CMS SOM App. H, Tag V552

address, but not be limited to, the following: (6) Psychosocial status. The interdisciplinary

team must provide the necessary monitoring and social work interventions. These include

counseling services and referrals for other social services, to assist the patient in achieving

and sustaining an appropriate psychosocial status as measured by a standardized mental

and physical assessment tool chosen by the social worker, at regular intervals, or more

frequently on an as-needed basis.

Interpretive Guidance § 494.90(a)(6):

To address the patient’s psychosocial needs and to achieve and sustain an appropriate

psychosocial status, each patient's plan of care must reflect the information obtained from the

applicable components of the IDT comprehensive assessment under the Condition for patient

assessment at V502-V515, including the psychosocial assessment at V510. The plan of care must

include interventions individualized to meet that patient’s psychosocial needs and aimed at

optimizing the patient’s adjustment to kidney failure and its treatment. The social worker is

expected to help patients achieve their psychosocial goals. Counseling services for patients and

their families should focus on helping them cope with kidney failure and dialysis, follow the

treatment plan, and achieve the patient’s rehabilitation goals.

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This regulation does not require facilities to use any specific assessment tool; rather, it requires

the social worker to choose a “standardized mental and physical assessment tool” that is used

as a monitoring aid to assist in determining the patient’s psychosocial status. There is flexibility

in the assessment tool used to evaluate a patient’s mental and psychosocial status; however, the

tool must be age-appropriate, i.e., adult and pediatric patients should be assessed using an

assessment tool tailored to their respective age groups. The tool must be administered and the

results measured at regular intervals, as well as on an as-needed basis.

The “regular intervals for which an assessment tool must be used may be specified by the form

or survey of choice. The social worker should adhere to the instructions and guidelines set for

the tool being used when measuring a patient’s mental and psychosocial status. If no such

specification exists, the dialysis facility should establish a regular interval for administering the

assessment tool. For example, the Kidney Disease Quality of Life 36 survey (KDQOL-36) is one

of the most widely used measures of Health-Related Quality of Life (HRQOL) for patients with

ESRD. The KDQOL-36 assessment survey is administered at the time of the first reassessment

(i.e., within 4 months of initiating treatment) and repeated at least annually thereafter. Examples

of use on an “as-needed basis” include repeating the survey with patients who have experienced

a significant life-changing event (e.g., loss of spouse or caregiver, loss of job, recent move to a

nursing home) or a change in their health status.

The social worker must have a system for routine use of the assessment survey, evaluation of the

results, and incorporation of the survey results into the development and updating of the

psychosocial portion of the plan of care.

Referrals for social services may include those to providers of community mental health services,

transportation providers, in-home support services, food banks, or other available community

resources. Patients will vary in their needs for interaction with the social worker and may

require referrals to other social services. Enhanced and more frequent social services

interventions are expected for patients who present with or develop greater psychological,

social, and/or financial issues.

The requirements for assessing patients’ psychosocial needs are outlined at V510.