse group of members (e.g., physicians, psychologists, social workers, and occupational and physical therapists), depending on the needs of the patient.

Question 9

1.Documentation procedures for program accountability, and payment for services

Answer 9

Accurate and complete documentation is necessary in order to: 1) assure the delivery of quality services, 2) facilitate communication among staff, 3) provide for professional accountability, 4) comply with administrative requirements and 5) provide data for quality improvement and efficacy research. TRSs, like other professionals are accountable for services rendered and outcomes achieved. Accurate documentation can provide the necessary evidence.
•The type of documentation required is set by the agency in which the TRS works.
•Accrediting agencies like the Joint Commission and CARF have standards that impact documentation.

Question 10

Centers for Medicare and Medicaid Services (CMS) Documentation Procedures/Requirements

Answer 10

require documentation to indicate that services are necessary. The CMS requires that the staff complete the Minimum Data Set for Resident Assessment and Care Screening (MDS) that includes section F which is, “Preferences for Customary Routine and Activities.” In the MDS, recreational therapy is defined as a skilled service, must meet the criteria for active treatment and is included in Section O, Special Procedures and Treatments, along with occupational therapy, physical therapy, speech, respiratory therapy and psychological services. Based on the information from the MDS the Resident Assessment Protocol Summary (RAPS) may be completed.

Question 11

3rd party payers & Documentation (why are they interested in?)

Answer 11

3rd party payers are interested in documentation because it is from this information they will make decisions about reimbursement. So, it is very important that the TRS is very clear when writing problems, goals and interventions used and responses of the patient to those interventions.

Question 12

Methods for interpretation of progress notes, observations, and assessment results of the person being served

Answer 12

• Very important that a TRS can interpret the medical chart. Need to understand the doctor’s orders, the assessment/notes from other disciplines and be able to interpret their meaning.
• Very often it is not necessary for a TRS to assess a patient in a certain area if it has already been thoroughly assessed by another discipline.
• Necessary for the TRS to understand what has been stated by the other disciplines and use that information when developing a treatment plan.

Question 13

FACT Charting Method

Answer 13

4 Key Elements: 1) Flow sheets individualized to specific services 2) Assessment w/ standardized baseline parameters 3) Concise, integrated progress notes and flow sheets documenting the patient’s condition and responses and 4) Timely entries recorded when care is given. FACT closely resembles charting by exception.

Question 14

Core system

Answer 14

Focuses on the nursing process and consists of a data base, plans of care, flow sheets, progress notes and discharge summaries. Core charting requires nurses to assess and record a patient’s functional and cognitive status within 8 hours of admission.

Question 15

Outcomes documentation system

Answer 15

Focuses on the process of care, especially the patient’s behaviors and reactions to interventions and teaching. System features a database, plan of care and expected outcome statements. Criteria for outcome statements include specification of a) specific behaviors showing that the patient has progressed toward or attained a goal, b) standards for measuring the patient’s behaviors, such as how much the patient does and for how long, c) conditions under which the behavior is expected to occur, and d) a target date or time by which the behaviors should occur (including short-term and long-term goals). Clinical pathways or care maps may be considered outcomes charting.

Question 16

Content of Progress Notes

Answer 16

Progress towards attainment of client goal, regression from attainment of client goal, new patterns of behavior, consistency in behavior, verbal information provided by the client, successful or unsuccessful attempts at a task, appropriate or inappropriate interactions w/ staff, peers or visitors, client responses to questions, instructions, requests, initiative w/ actions, idea, problem solving, decision making and follow-through or lack of follow-through with commitment. General behavior and participation patterns, physical cues (dress, hygiene, posture, movement, social distancing, face, mood and affect, speech, orientation) specific behavioral cues and environmental cues (weather conditions, temperature, surrounding objects, social patterns, positioning, setting) are all potentially significant information to be included in progress notes.

