PASRR Screening for

Mental Illness in

Nursing Facility Applicants and Residents

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Mental Health Services

www.samhsa.gov

Karen Linkins, Ph.D.

Anna Lucca, Ph.D.

Michael Housman

Shelagh Smith

March 2006

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents

Acknowledgments

This report was prepared by The Lewin Group for the Center for Mental Health Services

(CMHS), Substance Abuse and Mental Health Services Administration (SAMHSA), U.S.

Department of Health and Human Services (DHHS), under contract number 03M0029501D.

Authors include Karen Linkins, Anna Lucca, Michael Housman of The Lewin Group, and

Shelagh Smith of CMHS, SAMHSA. Shelagh Smith was also the Government project officer in

CMHS; Jeff Buck, Associate Director of Organization and Financing, CMHS, provided leadership, guidance, and substantive input over the course of the project. Dan Timmel, health

insurance specialist at the Centers for Medicare & Medicaid Services (CMS), and Jan Earle,

formerly of CMS, offered invaluable assistance in the development of this report. Cynthia

Hansen, psychologist and APA Fellow at SAMHSA, advised authors in interpreting clinical

data. We also acknowledge the contributions of the Technical Expert Panel (see Appendix B)

and the contributions of the 4 States and the 24 nursing facilities that participated in the case

study component of this project. We sincerely thank Dr. Joyce Berry, Director of the Division

of State and Community Systems Development, for cosponsoring this project.

Disclaimer

The views, opinions, and content of this publication are those of the authors and do not necessarily reflect the views or policies of SAMHSA or DHHS.

Public Domain Notice

All material appearing in this report is in the public domain and may be reproduced or copied

without permission from SAMHSA. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, SAMHSA.

Electronic Access and Copies of Publication

This publication can be accessed electronically through the following Internet World Wide

Web connection: www.samhsa.gov/. For additional free copies of this document, please call

SAMHSA’s National Mental Health Information Center at 1-800-789-2647 or 

1-800-228-0427 (TTD).

Recommended Citation

Linkins, K., Lucca, A., Housman, M., & Smith, S. (2006). PASRR Screening for Mental

Illness in Nursing Facility Applicants and Residents. DHHS Pub. No. (SMA) 05-4039.

Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health

Services Administration.

Originating Office

Office of the Associate Director for Organization and Financing, Center for Mental Health

iii
Services, Substance Abuse and Mental Health Services Administration, One Choke Cherry

Road, Rockville, MD 20857.

DHHS Publication No. (SMA) 05-4039

Printed 2006

iv Special Report
Table of Contents

I. Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

II. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

A. Purpose and Rationale of Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

B. Report Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

III. Overview of the PASRR Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

A. Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

1. History of the PASRR Program

2. How the PASRR Process Works

B. Current Issues and Concerns Regarding PASRR . . . . . . . . . . . . . . . . . . .12

IV. Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

A. Study Goals and Research Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

B. Study Components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

1. National Survey of PASRR Agencies

2. In-Depth State Studies

V. National Survey Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

A. PASRR Implementation at the State Level . . . . . . . . . . . . . . . . . . . . . . . .21

1. Organization and Administration of PASRR 

2. PASRR Level I and Level II Screening Documentation

3. PASRR Level I and Level II Screening Procedures

4. PASRR Change in Condition Assessment Procedures

5. PASRR Oversight Mechanisms

B. PASRR Impact on Policy Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

1. Overall Effectiveness of PASRR

2. Availability and Receipt of Mental Health Services

C. PASRR Issues Identified at the State Level . . . . . . . . . . . . . . . . . . . . . . . .35

1. How PASRR Relates to Broader System Issues

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents v
vi Special Report

2. State Respondent Perceptions of PASRR

3. Recommendations for Improving PASRR

VI. In-Depth State Study Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43

A. In-Depth Study Samples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43

1. State Sample

2. Nursing Facility Sample

3. Medical Record Review Sample

4. Clinical Interview Sample

B. PASRR Implementation at the Nursing Facility Level . . . . . . . . . . . . . . . .51

1. PASRR Level I and Level II documentation

2. PASRR Change in Condition Documentation and Procedures

3. PASRR Oversight Mechanisms 

C. PASRR Impact on Policy Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56

1. Overall Effectiveness of PASRR

2. Identification of Serious Mental Illness

3. Availability and Receipt of Mental Health Services 

D. PASRR Issues Identified From the Clinical Interview Sample . . . . . . . . . .65

1. Reviewing Method of Obtaining Interview Sample

2. Exhibits Overview

3. Validity and Reliability for the Three Clinical Screening Instruments

To Identify Residents With Significant Mental Illness

4. Demographics of the Clinical Interview Sample

5. PASRR Level I and II Screens

6. Current Diagnoses of Clinical Interviewees

7. Current Psychotropic Medications

8. Mental Health Services Currently Ordered and Received in Last

Month for Interviewees

9. Summary of Clinical Interview Sample

E. PASRR Issues Identified at the Nursing Facility Levels . . . . . . . . . . . . . . .71

1. Nursing Facility Staff Respondent Perceptions of PASRR

2. Recommendations for Improving PASRR

VII. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75
A. Summary of National Survey Findings . . . . . . . . . . . . . . . . . . . . . . . . . . .75

1. PASSR Policies and Procedures at the State Level

2. PASRR Impact on Intended Policy Goals

3. State-Level Issues Identified Through PASRR Implementation

B. Summary of In-Depth State Study Findings . . . . . . . . . . . . . . . . . . . . . . . .77

1. PASRR Policies and Procedures at the Nursing Facility Level 

2. PASRR Impact on Intended Policy Goals

3. PASRR Implementation Issues at the Nursing Facility Level

VIII. Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81

IX. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83

X. Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents vii
viii Special Report
List of Exhibits

Exhibit 1: Responsibility for Oversight of PASRR Screens . . . . . . . . . . . . . . . . .10

Exhibit 2: State-Level Interview Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

Exhibit 3: Nursing Facility Staff Interview Protocol . . . . . . . . . . . . . . . . . . . . . .19

Exhibit 4: Medical Record Abstraction Tool . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Exhibit 5: State Agency Involvement (n=51) . . . . . . . . . . . . . . . . . . . . . . . . . . .22

Exhibit 6: State PASRR Agency Location (n=51) . . . . . . . . . . . . . . . . . . . . . . . .22

Exhibit 7: Entity Conducting PASRR Screens (n=51) . . . . . . . . . . . . . . . . . . . . .23

Exhibit 8: State PASRR Training for Change in Condition Procedures

(n=51) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25

Exhibit 9: Average Number of Level I and Level II Screens 

Conducted Annually . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25

Exhibit 10: Time Frame for Completing PASRR Screens (n=51) . . . . . . . . . . . . .26

