Pre-Admission Screening and Resident Review (PASRR)

Purpose 

PASRR is a federally mandated screening process for individuals with serious mental illness (SMI), intellectual disability/developmental disability (IDD/DD), and/or related condition who apply for or reside in a Medicaid Certified bed in a nursing facility regardless of payment source. The screening identifies individuals who meet the federal criteria of SMI, IDD/DD, or related condition, evaluates the most appropriate setting, and identifies service needs based on the mental health condition. Resident Reviews are required for nursing facility residents experiencing a “significant change in condition” to ensure the evaluation reflects the most relevant and updated information. States are required to maintain a PASRR program that complies with relevant federal laws in order for the Center for Medicare and Medicaid Services (CMS) to approve the Medicaid state plan.

Process

When an individual is seeking admission to a Medicaid Certified nursing facility bed, a Level of care (LOC)/Level I application is submitted to the Department of Health and Senior Services (DHSS). A DHSS Medical Health Consultant reviews the LOC/Level I application to identify individuals with suspected SMI, IDD/DD, or related condition. DHSS verifies the individual meets the level of care requirements and if suspected of having a qualifying SMI, IDD/DD, or related condition under the federal definition, DHSS refers the individual to the Department of Mental Health (DMH) for a Level II evaluation. MI and ID have specific definitions under the federal regulation for the purpose of PASRR and do not necessarily correspond to the definitions used in other contexts. DMH reviews each Level II referral from DHSS and refers qualifying individuals who have never had a screening for a pre-admission screening to the DMH contracted provider Bock Associates. DMH also identifies the need for updated Level II evaluation on individuals who have a previous Level II evaluation, and refers qualifying individuals to Bock Associates for a resident review/change in conditions. Level II Evaluations determine the least restrictive and most appropriate setting in which the individual’s needs may be supported in order to meet the obligations of the. Americans with Disabilities Act (ADA) and the Supreme Court's Olmstead decision Level II Evaluations are current until the individual has a change in condition that affects their mental health symptoms or treatment needs. A nursing facility must notify DMH promptly after a significant change in the mental or physical condition of a resident with a mental illness or intellectual disability.  DMH reviews resident review/change in conditions submitted by the nursing facility to determine the need for an updated Level II Evaluation. If an individual has never had a Level II evaluation, DMH directs the facility to apply for a new LOC/Level I screening through DHSS. DMH reviews and approves completed level II pre-admission evaluations and resident reviews. Bock Associates uploads the approved Level II evaluation and determination for DHSS and the requesting entity. Bock also sends these documents to DMH regional offices for individuals who have open files with DMH Division of Developmental Disabilities. 

Who can apply?

Anyone can apply on behalf of someone seeking admission to a Medicaid Certified nursing facility bed. The LOC/Level I applications must have a physician signature to be considered complete. Instructions on how to apply and access the LOC/Level I application are on the DHSS website and any questions regarding the LOC or Level I should be directed to DHSS. 

Contact DHSS at http://health.mo.gov/seniors/nursinghomes/pasrr.php

What is included?

A Level II Evaluation is a comprehensive assessment of current and historical treatment. The full comprehensive screening, findings, and determination completed by a Mental Health Professional are included. Findings include confirming mental health condition under the Federal Regulation, mental health services needed while in the NF, and if the person requires mental health services beyond what a nursing facility can provide.

For information on applying to a Missouri nursing facility and being outside the state, please follow the out of state PASRR operational guideline can be found at DOR 4.810 | dmh.mo.gov.

What is considered a "significant change in condition?"

Resident Reviews are required for nursing facility residents experiencing a “significant change in condition.”  A change requires a referral for a PASRR Resident Review assessment if a mental illness, intellectual disability, or related condition is present or is suspected. 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.

For individuals previously identified by PASRR to have mental illness, intellectual disability, or a related condition.  Examples of changes include but are not limited to: 

• A resident who demonstrates increased behavioral, psychiatric, or mood-related symptoms.
• A resident with behavioral, psychiatric, or mood-related symptoms that have not responded to ongoing treatment.
• A resident who experiences an improved medical condition—such that the resident’s plan of care or placement recommendations may require modification.
• A resident whose significant change is physical, but with behavioral, psychiatric, or mood-related symptoms, or cognitive abilities, that may influence adjustment to an altered pattern of daily living.
• A resident who indicates a preference to leave the facility. (This preference may be communicated verbally or through other forms of communication, including behavior.)
• A resident whose condition or treatment is or will be significantly different than described in the resident’s most recent PASRR Level II evaluation and determination.