Question 17

Observations

Answer 17

Involves the CTRS viewing the clients’ behaviors, either directly or indirectly. In some cases the client will know he/she is being observed; in other cases the client may not know. CTRS should be aware of client autonomy and rights in conducting observations unknown to the client. Primary reason for conducting observations is to record the client’s behavior (not perceptions of behavior as in interviews) in situations as close to real life as possible. Typically, the CTRS chooses to create close-ended rating systems to shorten the length of time spent recording the observations and to increase compatibility across clients.

Question 18

Principles for Observations

Answer 18

1) Be consistent- protocols for administering observations should include the informed consent of the client, the environment or situation in which the client is to be observed, the scoring mechanism(s) for recording observations and how scores result in program placement. 2) Determine which scoring system suits the purpose of the observation- There are 4 basic types of observational recording systems: tally, duration, interval and instantaneous time sampling. Tally systems record how frequently a behavior occurs. Duration systems record how long a behavior occurs. Interval recording systems measure both frequency and duration. Instantaneous time sampling is reserved for those instances when continuous observation is not possible and periodic checks are used.
3) Select behaviors that are clearly defined and observable within the available time- behavioral rating systems are more easily created when the behaviors of interest are easily observable and happen w/ enough regularity to occur within the observation time frame. Ex.- “interacting w/ other clients” is too vague to be usable and consistently recorded. Better examples of observable behavior might include: “greets other clients”, “initiates conversation” and “maintains eye contact.”
4) Understand the limitations of observations- observations are excellent for recording client behaviors. They do NOT explain the reasons or motives for the behaviors. CTRS should always separate the action or behavior from the interpretation of that action or behavior.

Question 19

Methods for evaluating agency or TR/RT Service program

Answer 19

A TR department must determine what is important to be evaluated. Usually it is determined that the quality of services delivered, effectiveness of those programs and the outcomes of those programs are of most interest to the department, the agency, 3rd party payers and the receiver of services. Program evaluation is used to determine program effectiveness and to improve services. The need to establish an administrative schedule for evaluation and determine the program revision process following data collection for the therapeutic recreation program is a task for the TRS.

Question 20

How The Program Evaluation Is Conducted

Answer 20

First, one must differentiate between formative and summative evaluation. When the evaluation is formative, it is ongoing and occurs while the program is in progress. Staff can make changes on a daily or weekly basis dependent on what the evaluation data indicates. Summative evaluation is conducted at the end of a program and can be used to compare programs or provide information for the next session of programming. For summative evaluation, the program is completely finished when the data is collected and analyzed. It is necessary to understand the importance of an evaluation plan and the need to develop specific date collection instruments.

Question 21

Formative Evaluation definition

Answer 21

On-going evaluation using a step-by-step process of decision making relating to numerous specific aspects of a program rather than one final evaluation. Leads to immediate change: room temperature, supplies.

Question 22

Summative Evaluation definition

Answer 22

Terminal & overall assessment of a program intended to judge its impact and effectiveness. A decision to continue or discontinue program is imminent. Done at end of program and leads to a decision regarding the future.

Question 23

Discrepancy Evaluation Model

Answer 23

Evaluate what you intended to do & what actually happened. A comparison of what is, a performance, to and expectation of what Should be a standard. If a difference is found > discrepancy. If performance has exceeded the standard > it is a positive discrepancy. If performance is less than standard > it is a negative discrepancy.

Question 24

Ways To Collect Evaluation Data

Answer 24

Using surveys or questionnaires, by observation, interviews or by record documentation (client records).

Question 25

Levels of Evaluation

Answer 25

individual client, specific activity, specific program and comprehensive program.

Question 26

Evaluation is Represented on the Therapeutic Recreation Accountability Model by 3 Boxes…

Answer 26

1) Program Outcomes, 2) Client Outcomes and 3) Quality Improvement

Question 27

Internal Evaluation

Answer 27

someone from the agency is gathering data

Question 28

External Evaluation

Answer 28

outside agency/person is gathering the info.