Exhibit 11: Professional Qualifications of Level I and 

Level II Screeners (n=51) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

Exhibit 12: Location of PASRR Preadmission and 

Resident Review Screens (n=51) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

Exhibit 13: Data Collection Methods for Level I and Level II Screens (n=51) . .28

Exhibit 14: Documentation and Storage of PASRR Screens (n=51) . . . . . . . . . .28

Exhibit 15: Change in Condition Criteria and Procedures (n=51) . . . . . . . . . . . .29

Exhibit 16: Primary PASRR Oversight Responsibilities (n=51) . . . . . . . . . . . . . .30

Exhibit 17: How States Use PASRR Data (n=51) . . . . . . . . . . . . . . . . . . . . . . . .30

Exhibit 18: Primary Responsibility for Direct Oversight of 

PASRR in Nursing Facilities (n=51) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

Exhibit 19: State-Level Monitoring Systems (n=51) . . . . . . . . . . . . . . . . . . . . . .31

Exhibit 20: Level II Preadmission Screening Outcomes . . . . . . . . . . . . . . . . . . . .32

Exhibit 21: Perceived Effectiveness of PASRR Programs (n=51) . . . . . . . . . . . . .33

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents ix
Exhibit 22: Mental Health Services in Nursing Facilities (n=51) . . . . . . . . . . . . .34

Exhibit 23: Access to Mental Health Services in Nursing Facilities (n=51) . . . . .34

Exhibit 24: PASRR and Olmstead (n=51) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

Exhibit 25: Alternative Placements (n=51) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

Exhibit 26: PASRR Strengths (n=51) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

Exhibit 27: PASRR Weaknesses (n=51) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

Exhibit 28: Recommendations to CMS for the PASRR Process (n=51) . . . . . . . .38

Exhibit 29: Recommendations to State Agencies 

for the PASRR Process (n=51) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39

Exhibit 30: Recommendations to Nursing Facilities 

for the PASRR Process (n=51) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40

Exhibit 31: Barriers to Changes in the PASRR Process (n=51) . . . . . . . . . . . . . .41

Exhibit 32: Organizational and Structural Characteristics of 

In-Depth Study States (n=4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44

Exhibit 33: Annual PASRR Screens Completed by 

In-Depth Study States (n=4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44

Exhibit 34: Characteristics of Nursing Facility Sample (n=24) . . . . . . . . . . . . . .46

Exhibit 35: Primary Diagnoses of Nursing Facility Resident 

Record Review Sample (n=786) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47

Exhibit 36: Physical Health Conditions of 

Nursing Facility Resident Sample (n=786) . . . . . . . . . . . . . . . . . . . . . . . . . . .48

Exhibit 37: Number of Physical Health Diagnoses per Resident for 

Nursing Facility Resident Record Review Sample (n=786) . . . . . . . . . . . . . .49

Exhibit 38: Demographics of Nursing Facility Resident 

Record Sample (n=786) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50

Exhibit 39: Referral Source for Nursing Facility Resident 

Record Review Sample (n=786) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51

Exhibit 40: Presence of PASRR Documentation in 

Medical Records (n=786) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52

Exhibit 41: Change in Condition Issues for Nursing Facility 

Resident Record Review Sample (n=24) . . . . . . . . . . . . . . . . . . . . . . . . . . . .54

x Special Report
Exhibit 42: Coordination and Communication With State (n=24) . . . . . . . . . . .54

Exhibit 43: State Oversight of PASRR Screens (n=24) . . . . . . . . . . . . . . . . . . . .55

Exhibit 44: Effectiveness of State Oversight of PASRR Screens (n=24) . . . . . . . .55

Exhibit 45: Nursing Facility Staff Perceptions of PASRR Effectiveness 

(n=24) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56

Exhibit 46: Nursing Facility Residents With 

Primary Mental Health Diagnoses at Admission (n=786) . . . . . . . . . . . . . . .57

Exhibit 47: Psychiatric Diagnoses of Nursing Facility 

Resident Sample (n=786) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

Exhibit 48: Mental Health Services Available in Nursing Facilities (n=24) . . . . .60

Exhibit 49: Prescription of Psychotropic Medications for 

Nursing Facility Resident Record Review Sample (n=786) . . . . . . . . . . . . . .60

Exhibit 50: Mental Health Services Ordered and Received for 

Nursing Facility Resident Record Review Sample (n=786) . . . . . . . . . . . . . .61

Exhibit 51: Type of Service Received by Psychiatric Diagnosis . . . . . . . . . . . . . .62

Exhibit 52: Availability of Mental Health Specialists (n=24) . . . . . . . . . . . . . . . .64

Exhibit 53: Availability of Mental Health Professionals in Nursing 

Facilities (n=24) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64

Exhibit 54: Nursing Facility Staff Perceptions of Challenges to 

Treating Residents With Mental Illness (n=24) . . . . . . . . . . . . . . . . . . . . . . .65

Exhibit 55: Demographics of Clinical Interviewees . . . . . . . . . . . . . . . . . . . . . .68

Exhibit 56: PASRR Level I and II of Clinical Interviewees . . . . . . . . . . . . . . . .69

Exhibit 57: Major Categories of Diagnoses of Clinical Interviewees, 

Currently . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70

Exhibit 58: Current Psychotropic Medications of Clinical Interviewees . . . . . . .71

Exhibit 59: Mental Health Services Currently Ordered and Received in 

Last 30 Days of Clinical Interviewees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72

Exhibit 60: Nursing Facility Staff Perceptions of Usefulness of 

PASRR (n=24) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73

Exhibit 61: PASRR Impact on Admissions Process (n=24) . . . . . . . . . . . . . . . . .74

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents xi
Exhibit 62: Recommendations for Improving State Oversight of 

PASRR (n=63) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .74

xii Special Report
The program’s intent is to ensure that

individuals are placed in the most

appropriate setting and have access to

specialized mental health services where

appropriate. A number of recent studies have

questioned the efficacy of the PASRR process

in identifying individuals with mental health

needs. Many (for example, SSWLHC, 1995)

assert that the program unnecessarily delays

nursing facility placement for individuals

with no psychiatric needs. In the absence of

existing studies examining these issues at

both the State and nursing home level, the

current study attempts to fill an important

gap.

The first phase of this study involved a

review of the existing literature on PASRR

and of the mental health services for those in

nursing facilities. That review was published

as a Substance Abuse and Mental Health

Services Administration (SAMHSA) separate

report, Screening for Mental Illness in

Nursing Facility Applicants: Understanding

Federal Requirements (Linkins et al., 2001). 

