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Running Head: COMPREHENSIVE PROGRAM PLAN 1

Comprehensive Program Plan

Dunatos Physical Rehabilitation Center

Amy Calderon

Taylor Cox

Kelsey Obando

Florida International University

COMPREHENSIVE PROGRAM PLAN 2

Abstract

This Comprehensive Program Plan (CPP) examines the design of Dunatos Rehabilitation.

Dunatos is a non-profit outpatient rehabilitation facility that provides therapeutic recreation

services to adults with physical disabilities, neurological disorders, and surgical rehabilitation, in

the Miami-Dade County area. It also provides physical, occupational, and speech/language

therapy. This CPP contains two parts. The first section describes the analysis, which is divided

into five sections: the community, the agency, the therapeutic recreation department, the clients

and the therapeutic recreation program. The conceptualization section has three sections:

implementation description, the program plan, and content and process.


Table of Contents

Abstract……………………………………………………………………………………. 2

Table of Contents………………………………………………………………………….. 3

Analysis……………………………………………………………………………………. 6

Community………………………………………………………………………… 6

Demographics and Geographic Variables………………………………….. 6

Seasonal Variable, Economic Conditions and Resources…………………... 6

Agency……………………………………………………………………………… 7

Description………………………………………………………………….. 7

Mission…………………………………………………………………......... 8

Regulatory Body(ies)……………………………………………………….. 8

Organizational Chart………………………………………………………... 9

Resources…………………………………………………………………..... 10

Staff………………………………………………………………….. 10

Facilities……………………………………………………………… 11

Budget……………………………………………………………….. 11

Therapeutic Recreation Department……………………………………………....... 12

Mission……………………………………………………………………... 12

Background and History…………………………………………………..... 12

Staffs………………………………………………………………………... 13

Volunteers………………………………………………………...... 17

Internships………………………………………………………….. 19

Facilities…………………………………………………………………….. 21

Budget………………………………………………………………………. 23

Clients……………………………………………………………………………… 27

Demographic……………………………………………………………….. 27

Diagnoses/Disabilities………………………………………………………. 27


Description of Clients………………………………………………………… 32

Therapeutic Recreation Profession…………………………………………………… 33

Philosophy of TR Practice Model…………………………………………….. 33

Impact of Standard of Care and Code of Ethics………………………………. 33

Credential/Professional Preparation of Staff………………………………….. 34

Professional Membership Held by Staff………………………………………. 34

Continue Education/Professional Development………………………………. 34

Other Professional Resources…………………………………………………. 34

References…………………………………………………………………………………….. 36

Appendix…………………………………………………………………………………….... 43

Appendix A: Hospital, Services, and Department’s Organizational Chart…………… 43

Appendix B: Dunatos’ Organizational Chart…………………………………………. 44

Appendix C: Dunatos’ Floor Plan…………………………………………………….. 45

Appendix D: Dunatos’ Line Item Budget……………………………………………... 46

Appendix E: Job Descriptions of TR………………………………………………….. 47

Appendix F: Competency Assessment………………………………………………... 55

Appendix G: Description for Music Therapist………………………………………... 58

Appendix H: Volunteer Application…………………………………………………... 59

Appendix I: Therapeutic Recreation Programs………………………………………... 62

Appendix J: Internship Guidelines, Job Description, and Application……………….. 65

Appendix K: Intern Clinical Performance Appraisal………………………………..... 69

Appendix L: Outline of the TR Rooms……………………………………………….... 83

Appendix M: Dunatos’ TR Department Line Item Budget and Details……………….. 85

Appendix N: Miami-Dade County Population…………………………………………. 88

Appendix O: Age by Number of Disabilities………………………………………….. 89

Appendix P: Leisure Ability Model……………………………………………………. 91

Appendix Q: ATRA Code of Ethics…………………………………………………..... 92


Appendix R: ATRA Standard of Practice………………………………………………. 94

Appendix S: ATRA Patient’s/Client’s Bill of Rights………………………………….. 95

Appendix T: ATRA Self-Assessment Guide…………………………………………… 96

Appendix U: Client Questionnaire…………………………………………………….. 118

Appendix V: Professional Eligibility Application…………………………………….. 119

Appendix W: Public Agency Membership Application………………………………. 122

Appendix X: ATRA Annual Conference……………………………………………... 123


Comprehensive Program Plan: Physical Rehabilitation Center

Analysis

The Community

Demographics and Geographic Variables. Dunatos Rehabilitation Center is a health

care organization with an outstanding reputation for medical and service excellence. Dunatos is a

primary healthcare, not-for-profit organization located in South Florida. Our outpatient

rehabilitation facility, located in Kendall, provides occupational therapists, physical therapists,

speech/language therapists, and recreational therapists to service individuals with physical

disabilities, neurological disorders, and surgical rehabilitation.

Being located in Miami, Dunatos Rehabilitation Center can serve a myriad of

demographics. The population receiving treatment will consist primarily of adult residents of

Miami-Dade County. The state of Florida, as a whole, exhibits a graying population (Jacobsen,

Kent, Lee, Mather, 2014). However, the median age of Miami is 38.2 years, the lowest median

age in the state of Florida. According to the 2010 Census, the largest Miami racial/ethnic groups

are Hispanic (70.3%), followed by Black (16.9%), and White (11.3%). The largest reported

religious affiliation in Miami-Dade County is Catholic, which comes in at 21.8% of Miami’s

population (Religions in Miami-Dade County, Fl).

Seasonal Variables, Economic Conditions, and Resources. A multitude of variables

such as weather, socioeconomic conditions, and available resources affect the population we

serve. Miami has a tropical climate with hot summers and comfortable winters. This allows for

outdoor activities to be pursued year round. According to the Census Bureau, the median

household income for Miami was $57,927, while 10.2% of the county falls below poverty level


(Miami-Dade County QuickFacts from the US Census Bureau). Community transportation is

easily accessible by SR 821 (the Turnpike) and SR 826 (The Palmetto Expressway) via exiting

on North Kendall Dr. The city of Miami provides several options for public transportation to and

from the facility: STS (Special Transportation Services), Metrorail, and Metrobus. STS provides

paratransit to people with disabilities. The Metrorail system is an elevated transit system that

provides service to Miami International Airport and runs from Kendall through South Miami,

Coral Gables, and downtown Miami. The Metrobus serves all major shopping, entertainment and

cultural centers, as well as major hospitals and schools.