Question 29

5 Steps in an Evaluation Model

Answer 29

1) Planning, 2) Designing, 3) Implementing, 4) Analyzing and 5) Applying Results

Question 30

Comprehensive Program Evaluation (purpose of)

Answer 30

purpose is to ensure that professional collectively are performing their job tasks in similar fashion to ensure safety, efficiency and effectiveness of services provided. External agencies mandate some form of comprehensive program evaluation.

Question 31

Methods for quality improvement/ performance guidelines and techniques

Answer 31

utilization review, risk management, peer review, outcome monitoring

Question 32

Quality improvement

Answer 32

The most common method of evaluating TR services at the comprehensive program level. Defined as a wide spectrum of activities ranging from determining an appropriate definition of care to establishment of actual standards of practice, that, if implemented will result in acceptable levels of service. Aim is to provide mechanisms for health care agencies to continually improve the services delivered to clients through self-inspection and on-site visitations by surveyors. Not just one activity but a variety of activities that provide useful data on the quality of care for patients. A basic approach to “comprehensive service evaluation” involves a process that focuses on a) seeking out problematic areas that lower quality, b) correcting those problems, and c) evaluating how well those corrections are solving the problems. TRS needs to understand and be able to design an effective evaluation plan, focusing on identifying important aspects of care (ex., client assessment, treatment plans, specific intervention techniques used, patient safety or risk management, staff training and continuing education, etc.). After identifying the aspects of care on which the evaluation will be focused, the TRS identifies how to collect the data, collects the data, analyzes the data and then makes the identified changes in patient care.

Question 33

Performance Improvement

Answer 33

Intends to focus the comprehensive evaluation on the organization’s performance in providing the best care possible. Focuses on the quality of the process used in delivering services to the quality of the outcomes produced. Performance improvement is seen as a total management process that should be integrated into the overall operations of the agency on a daily basis. First portion of performance improvement that is addressed through this competency is utilization review.

Question 34

Utilization Review

Answer 34

A program usually initiated by reimbursement agents to maintain control over use of resources by patients and health are providers; may focus on length of stay, treatment regimen, validation of tests and procedures and verification of the use of medical supplies and equipment. Refers to looking at how effectively a department uses its resources. Addresses over-utilization, under-utilization and inefficiency. This is a program management function that should be in a written plan of operation for a health care agency. A TR department that is well integrated into the overall agency’s functioning will be involved frequently in the utilization review program.

Question 35

Risk Management Plans

Answer 35

Involves developing processes and procedures for controlling the delivery of safe, quality services. Looks at injury or death from environmental hazards, poorly maintained or dangerous equipment, inadequately supervised recreation areas and user behaviors. An important part of all therapeutic recreation services. Every department needs to develop risk management plans for each of their service areas and programs. A risk management plan identifies all potential risks that could occur in a facility, with equipment or during a program to an employee, patient or family member. Then, the TRS develops a plan or procedure that will eliminate, reduce or manage that risk. It involves loss prevention and control, and handling all incidents, claims and other insurance, or litigation-related (lawsuit) tasks.
Risk management in Action- (1) identify, characterize, and assess threats; (2) assess the vulnerability of critical assets to specific threats; (3) determine the risk (expected consequences of specific types of attack on specific assets); (4) identify ways to reduce those risks and (5) prioritize risk reduction measures based on a strategy. Risk management in the leisure domain refers to factors that are inherent in clients, the activity (high or low risk), and the environment. Examples of risk management include: counting the number of supplies, such as scissors before and after the program, using safety devices in transport of clients and specifying staff/client ratios. Intent of risk management it to develop, monitor and evaluate procedures so both providers and participants avoid harm.

