Government Relations Update

Thomas A. Scully, Administrator
Centers for Medicare and Medicaid Services
U.S. Department of Health and Human Servic Comment to OIG June 2003es
200 Independence Avenue, SW
Mail Stop 314G
Washington, DC 20201

RE: Office of Inspector General, Report on Psychosocial Services in Skilled Nursing Facilities (OEI-02-01-00610)

Dear Mr. Scully:

The National Association of Social Workers (NASW), the largest professional social work organization in the world, has a long history of providing and advocating for quality health services for children, adults, and families. In this country, professionally trained and credentialed social workers provide the majority of psychosocial services in skilled long-term care facilities (SNFs), hospitals, home care agencies, and in the community at large. We are therefore concerned by the findings of the recent Office of Inspector General’s report Psychosocial Services in Skilled Nursing Facilities, #OEI-02-01-00610.

NASW values the report for its initial efforts to determine whether Medicare SNF residents are receiving psychosocial services in compliance with federal requirements.  We believe that psychosocial assessments and interventions are critical components in addressing the issues of quality care in this country for providers, consumers, and their families.

Consumers of long-term care services, many of whom are older adults, present with complex problems including: multiple medical diagnoses, cognitive deficits, mental health issues, limited access to social supports and limited financial resources.  NASW agrees that there is a great need for psychosocial services in SNFs. We also believe strongly that professionally trained social workers serving in SNFs with adequate time and resources are essential to meet the requirements of existing law and regulations. 

Definition of a qualified social worker

A major issue of concern to NASW is the definition of a qualified social worker within the federal regulations and how that definition relates to our professional standards. According to federal regulations, “a qualified social worker is an individual with a bachelor’s degree in social work or a bachelor’s degree in a human services field including but not limited to sociology, special education, rehabilitation counseling and psychology; and one year of supervised social work experience in a health care setting working directly with individuals” (42 CFR § 483.15 (g)(3)(i)(ii)).

The Omnibus Budget Reconciliation Act (OBRA) of 1987 specifies that “the services provided or arranged by the facility must meet professional standards of quality” (42 CFR § 483.20(d)(3)(i)). However, the professional standard for a social worker as defined by NASW Standards for Social Work Services in Long-Term Care Facilities (2003) reads as follows:  “A social worker has: at minimum, a bachelor’s degree from an accredited school or program of social work; has two years of postgraduate experience in long-term care or related programs; and, meets equivalent state requirements for social work practice, or, in jurisdictions not having such legal regulation, holds certification or credentialing from the National Association of Social Workers.  In no instance shall a social worker have less than a baccalaureate degree from an accredited school or program of social work.”

There is a clear disparity between the federal definition of a qualified social worker, the specifications outlined by OBRA, and current professional social work standards of practice. Since social work practice is regulated in all 50 states, which includes the protection of the title “social worker,” the federal definition of a qualified social worker as it currently is written, does not reflect the profession’s own best practice standards. Furthermore, this federal definition is not sufficient to guarantee the quality of services that residents of SNFs require and deserve.

Inadequate care plans and failure to deliver planned services

The OIG found in its medical record review that almost all Medicare beneficiaries had at least one psychosocial need identified during their SNF stay. However, of those with identified needs, only 61 percent had care plans that addressed all of their psychosocial needs during their SNF stay. Furthermore, the OIG’s review showed that only 54 percent of residents received all of their psychosocial services as planned during their stay. Forty-one percent did not receive all of their planned psychosocial services and five (5) percent received none of their planned psychosocial services. NASW is deeply concerned with OIG’s finding of widespread failure by SNFs to provide the necessary psychosocial services and with CMS’s failure to adequately enforce the requirements of the law.

Adequacy of the 120-bed rule

We are pleased that virtually all beneficiaries reside in SNFs that comply with the over 120-bed rule, and some 51 percent of residents in large facilities are served by social workers with a graduate degree. However, OIG’s finding that such a large percent of residents actually do not receive all of the required psychosocial services leads NASW to conclude that the staffing standard must be inadequate to meet the psychosocial service needs of residents. We think it is important that OIG found that 45 percent of social workers report a lack adequate time and insufficient staff as barriers to providing psychosocial services in SNFs that affect their ability to provide psychosocial services. Just 19 percent of social workers report no obstacles in providing social work services. We strongly urge that CMS examine the adequacy of the 120-bed rule and prepare a recommendation to Congress to change this requirement to ensure adequate staffing is available to meet the level of care required in current law.

Need for stronger CMS oversight

NASW strongly concurs with the OIG’s finding that CMS should engage in more effective oversight of all administrative procedures to ensure that residents receive necessary and appropriate psychosocial care. NASW is concerned that CMS efforts in this area fall far short in addressing the needs of residents and in meeting the requirements described in law. NASW believes the release and implementation of Proposed Rule 1088-P by CMS would be a positive and clarifying step in accelerating the availability of professional social work services to help meet the psychosocial needs of those who reside in skilled nursing facilities.

NASW intends to actively support regulatory and legislative actions to correct the deficiencies described by the OIG and to ensure that residents receive the care they need and to which they are entitled under federal law. We request your increased attention to these difficult problems, particularly in developing stronger regulatory processes to enforce CMS’s own requirements and in recommending necessary statutory changes to Congress.

While the OIG report highlights important issues about delivering psychosocial services to residents of SNFs, we have inherent concerns about the methodology used in this study. The random sample from the universe of recently admitted Medicare SNF residents is not necessarily representative of the SNF population because those who pay privately and those who are recipients of Medicaid are excluded. The sample also consisted of those who primarily resided in a nursing home for a relatively short period of time. As a result, the sample is not representative of the general population of nursing home residents who may have more complex psychosocial needs.

NASW invites CMS leadership and staff to consider our association as a resource on this issue as well as future initiatives. We look forward to working with you further on this important issue.

Yours truly,

Elizabeth J. Clark, PhD, ACSW, MPH
Executive Director

cc:  Dara Corrigan, Principal Deputy Inspector General