According to US disability statistics, 25.7% of Miami’s residents are considered disabled;

making Miami above the national average (Florida Disability Population Statistics, 2007). The

city of Miami, in comparison to cities with over 100,000 residents, has the second highest

percentage of people with disabilities in the nation. Besides our agency, other facilities that

provide rehabilitation care within Miami-Dade County include but are not limited to: Jackson

Memorial Hospital, Miami VA Healthcare System, and St. Anne’s Nursing Center.

The agency

Description. Dunatos’ outpatient facility provides modern surgical, diagnostic, and

urgent care services to its population. The therapeutic recreation department at our facility

services primarily adults with physical disabilities, neurological disorders, and surgical

rehabilitation. In 1980, Dunatos Rehabilitation was founded on its Greek meaning. Defined as

meaning “to be able”, to do something with excellence, and to be strong, Dunatos encompassed

everything that therapy sought out to provide: to make its patients able again. Our facility

focuses on abilities and not on the disabilities, as seen in the definition of Dunatos. The agency is


committed to serving the community. We are dedicated to providing cutting-edge medical care

as a non-profit healthcare organization. Our goal is to provide a patient-centered health care

experience. Our outpatient rehabilitation center is dedicated to continuing the recovery process

after hospital admission and inpatient rehabilitation.

Agency Mandate, Mission, and Vision

Mandate

The facility is dedicated to providing a broad range of health care services to the Miami

area. Dunatos provides high-quality care to the sick, injured, and disabled on an

outpatient basis.

Mission

Dunatos Rehabilitation strives to make people able again. It exists to provide quality;

patient-centered therapeutic services, and health education while improving function,

instilling independence, and above all, improving one’s quality of life.

Vision

We will continue to be the forerunners in therapy by applying clinical research to our

repertoire of therapeutic services.

Regulatory Bodies. The center is fully accredited by the Joint Commission on

Accreditation and Healthcare (JCAHO) and the Commission on Accreditation of Rehabilitation

Facilities (CARF). The JCAHO recognizes quality care and reflects an organization’s

commitment to meeting checkpoints of performance standards. Their vision is to always provide

people with the safest, highest quality, best-value health care across all settings (The Joint


Commission: About Us). Through accreditation, CARF assists healthcare providers in improving

the quality of their services, demonstrating values, and meeting internationally recognized

organizational and program standards (Commission on Accreditation of Rehabilitation

Facilities). Ultimately, accreditation by CARF, applies a set of standards to service areas and

practices. Further, the therapeutic recreation department follows the standards set by ATRA and

NCTRC, which will be further described in the discussion of the therapeutic recreation

profession. Accreditation is not a once-for-all process; instead accreditation is an ongoing

practice that makes it known to the public that the facility is committed to continuously

improving. The Rehabilitation Service Administration, often known as the “Rehab Act,” was

installed in 1973 and prohibits discrimination on the basis of disability in federal run programs,

agencies that receive federal funding, federal employment, and in the employment federal

contractors. Regulatory bodies are verification bodies of competent, quality care that is provided

by Dunatos’ outpatient facility.

Agency Organization. Since we function as a hospital’s outpatient rehabilitation facility, we

ultimately abide under the board of directors. The rehabilitation organization tiers allow for

efficient management of all departments. It also designates where each department reports to. A

board of directors is in charge of the hospital. The Therapeutic Services department falls under

rehabilitation and covers OT, PT, and Speech/Language Therapists. The hospital we are

associated with is run by a board of directors. The chief financial officer, medical director, and

administration are all under the chief executive officer of the hospital. After this tier,

informational services, therapeutic services, diagnostic services, and support services are further

broken down. The therapeutic recreation department reports to the Therapeutic Services

Department. The organizational breakdown of the hospital, its services, and array of departments


can be seen in Appendix A. Specifically, Dunatos’ Rehabilitation hierarchy is depicted in

Appendix B.

Agency Resources

Staff. Dunatos Rehabilitation has 3 full-time physical therapists, 3 full-time occupational

therapists, 2 full-time speech/language therapists, and several therapeutic recreation specialists

employed. The therapeutic recreation department staffs: a full-time manager of therapeutic

recreation, two full-time therapeutic recreation specialists, one full-time therapeutic recreation

assistant, one- part time aquatic therapist, and one part-time art therapist. Our contracted services

provide transportation for therapeutic outings and 1 part time music therapist. Not only does

Dunatos hire and supply an array of therapists and therapy, they also provide volunteer and

internship opportunities. Our facility first opened in 1980, where it had only PT’ and OT’s. As

we expanded our facilities, Dunatos began to provide speech/language therapy in 1985, and in

1991, two therapeutic recreation specialists were hired. Today, Dunatos is a state of the art

agency that provides excellence. The hospital we are associated with is non-profit resulting in

our facility being a non-profit as well.

All of the departments work together to better client’s quality of life. There are times

where the client may be assigned to physical and occupational therapist for treatment. There are

several clients that may complete physical therapy, and then once they finish their session, that

same client may also work with a therapeutic recreation specialist to understand their disability,

and to learn how to find resources where he/she can participate without their disability being a

barrier. The occupational and speech/language therapy department may also work with the

therapeutic recreation department. The clients who seek speech/language therapy may have some


trouble socializing with others. The therapeutic recreation specialist can help clients feel

comfortable speaking and socializing with others by having them participate in interventions that

available in the TR department. All departments are available for co-treatments.

