Preadmission Screening

Preadmission Screening and Resident Review (PASRR) is a tool that states are to use for both nursing facility (NF) diversion and deinstitutionalization in order to meet their obligations under the Americans with Disabilities Act (ADA) and the Supreme Court's Olmstead decision. For a state to have its Medicaid plan approved by the Centers for Medicare and Medicaid Services (CMS), it must maintain a Preadmission Screening and Resident Review (PASRR) program that complies with the relevant federal laws and regulations. Everyone who applies for admission to a nursing facility (NF) must be “screened” for evidence of serious mental illness (MI) and/or intellectual disabilities (ID), developmental disabilities (DD), or related conditions (RC).

A NF must not admit an applicant who has MI and /or ID/RC unless the appropriate state agency has determined whether a) the individual needs the level of services that a NF provides, and b) whether individuals who need NF services also need high-intensity “specialized services.” Generally speaking, the intent of PASRR is to ensure that all NF applicants are thoroughly evaluated, placed in nursing facilities only when appropriate, and receive all necessary services while they are there.

Three state agencies have a major role to play in PASRR: the Medicaid agency, the state mental health authority (SMHA), and the state intellectual disability authority (SIDA). The Medicaid agency is ultimately responsible for overseeing the PASRR program. The SMHA has responsibility for Level II determinations (the final legal document), but not for Level II evaluations, which must be performed by an entity independent of the SMHA. The State Intellectual Disability Authority (SIDA) has responsibility both for Level II evaluations and for Level II determinations. Either agency may delegate its responsibilities to another party, such as a vendor of PASRR services.

The Department of Health and Senior Services (DHSS) utilizes the Initial Assessment-Social and Medical forms (DA124 A/B) to initiate the process for admission to a Nursing Facility. DHSS determines the need for nursing facility services through established NF level of care criteria. The Medicaid level of care criteria can be found in DHSS regulation 19 CSR 30-81.030. A special admission category must be granted / approved by DHSS to admit an individual to a SNF before a PASRR assessment is completed.

PASRR has two core components. The Level I screen (DA 124C) given to all NF applicants is reviewed by DHSS Central Office Medical Review Unit (COMRU). The second component of PASRR, the Level II evaluation, is executed by Department of Mental Health. The Level II evaluation examines the diagnosis of record to confirm or disconfirm whether the individual with a positive Level I has MI or ID/RC, determines whether placement or continued stay in the requested or current NF is appropriate; and calculates the individual's MI/ID service needs, including services the NF can provide under its per diem. Only the DMH state contracted entity (Bock Associates) can complete the Level II evaluations. Bock Associates' assessors determine the least restrictive and most appropriate setting in which an individual’s needs may be supported in order to meet obligations of the Americans with Disabilities Act (ADA) and the Supreme Court's Olmstead decision.

Resident Review

What is considered a "significant change in condition?"

Per Section 1919(e) (7) (B) (iii) of the Social Security Act, Resident Reviews are required for NF residents experiencing a “significant change in condition.” The Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual (RAI) provides guidance to nursing facilities (NF) on when a significant change requires referral for a PASRR Resident Review assessment if a mental illness, intellectual disability, or related condition is present or is suspected. The RAI manual notes that a “significant change” is a major decline or improvement in a resident’s status that:

  • Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered “self- limiting”;
  • Impacts more than one area of the resident’s health status; and
  • Requires interdisciplinary review and/or revision of the care plan.

In instances where the individual had not previously been found by PASRR to have a mental illness, intellectual disability/developmental disability, or a related condition, the following conditions may be noted as the reason for referral (this is not an exhaustive list):

  • A resident who exhibits behavioral, psychiatric, or mood-related symptoms suggesting the presence of a diagnosis of mental illness as defined under 42 CFR §483.102 (where dementia is not the primary diagnosis).
  • A resident whose intellectual disability as defined under 42 CFR §483.102, or whose related condition as defined under 42 CFR §435.1010, was not previously identified and evaluated through PASRR.
  • A resident transferred, admitted, or readmitted to a NF following an inpatient psychiatric stay or equally intensive treatment.

Resident assessments Rule (§483.20)

Section 1919(e) (7) (B) (iii) of the Act added a requirement that a nursing facility must notify the state mental health authority or intellectual disability authority for resident evaluation promptly after a significant change in the mental or physical condition of a resident with a mental illness or intellectual disability. Please note that the rule does not change or replace the need for completing the required MDS assessment for change in condition and /or submitting updated DA124 forms to DHSS COMRU. Please include the full name of the Individual, the date of birth, the DCN and a summary describing the change in condition. Please send the notification to:

Attn: PASRR Program

Department of Mental Health

1706 East Elm Street / PO Box 687

Jefferson City, Missouri 65102


Contact Information for PASRR

To check the status of a nursing facility application, please contact DHSS COMRU at 573-522-3092 or by email at Information concerning Level One screening is located on the DHSS webpage at

To request copies of previous PASRR evaluations contact Bock and Associates at Find the answers to FAQ concerning PASRR at Contact Michelle Newberry, Bock Associates Project Director, for any other questions or concerns.

To appeal a PASRR decision or to report a significant change in condition related to intellectual disability and /or mental illness, contact Kathy Schafer at 573-751-8070 or at .

PASRR Resources

Pre-Admission Screening and Resident Review (PASRR 101)

The Behavioral Health Crisis Hotline:

The BHCH is staffed by mental health professionals who can respond to your crisis 24 hours per day and 7 days per week. They will talk with you about your crisis and help you determine what further help is needed, for example, a telephone conversation to provide understanding and support, a face-to-face intervention, an appointment the next day with a mental health professional, or perhaps an alternative service that best meets your needs. They may give you other resources or services within your community to provide you with ongoing care following your crisis. All calls are strictly confidential.


Therapy Aide, worksheets and Tools:  

Therapist Aid is dedicated to helping mental health professionals improve their craft by providing free evidence-based education and therapy tools. Therapist Aid resources are created with individuals in mind, which means avoiding jargon, and creating tools that are useful in theory and practice.


Managing Difficult Behaviors in Dementia, By Linda Conti, RN, CHPN, Today's Geriatric Medicine

Mental Health First Aid Training

Mental Health First Aid is an 8-hour course that teaches you how to identify, understand and respond to signs of mental illnesses and substance use disorders. The training gives you the skills you need to reach out and provide initial help and support to someone who may be developing a mental health or substance use problem or experiencing a crisis.

Person-Centered Care Planning

Money Follows the Person

The objectives of Money Follows the Person are to move people from a facility to the community; identify and eliminate barriers that prevent people from being able to move to the community; improve the ability of MO Health Net to provide in-home services; and to ensure that there is continuous quality improvement of in-home services provided. If you have questions about Money Follows the Person, call 573-751-8021 or send an email inquiry to

PASRR Technical Assistance Center

The Centers for Medicare & Medicaid Services (CMS) contracted with Acumen, LLCand subcontracted with Mission Analytics Group, Inc. to develop the PASRR Technical Assistance Center.

The purpose of this site is to provide technical assistance to states that may need assistance with their Preadmission Screening and Resident Review (PASRR) programs.

Missouri Protection and Advocacy

MO P&A is a federally mandated system in the state of Missouri which provides protection of the rights of persons with disabilities through legally-based advocacy. MO P&A provides nine federally-funded programs to protect the legal rights of persons with disabilities.

Positive Behavior Intervention and Crisis Plans

Structured Environment, Socialization and Personal Support Network