Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
Psychosocial Services in 
Skilled Nursing Facilities 
JANET REHNQUIST 
INSPECTOR GENERAL 
MARCH 2003 
OEI-02-01-00610  O I G
FFICE OF  NSPECTOR  ENERAL

http://www.oig.hhs.gov 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as amended, 
is to protect the integrity of the Department of Health and Human Services (HHS) programs, as well as 
the health and welfare of beneficiaries served by those programs.  This statutory mission is carried out 
through a nationwide network of audits, investigations, and inspections conducted by the following 
operating components: 
Office of Audit Services 
The OIG's Office of Audit Services (OAS) provides all auditing services for HHS, either by conducting 
audits with its own audit resources or by overseeing audit work done by others.  Audits examine the 
performance of HHS programs and/or its grantees and contractors in carrying out their respective 
responsibilities and are intended to provide independent assessments of HHS programs and operations in 
order to reduce waste, abuse, and mismanagement and to promote economy and efficiency throughout the 
Department. 
Office of Evaluation and Inspections 
The OIG's Office of Evaluation and Inspections (OEI) conducts short-term management and program 
evaluations (called inspections) that focus on issues of concern to the Department, the Congress, and the 
public.  The findings and recommendations contained in the inspections reports generate rapid, accurate, 
and up-to-date information on the efficiency, vulnerability, and effectiveness of departmental programs. 
Office of Investigations 
The OIG's Office of Investigations (OI) conducts criminal, civil, and administrative investigations of 
allegations of wrongdoing in HHS programs or to HHS beneficiaries and of unjust enrichment by 
providers.  The investigative efforts of OI lead to criminal convictions, administrative sanctions, or civil 
monetary penalties.  The OI also oversees State Medicaid fraud control units which investigate and 
prosecute fraud and patient abuse in the Medicaid program. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, rendering 
advice and opinions on HHS programs and operations and providing all legal support in OIGs internal 
operations.  The OCIG imposes program exclusions and civil monetary penalties on health care providers 
and litigates those actions within the Department.  The OCIG also represents OIG in the global settlement 
of cases arising under the Civil False Claims Act, develops and monitors corporate integrity agreements, 
develops model compliance plans, renders advisory opinions on OIG sanctions to the health care 
community, and issues fraud alerts and other industry guidance.  E X E C U T I V E  S U M M A R Y  
OBJECTIVE 
To determine whether Medicare skilled nursing facility residents are receiving psychosocial 
services in compliance with federal requirements. 
BACKGROUND 
The Omnibus Budget Reconciliation Act (OBRA) of 1987 requires skilled nursing facilities 
(SNFs) to provide "medically-related social services to attain or maintain the highest practicable 
physical, mental and psychosocial well-being of each resident" and specifies that "the services 
provided or arranged by the facility must meet professional standards of quality."  The OBRA 
of 1987 further states that a skilled nursing facility with over 120 beds is required to employ a 
minimum of one full-time social worker with at least a bachelors degree in social work, or 
another human service field, and 1 year of supervised social work experience in a health care 
setting working directly with individuals. For facilities with 120 beds or less, medically-related 
social services must still be provided. However, there is no specific requirement that they be 
performed by a qualified social worker, on either a full-time or part-time basis. 
The OBRA of 1987 also mandates that each resident have a comprehensive initial assessment 
and periodic assessments, which include mental health evaluations.  In addition to mental health 
evaluations, examples of medically-related social services include conducting psychosocial 
interventions, such as counseling residents and their families, and evaluating residents progress 
and functioning.  Ideally, all identified psychosocial needs are addressed in a care plan, and all 
needed services are provided. 
Our review of skilled nursing facilities compliance with federal psychosocial service 
requirements is based on data from multiple sources.  We used a random sample of 299 
recently admitted Medicare skilled nursing home beneficiaries to review the credentials of social 
workers associated with the skilled nursing facilities serving these beneficiaries.  In addition, we 
reviewed the medical records of these same 299 SNF residents to determine the extent to 
which they were assessed for and received psychosocial services. We selected a separate 
sample of Medicare certified skilled nursing facilities and interviewed 84 social workers and 
nursing home administrators.  Using data from a third sample, we interviewed 32 state 
surveyors. Finally, we analyzed Online Survey and Certification Reporting System (OSCAR) 
data and National Ombudsman Reporting System (NORS) data for deficiencies and complaints 
related to psychosocial services. 
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i 
Psychosocial Services in SNFs  OEI-02-01-00610  FINDINGS 
Almost all Medicare SNF beneficiaries have at least one 
psychosocial service need; however, 39 percent of those with 
needs have inadequate care plans and 46 percent of those with 
care plans do not receive all planned services 
While 90 percent of Medicare beneficiaries have all their required minimum data set (MDS) 
assessments completed, 10 percent are missing one or more of their required assessments.1 
Our medical record review shows that, of those Medicare beneficiaries with either a formal 
MDS assessment or an informal psychosocial assessment, almost all (95 percent) have at least 
one psychosocial need identified during their SNF stay. Of these, only 61 percent have care 
plans that address all of the psychosocial needs identified during their SNF stay. Our review 
shows the following for those beneficiaries with a care plan: 54 percent of Medicare SNF 
residents receive all their psychosocial services as planned during their stay; 41 percent do not 
receive all of their planned psychosocial services; and, 5 percent receive none of their planned 
psychosocial services. 
OSCAR data show over 15 percent of facilities have been cited for 