Facilities. Our multi-disciplinary clinical team allows the clients to experience and

benefit the most from their therapy. Our 10,000 square foot facility includes: a RT Room for

Discussion & Activities on Leisure Development, Leisure Education, & Community

Reintegration, an RT Room for Discussion & Activities on Music and Art Therapy, 2

speech/language therapy rooms, 2 Occupational Therapy rooms, 2 Physical Therapy rooms, an

Olympic sized lap pool to be used by all departments, and an area for balance, strength, exercise,

and additional adaptive products. The floor plan for Dunatos Outpatient Rehabilitation facility

can be seen in Appendix C. The Olympic sized lap pool can be used for physical therapy,

occupational therapy, or aquatic therapy. Dunatos rehabilitation center is available to all the

forms of therapeutic services offered within the agency. The concept behind our facility is to

offer the most “inclusive” therapy that can be provided.

Budget. The agency receives its budget from service fees, external funds and fundraisers.

Fundraisers are held throughout the year, and the money made from the fundraiser events are

distributed to all departments. The external funds come from grants and donations. In a year, the

agency receives 1.2 million from grants and $150,000 from donations. To review the agency

budget, the head chair of therapeutic services first meets with the managers of the physical

therapy, occupational therapy, speech/language therapy, and the therapeutic recreation

department to review the expenses and revenues for each department. Then the head chair,

discusses how the money will be distributed throughout the agency. The head chair of

therapeutic services will point out that since the exercise equipment is used by all, it will be


covered by the agency. After this meeting with the managers, the head chair would send out the

proposed budget to the board of directors, and wait for their approval. The yearly budget for

Dunatos Rehabilitation Center can be seen in Appendix D.

The TR Department

Mission

Dunatos’ Therapeutic Recreation department’s mission is to help people with a

temporary or permanent disability caused by injury or disease be able to live as independently as

possible and to improve their quality of life through the use of recreation activities, leisure

education, skill development, and community reintegration.

Background and History. As mentioned before, in 1980, Dunatos open its doors. The

first services offered were physical therapy and occupational therapy. Therapeutic recreation

wasn’t well known to people and for some; leisure activities seemed like a waste of time.

According to Recreational Therapy Timeline, around the time Dunatos was in service, the field

of therapeutic recreation was slowly progressing by developing their standards of practice and

guidelines for administration of therapeutic recreation services for clinical settings (1979), the

National Council for Therapeutic Certification became a credentialing body (1981), and the

philosophy of therapeutic recreation was published (1987). Therapeutic Recreation was defined

as a “health care and human service discipline that delivers treatment services designed to

restore, remediate and/or rehabilitate functional capabilities for persons with injuries, chronic

illnesses and all types of disabling conditions.” (ATRA)

The progression of the therapeutic recreation field caught the attention of Dunatos. The

board of directors gathered for a meeting about expanding the facility to provide more services.


After several meetings and research, in 1991, the board of directors decided to hire two certified

therapeutic recreation specialists. As the abilities of the clients began to improve with the help of

the therapeutic recreation specialist, the agency decided to develop a department solely on

therapeutic recreation. A year after expanding the facility, the therapeutic recreation department

became official and more staffs were hired. By 2000, the department had a manger, three full-

time employees, two part-time employees, and an agreement with several contract services. This

is the same year that the NTRS developed the “Therapeutic Recreation – The Benefits are

Endless.” (Recreation Therapy Timeline) This improved the services in Donatos by attracting

more clients to try the program and to understand that the interventions done in the TR

department are used to enhance the client’s quality of life.

Staff. All staffs in the TR department play an important role in helping the clients better their

lifestyle. The manager of the TR department is a full-time employee who is primarily responsible

for planning and coordinating the therapeutic recreational activities for the clients of the program

with the proper guidelines and regulations. The manager must have a master’s degree in

therapeutic recreation, be a NCTRC certified TR specialist, and must have at least two years

experience with the adult population. Under the manager, there are two full-time therapeutic

recreation specialists. These employees need to have a bachelor’s degree in therapeutic

recreation, be NCTRC certified TR specialist, and have experience with the adult population

with physical disabilities. There is a full time therapeutic recreation assistant employed as well.

The therapeutic recreation assistant’s job purpose is to assist in planning, organizing,

documenting and implementing recreational activities for people with physical disabilities

(Recreation Therapy Aide, 2015). As an assistant, this individual will need a bachelor’s degree in

therapeutic recreation, and one year experience in the field. The TR department has a part-time


art therapist employed. This individual needs to be a registered art therapist, must become board

certified (ATR-BC), and be a licensed clinical professional counselor. An aquatic therapist is

employed as a part-timer. This employee needs an Aquatic Therapy and Rehab Industry

Certification, an Aquatic Fitness Certification, NCTRC certified therapeutic recreation specialist,

and basic aquatic certifications, which includes being a certified water safety instructor, and

lifesaving through the Red Cross (Jake, 2008).

As a manager of the TR department, this individual has the ability to serve as a resource

to the staff, to communicate effectively, to plan and provide both group and individual activities

pertaining to the therapeutic recreation goals, and can reflect the mission of the TR department in

all actions among the staff, with the clients, and in the community in which the agency serves

(Pledmont Health, 2014). The manager is responsible for “documenting in the plan of operation

their staff member’s credentials and the procedures that ensure staffs maintain their competence

in areas relevant to the programs/services offered.” (Carter, Andel, & Robb, 2003) The manager

is also considered the volunteer and internship supervisor.

As a certified therapeutic recreation specialist who works under the manager of therapeutic

recreation, this individual is able to create treatment plans and programs that meet the clients’

needs and interest; is able to implement interventions that are “right” for the client; can

intrinsically involve the clients in therapeutic activities; has the ability to help the clients learn how

to be socially interacted in the community; a knowledge in how to record and analyze a client’s

progress effectively; and is able to evaluate interventions for effectiveness (Bureau of Labor

Statistics, 2014).


As a therapeutic recreation assistant, this individual has the ability to assist with or conduct

groups and individual activities; assist the therapeutic recreation specialist in assessments and

interventions; motivate clients to encourage participation in activities; ability to interact and get

feedback from other staffs; understand how to assess client activity needs, documents client’s

participation, and progress; and has the ability to produce and maintain accurate records and

reports (Description-Therapeutic Recreation Assistant, 2015).