The current report outlines the findings

from the second phase of the study, which

involved a national survey of the relevant

agencies in all 50 States and the District of

Columbia to determine how they have

organized and administered Federal

requirements under PASRR. The second

phase of the study also included case studies

of four States, which were selected to include

each of the entities that conduct Level II

screens: private mental health agencies,

community mental health centers, individual

mental health practitioners, and referring

agencies or State agencies. In each State, a

total of six nursing homes were selected,

with three located in an urban county and

three located in a rural county. In each of

those 24 nursing facilities, the administrators

were interviewed about the PASRR process,

and the medical records for the nursing

facility residents were reviewed. In two of

the four States, clinical interviews were

conducted with a total of approximately 50

nursing facility residents.

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 1

I. Executive Summary

Medicaid regulations require States to maintain a Preadmission

Screening and Resident Review (PASRR) program to screen

nursing facility applicants and residents for serious mental illness.

The purpose of PASRR is to assess, through progressive screening, whether

applicants for nursing facilities have mental illness or retardation, and if the

nursing facility is an appropriate placement. The first test, Level I, screens for

potential mental illness. All those who test “positive” must receive a more indepth screen, Level II, which more accurately identifies mental illness and

assesses whether the individual needs specialized services and nursing facility

level of care.
National Survey Findings

■ States have pursued several different

courses in designating State agency

responsibility for administration of

PASRR. Approximately half (27) of the

States divide PASRR responsibilities

among Medicaid agencies and State

mental health authorities (SMHAs). In

four States, three agencies maintain

direct involvement in the Level I or Level

II screening process. In 13 States, either

the Medicaid agency or the SMHA (but

not both, although both have required

responsibilities) is involved in PASRR

and works with a third State agency.

Most States do not report adequate

oversight and tracking mechanisms for

PASRR.

■ States vary, as is permitted, in their

designation of entities that can conduct

Level I assessments. Level I screens are

conducted by nursing facilities in six

States, by referral sources (e.g., acute

care facilities, community-based

programs) in 10 States, and by a

combination of the nursing facilities and

referral sources in 16 States. Eight States

contract out Level I screening

responsibilities, while 11 States have

Level I screens completed by State

agencies, such as Medicaid and aging

authorities.

■ Federal statute requires that Level II

assessments be completed by an

independent entity other than the

SMHAs. Nursing facilities may not

conduct Level II screens. The majority of

States (44) contract with mental health

entities to conduct Level II assessments.

Specifically, 17 States contract with

private mental health agencies (e.g.,

managed behavioral health companies),

18 contract with community mental

health clinics or other public mental

health agencies, and 9 contract with

individual mental health practitioners.

The remaining States have the referring

agency conduct Level II screens (three

States) or delegate responsibility to a

State agency (four States) other than the

mental health authority.

■ With the elimination of the annual

resident review requirement in 1996,

States were required to develop criteria

and procedures for identifying when

nursing facility residents experience a

significant change in condition to trigger

a Level II review. While most States have

developed acceptable procedures for

identifying significant changes in

condition (e.g., use of the Minimum

Data Set [MDS], specific

behavioral/functional criteria,

requirements for nursing facilities to

notify the State), there is evidence that

rates of compliance with this

requirement may be low. This

information is consistent with the finding

of the PASRR study conducted by the

Office of the Inspector General (OIG)

(2001).

■ While respondents faulted PASRR as

currently implemented, many indicated

that PASRR could be more effective with

improved training and oversight. Most

rated PASSR as doing a “good” job of

meeting its main policy goals of

identifying individuals with serious

mental illness, screening appropriateness

for nursing facility care, and ensuring

provision of specialized services. About

half also reported that it has positively

affected the type, amount, and quality of

mental health services in their State.

2 Special Report
In-Depth Case Study Findings

■ Across the four States, percentages of

Level I screens found in medical records

ranged from 71 to 93 percent. Level II

screens, which are required to be in

medical records, were far less prevalent

in medical records (ranging from 0 to 14

percent). Even fewer medical records

(<10 percent) had any record of a

resident review (clinical or medical chart

evaluation by a health professional),

which is of concern because 53–81

percent of the residents sampled had a

diagnosable mental illness at the time of

review, and 43–61 percent had a

dementia-related condition.

■ In the two States, clinical interviews were

conducted with a sample composed of

residents likely to have mental illness.

This subset of residents did not receive a

Level II Screen as required or services

other than medication management and

some case consultation.

■ Very few of the interviewed residents

received psychological testing/evaluation

or the services of a psychologist, and no

residents received individual or group

therapy, case management, psychosocial

rehabilitation, behavior management,

psychoeducation, day treatment,

outpatient, or other mental health

services. This finding suggests that

PASRR may not be meeting its second

important purpose of ensuring that

needed mental health services are

provided to nursing facility residents.

■ Interviews with nursing facility staff

revealed that PASRR was not perceived

as an effective tool for properly

identifying and treating mental illness in

the elderly population. Very few facility

respondents rated PASRR as doing an

“excellent” job in achieving desired

outcomes. In two States, the majority of

nursing facility respondents rated PASRR

in the “good” to “fair” range. Ratings in

the other two States were slightly lower,

with most respondents rating PASRR in

the “fair” to “poor” range. Ratings were

even lower when respondents were asked

about PASRR’s ability to ensure the

provision of specialized services. Few

respondents said that PASRR was an

administrative burden.

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 3

A. Purpose and Rationale of Study

Congress enacted the Preadmission Screening

and Annual Resident Review (PASARR)

program to prevent the inappropriate

admission and retention of people with

serious mental disabilities in nursing

facilities. The program was enacted as part

of the Nursing Home Reform Act under the

Omnibus Reconciliation Act (OBRA) of

1987, as amended by OBRA 1990, 42 USC

1396r(e)(7).

Originally, the program included an annual

resident review and was referred to as the

Preadmission Screening and Annual Resident

Review (PASARR) program. Under the

Balanced Budget Amendment (BBA) of 1996,

P.L. 104–315, or 42 USC 1396r, the

requirement for an annual resident review

was eliminated and replaced with a

requirement to screen when “there is a

significant change in physical or mental

condition.” The current abbreviation of

PASRR is used to refer to the program

throughout this paper. It should be noted

that PASRR screens for serious mental illness

and mental retardation, with requirements

for each, but this report concerns only

PASRR screening for serious mental illness.