psychosocial deficiencies and just over 1 percent of NORS 
complaints relate to psychosocial services 
Analysis of OSCAR data shows just over 15 percent of SNFs were cited for one or more 
psychosocial service-related deficiency in each of the years 1998-2001.  Psychosocial 
deficiencies represented just under 4 percent of all deficiencies in each of the years between 
1998 and 2001. However, interviews with a purposive sample of 32 state surveyors reveals 
that surveyors do not routinely look at all areas that SNFs can potentially be deficient in with 
regard to the provision of psychosocial services.  An analysis of NORS data shows that 
complaints related to psychosocial services make up 1 percent of all nursing facility complaints. 
1 
When broken down by MDS period, 5 percent of beneficiaries who require a 5-day MDS do not get this 
assessment; 7 percent of beneficiaries who require a 14-day MDS do not get one; and 12 percent of a relatively small 
number of beneficiaries who require a 30-day MDS do not get this assessment. 
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ii 
Psychosocial Services in SNFs  OEI-02-01-00610  Virtually all Medicare beneficiaries reside in skilled nursing 
facilities that comply with the over 120-bed rule 
Our review of credentials indicates that 98 percent of beneficiaries (116 out of 118) in larger 
facilities receive psychosocial services from facilities that are in compliance with the over 120-
bed regulation. Smaller facilities are not required by federal regulations to employ a qualified 
social worker; however, just over 80 percent (148 out of 181) of beneficiaries receive services 
in smaller facilities that employ a full-time social worker with either a bachelors degree or a 
graduate degree. 
Forty-five percent of social workers report barriers that affect their 
ability to provide psychosocial services 
Many social workers report numerous barriers that affect their ability to provide comprehensive 
psychosocial services to all SNF residents.  Forty-five percent of social workers report that 
they face one or more of the following barriers: not having enough time; burdensome 
paperwork that limits their ability to provide psychosocial services; and, insufficient staff 
including social workers and other disciplines in the SNF. Over half of social workers (62 
percent) say that their role includes a number of responsibilities beyond providing the 
psychosocial services which most have been trained to provide. Only 19 percent of social 
workers report no obstacles in providing social work services. Barriers reported by social 
workers provide some insight into the reasons that not all residents are getting all of the 
psychosocial services they need. 
CONCLUSION 
While SNFs with over 120 beds are complying with the federal requirement that SNFs employ 
a full-time social worker with at least a bachelors degree, over a third of SNF beneficiaries 
have incomplete psychosocial care plans and 46 percent of Medicare beneficiaries do not 
receive all of their planned psychosocial services during their SNF stay. 
We found that almost all (98 percent) of beneficiaries reside in SNFs that are in compliance 
with the over 120-bed rule.  In addition, 82 percent of beneficiaries reside in smaller facilities 
that meet the larger facility standard, even though they are not required to do so.  However, our 
medical record review determined that while 95 percent of those SNF Medicare beneficiaries 
with a psychosocial assessment have at least one psychosocial service need identified, 39 
percent of these residents do not have care plans 
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iii 
Psychosocial Services in SNFs  OEI-02-01-00610  that address all their psychosocial needs, and 41 percent do not receive all the services outlined 
in their care plans. In addition, we found that 5 percent of Medicare residents have none of 
their planned services provided.  Our medical record review data, combined with social worker 
reports that some service barriers exist, lead us to conclude that not all residents are getting all 
of the psychosocial services they need. There is evidence that, despite the fact that SNFs are 
complying with the over 120-bed rule, there is not full compliance with the requirement that 
SNFs provide medically related social services to attain or maintain the highest practicable 
physical, mental and psychosocial well-being of each resident.2 Therefore, we question 
whether the present federal rule regarding social worker credentials is effective in achieving the 
desired level of psychosocial services for SNF residents. 
RECOMMENDATIONS 
Oversight of the psychosocial service portion of the resident assessment process 
should be strengthened. We found evidence that substantial numbers of SNF beneficiaries 
have incomplete psychosocial care plans and many Medicare beneficiaries do not receive all of 
their planned psychosocial services during their SNF stay.  Our medical record review reveals 
that 39 percent of beneficiaries do not have care plans that address all their psychosocial needs. 
In addition, 46 percent of SNF residents do not receive needed psychosocial services in 
accordance with their plan of care. The psychosocial assessment portion of the periodic 
resident assessment tools (comprehensive initial assessment, 5-day MDS, 14-day MDS, etc.) 
drives the preparation of care plans which are then used to document all needed services that 
should be provided. If the assessments or the care plans are incomplete, all needed services 
are not likely to be provided. Therefore, we recommend that the Centers for Medicare & 
Medicaid Services (CMS) strengthen the oversight processes associated with the psychosocial 
service portion of the resident assessment and the resulting care plans to ensure that SNF 
residents receive necessary and appropriate care. 
AGENCY COMMENTS 
The CMS provided comments on our draft report.  They concur with our recommendation that 
the oversight of the psychosocial service portion of the resident assessment process can be 
strengthened.  Additionally, in their comments, they highlight actions they have taken to date in 
this regard, as well as on-going initiatives. CMS also provided a number of technical 
comments.  As appropriate, these have been incorporated into this final report. 
2
42 CFR 483.15(g) 
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iv 
Psychosocial Services in SNFs  OEI-02-01-00610  T A B L E   O F   C O N T E N T S  
PAGE 
EXECUTIVE SUMMARY ...................................................... i