In the TR department, the art therapist is much part of the team as the other staffs. The art

therapist has the ability to provide an open and comfortable atmosphere that promotes learning and

participation; must be patient, calm, and respectful to others; has the ability to deal with difficult

situations; is committed to helping others; has artistic abilities, creativity, and imagination; and has

a strong knowledge and understanding of the program and its ability to play a role in the clients’

treatment (target jobs, 2015).

As an Aquatic therapist specialist, this individual must be comfortable in water; is an

effective communicator, and enjoys working with groups or one on one with clients (Human

Kinetics, 2011). According to Human Kinetics (2011), aquatic therapist must be able to modify

rehabilitation exercises done on land in water. Aquatic therapist as well as all the employees under

the TR department must be aware of specific safety precautions when it comes to working with

people with physical disabilities.

The job descriptions for the Manager of Therapeutic Recreation, the Therapeutic

Recreation Specialist, the Therapeutic Recreation Assistant, the Certified Art Therapist, and the

Certified Aquatic Therapist can be seen in Appendix E. For all the TR department staffs, there are

several important qualities they must have in order to successfully help the clients through the


program. Those qualities are compassion, critical-thinking skills, leadership skills, listening skills,

patience, and speaking skills (College Grad, 2015). The job description for each TR position

describes their purpose, responsibilities, and qualifications. Another component that the Manager

of the TR department does is for new staffs, they must undergo a competency assessment

developed by the ATRA Standards of Practice. The competency assessment can be seen in

appendix F. The assessment is done in the first three weeks of employment. The assessment will

be done for the purpose of seeing whether the employee can demonstrate the knowledge, abilities,

and skills needed to achieve the job. (Standard for the Practice of Recreational Therapy)

The likelihood of increasing the therapeutic recreation staff is probable. The employment

of therapeutic recreation specialist is expected to increase by thirteen percent from 2012 to 2022.

This is as fast as the average of all occupations (Bureau of Labor Statistics, 2014). Since the

number of people with chronic conditions and obesity are growing, therapeutic recreation

specialists will be needed to help the clients manage their conditions. According to the NCTRC,

there has been a steady growth of certified professionals over the past 33 years. This signifies that

more and more individuals are becoming aware of the profession; hence, spreading the beneficial

outcomes of therapeutic recreation. Also, according to Bureau of Labor Statistics (2014), in order

to cut cost of clients’ recoveries from injuries or illnesses, third party payers will continue to use

therapeutic recreation services. As more people become aware and come to respect the role the TR

profession plays in an individual’s life, the more TR staff will be needed to help the department.

Contract Services. The TR department has a part-time music therapist employed to help

the client progress through their treatment. This will expand the TR department by providing a

different intervention that can be incorporated to the program. The music therapist needs to have a

bachelor’s degree in music therapy, be certified under the certification board for music therapists,


and have at least two years experience with the adult population with physical disabilities. This

individual will need to have interpersonal skills as well as be open to new ideas (music therapy,

2015). The music therapist will come in three times a week, and will instruct several sessions

throughout the day. The job description can be seen in Appendix G. They are paid differently from

the staff in the department. The TR department hires a transportation service to provide accessible

vans for recreational trips. This will enhance the TR department’s community reintegration

sessions by actually taking the clients to outings such as the zoo, park, and museums around the

Miami, FL area. On occasion, the department will use the transportation services. They will be

notified by the TR department manager when the staff will need to utilize their services.

Volunteers. Volunteers are welcomed to join the therapeutic recreation department. They

play a significant role in the department and are respected like an employee and an intern. The

TR department recruits volunteers by visiting high schools near the facility, and asking the

principal to make an announcement about volunteering opportunities at the facility. The TR

department is also registered under service learning. Most of the time, the volunteers hear about

the facility by word of mouth. If there are individuals who are interested in volunteering, they

must complete several requirements prior to starting. The individual must be at least 16 years of

age to volunteer, must have a valid photo ID, and must commit to at least 50 hours of volunteer

service. They will need to contact the volunteer supervisor of the department by emailing,

calling, or visiting (preferably email), and express their interest, and request information

regarding becoming part of the team. The individual will first need to fill out an application (See

Appendix H). The volunteer supervisor will notify the individual of an interview opportunity.

The department, as well as the whole agency, is dedicated to providing care of the highest quality


and in doing so, background checks are required for all volunteers (If under the age of 18,

background check are not required).

Once the individual has successfully shown the volunteer supervisor that he/she has

interest and quality that the TR department is looking for, and has passed the background check

(if over 18), he/she must attend a volunteer orientation. They will be given an outline of what will

be discussed during the orientation; that way they could follow the speaker. The topics that will

be covered in the orientation include the TR department services, their values, their mission,

policies, procedures, infection control, customer service, TB skin test, and confidentiality

(Sheltering Arms Volunteer Requirements, 2015). If the individual is under the age of 18, he/she

will need a parent/guardian to attend the orientation as well. The TR department will want the

parent/guardian to understand what it is to be expected from the individual, and to be aware of

certain rules and regulations under the department. These orientations are held every other month

on Wednesdays.

The volunteer program requires all the volunteers to have a tuberculin skin test and a

screening for tuberculosis prior to the start of their volunteer services. If the volunteer already

had a tuberculosis test in the last 12 months, and has a copy of records demonstrating the date the

test was administered, the individual does not need to retake the test. Once the individual fills out

the application, has gone through the interview, attended the mandatory orientation, has done the

background check, and has been cleared for the tuberculin skin test and screening for

tuberculosis, the individual can start volunteering. The volunteers will be able to choose their

schedule as long as they complete the 50 hours of service required.