Since the program began, many

organizations have expressed concerns about

its value and effectiveness. For example, the

Society for Social Work Leadership in Health

Care, the American Psychiatric Association,

and the American Association for Geriatric

Psychiatry conclude that while the program’s

goals are laudable, PASRR can create

logistical barriers for persons requiring

nursing facility placements, and it does not

necessarily ensure access to appropriate

mental health services. 

Research also highlights ongoing concerns

that PASRR may not be working as

originally intended. The following studies

underscore the need to take a closer look at

how well the program is working. Results

from one study indicate that nursing facility

residents with mental health needs often do

not receive needed mental health services,

and a significant minority are not placed in

alternative placements when appropriate

(Snowden, Piacitelli, & Koepsell, 1998).

Similarly, other researchers have found that

both clinicians and consumers are likely to

view elderly nursing facility residents with

serious mental illness as more appropriately

served in community settings as long as they

are not suffering from severe dementia

(Bartels, Miles, Dums, & Levine, 2003). 

Two additional investigations have

examined PASRR implementation and

effectiveness more directly. In 1996, the

Bazelon Center for Mental Health Law

reported on results from a national survey of

State Medicaid agencies. The Bazelon Center

for Mental Health Law (Bazelon) found

tremendous State variation in definitions,

responsibility, and personnel qualifications

for conducting PASRR screens, and in the

type and availability of mental health

services offered in nursing facilities and

alternative placement options. Even more

recently, the U.S. Department of Health and

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 5

II. Introduction
Human Services (DHHS), Office of the

Inspector General (OIG) completed an

investigation of PASRR involving site visits

to five States, a national survey of PASRR

agencies, and analysis of MDS and Medicaid

claims data (OIG, 2001).

In examining the mental health treatment

of younger Medicaid beneficiaries with a

serious mental illness residing in nursing

facilities, OIG found that (1) many State

PASRR programs are not in compliance with

Federal requirements and do not ensure that

mental health needs are assessed; (2) States

may violate Federal intent when defining

“specialized” services as 24-hour, inpatient

psychiatric care; and (3) many PASRR

systems function with little oversight from

State and Federal authorities. OIG

specifically recommended that the Substance

Abuse and Mental Health Services

Administration (SAMHSA) and the Centers

for Medicare & Medicaid Services (CMS)

work collaboratively to better define their

roles in overseeing and supporting States in

implementing PASRR programs. 

In addition to these studies, statutory

changes and judicial rulings also signal a

need for a closer examination of how well

PASRR is working. While the 1996 BBA

eliminated the requirement for States to

conduct annual resident reviews, compliance

with the provision to screen when significant

changes occur has not been evaluated.

The 1999 Olmstead Supreme Court

decision is also prompting States to

reexamine how decisions are made about

institutional and community-based

placements for disabled populations,

including people with mental illness. The

decision mandates that States “provide

community-based treatment for persons with

mental disabilities when the State’s treatment

professionals determine that such placement

is appropriate.” States must take into

consideration their resources and the needs

of other people with disabilities in making

such determinations. As part of this

reexamination, some States are considering

changing their approach to administering

and monitoring PASRR.

To address these ongoing concerns, this

study explores how States implement PASRR

and examines how the program has affected

the identification and delivery of mental

health services to people with serious mental

illness in nursing facilities. Phase I of the

study involved a comprehensive literature

and legislative review of PASRR and mental

health services for persons in nursing

facilities. This literature review was

published as a separate SAMHSA report,

Screening for Mental Illness in Nursing

Facility Applicants: Understanding Federal

Requirements (Linkins et al., 2001).

The current report presents findings from

Phase II, which had two parts. The first part

of Phase II involved a national 50-State

survey of PASRR agencies examining State

experiences with PASRR implementation and

outcomes. The second part of Phase II

involved in-depth studies of four States,

conducted to understand how and how well

the PASRR process works at local levels.

Interviews were conducted with nursing

facility staff, and some clinical interviews

were conducted with nursing facility

residents for the in-depth studies. Medical

charts were also reviewed.

B. Report Organization

The remaining sections of this report are

organized as follows:

■ Section III: Overview of the PASRR

Process briefly highlights the program’s

history, describes the PASRR process,

6 Special Report
and discusses current policy issues.

■ Section IV: Methodology reviews core

research questions and methodology

used for the study. 

■ Section V: National Survey Findings

presents findings from the national

survey of State mental health authorities

(SMHAs) and Medicaid agencies. 

■ Section VI: In-Depth State Study

Findings integrates findings from

multiple data sources, including

interviews with nursing facility staff,

reviews of resident medical records, and

clinical interviews with residents. 

■ Section VII: Conclusions presents a

summary of findings from the national

survey and State studies to highlight

ongoing issues and concerns regarding

PASRR operation and administration.

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 7

A. Background 

1. History of the PASRR Program

Congress created the PASARR program

under the Omnibus Budget Reconciliation

Act (OBRA) of 1987 to address concerns

that many people with serious mental illness

or mental retardation were inappropriately

placed in nursing homes. At the time,

Congress was becoming increasingly aware

that some States were using nursing facility

placements as a way to reduce overcrowding

in State facilities for people with serious

mental illness. In the decade leading up to

the program’s creation, nursing facilities

typically did not have adequate resources to

provide appropriate care for this new

category of residents (Emerson Lombardo,

1994; GAO [General Accounting Office],

1982).

Congress responded to these concerns by

directing CMS and GAO to investigate

nursing home quality. In response, CMS

funded an Institute of Medicine (IOM) study

that reported widespread problems and

recommended strengthening Federal

regulations to address patient rights, quality

of care, and quality of life in nursing

facilities (IOM, 1986). In 1987, GAO issued

a report that corroborated IOM findings,

indicating that more than one third of U.S.

nursing homes were operating at a level

below minimum Federal standards. The

report cited evidence of untrained staff,

inadequate provision of health care,

unsanitary conditions, poor-quality food,

unenforced safety regulations, and many

other problems related to nursing facility

quality and safety. 

Accumulatively, these reports spurred

Congress to enact nursing home reform

legislation under OBRA in 1987. In addition

to detailed requirements concerning patient

rights, patient assessments, and staffing

criteria, the legislation also included several

provisions that pertained directly to the

problem of inappropriate placement and

inadequate treatment of people with severe

mental illness in nursing facilities. These

provisions, revised and updated in the Code

of Federal Regulations in 1992, included

regulating the use of antipsychotic

medications and physical restraints and

established the Preadmission Screening and

Annual Resident Review (PASARR)

program. The purpose of these provisions

was to determine whether or not individuals

have a serious mental illness, require

specialized mental health services, and need

the level of care provided by a nursing

facility. However, the requirement for an

annual resident review was eliminated by the

BBA of 1996 and replaced with a

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 9

III. Overview of the

PASRR Process

This section presents an overview of the history of PASRR, details

regarding the screening process, and current issues concerning the

implementation and administration of the policy. 
requirement to screen when nursing facilities

determine that “there is a significant change

in physical or mental condition.” 