For individuals who have not previously been identified by PASRR to have a mental illness, intellectual disability, or a related condition. Examples of changes include but are not limited to:

• 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 nursing facility following an inpatient psychiatric stay or equally intensive treatment.

Section 1919(e) (7) (B) (iii) 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 complete the notification of change in condition form.   

For online notification of change in condition/resident review to the Department of Mental Health: 

“Change in Condition” Not to be confused with “Change in Status”.

Please visit link below for information on COMRU’s change in status:
https://health.mo.gov/seniors/nursinghomes/pdf/ChangesinStatus.pdf 

To check the status of a nursing facility application, please contact DHSS COMRU at 573-522-3092 or by email at comru@health.mo.gov. 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 within the last 12 months contact Bock and Associates at bock.mo@bock-associates.com . If it has been longer than 12 months please submit a new Level I/Level of Care application and select replacement forms through COMRU’s website at http://health.mo.gov/seniors/nursinghomes/pasrr.php

Find the answers to FAQ concerning PASRR at http://www.bock-associates.com/Missouri/

To request an appeal of an adverse PASRR decision contact DMHNotification@dmh.mo.gov 

For any other questions or concerns contact: 
Michelle Newberry, Bock Associates Project Director, Michelle.newberry@bock-associates.com 

General Information on Mental Illness

Services Available:

• Behavioral Health 
• Intellectual/Developmental Disability
• Crisis Services
  • 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. For additional information The Behavioral Health Crisis Hotline.
  • If you or someone you know is in a mental health, suicide, or substance use crisis, help is available.
  • Reach out to the 988 Suicide & Crisis Lifeline by calling or texting 988, or chatting at https://988lifeline.org/.
  • The 988 Suicide & Crisis Lifeline is a free and confidential service available to everyone.
• Training to assist Public Administrators in navigating supports and services for those with intellectual/developmental disabilities.

The Centers for Medicare & Medicaid Services (CMS) contracted with Acumen, LLC and 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.

Positive Supports Podcasts

Tools of Choice is a widely used successful behavior and relationship improvement training program. One important concept of the Tools of Choice training includes teaching people to be aware of common negative interactions. These negative interactions are labeled as coercive behaviors. This podcast series describes 10 Common Coercives and demonstrates how they may affect others. Learning about the coercives can help individuals to know how to respond to people in a positive way that makes everyone's life better. This series consists of an introduction and ten separate tracks that can be listened to individually or collectively.

• Introduction
• Coercive 1-Questioning
• Coercive 2-Arguing
• Coercive 3-Sarcasm and Teasing
• Coercive 4-Force
• Coercive 5-Threats
• Coercive 6-Criticism
• Coercive 7-Despair
• Coercive 8-Lecturing or Logic
• Coercive 9-Taking Away
• Coercive 10-Talking About Bad Behavior

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

DMH Responsibilities and Requirements for Preadmission Screening (PAS) and Resident Review (RR)

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.

Positive Behavior Intervention and Crisis Plans
Person-Centered Care Planning
Structured Environment, Socialization and Personal Support Network
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. 

To appeal a PASRR decision contact DMHNotifications@dmh.mo.gov.  

DMH will perform the following steps to execute the appeal of the PASRR decision:

1. Verify that the caller has the legal authority to act on the person’s behalf to  initiate the appeal (e.g. guardianship, active durable power of attorney for health care decision making, other). 
2. Collect information from caller and the DMH file to complete the DSS Division of Legal Services form titled PASRR Program Preadmission Appeal. 
3. Forward the form to the Chief Counsel of Administrative Hearings at the Division of Legal Services (Administrative Hearings Section) and verify receipt. 
4. DMH will forward the case exhibits and PASRR file to the individual who filed the appeal, the hearings officer and other parties as indicated.  
5. DMH and Bock Associates (assessor) will give testimony during the hearing. 

Background on the Olmstead Decision

The U.S. Supreme Court’s 1999 landmark decision in Olmstead v. L.C. (Olmstead) found the unjustified segregation of people with disabilities is a form of unlawful discrimination under the Americans with Disabilities Act (ADA) and that individuals with disabilities must receive services in the most integrated setting appropriate to their needs. This principle is central to the Supreme Court's Olmstead decision.