The volunteer services are used in the TR department several ways. They will be

assigned to do different task throughout the time they are volunteering in the department. The

volunteers will assist the employees in reinforcing social and therapeutic processes by helping

clients participate in crafts, games, and entertainment activities. The TR department offers

different programs to their clients in which the volunteers may be incorporated into. Appendix I

will illustrate the different programs offered in the TR department. The volunteer may be

partaking in setting up a room with paint, paper, color pencils, and other equipment needed for

creative arts. They may also assist the therapeutic recreation specialist in watching over the

clients playing recreational games such as board games or cards. Again, these are just a few tasks

the volunteers may participate in; the TR department, as well as the agency, appreciates all the

help from the volunteers. The volunteers will benefit from working under the TR department by

gathering hours that are needed to graduate high school, fulfilling a requirement for a college

course and by opening their mind to understand that they can make a difference in an

individual’s life.

Internships. Another element of the TR department within the physical rehabilitation

agency is the TR internship program. The individuals eligible to partake in this program are

college students who are majoring in therapeutic recreation. The internship program is year

round and would take up to 8 interns a time. Just like volunteers, there are several necessities that

need to be done prior to the start date. The individuals who are interested in joining the program

will need to complete an application and answer several essay questions, provide a copy of their

transcripts, and provide one letter of recommendation. A job description as well as several

guidelines and general information about the internship program are attached to the application

(see application in Appendix J). The individual will be emailed by the internship supervisor to


schedule an appointment for an interview, and he/she will need to provide a resume. A level 1

background check will be done as well.

Once the individual has done the requirements that were previously mentioned, they will

need to attend a mandatory orientation. The interns will attend the same orientation as the

volunteers. Once again, these orientations are held every other month on Wednesdays. They will

also need to complete a tuberculin skin test and a screening for tuberculosis just like the volunteers

are required to do. The individuals who are interested in interning at the agency under the TR

department will need to understand that these requirements will take some time to complete, so it

is the individual’s responsibility to contact the internship supervisor with sufficient amount of time

to get all the paperwork as well as the other requirements done. The TR internship program will

also require the interns to be able to communicate effectively, and to be patient when addressing

the clients. The dress code is closed shoes, slacks or neat khaki pants, shirt/blouses with sleeves,

and name badge. The intern is expected to come to work on time and to be professional.

The TR internship program abides by the requirements acknowledged by the National

Council for Therapeutic Recreation Certification (NCTRC), and respects their standards. The

intern will be required to complete a minimum of 560 hours in 14 consecutive weeks under the

supervision of both academic and agency internship supervisor who is NCTRC CTRS certified

(NCTRC, 2015). The intern will need to come in Monday through Friday from 9:00a.m to

6:00p.m. (One hour lunch break). There may be times that due to a recreational event, they will be

schedule in during a different time slot; however, they will be notified two weeks prior to the

event. The intern must understand that they will be working full time (40 hours a week) and will

not get paid; however, they must not treat this any less than a job.


During the time the intern is on duty, they will either be accompanied by the internship

supervisor or by a NCTRC certified therapeutic recreation specialist. They will assist the TR

specialist in preparing activities, incorporating the clients to the activities, cleaning up, giving

constructive feedback to the supervisor, and making sure that the program in which they are

partaking in are running smoothly with the help of the supervisor. The intern will rotate every two

weeks to the different programs in the TR department. This will give the intern an opportunity to

help and explore different interventions that are offered in the TR department. The intern will need

to demonstrate acknowledgment and progress throughout the time he/she is working in the agency.

The internship supervisor will conduct a clinical performance appraisal from the “Standard for the

Practice of Recreational Therapy” in week 7 as well as at the end of the internship program. This

appraisal is done so the intern supervisor can observed performance levels of the interns and give

the opportunities for improvement (SOP, 2013). It is also done to assure that the clients are

receiving the best care. The clinical performance appraisal can be seen in Appendix K.

This Interning under the TR department in the psychical rehabilitation agency will give the

intern an in-depth experience with people with physical disabilities. This experience will help the

interns better understand and respect the difference that a therapeutic recreation specialist does to

an individuals’ quality of life. Most of all, it will be an enjoyable and educational experience.

Facilities. The whole agency has been checked by the ADA for any sort of accessibility

barriers or issues that can come about from the structure of the building as well as placements of

certain objects. The TR department has two rooms reserve in the facility for their use. One of

these rooms is particularly used for music and art therapy. The other room is used for sessions on

leisure skill development, leisure education, and knowledge of accessibility issues and problem

solving skills for community reintegration training (RIC, 2015). These two rooms are used daily;


while a TR specialist is instructing a session in one room, the art therapist can be leading a

session in the other room. The layout of the rooms can be seen in appendix L. The TR

department and the other departments in the facility share the exercise equipment. The staffs of

all departments are constantly contacting each other to arrange a schedule where each

department has a certain time in the day to utilize the exercise equipment. Sometimes, both of

these departments will be utilizing the equipment at the same time; however, the TR staffs and

the other department have come into an agreement of who uses certain equipment. There is also

a therapeutic pool available in the facility. The sessions held in the pool are done by an

individual who is certified in CPR, water safety, and lifesaving and other certifications that were

previously mention for an aquatic therapist.

Equipment. The equipment that the TR department uses are art and craft supplies such as

construction paper, color pencils, crayons, paint, palettes, paint brushes, watercolor, yarn,

ribbons, beads, glue, scissors and other related equipment; musical instruments such as a piano,

three guitars, three percussions, and a radio; and aquatic equipment such as water dumbbells, hip

floats, noodles, posture pillows to support the neck, aquatic foam collars, and belts. The pool is

equipped with a lift, stainless steel ramps, and two platforms. Radios, billiards supplies, play

cards and several board games will also be utilized by the TR department. The exercise

equipment is funded by the agency; all departments utilized these equipments. The equipment

used is dumbbells, therapy balls, treadmills, stationary bicycle, hand cycles, and exercise steps.

These equipments would help enhance the sessions by encouraging the clients to utilize their

cognitive, physical, and social functions. The equipment will also present the client with

activities that will both be helpful and fun. It will have the clients think about their abilities rather

than their disabilities.