INTRODUCTION ............................................................. 1

FINDINGS 
Thirty-nine percent of beneficiaries have inadequate care plans; 

forty-six percent do not receive all services ......................................7

Over 15 percent of facilities have been cited for psychosocial deficiencies, and just over 

1 percent of NORS complaints relate to psychosocial services  .......................9

Virtually all Medicare beneficiaries reside in SNFs that comply with the over 120-bed 

rule  ..................................................................11

Forty-five percent of social workers report multiple barriers that affect their ability to provide

psychosocial services .....................................................13

CONCLUSION  ............................................................. 14

RECOMMENDATION  ....................................................... 15

AGENCY COMMENTS  ...................................................... 16

APPENDICES 
A:Summary Analysis of Needs, Care Plans, and Services  .........................17

B: Selected List of Recent OIG Nursing Home Inspections ......................... 18

C: Confidence Intervals For Key Findings ...................................... 19

D: Agency Comments  ....................................................21

ACKNOWLEDGMENTS ..................................................... 23

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v 
Psychosocial Services in SNFs  OEI-02-01-00610  I N T R O D U C T I O N  
OBJECTIVE 
To determine whether Medicare skilled nursing facility residents are receiving psychosocial 
services in compliance with federal requirements. 
BACKGROUND 
Recent studies have determined that the needs of the nursing home population, including 
psychosocial needs, are increasing.3 In this study, we assessed the degree to which 
psychosocial services provided in skilled nursing facilities (SNFs) are in compliance with federal 
requirements. This inspection includes an analysis of the types and quantity of psychosocial 
services being provided, as well as the educational credentials of the professionals who are 
providing this care. There is no minimum federal requirement on the number of social workers 
or the educational credentials of social work staff in nursing homes with 120 beds or less. This 
inspection looks at the following: whether vulnerabilities exist in these smaller facilities; whether 
facilities with over 120 beds are complying with federal credential requirements; and, finally, 
whether or not psychosocial services that attain or maintain the highest practicable physical, 
mental and psychosocial well-being of each resident4 are being provided in all Medicare 
skilled nursing facilities. 
Federal Regulations Regarding Social Services in Nursing Home 
The Omnibus Budget Reconciliation Act (OBRA) of 1987 requires SNFs5 to provide 
"medically-related social services to attain or maintain the highest practicable physical, mental 
and psychosocial well-being of each resident" and specifies that "the services 
3
Sayhoun NR, Pratt LA, Lentzner H, Dey A, Robinson KN. The Changing Profile of Nursing Home 
Residents: 1985-1997. Aging Trends; No.4. Hyattsville, Maryland: National Center for Health Statistics. 2001. 
4
42 CFR 483.15(g) 
5
The OBRA of 1987 requires both Medicare SNFs and Medicaid custodial care nursing facilities to meet this 
criteria; however, the scope of this inspection is limited to Medicare nursing skilled facilities. 
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1 
Psychosocial Services in SNFs  OEI-02-01-00610  provided or arranged by the facility must meet professional standards of quality."  This law 
applies to all residents within the federally certified SNFs. 
The OBRA 1987 further states that when any federally-certified nursing facility has over 120 
beds, the facility is required to employ, on a full-time basis, a minimum of one social worker. 
Federal regulations state that this social worker must have at least a bachelors degree in social 
work, or in another human services field, and 1 year of supervised social work experience in a 
health care setting working directly with individuals.6 For facilities that have 120 beds or less, 
medically-related social services must still be provided.  However, there is no specific 
requirement that they be performed by a qualified social worker. 
The OBRA 1987 also mandates that each nursing home resident have a comprehensive initial 
resident assessment, as well as periodic assessments using a standard form called the Minimum 
Data Set (MDS). Under Medicare payment rules, the Centers for Medicare & Medicaid 
Services (CMS) requires that a 5-day, 14-day, 30-day, and 60-day MDS be completed for all 
residents. These assessments include psychosocial assessment indicators that guide the 
preparation and maintenance of psychosocial-related care plans for each resident. Ideally, all 
identified psychosocial needs are addressed in a care plan, and for all care plans developed, 
there is documentation that all services are provided. 
Services Provided by Nursing Home Social Workers 
State surveyor guidelines used to monitor the quality of care in SNFs spell out a wide array of 
medically-related social services that should be provided to SNF residents. These include the 
following: completing the mental health evaluation section of assessment plans, conducting 
psychosocial interventions, counseling residents and their families, making referrals to other 
service providers, advocating for the resident on interdisciplinary teams, evaluating the 
residents progress and functioning, preparing a discharge plan, and assisting the resident with 
palliative care.7 
Nursing Home Survey and Certification Requirements 
All Medicare participating nursing homes must meet certain federal requirements.  Nursing 
home certification is achieved through routine surveys. The CMS contracts with 
6
42 CFR 483.15(g) 
7
End of life planning 
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2 
Psychosocial Services in SNFs  OEI-02-01-00610  states to perform these surveys for Medicare and Medicare/Medicaid nursing homes. All 
nursing homes are subject to an unannounced standard survey no later than 15 months after 
the date of the previous standard survey. 8 If, during the standard survey, a nursing home is 
found to have provided substandard quality of care, an additional extended survey will be 
conducted within 2 weeks. During either type of survey, a surveyor may cite the nursing home 
for a deficiency, if that facility fails to meet specific requirements. 
Survey deficiencies are categorized and reported in the Online Survey Certification and 
Reporting System (OSCAR).  The deficiencies that relate to social work services include the 
following: F251, which is used to cite a facility that has more than 120 beds and does not have 
a qualified social worker; F250, which is used to cite a facility that does not provide medically 
related social services to residents; F319, which cites a facility for failing to provide residents 
with appropriate treatment for mental or psychosocial problems; F320, which is cited when a 
facility fails to ensure that residents do not experience an avoidable decline in their psychosocial 
functioning; F246, which cites a facility for not having policies that accommodate residents' 
needs and preferences; and F243, which is cited in cases where residents have been denied the 
right to organize and participate in resident groups. 
METHODOLOGY 
