PASRR Level II Assessments
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.
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.
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 866-835-3505 or by email at email@example.com. Information concerning Level One screening is located on the DHSS webpage at https://health.mo.gov/seniors/nursinghomes/pasrr.php.
To request copies of previous PASRR evaluations contact Bock and Associates at firstname.lastname@example.org. Find the answers to FAQ concerning PASRR at http://www.bock-associates.com/Missouri/. Contact Michelle Newberry, Bock Associates Project Director, email@example.com 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 kathy.schafer@DMH.mo.gov .
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