Question 36

Outcome Monitoring

Answer 36

“Outcomes” are they differences that occur in a person from when they begin treatment or enter the health care facility to when they leave treatment or the health care facility. Hoped that these changes will be positive. Currently outcome measurement is being discussed rather than outcome monitoring. The Joint Commission has identified 3 categories of outcome measures: health status (functional well-being of an individual), patient perceptions of care (satisfaction measures of care from patient or family perspective) and clinical performance outcomes (outcomes of processes of care). TRSs need to understand outcomes and be able to support positive outcomes as a result of their treatment. This will entail some efficacy research. Efficacy research is designed specifically to scrutinize how effective programs are or were in attaining client outcomes. This research is usually done to determine the effectiveness of an intervention with a particular diagnosis.

Question 37

Efficacy Research Benefits

Answer 37

consumers, CTRSs, profession, 3rd party payers, accrediting agencies and collegiate institutions.

Question 38

Peer Review definition

Answer 38

evaluation of scientific, academic, or professional work by others working in the same field.

Question 39

Components of agency or TR/RT Service plan of operation

Answer 39

This competency relates to the development of a plan of operation or how the agency or therapeutic recreation services operate. For some organizations, specifically in the community, this will be known as a policy and procedures manual. For most health care organizations, the policy and procedure manual is contained within the Plan of Operation.

Question 40

2 Types of Plans of Operation for TR Needs to Be Concerned With

Answer 40

1) the agency’s plan of operation.

2) the therapeutic recreation department’s plan of operation.

Question 41

Agency Plan of Operation

Answer 41

Agency’s plan of operation should adequately include TR services as a component of service. Accreditation surveyors will review thoroughly the overall agency’s plan of operation, including services provided by TRSs. The agency plan of operation should include patient management functions and program management functions, with therapeutic recreation included as appropriate. Examples of patient management functions include client assessment, treatment plans, progress notes, treatment plan reviews and discharge summaries. Examples of program management functions include a quality improvement process, utilization reviews, and patient care monitoring procedures. A risk management plan for each area and facility for which the TRS is in charge is important to develop. The risk management plan will evaluate the amount of risk that an area, program, or piece of equipment may present and establish policies and procedures that staff must follow in order to reduce risk.

Question 42

Therapeutic Recreation Department’s Written Plan of Operation

Answer 42

Every TR department/unit needs to have a written plan of operation. All staff should be familiar with this document and utilize its procedures. The therapeutic recreation department’s or unit’s plan of operation should have a written philosophy that reflects the philosophy of the agency, have overall goals for the program and describe the purpose and function of therapeutic recreation within the agency. It also should have information regarding the nature and diversity of activities to be utilized with clients and include information related to both patient management functions and program management functions. Includes philosophy of TR department within the agency, goals of the comprehensive TR program, knowledge of the components of the comprehensive TR program (functional intervention, leisure education and recreation participation), client involvement, goals of each program component, client assessment process, policies and procedures, interaction and collaboration with other professional services, role of TRS in relation to patient management and role of TRS in relation to program management. Examples of patient management functions within the therapeutic recreation department’s plan of operation include the client assessment process, treatment plans, interventions used, discharge planning, etc. Examples of program management functions within the therapeutic recreation department’s plan of operation include staff organization and development, quality improvement, utilization review, patient care monitoring, etc. A plan of operation is a requirement for a department and is part of the ATRA Standards of Practice.

Question 43

Personnel, intern, and volunteer supervision and management

Answer 43

Entry-level TRSs need to be able to supervise a variety of people. Primarily it focuses on the supervision of staff, volunteers and student interns.

Question 44

Clinical Supervision definition

Answer 44

Supervision of other therapists.

Question 45

Purposes of Clinical Supervision

Answer 45

To improve clinical practice skills and to ensure that the therapeutic intents of a program are being provided or met.

