Elizabeth J. Clark, PhD, ACSW, MPH
Executive Director
National Association of Social Workers
750 First Street, NE, Suite 700
Washington, DC 20002-4241

Dear Dr. Clark:

Thank you for your letter to Thomas Scully, Administrator of the Centers for Medicare & Medicaid Services (CMS), addressing the National Association of Social Workers (NASW) concerns regarding the findings of the Office of Inspector General's (OIG) report, Psychosocial Services in Skilled Nursing Facilities, #OEI-02-0 1-00610. In your letter you noted several concerns of the OIG, including the OIG's findings regarding the delivery of psychosocial services to beneficiaries and CMS' enforcement of the requirements in this area.

One issue you raise concerned the definition of a qualified social worker. CMS recognizes that nursing home residents deserve and expect access to psychosocial services. Although we have no immediate plans to change the definitions of a qualified social worker, we hold nursing homes accountable for providing residents with quality care. Additionally, 42 CFR 483.75(b), indicates that social workers must meet both the Federal definition, as well as meet state and local laws and professional standards.

Your second comment had to do with OIG's findings of inadequate care plans. In response to this finding, CMS recently sponsored conferences and satellite programs designed to assist State Survey Agency surveyors and nursing home professional staff, those responsible for assessing residents, to appropriately identify and assess residents with psychosocial needs.

A third concern centered around the "adequacy of the 120-bed rule," that rule requires that a facility with more that 120 beds must employ a qualified social worker on a full time basis. You recommend that the rule should be more stringent to ensure that adequate staffing is provided to as~ure appropriate care. We believe that our current requirements ensure that appropriate services are provided when each resident's care plan is developed and implemented based on individually identified needs. For example, the requirement found in Appendix PP of the State Operations Manual for tag F250, 42 CFR 483.15(g)(1) states "The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident." Guidance to surveyors states that "Regardless of size, all facilities are required to provide for the medically-related social services needs of each resident." Our requirements also state that facilities aggressively identify the need for medically-related social services, and pursue the provision of these services.

Further, you mentioned the OIG's finding that CMS engage in more effective oversight to ensure that residents receive necessary and appropriate psychosocial care. CMS has several initiatives for oversight and monitoring including: 1) the Federal Oversight and Support Survey (FOSS) monitoring survey process conducted by CMS Regional Offices to evaluate the State Survey Agencies performance dUring survey of nursing homes; 2) the Data Assessment and Verification (DAVE) project, which assesses the accuracy of Minimum Data Set (MDS) assessments of residents residing in nursing homes; and 3) the Quality Improvement Organizations (QIOs), who work with State Survey Agencies promoting improvement and excellence in care in nursing homes. We continue to look for meaningful ways to ensure that we are as effective as possible in our oversight role.

Finally, you indicated that the October 19, 2000, Proposed Rule: HCFA-1088-P, Medicare Program; Clinical Social Worker Services, (65 FR 62681) was a positive and clarifying step in accelerating the availability of professional social work services to help meet the psychosocial needs of residents residing in skilled nursing facilities. You indicate that this proposed rule "would permit separate Medicare Part B pa~ent for certain psychotherapy services of clinical social workers furnished to a skilled nursing facility resident whose stay is not covered by Medicare... [and] would benefit residents of skilled nursing facilities who receive psychosocial services from clinical social workers." We appreciate your thoughts on the proposed rule and note that this issue will be addressed in future rule making, as noted in the December 31, 2002, Federal Register.

Thank you for informing CMS of NASW's concerns. We will continue to work to ensure that each facility provides medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well being of each resident. I hope this information has been helpful in clarifying CMS' existing requirements and ongoing activities in this important area.

If you have additional questions or concerns, please contact Melissa Hulbert, Acting Deputy Director of our Survey and Certification Group at (410) 786-6568.

Sincerely,

Dennis G. Smith

Director