The Olmstead decision fundamentally changed the way our country approaches disability rights and opened doors for millions of Americans to live the lives we want to live, in the community, alongside people of all ages, with and without disabilities.

The Court held that states are required to provide community-based services for people with disabilities who would otherwise be entitled to institutional services when: (a) such placement is appropriate; (b) the affected person does not oppose such treatment; and (c) the placement can be reasonably accommodated, taking into account the resources available to the state and the needs of other individuals with disabilities.

As a result of this court decision and enforcement activities, many individuals have transitioned from an institution to the community, and many individuals have avoided unnecessary institutionalization. For example:

• Individuals who had been institutionalized for decades are now receiving services in their community;
• Individuals who lost their housing and/or community-based supportive services when they were forced to enter institutions due to an acute health care problem have had the needed services provided or restored;
• Individuals with disabilities are able to access home and community-based services through Medicaid "Waiver" programs;
• Increased hours of personal care and assistance are being provided to individuals who require additional services to remain in the community; and
• Individuals with disabilities now have greater control over their community-based care and services.

For more details, visit: https://www.hhs.gov/civil-rights/for-individuals/special-topics/community-living-and-olmstead/index.html.

Administration for Community Living

Advancing independence, integration, and inclusion throughout life

The Administration for Community Living was created around the fundamental principle that older adults and people of all ages with disabilities should be able to live where they choose, with the people they choose, and with the ability to participate fully in their communities. By funding services and supports provided by networks of community-based organizations, and with investments in research, education, and innovation, ACL helps make this principle a reality for millions of Americans.

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 MHD.MoneyFollowsPerson@dss.mo.gov

Money Follows the Person Powerpoint

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.

Reporting a Complaint with Health Service Regulation (HSR)

Missouri Department of Health and Senior Services
Bureau of Health Services Regulation
P.O. Box 570
Jefferson City, MO 65102-0570
fax: (573) 526-3621
complaint@health.mo.gov

Reporting abuse, neglect or exploitation

The Missouri Department of Health and Senior Services (DHSS) investigates abuse, neglect, and exploitation of vulnerable individuals 60 and older and people with disabilities between 18 and 59. These individuals may live in the community or in long-term care facilities. Either way, they are unable to protect their own interests or adequately perform or obtain services necessary to meet their essential human needs (192.2400, RSMo).

Missouri’s Adult Abuse and Neglect Hotline responds to reports of abuse, neglect, and financial exploitation. If you suspect someone is being abused, neglected or exploited, call the hotline at 800-392-0210. The hotline operates 365 days per year from 7 a.m. to 12 a.m. Hearing-impaired persons may call the Telecommunications Device for the Deaf (TDD), at 800-735-2466 or 800-735-2966 to utilize Relay Missouri. Due to the possible need for mandated reporters to report a concern to the Central Registry Unit (CRU) during the hours of 12:00 a.m. and 7:00 a.m. (when the hotline is not in operation), a Mandated Reporter Form is available for use.

What is abuse?

Abuse happens to people of all ethnicities and income levels and can be physical, sexual or emotional in nature. For information on abuse statistics in Missouri, see Elder Abuse - It is a Crime.
FY16

Abuse – the infliction of physical, sexual, or emotional injury or harm including financial exploitation by any person, firm, or corporation (192.2400, RSMo).

• Neglect – the failure to provide services to an eligible adult by any person, firm or corporation with a legal or contractual duty to do so, when such failure presents either an imminent danger to the health, safety, or welfare of the client or a substantial probability that death or serious physical harm would result (192.2400, RSMo).
• Financial Exploitation - A person commits the crime of financial exploitation of an elderly or disabled person if such person knowingly and by deception, intimidation, or force obtains control over the elderly or disabled person's property with the intent to permanently deprive the elderly or disabled person of the use, benefit or possession of his or her property thereby benefiting such person or detrimentally affecting the elderly or disabled person (570.145, RSMo).

Resources

• Ombudsman
• Missouri Protection and Advocacy
• CMS Federal Regulation Discharge
• Discharge planning requirements for SNF / Hospital
• Guide Revised NF regulations for Discharge
• DHSS Reporting a Complaint
• DHSS Abuse, Neglect, and Exploitation of the Elderly and Disabled
• Missouri Mandated Reporters List and Law