Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

JANET REHNQUIST 

INSPECTOR GENERAL 

MARCH 2003 

OEI-02-01-00610 

Psychosocial Services in 

Skilled Nursing Facilities 
OFFICE OF INSPECTOR GENERAL

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 OIG’s 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. 
EXECUTIVE SUMMARY 

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. 

_________ Psychosocial Services in SNFs i 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. 

_________ Psychosocial Services in SNFs ii 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 

_________ Psychosocial Services in SNFs iii 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) 

_________ Psychosocial Services in SNFs iv OEI-02-01-00610 
TABLE OF CONTENTS 

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

_________ Psychosocial Services in SNFs v OEI-02-01-00610 
INTRODUCTION 

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 resident”4 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. 

_________ Psychosocial Services in SNFs 1 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 

resident’s 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 

_________ Psychosocial Services in SNFs 2 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) 

_________ Psychosocial Services in SNFs 3 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 resident’s 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 

_________ Psychosocial Services in SNFs 4 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. 

_________ Psychosocial Services in SNFs 5 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 inperson 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 President’s Council on Integrity and Efficiency. 

_________ Psychosocial Services in SNFs 6 OEI-02-01-00610 
FINDINGS 

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 patient’s chart. While 90 percent of 

_________ Psychosocial Services in SNFs 7 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. 

_________ Psychosocial Services in SNFs 8 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 resident’s 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. 

11Most 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. 

_________ Psychosocial Services in SNFs 9 OEI-02-01-00610 
Table 2 

Psychosocial Service Deficiencies, 1998-2001 

Year Psychosocial 

deficiencies as 

% of all 

deficiencies 

% of facilities 

with one or 

more 

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 psychosocialrelated 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. 

_________ Psychosocial Services in SNFs 10 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 workrelated 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 

13As 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 

bachelor’s 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. 

_________ Psychosocial Services in SNFs 11 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 

14Percentage is based on the highest education-level social worker in each facility. 

_________ Psychosocial Services in SNFs 12 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. 

_________ Psychosocial Services in SNFs 13 OEI-02-01-00610 
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 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. 

1542 CFR §483.15(g) 

_________ Psychosocial Services in SNFs 14 OEI-02-01-00610 
RECOMMENDATION 

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. 

_________ Psychosocial Services in SNFs 15 OEI-02-01-00610 
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. 

_________ Psychosocial Services in SNFs 16 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 

38% 

41% 

3% 

1% 

17% 

All needs are addressed 

in care plans; all services 

are provided 

All needs are addressed 

in care plans; not all 

services are provided 

Not all needs are 

addressed in care plans; 

not all services are 

provided 

Assessments identify no 

needs 

No assessments 

conducted 

Source: OIG medical record review, 2002 

_________ Psychosocial Services in SNFs 17 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. 

_________ Psychosocial Services in SNFs 18 OEI-02-01-00610 
_________

Psychosocial Services in SNFs 19 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 

ESTIMATE

CONFIDENCE 

INTERVAL

Ninety percent of Medicare beneficiaries have all their

required MDS assessments completed. 

299 90% 87% - 93% 

Of the Medicare beneficiaries who have an assessment, 95

percent have at least one need identified during their SNF

stay. 

296 95% 93% - 98%

Thirty-nine percent of SNF beneficiaries have care plans

that do not address all of Medicare beneficiaries’

psychosocial needs.

288 39% 33% - 45%

Forty-six percent of SNF beneficiaries do not receive all

their planned psychosocial services. 

275 46% 40% - 52%

Forty-one percent of Medicare beneficiaries have all their

psychosocial needs addressed in care plans and receive all

psychosocial services as planned. 

299 41% 35% - 47%

Seventeen percent of Medicare beneficiaries have all their

psychosocial needs addressed in care plans, but not all

services are provided. 

299 17% 13% - 21% 

Thirty-eight percent of beneficiaries do not have all needs

addressed in a care plan and not all services are provided. 

299 38% 32% - 44%

Ninety-eight percent of beneficiaries receive psychosocial

services from facilities that are in compliance with the over

120-bed regulation. 

118 98% 96% - 100%

Forty-seven percent of beneficiaries are cared for in larger

facilities that employ at least one social worker with a

bachelors degree. 

118 47% 38% - 56%
Fifty-two percent of beneficiaries are cared for in larger 

facilities that employ at least one social worker with a 

graduate degree. 

118 52% 43% - 61% 

The over 120-bed social work rule does not apply to 61 

percent of beneficiaries receiving services in skilled nursing 

facilities. 

299 61% 56% - 67% 

Eighty-two percent of beneficiaries receive services in 

smaller facilities that employ a social worker with either a 

bachelors degree or a graduate degree. 

181 82% 76% - 88% 

Twenty-eight percent of social workers report that one of 

the barriers they face is not having enough time.* 

84 28% 17% - 40% 

Nineteen percent of social workers say that burdensome 

paperwork limits their ability to provide psychosocial 

services.* 

84 19% 9% - 29% 

Six percent of social workers say that not having enough 

staff, including social workers and other disciplines, is also 

an obstacle.* 

84 6% 2% - 10% 

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. 

84 62% 50% - 74% 

Only 19 percent of social workers report no obstacles in 

providing social work services. 

84 19% 9% - 29% 

* Presented as unduplicated obstacles on page 13. 

_________ Psychosocial Services in SNFs 20 OEI-02-01-00610 
APPENDIX D 

AGENCY COMMENTS

In this appendix, we present in full the comments from the Centers for Medicare & Medicaid 

Services. 

_________ Psychosocial Services in SNFs 21 OEI-02-01-00610 
_________ Psychosocial Services in SNFs 22 OEI-02-01-00610 
ACKNOWLEDGMENTS 

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 General’s

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

_________ Psychosocial Services in SNFs 23 OEI-02-01-00610