2. How the PASRR Process Works

The process of screening and determining if

nursing facility services and specialized

mental health services are needed by nursing

facility applicants and residents is called the

Preadmission Screening and Resident Review

(PASRR) program. PASRR is a required

component of each State’s Medicaid plan.

While SMHAs have specific responsibilities

under Federal statute and regulations, and

some responsibilities may be delegated to

other State agencies (e.g., aging

administration, Department of Health), State

Medicaid agencies bear the ultimate

responsibility for PASRR program

operations, as illustrated in Exhibit 1.

State PASRR programs typically are

composed of two main parts: Preadmission

Level I prescreen (for potential mental

illness) and Level II screen (PAS) for

verification of serious mental illness and

determination of the need for specialized

services and the services of a nursing facility.

Level II evaluations may also include a postadmission assessment called a Level II

resident review, if and when a patient’s

condition changes.

10 Special Report

Exhibit 1: Responsibility for Oversight of PASRR Screens

PASRR Screens Responsibility Eligible To Conduct Screen

Level I

Screen

State Medicaid Agency: oversight

All involved parties, including nursing

facilities, SMHA, or an independent

entity

Level II Preadmission

Screen

State Medicaid Agency: oversight

SMHA: determinations for

mental illness that nursing facility is appropriate and specialized services are needed

Independent entity (other than SMHA)

without ties to a nursing facility

Level II Resident Review

(change in condition

assessment) 

SMHA: determination, after

nursing facility identifies

change, that nursing facility is

appropriate and specialized

services are needed

Independent entity (other than SMHA)

without ties to a nursing facility
Level I Screen. To identify nursing facility

applicants who might have a serious mental

illness, Medicaid regulations require States to

conduct a Level I screening of all prospective

nursing facility applicants. Federal

regulations provide no rules on the tools

used or the personnel who implement the

Level I screenings. The screens may be

conducted by the State Medicaid agency,

nursing facilities, hospitals, physicians, or

any other entity specified by the State. The

screens typically involve a record review

and/or clinical patient interview to determine

whether or not there is evidence of a serious

mental illness requiring administration of a

Level II screen. Patients being readmitted to

a nursing facility or being transferred from

one nursing facility to another are not

considered new admissions and are not

required to undergo preadmission screening.

Level II Preadmission Screen (PAS). Based

on Level I screen results, States are required

to administer a more extensive preadmission

screen—referred to as the Level II screen—to

individuals who are suspected of having a

serious mental illness. Level II assessment

typically involves an in-depth clinical

evaluation by a trained mental health

professional to verify whether or not an

individual has a serious mental illness. For

PASRR purposes, mental illness is defined in

42 CFR 483.102(b)(1) as one of the serious

mental illnesses listed. The regulation refers

to one particular version of the Diagnostic

and Statistical Manual of Mental Disorders,

published in 1987 (DSM-III-Revised), rather

than specifying the most current edition of

the DSM. This way, the population covered

by the particular regulation will not change

even if the definition of serious mental illness

changes in subsequent DSM editions.

If the Level II screen is positive for serious

mental illness, a two-pronged determination

must be made as to whether or not the

individual requires (a) specialized mental

health services and (b) nursing facility

services (specific to the facility where

application is made). The Level II screening

may be omitted for groups of individuals

who belong to certain advance determination

categories, such as individuals with a

primary diagnosis of dementia or those being

discharged from an acute care facility who

require convalescent care for less time than

30 days.

Although responsibility for determinations

and oversight officially resides with the

SMHA, determinations must be based on an

independent evaluation conducted by an

entity designated by the State Medicaid

agency other than the SMHA or a nursing

facility. The SMHA (or designated State

agency other than a nursing facility),

however, is held responsible for ensuring the

screenings are conducted and for using the

results to make a determination.

If the State determines that an individual

with mental illness requires nursing facility

services and also requires specialized

services, the State Medicaid agency must

provide or arrange for the needed specialized

services. Federal regulations allow States to

determine what mental health services

specifically constitute specialized services.

Furthermore, the Medicaid statute requires

nursing facilities to provide services “not

otherwise provided or arranged for (or

required to be provided or arranged for) by

the State.” This requirement is interpreted in

regulations to include all services provided

by the facility under the nursing facility’s per

diem rate that are of lesser intensity than the

specialized services provided by the State. 

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 11
Level II Resident Review (RR) Screens:

Change in Condition Assessment. Current

law (since 1996) requires nursing facilities to

notify the SMHA (or appropriate State

agency) promptly after a significant change

in the physical or mental condition of a

resident with serious mental illness.

Regulations further specify that an

independent agency must conduct a Level II

screen to evaluate such residents, and the

SMHA must determine whether their

placements continue to be appropriate, as

well as which, if any, specialized services are

needed. 

B. Current Issues and Concerns

Regarding PASRR 

Advocacy organizations representing mental

health and aging communities, including the

American Psychiatric Association, the

American Association for Geriatric

Psychiatry, AARP, the Alzheimer’s

Association, the Bazelon Center for Mental

Health Law, and the Society for Social Work

Leadership in Health Care, continue to have

concerns regarding the effectiveness of

PASRR programs in achieving intended

policy goals. These concerns have been

summarized in SAMHSA’s 2001 policy

report (Linkins et al., 2001) and include the

following:

■ There is a lack of clear definitions in the

legislation. Although diagnosing serious

mental illness is subject to Federal

minimum requirements, States are

allowed to establish their own definitions

of serious mental illness and administer

their own instruments to screen for

suspected mental illness. As a result, an

individual might be identified as

experiencing a serious mental illness in

one State but not in another. Similarly,

with no standardized definition for

“specialized services,” the mental illness

may be addressed differently across

States. State definition of specialized

services as acute inpatient care (not in a

nursing facility) is a significant concern

as this definition eliminates the

individualized treatment services that the

regulations establish for nursing facility

residents with mental illness or mental

retardation. Some States limit these

services to acute inpatient care, while

others include a combination of inpatient

and community-based services (OIG,

2001; Bazelon, 1996). 

