What is PASRR?

Written by Lori Crawford, Program Manager

PASRR, which stands for Preadmission Screening Resident Review, is a federally mandated program which requires that everyone being considered for admission to a Medicaid certified nursing facility (NF), regardless of their payor source, be screened for Serious Mental Illness (SMI), Intellectual disabilities (ID) or Related Conditions (RC) in order to prevent inappropriate institutionalization. PASRR was implemented in 1987 by CMS (Center for Medicaid Services) as part of the OBRA (Omnibus Budget Reconciliation Act - also known as the Nursing Home Reform Act), part of the largest and most comprehensive nursing home reform since the inception of Medicaid and Medicare in 1965.

As the name states, the PASRR screening is intended to be completed on a “preadmission” basis. However, compliance, as well as processes, vary across states. 

Two Main Components of the PASRR Process

Level I Screen

This is the identification portion of the PASRR process. Each state uses their own Level I screening form that typically includes basic demographic and identifying questions, along with others to determine if a person many have a PASRR condition which includes a Serious Mental Illness (SMI), Intellectual Disability (ID) or Developmental Disability (DD), often referred to as an Related Condition (RC) in many states. Many states now utilize an electronic submission system and algorithm to identify if a referred individual may have a PASRR condition.

A Level I screen may be an initial referral (submitted at or prior to admission to a NF) or a Resident Review. If, after admission to a nursing facility, a person experiences a significant change in condition (as identified in the MDS – Minimum Data Set), the facility is responsible to submit a Resident Review which may result in the need for a Level II assessment. 

Level II Assessment

Prior to making a referral for a comprehensive Level II assessment, most states also perform a review of triggered screens to identify if a person with a known or suspected PASRR condition is eligible for any state approved categorical, exemption or exclusions from the PASRR process. Maximus refers to this as a Clinical Review, which is considered brief Level II activity.

As appropriate, the person is then referred for a comprehensive evaluation called a Level II assessment to confirm/deny any PASRR condition, setting appropriateness and services needed. This assessment is completed by an QMHP (Qualified Mental Health Professional) or a QIDP (Qualified Intellectual Disability Professional), in the state where the person resides. 

The Level II assessor is responsible to complete:

1. A record review
2. A biopsychosocial assessment with the individual – to gather details about the person to be able to paint a clear picture of the person (likes, dislikes, hobbies, MH background that includes diagnoses, treatment history, current cognition, etc.)
3. Supplemental interviews, as able, with a loved one or caregiver and/or a provider - to gather additional information about the person’s behaviors, mental health symptoms observed/reported since coming onsite, and general functioning since admission. 
4. A written report of all the information obtained.

At Maximus, a Quality Clinician (QC) then reviews the assessment for thoroughness and quality, using the information provided to create a Summary of Findings (SOF). Included in the SOF are recommendations for both placement and specialized and/or rehabilitative services based on the person’s needs. The Level II determination and SOF are provided to the individual and/or their legal representative, the Level I submitter, as well as the physician and admitting facility when known. These are documents that must remain on the person’s chart and all recommendations must be included in their care plan.

Even though PASRR is a federal requirement, and the same federal regulations (found at 42CFR-483,100-138 Subpart C) apply to all states, PASRR programs and how they operationalize their related processes do vary. For example, some states use a vendor, like Maximus, for their entire PASRR program while others may only do so for certain aspects or none at all. Another area of variability across states is the availability and use of PASRR exemptions, exclusions and categoricals. Conducting a comprehensive Level II assessment requires time and the use of various resources and, because of this, CMS regulations allow states to select and offer options for individuals to admit to a NF more expeditiously if eligibility criteria are met. Specific PASRR exemptions, exclusions and categoricals options (and more!) will be discussed in greater detail in an upcoming newsletter. In the interim, check out the chart linked here, which outlines the 13 state PASRR programs and their various components supported by Maximus.



PASRR Specialized Services

Written by Jen Sieminski, Clinical Implementation Manager

What do you think of when you hear the term specialized services (SS)? Assuming this term is known to you at all, your response may depend on which contract(s) you support. Starting with the basics, determining whether or not a person needs specialized services is at the very heart of our PASRR work. When it is decided that an individual requires the level of services provided by a nursing facility (NF), Federal Regulations require us to determine if a NF applicant will also need specialized services for their mental health or intellectual/developmental disability, or if services of a lesser intensity will suffice.

We usually refer to services of a lesser intensity informally as “rehabilitation” or “rehab” services and such services are typically offered as part of the standard NF setting and therefore available to all NF residents who need them, regardless of whether or not they have an identified PASRR condition. Generally speaking, rehab services are typically intended to help people keep, get back, or improve their daily living skills and functioning which may have been diminished or lost due to a wide variety of reasons. Common examples include physical, speech, and occupational therapy. However, available services do vary by state depending upon the state’s Medicaid authority and the arrangements that have been made with their healthcare organizations such as nursing facilities. These variable arrangements are called Conditions of Participation (CoP) and they must be met in order for, a NF (in this case), to participate in Medicaid and Medicare programs and receive funding. This is also the very reason why the PASRR regulations simply differentiate between specialized services and services of a lesser intensity.

To summarize the CFR:

• SS for those with a mental illness refers to services specified by the state, which in combination with services provided by the NF, results in the continuous and aggressive implementation of an individualized plan of care. These must be developed and supervised by an interdisciplinary team and which prescribes specific therapies and activities for the treatment of persons experiencing an acute episode of serious mental illness. SS is also directed toward diagnosing and reducing the resident's behavioral symptoms to permit reduction in the intensity of mental health services to those below the level of specialized services at the earliest possible time.

• SS for those with IDD refers to services specified by the State which, combined with services provided by the NF or other service providers, results in treatment which meets the requirements of Sec. 483.440(a)(1)-- continuous active treatment program, which includes aggressive, consistent implementation of a program of specialized and generic training, treatment, health services and related services. These are directed toward the acquisition of the behaviors necessary for the client to function with as much self-determination and independence as possible; and the prevention or deceleration of regression or loss of current optimal functional status.

So at what point does a service go from being “of a lesser intensity” to one that is specialized? Great question! Unfortunately, you will need to stayed tuned for the next edition of the PASRR LOB newsletter. In the interim, consider the following questions the next time you find yourself summarizing a PASRR Level II assessment:

• How can I highlight the way this person's disability affects their services needs and how those services might affect their disability?

• How can I help an individual to maintain continuity of care between where they were and where they are going?

PASRR Community of Practice News

Hosted by Lori Crawford

Have we sparked your interest? Do you want to learn more about PASRR? Do you have something to share about the PASRR program you’re working on? Do you want to have time to discuss all things PASRR related with other staff?

If you answered yes to any of the questions noted above, please join us on third Thursday of each month for some exciting and intriguing conversation during the PASRR Community of Practice! COP - not to be confused with CoP noted above. 

Join on your computer or mobile app

Click here to join the meeting

Or call in (audio only)

+1 651-964-2079,,150216984# United States, St. Paul

Phone Conference ID: 150 216 984# 

The joy of attending a COP is there’s no agenda, no preparation, and lots of time to engage with other PASRR engaged/interested individuals.