Question 46

3 Roles of a Clinical Supervisor

Answer 46

Teacher, counselor and consultant. The supervisor and supervisee together establish goals that the supervisee wishes to attain. Based on those goals, the content of the supervision program and a time frame is established. The last step is evaluation. As an entry-level TRS, you are NOT expected to provide clinical supervision at this point in your career; but a quality clinical supervision program will help you grow and expand your ability to deliver quality services. It is important to note that clinical supervision is not a performance evaluation by Human Resources but a process to help someone improve his/her clinical skills.

Question 47

Volunteers Purpose

Answer 47

Play an important role in many TR departments and many entry-level practitioners need to be able to supervise them. It is important that when a department determines it has a need for volunteers, that the department establishes a volunteer plan including policies, job descriptions and a marketing plan with promotional materials for recruitment and retention. It is important that the program guidelines be established and that while the volunteers may be used for parts of the program, they may NOT be used for the implementation of an intervention. For example, volunteers may be used to provide animals for an animal-assisted therapy program, but it is the TRS who is responsible for the assessment, development of the goals for the program, and the therapeutic use of animals. Many long-term care facilities use volunteers to “call Bingo” but if the therapist is using Bingo as a therapeutic activity, it is up to the TRS to determine if the patient’s objectives were met and to document the intervention process.

Question 48

Supervision of Interns

Answer 48

It is NOT expected that an entry-level TRS would be supervising an intern. But in preparation for an intern, a department should identify internship goals and objectives, establish policies and procedures, ensure the staff and facility are prepared to accept interns, develop training materials, establish an intern manual, determine selection procedures and establish a recruitment plan.
There are 3 major tasks that an intern supervisor needs to provide: 1) communication w/ and observation of the intern 2) documentation of intern activities and experiences 3) provision of training and education opportunities.

Question 49

Types of Payment Systems

Answer 49

Ex.- managed care, preferred provider option (PPO), private contract, Medicare, Medicaid, DRG)

Question 50

Managed care systems

Answer 50

the predominant payment method in health care organizations. Insurance companies dictate the services patients need. Managed care reduces costs. Managed care systems have shifted the authority of determining the services the patient needs from the providers of care to the payers for care. Purpose of managed care is to protect consumers’ rights, improve care, incentives for organizations to offer higher quality of care, provide framework for consistency and contains costs. Consequences of Managed Care- shorter lengths of stay, higher client to staff ration, reluctance to enroll “high cost individuals”, decisions made by the payers of care (insurance) rather than the providers or care. Role of Case Manager in Managed Care- referral of new patients, planning and delivery of care, evaluation of results for each patient and adjustment to care plan and evaluation of overall program effectiveness and adjustment to the program. TRSs are often challenged by the insurance companies regarding the need for their services, we have to justify why people need TR, ex- instead of taking meds, TR is more cost effective.

Question 51

Prospective Payment System (PPS)

Answer 51

1) Price-based system 2) Prices are set in advance 3) The price is inclusive of all services provided 4) No additional payment or settlement will occur 5) The current year’s actual costs do not impact the price established. Uses diagnostic related groups (DRG) as a way to classify individual as purpose of payment. Established to contain health care costs and ensure quality.

Question 52

Preferred Provider Option (PPO)

Answer 52

Established to contain healthcare costs, ensure quality, assure Medicare recipients access to care, and it has a beneficiary-centered focus. A Medicare PPO Plan is a type of Medicare Advantage Plan (Part C)offered by a private insurance company. In a PPO Plan, you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. You pay more if you use doctors, hospitals, and providers outside of the network.

Question 53

Medicare

Answer 53

A federal health insurance program that provides care for people 65 and over, for people with certain disabilities, and people with end-stage renal disease. The program has 4 parts: Part A (Hospital Insurance)- provides for hospital care, skilled nursing care, home health care and hospice services; Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. Part B (Medical Insurance)- provides supplemental medical insurance. It covers physician services, outpatient services, emergency department visits and medical equipment. Part B covers certain doctors’ services, outpatient care, medical supplies, and preventive services. Part C (Medicare Advantage Plans)- A Medicare Advantage Plan is a type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. If you’re enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan and aren’t paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage. Medicare Part D (prescription drug coverage)- Part D adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans. These plans are offered by insurance companies and other private companies approved by Medicare. Medicare Advantage Plans may also offer prescription drug coverage that follows the same rules as Medicare Prescription Drug Plans.

