Adult Mental Health – Preadmission Screening and Resident Review (PASRR)
Technical Assistance Resources
What is PASRR?
Congress developed the Preadmission Screening and Resident Review (PASRR) program to ensure that admission and retention of people with serious mental illness in nursing and boarding care facilities is appropriate, as part of the Omnibus Budget Reconciliation Act (OBRA) 1987 commonly referred to as OBRA regulations. Federal Medicaid law and regulations require states
to have a PASRR program to determine whether nursing facility applicants and residents meet nursing facility level of care and/or require specialized services for mental health care.
Under the PASRR program, the Medicaid regulation prohibits Medicaid certified nursing facilities (NFs) from admitting any person with a serious mental illness (SMI) unless the state mental health authority (SMHA) or state Medicaid agency has determined that the person requires the level of services the facility provides. Further, the SMHA must determine whether the person requires specialized services to treat mental illness. If placing the person in a NF is deemed appropriate and the person requires specialized mental health services, the SMHA must provide or arrange the provision of such services. The SMHA also must review the needs of NF residents with SMI for NF services and specialized care. The SMHA delegates admission and determination decisions to an entity without direct or indirect ties to a nursing facility. In
Minnesota, the SMHA has delegated responsibilities for PASRR to the county human service agency as the local mental health authority (LMHA) in the county where the person is physically located. This may not be the county of financial responsibility. Regulations require that states complete specific procedures for preadmission screening to identify people who have or are suspected of having a mental illness. All applicants to either a Medicaid certified NF or boarding care facility, regardless of income, assets, or funding sources, must receive a Preadmission Screen (PAS) and Level I screening prior to admission.
Nursing facilities must not admit any new resident with a serious mental illness before a PASRR determination is made, which indicates the person requires NF services and which determines whether the person needs specialized services. No federal payment may be made for NF services provided to a person with a serious mental illness who has not been screened and approved for admission.
What services are available?
Preadmission Screening - The PAS identifies the person’s need for NF level of care through a screening of the person’s health status, independence in activities of daily living, and the availability of supports and services that could meet the person’s needs either in an NF or in the community. The Preadmission Screening is conducted by the county social worker and/or public health nurse.
Level I preliminary screen - The Level I screening identifies whether the applicant may have a serious mental illness and is conducted by the Long Term Care Consultation intake team, county worker, or public health nurse. A Level I screening must be completed for all referrals independent of and prior to a NF admission. If Level I screening indicates the person may have a serious mental illness, a Level II evaluation and determination must be conducted.
Level II Evaluation and Determination - The Level II is implemented to determine whether the person has a mental illness and must be conducted by the LMHA in the county where the person physically resides. If a primary or secondary diagnosis of mental illness exists, the screening also determines if the person is covered by regulations under the Omnibus Budget Reconciliation Act (OBRA). An evaluation and determination of mental illness must be based upon current diagnostic and functional assessments and, in part, on the severity of the condition. The Level II process includes the determination of need for further evaluation. If a serious mental illness is suspected and there is insufficient current diagnostic information or the information is older than 90 days, an independent mental health professional must complete a diagnostic assessment. The purpose of the diagnostic assessment is to confirm the diagnosis and determine if specialized services are needed or, if not, which routine mental health services would be beneficial.
Who is eligible for this service?
Any new resident to a Medicaid Certified Nursing Facility, who has a serious mental illness, and the State Mental Health Authority has determined that the person requires the level of services that the facility provides.
How to become a provider – Applications/Certifications/Licensure
At minimum, a copy of the Level II paperwork must be sent to state mental health authority (SMHA) on a monthly basis, along with all supporting documents (including Level I and referral to: DHS/Adult Mental Health Division PO Box 64981 St. Paul, MN 55164-0981 (651) 431-2225
How can I get more information?
PASRR Policy Lead, 651-431-2225 or firstname.lastname@example.org
Out-of-state arrangements - The LMHA receiving the initial intake call for a NF admission must conduct the Level I screening. If the results indicate the need for a Level II evaluation and determination, the screening must be completed before the person leaves the state of residence. Title 42 of the CFR requires that the state where the person is currently residing conduct and pay for the preadmission Level I screening and Level II evaluation and determination. Prior to admission, the completed Level I and Level II materials must be faxed to the NF intake worker and the LTCC or LMHA contact person in the county where the NF is located. The LTCC or LMHA contact person must sign off prior to admission. NOTE: A reciprocal agreement is in place between Wisconsin and Minnesota. Therefore, the above procedure does not apply to Wisconsin residents seeking admission to a NF in Minnesota, or Minnesota residents seeking admission to a Wisconsin NF. LMHAs are expected to use Minnesota’s procedures for Wisconsin residents seeking admission to a Minnesota Medicaid certified NF.
Appeals process - A Level I screening determination or finding is not subject to appeal. However, Level II determinations may be appealed. As part of a Level II appeal, Level I screening findings are subject to review and consideration. Any person who is a potential NF resident or already a resident of a NF and who is adversely affected by a PASRR preadmission screening or resident review determination may initiate an appeal by contacting the Appeals Division, Department of Human Services at (651) 431-3600 or (800) 657-3510. Appeal processes apply only to the person who is seeking admission or his/her legal representative.
Non-compliance penalties - Federal and state agencies are committed to protecting the rights of people with mental illness. The preadmission process has been developed to assure appropriate admission to a NF for a person with a diagnosis of serious mental illness. The NF is responsible for having a copy of the Level I and Level II on file in the active resident care record. Reimbursement to a NF for resident days of service for a person with a primary or secondary diagnosis of mental illness is authorized by the LMHA through the Level II determination process. Failure to comply with the preadmission screening process may result in non-payment and/or disallowance of Medicaid reimbursement for NF services. The penalty will be applied retroactively from the time the non-compliance is discovered. Repeated non-compliance could result in loss of Medicaid certification. Counties and facilities must work together to assure that a person with a mental health diagnosis is admitted or retained following the procedures outlined in this bulletin. The process must be corrected and completed immediately if it has not occurred or if it has been completed incorrectly.
Counties and nursing facilities are strongly encouraged to systematically and regularly review the status of NF residents who may have a primary or secondary mental health diagnosis. The review process and subsequent completion of required screenings and documentation does not prevent disallowance of MA funds if non-compliance with the PAS process is identified through an audit.
Legal references - Legal Authority for PASRR include:
Omnibus Budget Reconciliation Act (OBRA) 1987
Public Law 100-203, Title IV, Subtitle C, Part 2, Section 4211 (a)(3).
Minnesota Statutes, sections 256B.04, 256B.0911 and 256B.092.
Minnesota Rules, parts 9505.0175 to 9505.0475; 9505.2215; 9525.0004 to 9525.0036.
Code of Federal Regulations, title 42, chapter IV, parts 447.31; 483.1 - 483.75; and, 483.100 - 138.