PASRR stands for Preadmission Screening and Resident Review. It is a federal program that requires every person applying to a Medicaid-certified nursing facility to be screened for serious mental illness, intellectual disability, or related developmental conditions. The goal is to make sure people with these conditions end up in the right care setting and receive appropriate services, rather than being placed in a nursing home by default when a different environment might serve them better.
Why PASRR Exists
Congress created PASRR as part of the Omnibus Budget Reconciliation Act of 1987. At that time, large numbers of people with serious mental illness and intellectual disabilities were being funneled into nursing homes without adequate evaluation of whether nursing home care was truly what they needed. Many of these individuals would have been better served in community-based settings with specialized support. PASRR was designed to stop that pattern by requiring an evaluation before admission and ongoing reviews afterward.
Every state is required to maintain a PASRR system. The specifics of how states run their programs vary, but the core federal requirements apply everywhere a nursing facility accepts Medicaid.
How the Two-Level Screening Works
PASRR operates in two stages. The first, called a Level I screen, is a preliminary assessment given to every person seeking admission to a Medicaid-certified nursing facility. It asks basic questions to flag whether the person might have a serious mental illness, an intellectual disability, or a related developmental condition. This screen is typically completed by the referring hospital, physician’s office, or the nursing facility itself.
If the Level I screen comes back positive, the person moves to a Level II evaluation. This is a much more thorough, in-depth assessment. It produces three things: a determination of what the person actually needs, a determination of whether a nursing facility is the appropriate setting, and a set of service recommendations that feed into the person’s care plan. Level II evaluations are generally conducted by the state’s mental health authority or intellectual disability agency, not by the nursing facility.
Who PASRR Applies To
PASRR targets three populations: people with serious mental illness, people with intellectual disability, and people with related developmental conditions. The definition of serious mental illness for PASRR purposes follows specific federal criteria. Importantly, a primary diagnosis of dementia or Alzheimer’s disease alone does not trigger PASRR. However, if someone has a primary diagnosis of a major mental disorder alongside dementia, PASRR does apply.
This distinction matters in practice because nursing homes serve many residents with cognitive decline. PASRR is not meant to screen every person with memory loss. It is focused on ensuring that people whose primary needs stem from psychiatric conditions or intellectual disabilities receive the specialized attention those conditions require.
What Happens After Someone Is Admitted
PASRR does not end at the nursing home door. The “Resident Review” portion of the program requires ongoing reevaluation when certain changes occur. For someone not previously identified through PASRR, a new review is triggered if they begin showing behavioral, psychiatric, or mood-related symptoms suggesting a mental illness, or if an intellectual disability or developmental condition is newly recognized. A review is also required if the person is readmitted to the nursing home after an inpatient psychiatric stay.
For residents already identified through PASRR, the triggers are broader. A review is needed if psychiatric or behavioral symptoms worsen, if ongoing treatment is not working, if the resident expresses a desire to leave the nursing home (verbally or through behavior), or if their medical condition improves enough that their placement or care plan may need updating. Even a significant physical change can trigger a review if it comes with behavioral or mood-related symptoms that alter the person’s daily patterns.
The Hospital Discharge Exemption
There is one common shortcut in the process. When a person is being discharged from a non-psychiatric hospital and is expected to need nursing facility care for 30 days or fewer, a hospital discharge exemption can be used. This allows the person to enter the nursing home without completing the full PASRR process, as long as the attending physician certifies that the stay will be short-term.
If the stay ends up lasting longer than 30 days, the nursing facility must initiate a Resident Review before the 30th day. The exemption is strictly time-limited, not a permanent waiver.
Categorical Determinations and Provisional Admissions
Not every positive Level I screen requires the full Level II evaluation. Federal regulations allow states to create “categorical determinations” for situations where the need for nursing facility care is obvious or the stay is time-limited. For example, a state may establish categories based on certain diagnoses or the need for specific medical equipment like a ventilator, where nursing home placement is clearly appropriate.
Provisional admissions are also allowed in a few specific scenarios. A person experiencing delirium can be admitted provisionally while further assessment is completed. Emergency protective services situations permit a stay of up to seven days. Respite care, where someone enters a nursing facility temporarily while their regular caregiver takes a break, also qualifies. Additionally, states can determine that a person with both an intellectual disability and dementia does not require specialized services, simplifying the process.
Specialized Services PASRR Can Unlock
One of the most practical outcomes of the PASRR process is the identification of specialized services a resident needs. For residents with intellectual or developmental disabilities, these can include habilitative therapy services (physical therapy, occupational therapy, and speech therapy designed to help a person learn, maintain, or improve daily living skills), customized manual wheelchairs, and durable medical equipment like gait trainers, positioning wedges, and pressure-reducing mattresses.
Beyond what the nursing facility itself provides, PASRR can also connect residents with services delivered by outside agencies. These include service coordination with help exploring alternative placements, employment assistance, supported employment, day habilitation programs, independent living skills training, and behavioral support. All of these services are delivered at the nursing facility but provided by the state’s designated intellectual disability agency rather than the facility’s own staff.
This is a key part of what makes PASRR more than just a gatekeeper. When the system works as intended, it does not simply approve or deny nursing home admission. It builds a roadmap of services tailored to the person’s actual condition, and it holds the care system accountable for delivering them.