■ Funding PASRR screens, specialized

services, and alternative placements is

challenging for States. From the

beginning, States have expressed

concerns about the costs associated with

implementing PASRR (Emerson

Lombardo, 1994). If individuals require

specialized services to treat their mental

illness, the State Medicaid agency

ultimately is responsible for providing or

arranging for provision of those

specialized services. The Medicaid statute

requires nursing facilities to provide

treatment and services of lesser intensity

than specialized services. To prevent

duplicate payment, no Federal financial

participation is available to reimburse

“special services” that are being paid for

as nursing facility services. However,

Federal financial participation is

available for specialized mental health

services that are State plan services

(other than nursing facility services). The

lack of specific definitions of specialized

services in Federal law or regulations has

resulted in considerable confusion over

which services must be provided by

States and which services must be

12 Special Report
provided by nursing facilities. If a State

chooses to limit its definition of

specialized services to reduce the scope

of this unfunded mandate, it shifts a

greater burden on nursing facilities to

provide or arrange for psychiatric

services. If PASRR determinations

recommend against nursing facility

placement, finding and funding

alternative placements becomes the

responsibility of the State, as this is not a

PASRR function. 

■ Individuals with dementia, including

Alzheimer’s disease and related disorders,

present unique challenges for nursing

facilities. A recent article by Cohen,

Hyland, and Kimhy (2003) concluded

that instituting a mandatory depression

screen for nursing facility residents with

dementia can increase the diagnosis and

psychotropic treatment of individuals

with both dementia and depression.

Nevertheless, the statutory definition of

mental illness (for PASRR) specifically

excludes persons with dementia-related

conditions, unless their primary

diagnosis is severe mental illness.

Because nursing facilities are not

required to conduct Level II screens on

these individuals, statutory exemptions

may have the unintended effect of failing

to identify the need for specialized and

other mental health services among

individuals with dementia or Alzheimer’s

disease (Emerson Lombardo, Fogel,

Robinson, & Weiss, 1995). Identification

and provision of mental health service

needs for this population becomes the de

facto responsibility of the nursing

facility. 

■ There are limited resources for

monitoring and enforcing PASRR. With

few resources to offer technical

assistance and monitor States, and with

limited statutory penalties except closing

a facility, denying payment, or issuing a

fine, CMS has had difficulty enforcing

PASRR. Consequently, advocates and

policymakers suspect that PASRR is not

having the full intended effects (Sherrell,

Anderson, & Buckwalter, 1998; Borson,

Loebel, Kitchell, Domoto, & Hyde,

1997; Bazelon, 1996; Marek, Rantz,

Fagin, & Krejci, 1996). 

■ There is inefficient utilization of the

expertise of mental health professionals.

The issue of which doctors or other

professionals provide mental health

services to nursing home residents

remains variable. Some researchers have

found that much of psychiatrists’ and

other mental health professionals’ time is

dedicated to evaluation and medication

management, leaving them unable to

provide therapy and other modes of

treatment (Emerson Lombardo et al.,

1995). Others charge that the underlying

problem restricting the utilization of

psychiatrists and psychologists is the low

reimbursement rates by Medicaid and

Medicare. Furthermore, there is concern

that nursing facility staff lack adequate

knowledge of mental health issues.

Unless staff members are trained in

managing mental health and behavioral

issues, they will be unable to provide an

environment conducive to each resident’s

mental health. PASRR nursing facility

determination is facility-specific, and a

determination that a nursing facility is

needed should not actually be made if

the facility does not have staff

adequately trained in meeting mental

illness needs.

■ There are delays in placement. Some

research has indicated that hospitals and

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 13
nursing facility staff are concerned about

delays in placement caused by the

PASRR screening process (SSWLHC,

1995). According to PASRR regulations,

individuals cannot be placed in nursing

facilities until after the PASRR screens

have been completed. However, the

Society for Social Work Leadership in

Health Care survey indicates that an

individual requiring both Level I and

Level II screens can be forced to wait up

to 3 weeks for a final determination.

Such delays in treatment are not only

detrimental to the individual desiring

placement, but are also costly in delaying

referral from expensive acute care

facilities.

14 Special Report
A. Study Goals and Research

Questions

This project addressed three main research

goals: (1) understand State and nursing

facility procedures for PASRR

implementation; (2) gauge the impact of

PASRR on achieving intended policy goals;

and (3) identify implementation issues of

concern to States. Specific research questions

and subquestions included the following:

1. How are States and nursing facilities

implementing PASRR?

a. How is PASRR organized and

administered at the State level? 

b. How and how well are States and

nursing facilities implementing PASRR

Level I and Level II screening

procedures? 

c. How and how well are States and

nursing facilities implementing PASRR

change in condition assessment

procedures?

d. How are States overseeing and

monitoring PASRR implementation?

2. How has PASRR affected intended policy

goals?

a. How has PASRR affected the

identification of serious mental illness

among nursing facility applicants and

residents?

b. How has PASRR affected the

availability and receipt of mental health

services in nursing facilities?

c. How has PASRR affected screening for

nursing facility level of care for nursing

facility applicants and residents?

3. What issues have States and nursing

facilities identified throughout PASRR

implementation?

a. What has been the impact of PASRR on

broader system issues, such as the

availability of community-based

alternatives to institutional care?

b. How do States and nursing facilities

perceive PASRR? 

c. What are State and nursing facility

recommendations to improve PASRR?

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 15

IV. Methodology

This section presents research questions and describes the overall

assessment approach used to conduct the study. An advisory panel of

experts (see Exhibit 1 in Appendix B) representing organizations in

the fields of mental health, aging, and long-term care provided guidance on

all aspects of study methodology. 
The breadth and depth of these questions

underscore the importance of obtaining

perspectives from multiple stakeholders at

the State and nursing facility levels. The

resulting multilevel study design (described

below) reflects this awareness. 

B. Study Components

To gather relevant information on both State

and nursing facility experiences with PASRR

implementation and outcomes, a multilevel

approach was used, consisting of a national

survey of all 50 States and the District of

Columbia, augmented by in-depth studies of

4 States. Qualitative and quantitative data

were collected from multiple data sources

using a variety of data collection tools. In

the following section, these two study phases

are described in more detail.

1. National Survey of PASRR Agencies

a. Data Collection Procedures and Tools

To obtain State-level perspectives from all 50

States and the District of Columbia, a survey

was conducted of PASRR representatives

from State agencies involved in PASRR

administration. These respondents typically

included Medicaid and SMHAs, but in some

States, aging or health authorities responsible

for administering PASRR Level I or Level II

screens were interviewed. Individuals most

knowledgeable about PASRR operations

were identified and mailed invitation letters.

Follow-up calls were made to schedule

telephone interviews. 

Interviews were conducted with at least

one State PASRR agency in all 50 States and

the District of Columbia, yielding an overall

State-level response rate of 100 percent. In

total, 47 interviews with SMHAs, 43 with

State Medicaid agencies, and 5 with State

aging or health agencies were conducted.