Transportation. Transportation services will be used for outings such as the zoo,

museums, park, and bowling. This will be done to educate the client of several community

functions around Miami. This will make the clients realize the many resources and places they

could go to and still participate in. It will make them feel belonged in their community. The TR

department uses a transportation service that is accessible for people with physical disabilities.

When going to outings, the TR department manager will contact the transportation service a

month in advance to schedule a day and time they will need their services. On average, the

transportation service will be used twice a month (one outing every two weeks). For comfortable

riding, two vans will be utilized for these outings. These vans will have side and rear wheelchair

lift ambulattes that are ADA compliant (Mobility Works, 2015). These sessions are done, so the

clients can apply the strategies, thoughts, and techniques the therapeutic recreation specialist had

taught and discussed.

Budget. Dunato’s therapeutic department receives its current budget from the agency,

grants, donations, and fundraisers that are held during different times throughout the year. The

TR department budget is 27% covered by service fees. Out of the 27%, about 25% of it comes

from third-party reimbursement. Several clients may be under Medicaid that offers benefits in

being treated in therapeutic recreation services (Medicaid.gov). In donations and grants, the TR

department receives $240,000 a year, and in fundraising, the TR department makes $30,000. The

therapeutic recreation department budget is reviewed with the Dunato’s head chair of therapeutic

services. At the same time, the budgets of the physical, occupational, and speech therapy

departments are reviewed. The managers of all therapeutic departments get together with the

head chair of the therapeutic services for a meeting and discuss the annual expenses as well as

the revenue that each department receives. Once the budget for each department is reviewed and


agreed upon all the department heads, the head chair of therapeutic services will sent out this

data to the board of directors to inform them about the financial details that will be incorporated

into each department.

The level of funding for the TR department is relatively lower compared to the other

departments in Dunatos. The other departments have been part of the organization longer than

the TR department. These departments have been well developed throughout the years, and have

provided services to more clients than the TR department. Also, therapeutic recreation is not as

popular as physical therapy, occupational therapy, and speech therapy. For these reasons, the

level funding for the other department is more than the TR department. The TR department;

however, have been working very well with the funding they receive. The staffs, volunteers, and

interns have been working in their best ability to provide excellent services to the clients with the

funding the department receives.

To supplement the TR department budget, the agency allows the staffs, volunteers, and

interns from all departments to host special events in a nearby park. The individual in charge of

the therapeutic services would meet with the manager of the park near the agency, and reserve

dates throughout the year to host these events. The events will last five hours and would offer

bake sales, food, bounce houses, outdoor/indoor activities run by several TR staffs, and a

walkathon. The people in these events will be able to participate for a small fee. The baking

goods and food would be donated and sold by the staffs, volunteers, interns, and other

supporters. The staffs would remind the participants that the money that is being made in these

events is used for the good of the organization. The managers of all departments will inform their

clients about these events once the dates get closer, and would also inform the neighborhoods

near the facility by handing out fliers and by word of mouth. The staffs would encourage their


clients to bring their family as well to participate in these outings. The money fundraised by

these events will be distributed equally between all the departments.

In the job description of the manager of the TR department, it states that this individual

would need to seek ideas from the participants about other programs that they may like the

department to offer. This is another way the TR department can supplement their budget that is

allowable by the agency; the department can offer other programs that their clients would like to

participate in. The manager of the TR department would need to review it with the head chair of

the therapeutic services and discuss the financial benefits of having such program. The manager

of the TR department can have surveys done as well as documents with considerations and the

number of people who would participate as evidence to show the interest in such programs.

The budget of Dunato’s TR department can be seen in Appendix M. The TR department

strives to provide excellent services, and to do so, money will be spent. The total expense of the

TR department is $349,496. This includes salaries, contract services, utilities, trainings and

education, and equipment. The total revenue that the TR department receives/earns is $370,000.

This includes grants, service fee, donations, and fundraisers. Based on the expenses and

revenues, the TR department will remain with $20,504. This money is called a surplus and it is

not to be pocketed. Dunatos is a nonprofit organization, so the money is invested back into the

department.

The salaries of the employees are the largest portion of the expenses in the TR

department; it totals to $234,606. This includes one full-time manager who receives a salary of

$54, 046; two full-time certified therapeutic recreation specialists who receives a salary of

$43,180 each; one full-time therapeutic recreation assistant who receives a salary of $33,000; a


part-time certified aquatic therapist who receives a salary of $32,400; and a part-time certified art

therapist who receives a salary of $28,800. All of these employees are required to have

experience in the field, and an understanding of their specific job.

In health Insurance, and retirement benefits, the TR department spends $19,500 for all

full-time employees. In Medicaid benefits, the TR department puts $7,000 for all employees. For

the health insurance, since the agency is a non-profit organization, the TR department uses the

“defined contribution approach.” This approach gives the employees a health insurance

allowance based on their position in the department (Merhar, 2013). For our manager, this

individual will receive $250 a month, and for the two CTRS and the assistant, they will receive

$125 a month; coming out to a year total of $7,500 in the TR department expenses. The

retirement plan also falls along the “defined contribution approach.” For retirement benefits, the

defined contribution approach has a certain maximum contribution for employees and employer

(Kirchoff, n.d.). Due to this approach, $12,000 is put into retirement for full-time employees

only.

The TR department also uses contracted services. The TR department hires a part-time

certified music therapist for $28,800 a year, and transportation services. The daily rent for an

accessible van is $125. The outings will take place once every two weeks and most likely two

vans will be used, so the total for a year would come out to $6,000 (Mobility Works). This

however, does not cover gas; $1,440 will be spent in gas for a year of outings.

The total amount that is spent in equipment is $17,000. This includes art, music, aquatic,

and other equipment. The TR department spends $8,000 in office supplies. This includes desks,

computers, desk supplies, filing supplies, paper supplies, printer supplies, binding supplies, time


tracking supplies, and identification supplies. The details of all the equipments can be seen under

the line item budget in Appendix M. The TR department also covers the books, journals,

conferences, workshops, and the travel expenses for the TR staffs. For travel expenses, the TR

department has a budget of $10,000. This only used for work-related traveling. For ATRA

memberships, conferences, journals, and books, the TR department provides $5,000. The TR

department spends $200 a month for pool maintenance, and has $1,250 for computer

maintenance. All departments put a portion in for electricity, telephone, computer, and TV

services. The TR department puts $8,500 for the year; just to cover the areas/rooms.