We obtained data for this study from a number of different sources. These include: a review of 
SNF social worker credentials; a medical record review of recently-admitted Medicare 
residents; an analysis of OSCAR and the National Ombudsman Reporting System (NORS) 
data; a telephone survey of nursing home administrators and social work staff; and, finally, a 
telephone survey of state surveyors.  We pulled three separate samples for this study:  one was 
a simple random sample from the universe of Medicare SNF residents; the second was a 
stratified random sample from the universe of Medicare SNFs, which was used only to conduct 
interviews with nursing home administrators and social workers; and, the last was a purposive 
sample of state survey and certification surveyors in eight states. 
Nursing Home Resident Sample For Social Worker Credential and Medical Record 
Review 
Our nursing home resident sample was used for both our social worker credentials review 
8
42 CFR 488.308(a) 
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3 
Psychosocial Services in SNFs  OEI-02-01-00610  and our medical record review.  We used National Claims History data to identify our universe 
of all residents, who were admitted between September 1, 2001, and November 30, 2001, 
whose stay was covered under Medicare Part A, and whose stay was greater than 7 days.  We 
matched the stays to OSCAR current survey file data and limited the universe to the 303,891 
cases with matching OSCAR data.  We then pulled a simple random sample of 330 Medicare 
beneficiaries.  We sent letters to their associated skilled nursing facilities requesting medical 
records for each beneficiary and social work credentials of the relevant staff in these facilities. 
We received social work credentials and medical records from 305 SNFs, for a response rate 
of 92 percent. However, six beneficiaries were dropped from analysis because the 
documentation they submitted was insufficient for a review. As a result, our review of medical 
records and social worker credentials was based on 299 Medicare beneficiaries and their 
associated nursing homes. 
Although this sample was not stratified by bed size, we analyzed data associated with 
beneficiary experiences by bed size, as well as overall.  When data was broken down by bed 
size, we compared the experiences of beneficiaries in SNFs with over 120 beds to those in 
facilities with 120 or fewer beds. This allowed us to project our findings to the universe of 
beneficiaries who reside in larger and smaller facilities within the time frame associated with our 
sampling frame (September-November 2001).  However, because the unit of analysis was the 
beneficiary, we do not project our findings to the universe of all larger and smaller SNFs. 
Social Worker Credential Review. We requested information on the credentials of all social 
work staff from nursing homes associated with our sample of 330 nursing home residents. 
Nursing homes were asked to distinguish between employees of the facility and those who 
work on a consultant basis providing Part A reimbursed services. Nursing homes were also 
asked to provide information on the number of hours that social work staff work in an average 
week. 
Medical Record Review. For each of the residents in our sample, we requested complete 
clinical records from the date of the residents admission through the first 60 days of their stay in 
the nursing home (or their discharge, if they were discharged in less than 60 days).  We 
requested the following documentation: admission sheets; MDS assessments; plans of care; 
social worker, nurse, and physician notes; medication administration records; psychological and 
psychiatric assessments; behavior management records; physician orders; and, if relevant, 
discharge planning notes.  We used an independent contractor to conduct the medical record 
review. Together with the contractor, we developed a screening instrument to review 
residents records.  This screening instrument was based on requirements for psychosocial 
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4 
Psychosocial Services in SNFs  OEI-02-01-00610  services included in the OBRA 1987 and CMS guidance9 on the provision of these social work 
services.  Specifically, the medical record review looked at whether a given patient was 
evaluated for psychosocial needs; whether care plans were developed to address any such 
needs; and, finally, whether there was evidence that care plan items associated with 
psychosocial needs were provided as planned. Two licensed social workers with previous 
nursing home experience conducted the medical record reviews. A registered nurse provided 
quality assurance for all reviews. 
Social Worker and Nursing Home Administrator Interviews 
Through a separate selection process, we selected a random sample of Medicare-certified 
skilled nursing facilities. This sample was used to conduct interviews with nursing home 
administrators and social workers. Using the OSCAR current survey file, we stratified this 
population based on bed size; however, when we made comparisons by strata, no differences 
were found. Therefore, the results we report are for all respondents, not by strata. Our total 
sample size was 92 SNFs.  We were unable to conduct interviews with 8 of these, resulting in a 
response rate for this sample of 91 percent. 
We administered a telephone questionnaire to 84 nursing home administrators from our sample 
of skilled nursing facilities.  This survey instrument included questions related to the provision of 
psychosocial services to Medicare residents reimbursed under Part A.  During a separate 
telephone interview, nursing home social work directors in the same 84 nursing homes were 
asked a series of similar questions. 
Nursing Home State Surveyor Interviews 
We selected a sample of state surveyors from eight states, based on the number of nursing 
home beds, the average deficiency rate per nursing home, the CMS regional office jurisdiction, 
and geographical location.  They include:  Alabama, California, Connecticut, Maryland, 
Missouri, New York, South Carolina, and South Dakota.  We asked each of the state survey 
agencies for a list of all surveyors in their state who had been a nursing home surveyor for at 
least 3 years. We then selected a random sample of 4 surveyors in each of our 8 sampled 
states for a total of 32 respondents.  Our response rate was 100 percent. 
9 
Including survey and certification deficiency (f-tag) specifications and references included in federal 
regulations. 
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5 
Psychosocial Services in SNFs  OEI-02-01-00610  We spoke with surveyors about the practices they are currently using to monitor the provision 
of psychosocial services under Medicare Part A reimbursement rules. Because this was a small 
purposive sample, surveyor data cannot be projected to the universe. 
Analysis of Nursing Home Survey and Certification and Ombudsman Data 
We analyzed data from OSCAR and NORS for all Medicare-certified skilled nursing facilities. 
We used OSCAR data to identify nursing home deficiencies related to inadequate provision of 
psychosocial services from 1998 to 2001.  We used NORS data to look at related SNF 
complaint categories from 1999 to 2000. 
Limitations 
Our methodology had the a number of limitations. First, our findings, based on social work 
credentials and SNF medical records, can be projected only to Medicare beneficiaries 
admitted to a Part A Medicare-covered stay between September 1, 2001, and November 30, 