Fourteen of these interviews were conducted

jointly with multiple PASRR agencies. The

majority of interviews were conducted by

telephone; however, some individuals

preferred to submit written survey responses. 

Structured surveys were developed using a

core set of questions, augmented by

additional items tailored as appropriate to

Medicaid, SMHAs, or other State agencies.

To the extent possible, survey questions

replicated questions from existing surveys,

such as those used by Bazelon and OIG, to

enable comparison and response validation.

One survey version targeted agencies

involved in administering Level I screens

(e.g., Medicaid, aging/health authority), and

the other targeted agencies typically involved

in administering Level II screens (e.g.,

SMHA). The final “Medicaid” version

consisted of 45 closed and open-ended

questions, while the SMHA version consisted

of 43 closed and open-ended items. Exhibit 2

displays content areas of the State-level

interview protocols (for complete survey

protocols, see Appendix C). Interviews lasted

approximately 45–60 minutes. For States

where a single State agency administers

PASRR or when joint interviews with

multiple PASRR agencies were conducted,

the broader “Medicaid” version of the

survey was used. 

16 Special Report
States were asked for additional

information and documents using standard

forms for such requests. States were also

asked to submit PASRR policy and relevant

programmatic documents and statistics on

the number of Level I and Level II screens

conducted in the past fiscal year. Forty-four

States returned these data/document

supplement forms.

2. In-Depth State Studies

a. Selection Criteria

To augment national survey findings and

understand the PASRR experiences of

nursing facility staff and residents at the

local level, four States were selected for indepth study. 

State Selection Methodology. National

survey findings indicated that the single

greatest source of variation in PASRR

implementation was the type of entity States

designated to conduct the Level II PASRR

screens. Four types of entities were used to

conduct Level II screens: (1) private mental

health agency; (2) public mental health

agency; (3) individual mental health

practitioners; or (4) independent State

agencies and other sources. States were

sorted by the four Level II PASRR screen

types of entities and by geographic region

(South, West, Midwest, and Northeast) to

select the four study States. One State per

type of entity was selected, ensuring that the

four geographic regions were represented in

the final selection of States. 

Nursing Facility Selection Methodology.

SAMHSA and CMS identified geographic

variability (urban and rural) and variations

in facility size as two key stratification

criteria for selecting nursing facilities in each

of the four States. Using the 2000 census for

the urban area, the largest metropolitan

statistical area (MSA) in each State was

selected. For the nonurban area, a rural

county not contiguous to the selected MSA

was chosen. Within each urban and rural

county, a stratified random sample (stratified

by facility size) of three nursing facilities was

drawn using the CMS Nursing Home

Compare Database. Small nursing facilities

were those with fewer than 60 beds, medium

facilities had 61–90 beds, and large facilities

had more than 90 beds. 

Nursing Facility Resident Selection

Methodology. For the medical record

abstraction sample, the following three

selection criteria were used to identify

residents who might have a serious mental

illness: (a) received a PASRR Level II screen;

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 17

Exhibit 2: State-Level Interview Protocol

Interview Protocol: State Agency PASRR Representative

PASRR Implementation: Procedures. Included 21–23 questions on Level I/II screening process and

outcomes, change in condition procedures, mental health service delivery, and the process of categorical

determination.

PASRR Implementation: Oversight Responsibilities. Included six questions on State agency oversight

responsibilities and nursing facility responsibilities.

Issues Identified From PASRR Implementation. Included 16 questions on PASRR design and impact

on State agencies and the mental health system and the connection to Olmstead planning.
(b) currently prescribed psychotropic

medications from the following classes:

neuroleptics, antidepressant, anxiolytics, or

mood stabilizers; or (c) positive for any

primary or secondary diagnosis of mental

illness (not limited to severe mental illness).

Residents meeting any of these three criteria

were grouped together on a master list, from

which up to 40 residents (depending on the

size of the nursing facility) were randomly

sampled for medical record abstraction. In

two States, clinical interviews were

conducted with a subset of residents drawn

randomly from the medical record sample in

each facility. This ensured that clinical

interview information could be augmented

with diagnostic, care plan, and treatment

information collected through the medical

record review. In each nursing facility (six

per State), a random sample of 7–9 residents

was drawn from the sample of 30–40

medical records for each facility. Residents

were invited to participate in the study and

underwent a process of informed consent.

Only those agreeing to participate

voluntarily in the study were administered

the clinical interview. When residents refused

to participate, another resident was

randomly selected from the remaining list for

replacement. 

b. Data Collection Procedures and Tools

To recruit States for the in-depth studies,

invitation letters were mailed to PASRR

program administrators in the selected

States. Letters described the proposed indepth study and assured States of

confidentiality. All four States approached

agreed to participate in the study. After

attaining agreement at the State level, the

nursing facility sample was drawn according

to the selection criteria described earlier.

Introductory letters to selected nursing

facilities were mailed, followed by telephone

calls to secure facility participation. When

facilities declined participation, the sample

was redrawn. Data collection in each of the

four selected States was completed from May

through July of 2003.

Key Informant Interviews. A total of 24

key informant interviews were conducted

with nursing facility administrators and staff

from six nursing facilities in four States. To

guide these interviews, a structured protocol,

similar in content and organization to the

State-level protocols described earlier, was

developed. The final version consisted of 48

closed and open-ended questions (see Exhibit

3 for protocol content areas). Interviews

lasted between 45 and 60 minutes.

Medical Record Abstractions. In 6 nursing

facilities in each of the 4 States, resident

medical records were abstracted for 30–40

nursing facility residents per facility, for a

total of 786 records. An abstraction tool was

developed to extract key information on

PASRR documentation, resident background

characteristics, medical and psychiatric

history, psychotropic medications prescribed,

mental health services received, and the

number of acute care discharges (see Exhibit

4). These reviews yielded information that

enabled the comparison of resident PASRR

screen results with subsequent mental health

treatment prescribed and delivered (including

use of psychotropic medications).

18 Special Report
PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 19

Exhibit 3: Nursing Facility Staff Interview Protocol

Interview Protocol: Nursing Facility Staff

PASRR Process. Included 18 questions regarding respondent knowledge and perceptions about the

PASRR process, including knowledge of change in condition procedures.

Prevalence of Mental Disorders in Nursing Facilities. Included seven questions collecting information

on the number of residents with primary and secondary mental illness diagnoses.

Mental Health Services in Nursing Facilities. Included 13 questions regarding the availability and

scope, utilization, and access barriers for the provision of mental health services in nursing facilities.