Clients

Demographics. Dunatos Rehabilitation serves citizens of Miami- Dade County Kendall

area who have physical disabilities, neurological disorders and surgical rehabilitation. Based on a

2014 census (Appendix N) most of Miami-Dade County’s population is White (77.9%) and

Hispanic (66.9%). Based on our location a lot of our clients come from a Hispanic background

and may only speak Spanish. Our clients are adults ages 18 and up, there are a greater number of

physical disabilities that occur with age, therefore there is a larger adult population (see

Appendix O). The ratio for each program session will consist of a Recreational Therapist and a

Recreational Therapy Assistant for every 10 clients.

Diagnosis/Disability. Dunatos TR department serves about 100 clients a year. All

disabilities are welcome to participate in our program but generally we work with individuals

who have physical disabilities, neurological disorders and surgical rehabilitation.

A physical disability is when a person has limited functions and mobility of their body or

of one of their extremities. Physical disabilities can be long term, short-term or the person could


have been born with the disability. There are several disabilities under the physical disability

umbrella such as: cerebral palsy, muscular dystrophy, spinal cord injury, spina bifida,

amputations, arthritis, traumatic brain injuries and musculoskeletal injuries.

According to cerebralpalsy.org (2014), cerebral palsy is a loss or impairment of motor

function caused by brain damage, injury, or abnormal development while a child’s brain is still

developing, before, during or immediately after birth. An individual with cerebral palsy has

difficulty with body movement, muscle control and coordination, muscle tone, reflexes, posture

and balance. This can also have an impact on gross and fine motor skills as well as oral motor

skills.

Muscular dystrophy or Duchenne muscular dystrophy is a genetic disorder that weakens

and degenerate the muscles because of the absence of dystrophin; a protein that helps muscle

cells stay intact (“Muscular Dystrophy Association”, 2015). The muscle areas that are affected

first are, the hip, pelvis, shoulder, and thighs. Other symptoms include pain from muscle

cramping, cardiomyopathy, problems staying awake or concentrating, as well as some learning

disabilities.

A spinal cord injury (SCI) is when there is damage to the spinal cord or spinal nerves

where sensation and motor function can be affected. Injuries can be long-term or short-term.

There are two categories of SCI: complete which means there is no motor function or sensation

below injury level and incomplete which means there is some motor function or sensation below

injury level (Dvork & Mansfield, 2013d). A spinal cord injury can cause paralysis (quadriplegia,

paraplegia, hemiplegia, monoplegia), as well as pressure sores, spasticity, hyperreflexia, bladder

control, and difficulty breathing.


According to the Mayo Clinic Staff (2014a), spina bifida is a birth defect where a portion

of the spinal cord is not developed properly. There are three forms of spina bifida: spina bifida

occulta, meningocele and myelomeningocele. Myelomeningocele is the most severe form, when

the spinal canal remains open through several vertebrae and forms a sac that protrudes through

the middle or lower back. Exposed nerve fibers can cause life-threatening infections. Muscle

weakness of the legs can cause paralysis, problems with bladder and bowl control, seizures, feet

deformity, uneven hips and scoliosis.

An amputation is the cutting off of a limb or a body part due to traumatic injury, disease,

infection, or removal of tumors from bones or muscles (“Johns Hopkins Medicine Health

Library”, n.a.). Greif, depression, denial, anxiety are symptoms individuals feel after

amputations. Phantom pain is also a symptom after the loss of a limb that causes sensation or

pain of the limb that was amputated. Individuals who have limb amputations may often use

prosthesis. If the skin covering the stump is not made less sensitive before wearing the

prosthetic then it can cause swelling, fluid build-up, rubbing, and pulling of the skin around the

bone.

Arthritis is the common way of referring to joint inflammation, pain, or disease; but there

are over 100 types of arthritis (“Arthritis Foundation”, 2015). Common symptoms are swelling,

pain, stiffness, and limited range of motion, these systems is not always present and can range

from mild to severe. The higher the severity of the symptoms, the more it can cause chronic pain

and permanent joint damage. Arthritis can affect the heart, lungs and kidneys as well eyes and

skin.


A traumatic brain injury (TBI) according to the Mayo Clinic Staff (2014b) is cause by a

violent jolt or blow to the head or body. Any puncture through the skull that may cause it to

shatter is also considered a TBI. TBI can cause loss in coordination, weakness and numbness,

seizures, trouble staying conscious, slurred speech, and limited functions to arms or legs. TBI

may cause changes in the brain that can impact the individual’s family and their social life,

community interaction, and job, this leads to depression, anxiety, inability to focus or process

information.

Musculoskeletal injury or disorder affects the movement of tendons, ligaments, muscles,

nerves, and limbs in the musculoskeletal system. Musculoskeletal disorders are caused mostly

by an individual’s occupation or daily activities; repetitive or awkward postures, repetitive high

tasks and stress (Cherney, 2013). Symptoms include reoccurring pain, aches, stiffness in joints

and swelling.

Neurological disorders are diseases involving the spine, nerves, the brain and their

connection (“UCSF Medical Center”, 2002). There are hundreds of neurological diseases

including multiple sclerosis, memory disorders, Parkinson’s disease, stroke, and Lou Gehrig’s

disease (ALS).

Dovork and Mansfield (2013b), states that multiple sclerosis is when there is damage to

the myelin coating in the nerve fibers of the central nervous system and causes an interference

with the transmissions of signals from the brain to the rest of the body. Each individual is

different but some symptoms are weakness, numbness, walking difficulties, spasticity, vertigo,

dizziness, pain, numbness or tingling, vision problems and cognitive changes (“National

Multiple Sclerosis Society”, n.a.). Secondary symptoms may include depression, pressure sores


from immobility, urinary tract infections from bladder dysfunctions, and loss of muscle tone due

to loss of mobility.