2001, whose stay was greater than 7 days. Second, we assessed the degree to which required 
psychosocial services are being provided, based on a medical record review rather than on in-
person clinical assessments of residents in our sample.  Third, the interviews conducted with the 
purposive sample of state surveyors cannot be projected to the universe. 
This inspection was conducted in accordance with the Quality Standards for Inspections 
issued by the Presidents Council on Integrity and Efficiency. 
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6 
Psychosocial Services in SNFs  OEI-02-01-00610  F I N D I N G S  
Our review of skilled nursing facilities (SNF) compliance with Medicare psychosocial service 
requirements is based on data from a review of medical records of 299 SNF residents and a 
review of the credentials of the social workers in their facilities.  Additionally, we interviewed 
social workers, nursing home administrators, and state surveyors.  Finally we  analyzed 
OSCAR and NORS data for deficiencies and complaints related to psychosocial services. 
Medicare requires that SNFs with over 120 beds have a full-time social worker with a 
minimum of a bachelors degree.  We found that virtually all Medicare SNF beneficiaries reside 
in SNFs that are in compliance with the federal rule regarding social worker credentials. 
However, our medical record review determined that, while 95 percent of facility residents 
have at least one identified psychosocial service need, almost half do not receive all the services 
called for in their care plans.  This medical record review data, combined with social worker 
reports that numerous barriers exist, indicate that not all residents are getting all of the 
psychosocial services they need. 
Almost all Medicare SNF beneficiaries have at least one 
psychosocial service need; however, 39 percent of those with such 
needs have inadequate care plans, and 46 percent of those with 
care plans do not receive all planned psychosocial services 
Our medical record review consisted of a review of all MDS assessments, other medical 
record documentation of psychosocial needs and care plans, as well as a review of 
psychosocial services provided. We looked at this documentation to determine the following: 
the proportion of Medicare beneficiaries that have their required MDS completed; the 
proportion of beneficiaries who have identified psychosocial needs; the proportion of Medicare 
beneficiaries who are receiving all required psychosocial assessments; the proportion of 
Medicare beneficiaries who have care plans for all of their psychosocial needs identified; and 
finally, the proportion of beneficiaries who subsequently have all services provided. 
Psychosocial assessments and identified psychosocial needs.  Psychosocial needs 
assessments are performed one of two ways.  The first is the MDS assessment, a formal 
process for identifying residents needs, which involves collecting information in a standardized 
fashion. The second, a less formal way of identifying psychosocial needs, occurs through 
routine staff interactions with the resident.  Staff may document these psychosocial needs in 
their progress notes or on the patients chart. While 90 percent of 
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7 
Psychosocial Services in SNFs  OEI-02-01-00610  Medicare beneficiaries have all their required MDS assessments completed, 10 percent are 
missing one or more of their required assessments.10 One percent of all beneficiaries are 
missing both forms of assessments.  Of those Medicare beneficiaries who have an assessment, 
our medical record review shows that almost all (95 percent) have at least one psychosocial 
need identified during their SNF stay. The types of psychosocial needs vary greatly. Table 1 
below shows the most common psychosocial service needs. 
Table 1 
Percentage of Beneficiaries With Psychosocial Need Identified 
Need  Percent 
Depression, anxiety, or sad mood  42 
Behavioral symptoms  20 
Issues relating to past roles  20 
Indications of mood persistence  18 
Changes in mood  17 
Lack of initiative or involvement  14 
Unsettled relationships  13 
Changes in behavioral symptoms  10 
Source: OIG medical record review, 2002 
Developed care plans.  After an assessment is completed, a care plan should be developed 
that addresses each outstanding psychosocial need with an indication of the appropriate service 
to be provided. We found that 61 percent of Medicare beneficiaries with identified needs have 
care plans that address all of the psychosocial needs identified during their SNF stay. 
However, we found that 39 percent of beneficiaries have care plans that do not address all of 
their psychosocial needs. Five percent of these beneficiaries have none of their psychosocial 
needs addressed in a care plan. 
10 
When broken down by MDS period, 5 percent of beneficiaries, who require a 5-day MDS, do not get this 
assessment; 7 percent of beneficiaries, who require a 14-day MDS, do not get one; and 12 percent of a relatively 
small number of beneficiaries, who require a 30-day MDS, do not get this assessment. 
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8 
Psychosocial Services in SNFs  OEI-02-01-00610  Provided psychosocial services. All psychosocial services addressed in a care plan should 
be provided, as planned, at some point during a residents stay.  Our review shows that 54 
percent of Medicare SNF residents who have one or more care plans receive all their 
psychosocial services as planned during their stay, while 41 percent do not receive all their 
planned psychosocial services. An additional 5 percent of beneficiaries receive none of their 
planned psychosocial services. 
Based on our review of all documented services provided, we found that the three most 
common psychosocial services that SNFs provide are: assessments (such as a social history), 
discharge planning, and medications for mood or behavioral problems.  Other slightly less 
common psychosocial services include psychiatric or psychological consultations and social 
work visits with the resident. 
OSCAR data show over 15 percent of facilities have been cited for 
psychosocial deficiencies, and just over 1 percent of NORS 
complaints relate to psychosocial services 
Psychosocial deficiencies reported in OSCAR.  Federal survey and certification guidelines 
outline a number of items that surveyors are directed to look at during their routine nursing 
home surveys to determine whether or not facilities are providing adequate psychosocial 
services to residents. Our review of 6 psychosocial service-related deficiencies11 shows just 
over 15 percent of SNFs were cited for one or more of these psychosocial deficiencies in each 
of the years between 1998 and 2001. (See Table 2.) Facilities that were cited in 2001 
averaged 1.15 psychosocial deficiencies per facility.  In addition, we found that psychosocial 
deficiencies represented just under 4 percent of all deficiencies in each of the years between 
1998 and 2001. It is worth noting that two psychosocial deficiency F-tags make up a 
disproportionate percentage of the six psychosocial deficiencies total.  These two F-tags, F246 
and F250, are used to cite facilities without policies that accommodate residents needs and 
preferences and facilities that do not provide medically-related social services. 
11
Most of the substandard quality of care deficiencies related to the provision of psychosocial services fall 
under the quality of life section of federal regulations. These include the following: F251  to cite a facility with more 
