- 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). See definitions for PASRR for mental illness, intellectual disability and related condition at end of this section. It is important to understand that MI and ID have specific definitions for the purposes of PASRR. These definitions do not necessarily correspond to the definitions used in other contexts.
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 and Change in Status
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 was previously identified by PASRR to have mental illness, intellectual disability, or a related condition, the following conditions may be noted as the reason for referral (note, this is not an exhaustive list):
- 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.
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 (note that 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.
The relationship between the PASRR regulations and the updated regulations that govern the conditions of participation for long-term care facilities:
The Final Rule was published in November 2016 (80 FR 42168). Under this rule, nursing facilities (NFs) must notify the state mental health authority (SMHA) or state intellectual disability authority (SIDA) promptly after a resident experiences a significant change in status of any kind [CFR 483.20(k)(4)]. Resident care plans must include Specialized Services or Specialized Rehabilitative Services that the NF will provide as a result of the Level II recommendations made by PASRR. If the NF disagrees, it must indicate its rationale for disagreeing in the resident’s medical record [CFR 483.21(a)].
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 to DMH for resident review form and send the notification to:
- 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 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 contact Kathy Schafer at 573-751-8070 or at kathy.schafer@DMH.mo.gov.
To Report a change in condition related to disability or mental illness, complete the notification to DMH form and e-mail it to: DMHNotifications@dmh.mo.gov.
- How To Appeal a PASRR Decision
To appeal a PASRR decision contact Kathy Schafer at 573-751-8070 or at kathy.schafer@DMH.mo.gov.
DMH will perform the following steps to execute the appeal of the PASRR decision:
- 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).
- Collect information from caller and the DMH file to complete the DSS Division of Legal Services form titled PASRR Program Preadmission Appeal.
- Forward the form to the Chief Counsel of Administrative Hearings at the Division of Legal Services (Administrative Hearings Section) and verify receipt.
- DMH will forward the case exhibits and PASRR file to the individual who filed the appeal, the hearings officer and other parties as indicated.
- DMH and Bock Associates (assessor) will give testimony during the hearing.
- Behavioral Health Resources
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.
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.
- PASRR Resources
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.
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.
- Resources for Staff Training
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.
- 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
- Community Living
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.
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.
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
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.
- How to report abuse, neglect or make a complaint with HSR
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
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.
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).
- 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