Question 54

Medicaid

Answer 54

A combined program of state and federal insurance and medical assistance for qualified needy individuals of any age. When finances have been depleted by medical care, Medicaid will pay the difference between incomes and cost of care.

Question 55

Diagnostic-related groups (DRG)

Answer 55

the system of classifying or grouping patients according to medical diagnosis for purposes of reimbursement; pertains to the Medicare and Medicaid system for reimbursement of charges to private or public health care providers.

Question 56

1st, 2nd and Third Party Reimbursement-

Answer 56

First party is client, second party is health care provider and third party is the insurance carrier that reimburses services rendered.

Question 57

Therapeutic Recreation Financing Types

Answer 57

• Routine service- cost is built into the operating costs or overhead of facility.
• Ancillary service- the recipient in charge directly or the facility is reimbursed in part or whole by a 3rd party.
• Some TR services are financed through contributors, grants, fundraising projects and contracts.

Question 58

Area and Facility/ equipment management

Answer 58

Frequently TRSs are responsible for area and facility management. Important to understand how the areas and facilities are going to be used. A TRS needs to have a good understanding of accessibility standards and requirements for specific recreation areas such as trails or playgrounds or pools. Important for the TRS to develop and continually update a risk management plan for each area and facility. A risk management plan will evaluate the amount of risk that an area or piece of equipment may present and established policies and procedures that staff must follow in order to reduce risk.

Question 59

Accessibility Standards & Specific Recreation Areas

Answer 59

The 2010 Standards set minimum requirements – both scoping and technical – for newly designed and constructed or altered State and local government facilities, public accommodations, and commercial facilities to be readily accessible to and usable by individuals with disabilities. State and local government facilities must follow the requirements of the 2010 Standards, including both the Title II regulations at 28 CFR 35.151; and the 2004 ADAAG at 36 CFR part 1191, appendices B and D. Public accommodations and commercial facilities must follow the requirements of the 2010 Standards, including both the Title III regulations at 28 CFR part 36, subpart D; and the 2004 ADAAG at 36 CFR part 1191, appendices B and D. Restaurants and Cafeterias: In restaurants and cafeterias, an accessible route shall be provided to all dining areas, including raised or sunken dining areas, and outdoor dining areas. EXCEPTIONS: 1. In buildings or facilities not required to provide an accessible route between stories, an accessible route shall not be required to a mezzanine dining area where the mezzanine contains less than 25 percent of the total combined area for seating and dining and where the same decor and services are provided in the accessible area. 2. In alterations, an accessible route shall not be required to existing raised or sunken dining areas, or to all parts of existing outdoor dining areas where the same services and decor are provided in an accessible space usable by the public and not restricted to use by people with disabilities. Bowling Lanes: Where bowling lanes are provided, at least 5 percent, but no fewer than one of each type of bowling lane, shall be on an accessible route. Court Sports: In court sports, at least one accessible route shall directly connect both sides of the court. Ground Level Play Components: Examples of ground level play components may include spring rockers, swings, diggers, and stand-alone slides. When distinguishing between the different types of ground level play components, consider the general experience provided by the play component. Examples of different types of experiences include, but are not limited to, rocking, swinging, climbing, spinning, and sliding. Ground level play components accessed by children with disabilities must be integrated into the play area. Designers should consider the optimal layout of ground level play components accessed by children with disabilities to foster interaction and socialization among all children. Grouping all ground level play components accessed by children with disabilities in one location is not considered integrated. Pools-At least two accessible means of entry shall be provided for swimming pools. Accessible means of entry shall be swimming pool lifts complying with 1009.2; sloped entries complying with 1009.3; transfer walls complying with 1009.4; transfer systems complying with 1009.5; and pool stairs complying with 1009.6. At least one accessible means of entry provided shall comply with 1009.2 or 1009.3. Where more than one means of access is provided into the water, it is recommended that the means be different. Providing different means of access will better serve the varying needs of people with disabilities in getting into and out of a swimming pool. It is also recommended that where two or more means of access are provided, they not be provided in the same location in the pool. Different locations will provide increased options for entry and exit, especially in larger pools.