than 120 beds not employing a qualified social worker on a full-time basis; F250  to cite a facility that does not 
provide medically-related social services; F319  to cite a facility failing to provide residents with appropriate 
treatment for mental or psychosocial problems; F320  to cite facilities failing to ensure that residents do not have 
avoidable decline in their psychosocial functioning; F246  to cite facilities without policies that accommodate 
residents needs and preferences; and, F243  to cite facilities where residents have been denied the right to organize 
and participate in resident groups. 
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9 
Psychosocial Services in SNFs  OEI-02-01-00610  Table 2 
Psychosocial Service Deficiencies, 1998-2001 
Year  Psychosocial  % of facilities 
deficiencies as  with one or 
% of all  more 
deficiencies  psychosocial 
deficiencies 
1998  3.9 %  17 % 
1999  3.7 %  18 % 
2000  3.2 %  17 % 
2001  3.0 %  16 % 
Source: OSCAR data, 1998-2001 
Nursing home complaint data reported in NORS. We also reviewed NORS data, which is 
complaint data collected by nursing home long term care ombudsmen whose role is to monitor 
the quality of care of nursing home residents. We looked at the following three psychosocial
related complaint categories in NORS: G.56, for mental health psychosocial service-related 
complaints; I.67, for availability and appropriateness of social service complaints; and, finally, 
I.68, for other activity and social service complaints. The NORS data show that complaints 
related to psychosocial services make up only 1 percent of all nursing facility complaints. In 
terms of numbers, these complaints total in the low 2000 range each year. (See Table 3.) 
Table 3 
Psychosocial Service-Related Complaints, 1999-2000 
Year  % of all complaints  # of complaints 
1999  1.3 %  2211 
2000  1.2 %  2145 
Source: NORS data, 1999-200012 
12 
Complaints cover both SNFs and nursing facilities. 
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10 
Psychosocial Services in SNFs  OEI-02-01-00610  State surveyor interviews.  In addition to reviewing OSCAR and NORS data, we 
interviewed 32 nursing home state surveyors.  We asked them questions about how, if at all, 
they monitor the provision of psychosocial services and the credentials of those providing these 
services.  Twenty-nine of the 32 surveyors said that, during a standard survey visit, they do 
look at whether psychosocial services are being provided to residents that need them. When 
we asked surveyors if they look at whether facilities are providing one specific psychosocial 
service  family counseling  9 say yes, 10 say no, and the majority (13) say sometimes. 
Many of those that say sometimes indicate that they do not look at this unless they have 
reason to believe that a provider is deficient in this area.  With regard to the review of social 
worker credentials, almost all surveyors we interviewed (31 of 32) indicate that, during a 
standard survey visit, they check to see if a nursing home employs a social worker. However, 
22 of the 32 report that they either do not look at the educational credentials of social workers, 
or they sometimes do so. Sixteen of the 22 who volunteer that they do not look at credentials 
all the time say they only review this information when they see indications of social work-
related problems. Another two report that whether or not they look at this is dependent on the 
number of beds in the facility.  With regard to whether or not facilities are providing needed 
psychosocial services, we heard consistently from sample surveyors that they do not routinely 
look at all areas in which SNFs can potentially be deficient with regard to the provision of 
psychosocial services. 
Virtually all Medicare beneficiaries reside in skilled nursing 
facilities that comply with the over 120-bed rule 
Medicare regulations require that facilities that have over 120 beds employ a minimum of one 
full-time social worker with a minimum of a bachelors degree.13 We analyzed social worker 
credential data both overall and based on the bed size of the SNFs associated with our sample 
beneficiaries. Of our 299 sample SNF beneficiaries, 118 had been recently admitted to SNFs 
with over 120 beds (larger facilities) and 181 beneficiaries had been admitted to facilities with 
120 beds or fewer (smaller facilities). 
Our review of credentials indicates that 98 percent of beneficiaries (116 out of 118) in larger 
facilities receive psychosocial services from facilities that are in compliance with 
13
As defined by 42 CFR 481.15(g)(2)(3), a facility with more than 120 beds must employ a qualified social 
worker on a full-time basis. A qualified social worker is an individual with a bachelors degree in social work or a 
bachelors degree in the human services field, including, but not limited to, sociology, special education, 
rehabilitation counseling, and psychology, and 1 year of supervised social work experience in a health care setting 
working directly with individuals. Given the open ended nature of this requirement, for practical reasons, we limited 
our analysis to a determination as to whether or not the social worker had a bachelors degree and worked in the 
facility on a full-time basis. 
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11 
Psychosocial Services in SNFs  OEI-02-01-00610  the over 120-bed regulation.  With regard to beneficiaries in larger facilities, 47 percent are 
cared for by social workers with a bachelors degree and 51 percent of beneficiaries are served 
by facilities that go beyond the minimum requirements and employ at least one social worker 
with a graduate degree.14 Two percent of beneficiaries receive services in larger SNFs that did 
not send us the educational credentials of any staff who provide psychosocial services. 
The over 120-bed social work rule does not apply to 61 percent of Medicare beneficiaries 
receiving services in skilled nursing facilities; these smaller facilities are not required by 
Medicare regulations to employ a social worker with a bachelors degree, on either a full-time 
or part-time basis.  However, 82 percent of beneficiaries (148 out of 181) in smaller facilities 
receive services in facilities that employ a full-time social worker with a bachelors degree or 
higher, thus meeting the standard that applies to larger facilities, even though they are not 
required by federal rules to do so. Five percent of SNF beneficiaries receive services in 
smaller facilities that employ a social worker with an associates or high school degree.  The 
remaining 13 percent of Medicare beneficiaries receive care in smaller facilities that did not 
provide us with the educational credentials of their psychosocial service providers.  Charts 1 
and 2 below detail the highest degree held by a staff member in both larger and smaller skilled 
nursing facilities. 
Chart 1  Chart 2 
Social Worker Education  Social Worker Education 
in Larger Facilities  in Smaller Facilities 
Source: Social work credentials from SNFs associated with sample of nursing home residents, 2002 
We sought to determine whether or not SNFs, whose social workers have less education, are not as 
likely to meet federal requirements regarding the provision of psychosocial services. In order to test 
this hypothesis, at each educational level, we looked at the degree to which psychosocial services were 
provided to residents as planned.  Because there were so few facilities in our 
14