A memory disorder can cause memory loss that interferes with daily tasks and activities.

Alzheimer’s disease is a degenerative disorder that progressively declines mental functions

which ultimately causes memory loss and confusion (Dovork & Mansfield, 2013a). Symptoms

may be: loss of abstract thinking, disorientation, lack of initiative, mood swings and language

problems. Frontal temporal dementia is just as common as Alzheimer’s disease, it is found in

adults age 45-64. This degenerative disease damages or shrinks the frontal and anterior temporal

lobes, which also cause mood swings, unwillingness to talk, obsessive and repetitive behavior,

and weight gain due to over eating. Lack of awareness or concern that his or her behavior has

change may cause individual to neglect hygiene.

According to Dovork and Mansfield (2013c), Parkinson’s disease is caused by the loss of

dopamine producing cells in the brain, which disrupts nerve and muscle coordination.

Symptoms include stiffness, impairment of the autonomic nerve system, and loss of bladder

control, trouble controlling balance, slow initiation of movement, and tremors. Secondary

symptoms are depression, anxiety, difficulty swallowing, stooped posture, inability to make

facial expressions and shortness of breath.

A stroke is when a blood vessel in the brain becomes blocked or bursts; it can cause

permanent brain damage and sometimes death. Depending on the area in the brain the stroke

affected, each individual’s symptoms can vary. According to UPMC (2015), a stroke can cause

weakness, problems with balance and coordination, paralysis, unilateral neglect (not aware of the

other side of their body), memory problems, vision problems, speech and language problems,


and difficulty swallowing. Some secondary symptoms are depression, mood swings, and

anxiety.

Lou Gerig’s disease is another progressive degenerative disease. It affects the nerve cells

that control muscle movement. As the disease worsens, there is loss of strength and coordination

in the legs and arms, feet and ankles become weak, muscles in the arms, shoulders and tongue

cramp or twitch, swallowing, breathing, and speaking becomes difficult (Lewis, 2015). Being

unable to swallow can cause individual to get food or saliva in their lungs. This disease

ultimately paralyzes the muscles that are used for breathing and cause death.

Rehabilitation that helps return patient to prior physical function after surgery is

considered surgical rehabilitation (CORA, 2012). Surgical procedures that need rehabilitation

after surgery are: joint replacements, ligament or tendon repairs, joint fusions, nerve compression

release, and open reduction internal fixation implant.

Description of Clients. It is important as professional to understand the needs of the

client to implement the appropriate strategies to meet the client’s needs. Leisure related needs

for adults with physical disabilities, neurological disorders, or temporary physical impairment

may vary. Their leisure related needs would be socialization, leisure education, communication,

self-care, productivity, community reintegration, and leisure skills. Socialization skills can be

practiced in between clients during their favorite activity like painting or engaging in a group

activity as well as using the appropriate behaviors in different social settings. Clients should

learn how to identify barriers to leisure and learn how to overcome them; clients can also be

informed about leisure activities and resources that are available to them. Communication skills

can improve by providing opportunities for conversation and making sure there are no


distractions to improve listening skills and promote concentration. Self-care helps individuals

gain their independence, such as being able to take care of their belongings, dress, hygiene, eat

and groom themselves. For example, an individual must be able to recognize their belongings.

Productivity is important especially for individuals who plan on seeking employment or need to

regain vocational skills after injury. Community reintegration can be used to apply and practice

social skills learned, self-care skills, and communication skills in the community. Even if the

clients have long-term or short-term disabilities participation in leisure activities can help them

cope with their new injury or disability and help improve their quality of life.

Therapeutic Recreation Profession

Philosophy. Our recreational therapy department’s philosophy is based on the Leisure

Ability Model (See Appendix P). Through functional intervention, leisure education and leisure

participation we help improve our clients’ level of independence and leisure satisfaction.

Standard of Practice and Code of Ethics. Our department adopts the American

Therapeutic Recreation Code of Ethics (See Appendix Q) to promote the highest standard of

ethical behavior in the therapeutic recreation profession. The therapeutic recreation department

also applies the ATRA Standards of practice listed in Appendix R. Any client receiving

recreational therapy and treatment and care will be informed of their rights (Appendix S). It is

important that as an agency we provide effective, safe, and a quality level of practice provided by

recreational therapists and paraprofessionals.

The TR department has used the 2013 Standards of Practice of Recreational Therapy and

Self –Evaluation Assessment Guide for quality improvement and effectiveness of our department


and client outcomes (see Appendix T). Clients will also fill out the ATRA patient satisfaction

questionnaire available in Appendix U.

Credentials/Professional Preparation. The National Council for Therapeutic

Recreation Certification must certify the therapeutic recreational specialist. To qualify for the

NCTRC exam candidate must complete the certification standard, choose the appropriate path to

certification, and submit a professional eligibility application that can be found online at

NCTRC.org (see Appendix V). The CTRS complies with the minimum competency necessary

for the implementation to deliver therapeutic recreation services. In order to be qualified for the

recreational therapy assistant position the potential employee must have at least 1 year of

experience working with individuals with disabilities and a Bachelor’s degree with a recreational

therapy background.

Memberships. Employees are encouraged to actively participate as members of the

Florida Gold Coast TRA (ATRA Chapter). The agency has a membership with the National

Therapeutic Recreation Society (See Appendix W), which employees are also encouraged to

participate in.

Continuing Education/ Professional Development. To develop the staff’s knowledge

about current therapeutic recreation techniques and standards, employees are also encouraged to

attend trainings, workshops, webinars and conferences such as the ATRA annual conference.

The flyer for the upcoming 2016 annual conference is in Appendix X.

Professional Resources. The staff will also have access to: The American Journal of

Recreational therapy; Recreational Therapy Handbook of Practice: Diagnosis and Treatment


(2006) by Heather Porter and Joan Burlingame; and Quality Management: Applications for

Therapeutic Recreation by Bob Riley.


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