The Omnibus Budget Reconciliation Act of 1987 required state Medicaid programs to implement a Pre-Admission Screening and Resident Review (PASRR) process, which required every person entering or residing in a Medicaid funded or certified long-term care nursing facility be screened for evidence of serious mental illness, and/or intellectual disability, developmental disability or related conditions, such as autism and cerebral palsy. The PASRR review confirms those individuals with a PASRR-related diagnosis and determines the least restrictive environment to meet their needs, and identifies disability focused services to promote the individuals’ highest level of function and independence.
The Supreme Court’s landmark 1999 ruling, Olmstead v. L.C., reinforced the paramount importance of the PASRR federal regulations. The decision requires Medicaid agencies to provide community-based services to persons with disabilities when appropriate, and to ensure that people with serious mental illness and/or developmental disability, intellectual disability or related conditions are not placed in nursing facilities inappropriately for long-term care. To correctly screen individuals, Medicaid agencies must thoroughly understand how serious mental illness, intellectual disability, developmental disability, and related conditions are defined for the purposes of PASRR.
The PASRR process begins with a brief Level I screen that serves to identify individuals who may have a serious mental illness, intellectual disability, developmental disability, or related conditions. If an individual is screened positive for a PASRR-related diagnosis, then an in-person Level II evaluation must be completed to confirm (or not) the diagnosis. For serious mental illness, PASRR evaluators assess for conditions known as the 4Ds:
- Diagnosis or suspicion of a mental health condition, such as depression or bipolar disorder.
- Absence of Dementia, or if it exists, it can’t be more serious than the mental illness.
- Level of Disability: Must have experienced functional limitations in major life activities in the last three to six months.
- Duration: Intensive psychiatric treatment within the past two years.
For individuals who screen positive for intellectual disability, developmental disability or related conditions, PASRR evaluators conduct the in-person Level II evaluation to confirm:
- Age of onset (before 18 for intellectual disability or before 22 for developmental disability/related condition)
- IQ (for intellectual disability)
- Concurrent impairments in adaptive functioning (for intellectual disability) or functional limitations in three or more areas of life activities (for developmental disability/related condition)
- Expected to persist throughout a person’s life
In addition to confirming the PASRR-related diagnosis, the Level II evaluation determines if nursing facility placement is appropriate, and if so, whether the selected nursing facility can meet the individual’s total care needs. If nursing facility placement is inappropriate, recommendations must be made to support successful community living, including specific community-based services and long-term services and supports to facilitate transition back to the community.
When nursing facility placement is deemed as being the most appropriate setting to meet the individual’s total care needs (medical and PASRR-related condition(s) needs), specialized and support services must be made available in the nursing facility for the individual to attain the highest level of independence and quality of life. In addition, the individual must then be screened on a regular basis, or when there is a significant change in condition, to ensure that the individual’s total care needs continue to be met.
PASRR can serve as a powerful tool in supporting an individual to live in the most integrated setting that will best meet their total care needs; and assist to identify appropriate services and supports to independently live in such a setting.