Percentage is based on the highest education-level social worker in each facility. 
_________ 
12 
Psychosocial Services in SNFs  OEI-02-01-00610  sample that employ only a high school or associate level social worker, our analysis was 
inconclusive. 
Forty-five percent of social workers report barriers that affect their 
ability to provide psychosocial services 
Many social workers report numerous barriers that affect their ability to provide comprehensive 
psychosocial services to all SNF residents.  Forty-five percent of social workers report that 
they face one or more of the following barriers: not having enough time; burdensome 
paperwork that limits their ability to provide psychosocial services; and, insufficient staff in the 
SNF, including social workers and other disciplines. Over half of social workers (62 percent) 
say that their role includes a number of responsibilities beyond providing the psychosocial 
services which most have been trained to provide. The various other tasks social workers 
report performing range from running errands outside the facility to assisting with dining room 
arrangements to getting residents eyeglasses fixed.  Only 19 percent of social workers report 
no obstacles in providing social work services. Time constraints and paperwork demands are 
also the top two obstacles which nursing home administrators report that their nursing home 
faces in providing comprehensive social work services to all residents. Barriers reported by 
social workers and nursing home administrators provide a degree of insight into some of the 
reasons that not all residents are getting all of the psychosocial services they need. 
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13 
Psychosocial Services in SNFs  OEI-02-01-00610  C O N C L U S I O N  
While SNFs with over 120 beds are complying with the federal requirement that SNFs employ 
a full-time social worker with at least a bachelors degree, over a third of SNF beneficiaries 
have incomplete psychosocial care plans and 46 percent of Medicare beneficiaries do not 
receive all of their planned psychosocial services during their SNF stay. 
We found that almost all (98 percent) of beneficiaries reside in SNFs that are in compliance 
with the over 120-bed rule.  In addition, 82 percent of beneficiaries reside in smaller facilities 
that meet the larger facility standard, even though they are not required to do so.  However, our 
medical record review determined that while 95 percent of those SNF Medicare beneficiaries 
with a psychosocial assessment have at least one psychosocial service need identified, 39 
percent of these residents do not have care plans that address all their psychosocial needs, and 
41 percent do not receive all the psychosocial services outlined in their care plans. In addition, 
we found that 5 percent of Medicare residents have none of their planned psychosocial services 
provided.  Our medical record review data, combined with social worker reports that some 
service barriers exist, lead us to conclude that not all residents are getting all of the psychosocial 
services they need. There is evidence that, despite the fact that SNFs are complying with the 
over 120-bed rule, there is not full compliance with the requirement that SNFs provide 
medically related social services to attain or maintain the highest practicable physical, mental 
and psychosocial well-being of each resident.15 Therefore, we question whether the present 
federal rule regarding social worker credentials is effective in achieving the desired level of 
psychosocial services for SNF residents. 
15
42 CFR 483.15(g) 
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14 
Psychosocial Services in SNFs  OEI-02-01-00610  R E C O M M E N D A T I O N  
Oversight of the psychosocial service portion of the resident assessment process 
should be strengthened. We found evidence that substantial numbers of SNF beneficiaries 
have incomplete psychosocial care plans, and many Medicare beneficiaries do not receive all of 
their planned psychosocial services during their SNF stay. Our medical record review revealed 
that 39 percent of beneficiaries do not have care plans that address all their psychosocial needs. 
In addition, 46 percent of SNF residents do not receive needed psychosocial services in 
accordance with their plan of care. The psychosocial assessment portion of the periodic 
resident assessment tools (comprehensive initial assessment, 5-day MDS, 14-day MDS, etc.) 
drives the preparation of care plans, which are then used to document all needed services that 
should be provided. If the assessments or the care plans are incomplete, all needed services 
are not likely to be provided. Therefore, we recommend that CMS strengthen the oversight 
processes associated with the psychosocial service portion of the resident assessment and the 
resulting care plans to ensure that SNF residents receive necessary and appropriate care. 
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15 
Psychosocial Services in SNFs  OEI-02-01-00610  A G E N C Y  C O M M E N T S  
The CMS provided comments on our draft report.  They concur with our recommendation that 
the oversight of the psychosocial service portion of the resident assessment process can be 
strengthened.  Additionally, in their comments, they highlight actions they have taken to date in 
this regard, as well as on-going initiatives. CMS also provided a number of technical 
comments.  As appropriate, these have been incorporated into this final report. 
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16 
Psychosocial Services in SNFs  OEI-02-01-00610  APPENDIX A 
Summary Analysis of Needs, Care Plans, and Services 
When looking at the overall picture of care provided to all Medicare beneficiaries in SNFs, 41 percent 
of Medicare beneficiaries have all their psychosocial needs addressed in care plans and receive all 
psychosocial services as planned.  On the other end of the spectrum is the following picture: 17 percent 
of beneficiaries have all needs addressed in a care plan, but not all services are provided; and 38 
percent of beneficiaries do not have all needs addressed in a care plan and not all services are 
provided. Three percent of beneficiaries have assessments that do not identify any needs, and 1 
percent of beneficiaries do not receive any assessments during their stay. (See Chart 3.) 
Chart 3 
Needs Addressed and Services Provided 
All needs are addressed 
in care plans; all services 
are provided 
1% 
3%  All needs are addressed 
in care plans; not all 
services are provided 
Not all needs are 
41% 
addressed in care plans; 
38%  not all services are 
provided 
Assessments identify no 
needs 
No assessments 
conducted 
17% 
Source: OIG medical record review, 2002 
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17 
Psychosocial Services in SNFs  OEI-02-01-00610  APPENDIX B 
Selected List of Recent Office of Inspector General Nursing Home 
Inspections 
Physicial, Occupational, and Speech Therapy for Medicare Nursing Home Patients: 
Medical Necessity, Cost and Documentation Under the $1500 Therapy Caps, 
OEI-09-99-00560, August 2001. 
Medicare Beneficiary Access to Skilled Nursing Facilities - 2001, OEI-02-01-00160, 
July 2001. 
Trends in the Assignment of Resource Utilization Groups by Skilled Nursing 
Facilities, OEI-02-01-00280, July 2001. 
Younger Nursing Facility Residents with Mental Illness: Preadmission Screening and 
Resident Review Implementation and Oversight, OEI-05-99-00700, January 2001. 
Younger Nursing Facility Residents with Mental Illness: An Unidentified