Question 60

Physical Accessibility

Answer 60

Recreation areas are barrier-free and people w/ disabilities can approach, enter and use them unrestricted. Approach- People w/ disabilities should be able to approach a recreation facility without encountering obstacles. Ex.- curb cuts near the facility or ramps will allow for accessible routes of travel. Accessible, clearly marked and well-designed parking spaces. Enter- Once a person w/ disability approaches a recreation facility, the entrance must be accessible. Accessible entrances must be clearly marked. Doors that pull open easily or a bell that rings for access are examples of accessible entrances. Doors must be wide and light enough and thresholds low enough to allow entrance. Double doors must not impede entrance. Use- Once inside a recreation area or facility, people w/ disabilities must be able to use the facility. Are the restrooms accessible? Can a person w/ a disability access the concession area? Is playground equipment accessible? If a person can approach and enter a recreation area, but not use it like their peers, then it is NOT accessible. Often to use a facility or program effectively some accommodations or supports may be needed. Examples of accommodations include an interpreter, assistance from a volunteer, or a piece of adaptive equipment. Conveniences- Accommodations provided beyond approach, enter and use are considered conveniences. Ex.- automatic door opener.

Question 61

Universal Accessibility

Answer 61

A design approach that ensures maximum inclusion and participation by everyone. Based on the belief that people who have disabilities should have the same access to buildings and facilities that other citizens enjoy.

Question 62

Americans With Disabilities Act ADA (P.L. 101-336) & Titles

Answer 62

Passed in 1990. Purpose of the ADA is to end discrimination against individuals with disabilities and to welcome them into all walks of life so they may enjoy the same privileges as other citizens. ADA focuses on physical accessibility and program accessibility. ADA applies to public funded services (local, county, district, state, federal), not-for-profit agencies or services (YMCA, Girl Scouts, camps, Easter Seals) and private for profit enterprises (bowling alleys, movie theaters, amusement parks). ADA covers anyone who has a disability or is regarded as having a disability and anyone who may face discrimination due to their relationship w/ persons with disabilities. 5 Major Titles of the ADA- Title 1 employment, Title 2a state/local government, Title 2b transportation, Title 3businesses/public accommodations, Title 4 communications, Title 5 miscellaneous (enforcement issues).

Question 63

Improving Accessibility for Mobility Impairments

Answer 63

Path of Travel- A pathway should connect separate buildings or activity areas within the same site. Designate parking for people w/ disabilities as close as possible to the accessible entrance. A smooth, firm pathway of nonslip material at least 36 inches wide, with no unramped changes of level should lead from the parking area to the entrance. A 36 inch wide path of travel with no unramped changes of level should connect activity areas within the building. Securely anchor carpets and mats to floor surfaces. Rearrange furniture and remove obstacles for a 36 inch clear path of travel and a 5 foot diameter space wherever at 360 degree turn is necessary for wheelchair users. Replace widely spaced grates with ones with less than one half inch wide openings. Doors- at inaccessible entrances, place signs bearing the International Symbol of Accessibility and an arrow indicating the location of the accessible entrance. Doorways should have 32 inches minimum clearance. Replace doorknobs with lever or loop handles. Remove or lower thresholds, or add a wedge on both sides of threshold to ease movement and prevent tripping. Install doormats one half inch thick or less. Stairs, Ramps and Elevators- Hold meetings/events in spaces that do not require stairs. Add nonslip treads to stairs. Ramps should be sloped at 1:12 or less. Restrooms- Install a handle on the inside of the stall door. Replace stall door hinges with self-closing type. Relocate paper towel and other dispensers to a maximum of 42 inches above the floor. Provide knee space below the sink at 27 inches high, 30 inches wide and 22 inches deep. Enlarge the stall to accommodate grab bars and an accessible toilet. Provide a 5 foot turning space in the communal part of the restroom. Install paddle faucet controls. Insulate the pipes under the sink.