Population, 

OEI-05-99-00701, January 2001.

Medicare Payments for Psychiatric Services in Nursing Homes: A Follow-Up, 
OEI-02-99-00140, January 2001. 
Nursing Home Resident Assessment: Quality of Care, OEI-02-99-00040, January 2001. 
Nursing Home Resident Assessment: Resource Utilization Group, OEI-02-99-00041, 
January 2001. 
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18 
Psychosocial Services in SNFs  OEI-02-01-00610  APPENDIX C
Confidence Intervals For Key Findings 
We calculated confidence intervals for key findings.  The point estimate and 95 percent
confidence interval are given for each of the following:  
KEY FINDINGS N POINT  CONFIDENCE 
ESTIMATE INTERVAL
Ninety percent of Medicare beneficiaries have all their 299 90% 87% - 93% 
required MDS assessments completed.  
Of the Medicare beneficiaries who have an assessment, 95 296 95% 93% - 98%
percent have at least one need identified during their SNF
stay.  
Thirty-nine percent of SNF beneficiaries have care plans 288 39% 33% - 45%
that do not address all of Medicare beneficiaries
psychosocial needs.
Forty-six percent of SNF beneficiaries do not receive all 275 46% 40% - 52%
their planned psychosocial services. 
Forty-one percent of Medicare beneficiaries have all their 299 41% 35% - 47%
psychosocial needs addressed in care plans and receive all
psychosocial services as planned.  
Seventeen percent of Medicare beneficiaries have all their 299 17% 13% - 21% 
psychosocial needs addressed in care plans, but not all
services are provided.  
Thirty-eight percent of beneficiaries do not have all needs 299 38% 32% - 44%
addressed in a care plan and not all services are provided. 
Ninety-eight percent of beneficiaries receive psychosocial 118 98% 96% - 100%
services from facilities that are in compliance with the over
120-bed regulation. 
Forty-seven percent of beneficiaries are cared for in larger 118 47% 38% - 56%
facilities that employ at least one social worker with a
bachelors degree.  
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19
Psychosocial Services in  SNFs                      OEI-02-01-00610 Fifty-two percent of beneficiaries are cared for in larger  118  52%  43% - 61% 
facilities that employ at least one social worker with a 
graduate degree. 
The over 120-bed social work rule does not apply to 61 
percent of beneficiaries receiving services in skilled nursing 
299  61%  56% - 67% 
facilities. 
Eighty-two percent of beneficiaries receive services in  181  82%  76% - 88% 
smaller facilities that employ a social worker with either a 
bachelors degree or a graduate degree. 
Twenty-eight percent of social workers report that one of  84  28%  17% - 40% 
the barriers they face is not having enough time.* 
Nineteen percent of social workers say that burdensome  84  19%  9% - 29% 
paperwork limits their ability to provide psychosocial 
services.* 
Six percent of social workers say that not having enough  84  6%  2% - 10% 
staff, including social workers and other disciplines, is also 
an obstacle.* 
Over half of social workers (62 percent) say that their role 
includes a number of responsibilities beyond providing the 
84  62%  50% - 74% 
psychosocial services which most have been trained to 
provide. 
Only 19 percent of social workers report no obstacles in  84  19%  9% - 29% 
providing social work services. 
* Presented as unduplicated obstacles on page 13. 
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20 
Psychosocial Services in SNFs  OEI-02-01-00610  APPENDIX D 
AGENCY COMMENTS

In this appendix, we present in full the comments from the Centers for Medicare & Medicaid 
Services. 
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21 
Psychosocial Services in SNFs  OEI-02-01-00610  _________ 
22 
Psychosocial Services in SNFs  OEI-02-01-00610  A C K N O W L E D G M E N T S  
This report was prepared under the direction of John I. Molnar, Regional Inspector General for 
Evaluation and Inspections in the New York Regional Office, and Jodi Nudelman, Assistant Regional 
Inspector General. Other principal Office of Evaluation and Inspections staff who contributed include: 
Ellen Vinkey, Project Leader  Sandy Khoury, Program Specialist. Division

Christi Macrina, Lead Analyst  of Medicare and Medicaid, Baltimore

Judy Kellis, Program Analyst

David Rudich, Program Analyst

Renee Dunn, Former Deputy Regional Inspector General

Technical Assistance

Brian Ritchie, Director Technical Support Staff, Baltimore

Barbara Tedesco, Mathematical Statistician, Baltimore

For information or copies of this report, please contact

the Office of Inspector Generals

Public Affairs office at (202) 619-1343.

Reports are also available on the World Wide Web at our home page address:

http://www.oig.hhs.gov

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Psychosocial Services in SNFs  OEI-02-01-00610