Question 64

Improving Accessibility for Hearing/Speech Impairments

Answer 64

Have telephone amplifiers, assistive listening systems, real-time reporters, telecommunication display device (TDD) or teletypewriter (TTY), telecommunication relay services, interpreters and emergency warning systems (audible and visual).

Question 65

Improving Accessibility for Visual Impairments

Answer 65

Remove protruding objects, such as wall-mounted telephones and drinking fountains, or recess them into the wall to widen the passageway. Place handrails on both sides of stairs and ramps. Add a 1 inch strip of contrasting color to the nosing of each step to help people with limited sight or depth perception see the stair edge. Avoid reorganizing storage areas or furniture frequently. Improve lighting within the facility, especially in stairwells. Use high contrast colors in decorating the facility. Floors, sidewalks, stairs and ramps should be covered or constructed with a nonslip material. Secure the edges of carpets or mats to the floor. Install edge strips where floor surfaces change. Install tactile floor numbers in raised print and Braille on both sides of elevator door jams and on the control panel. Avoid installation of solid glass doors. If they are already installed, place a color decal on windows adjacent to glass doors to distinguish between the 2. Install signs that have large print, raised lettering and Braille. Light letters on dark background are easiest to see. Tactile and low vision signage should be placed on the wall next to the door opening, not on the door itself. Install audible signals in elevators to indicate the opening and closing of the doors and the passage of the floors.

Question 66

Equipment Management

Answer 66

Systems-designed programs may require specific facilities, equipment and/or supplies. Part of the implementation description delineates the necessary facilities and objects. Important to have a master list of all needed items at the beginning of the program materials.

Question 67

Variety of sources that TR services may receive funding

Answer 67

These revenue sources include tax based appropriations from the federal, state or local government, grants and contracts, contributions and donations, fees, charges and reimbursement and a combination of any of the sources mentioned above. Important for the entry-level TRS to understand the source of program revenue.
•Most community programs revenues are tax-based appropriations and fees for services. Within health care facilities, most consumers are charged directly for services and these charges may be paid by insurance companies or 3rd party payers.
•TR services are considered either ancillary services or routine services. Ancillary services are usually prescribed by a physician to meet a consumer need. Routine services are those provided as a part of basic services and are usually built into the overhead or operating costs.

Question 68

Types of Budgets

Answer 68

Revenue & Expense/ Operating Budget, Capital Expenditure, Program Budget, Zero-based Budget and Flexible Budget

Question 69

Revenue & Expense/ Operating Budget

Answer 69

This type of budget outlines the day-to-day expenses and revenues for a year.

Question 70

Capital Expenditure

Answer 70

Budget related to long range planning and usually spans a 3 to 5 year period.

Question 71

Program Budget

Answer 71

Focused on meeting goals and objectives or allocating resources based on costs and benefits of specific programs.

Question 72

Zero-based Budget

Answer 72

Requires that a manager is re-evaluating the programs within their department annually. Every program must be re-justified, and just because a program was funded one year at a certain level does not mean it will be again. A manager using a zero-based budgeting is forced to set priorities and justify resources annually.

Question 73

Flexible Budget

Answer 73

Allows a manager to adjust a budget dependent upon expected occurrences like a smaller number of patients or patients who are more severely injured and require different, perhaps more intense, interventions than previously budgeted.