Organizational Changes. Included three questions regarding respondent perceptions of the impact of

PASRR, including administrative burden, on the operation of the facility.

Communication With the SMHA. Included 11 questions capturing information on procedures used to

communicate regarding a change in condition, arrangement of specialized services, State monitoring,

and other regulatory requirements.

Exhibit 4: Medical Record Abstraction Tool

Medical Record Abstraction Tool

Background Characteristics. Captured information on resident demographics, referral source, and reason for admission.

Medical and Psychiatric History. Collected data on physical and mental health diagnoses at time of

initial admission and currently. 

PASRR Documentation. Captured information on whether charts contained Level I, Level II, and

Resident Review screens and key outcomes from these forms. 

Psychotropic Medications and Mental Health Services Ordered. Collected information on medications and services ordered at time of initial admission and currently. 

Mental Health Services Received. Reviewed progress notes from the previous 30 days to identify mental health services residents currently receiving.

Acute Care Discharges. Recorded the number of times residents had been discharged to acute care

facilities and for what reason (e.g., mental or physical health).
Clinical Interviews. In two States, clinical

interviews were conducted in six nursing

facilities with up to seven to nine nursing

facility residents per facility. A total of 93

residents were interviewed. Clinical

interviews involved a brief cognitive,

psychiatric, functional, and quality-of-life

assessment of nursing home residents with

instruments that are commonly used and

well validated on this population. These

interviews yielded additional information

about nursing facility residents’ current

clinical diagnosis and treatment profile as

compared to their PASRR status. During

clinical interviews, a dementia screen was

administered first to screen out residents

with significant cognitive impairment whose

responses on subsequent interview tools

would not have been valid. Interview tools

are described in more detail below.

The Blessed Orientation-MemoryConcentration (BOMC) Test is a six-item

instrument to screen for the presence of

dementia. Total scores range from 0 (all

items answered correctly) to 28 (all items

answered incorrectly), with higher scores

indicating greater impairment. Scores greater

than 10 are consistent with dementia

(Katzman et al., 1983). 

The Brief Symptom Inventory (BSI) is a

53-item self-report inventory that asks

people to use a 5-point scale to rate their

level of emotional distress across a range of

psychological experiences. There are nine

primary symptom dimensions: somatization,

obsessive-compulsive, interpersonal

sensitivity, depression, anxiety, hostility,

phobic anxiety, paranoid ideation, and

psychoticism. There is also a global severity

index. Higher scores indicate greater

symptom severity (Derogatis, 1982). 

The Geriatric Depression Scale is a 15-item

questionnaire that assesses level of

depression in older adults. It uses a series of

yes/no questions. Affirmative responses are

given a value of “1” and are tallied to create

a composite score. Higher scores indicate

more severe depression (Sheikh & Yesavage,

1986). 

The Short-Form Health Survey (SF-12) is a

12-item survey that assesses perceived health

and functional ability in physical and mental

domains. It uses a combination of yes/no

items and five-point Likert scales. A scoring

algorithm is used to aggregate items into two

composite scores (physical, mental), with

lower scores reflecting more impaired health

(Ware, Kosinski, & Keller, 1996). 

The Dementia Quality of Life Instrument

(DQoL) is a 29-item, 5-point scale assessing

quality of life for individuals with mild to

moderate dementia. It has five subscales:

self-esteem, positive affect, negative affect,

feelings of belonging, and sense of aesthetics.

Each scale is scored separately, and the scale

score is the mean of the items in that scale.

The DQoL also includes an optional single

item to assess overall quality of life (Brod,

Stewart, Sands, & Walton, 1999).

20 Special Report
A. PASRR Implementation 

at the State Level

This section presents survey results related to

State-level policies and procedures for

organizing and administering PASRR

programs, conducting Level I/Level II screens

and change in condition assessments, and

maintaining oversight of PASRR

implementation. 

1. Organization and Administration of PASRR 

a. What State Agencies Are Involved in PASRR

Administration?

State Agency Involvement in PASRR. Federal

law and regulations articulate specific

PASRR roles for Medicaid agencies and

SMHAs. Medicaid agencies are required to

include a PASRR program in their State plan

and develop a written agreement with the

SMHA detailing PASRR operations. In

addition, State PASRR agencies can delegate

only those functions for which they are

responsible and must maintain overall

oversight responsibility for those functions.

Survey results indicated considerable

variation in how States organize and

distribute PASRR responsibilities across State

agencies. Exhibit 5 shows the number of

agencies involved in State PASRR screening

activities. 

State agencies were considered to be

“involved” if they play an active role in

administering or overseeing some aspect of

the PASRR process. For example, a State

agency that maintains direct oversight for

tracking and reporting Level I outcomes

would be considered “involved,” while

another that has a memorandum of

understanding granting Level I tracking and

reporting oversight to a different State

agency would not. 

In seven States, a single agency assumes the

bulk of Level I and Level II screening

responsibilities, with very marginal

involvement from other State agencies.

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 21

V. National Survey

Findings

This section reports on findings from a national survey of State agencies

involved in PASRR administration. Sections A through C address the

following three research questions: 

1. How are States implementing PASRR? (Section A)

2. How has PASRR affected its intended policy goals? (Section B)

3. What issues have States identified through PASRR implementation?

(Section C) 

As described in Section III, the national survey achieved a 100 percent

response rate. Because not every respondent answered every question,

however, there is variation across individual item responses. 
Approximately half (27) of the States divide

PASRR responsibilities across Medicaid and

SMHAs. In 13 States, either the Medicaid or

SMHA (but not both) is involved in PASRR

and works with a third agency, typically the

aging authority or another health authority

(e.g., Department of Health). In four States,

three State agencies maintain direct

involvement in the Level I or Level II

screening process. While the present study

cannot assess the appropriateness of

interagency delegation of tasks, it is clear

that where the SMHA or State Medicaid

agency are not substantially involved, those

agencies cannot be in compliance with the

unique responsibilities each has under

Federal regulations.

State PASRR Agency Location. As shown

in Exhibit 6, in nearly half (24) of States,

agencies involved in PASRR administration

are located within the same central agency

(i.e., they are “centralized”). For example,

many States locate the mental health

authority and Medicaid in divisions under a

single umbrella agency, such as a

Department of Health and Human Services. 

22 Special Report

Exhibit 5: State Agency Involvement (n=51) 

Agency Involvement in PASRR States

One agency: (Medicaid or SMHA) 7 (14%)

Two agencies:

– Medicaid and SMHA 27 (53%)

– Medicaid, SMHA, and aging/health authority 13 (25%)

Three agencies: (SMHA, Medicaid, aging/health authority) 4 (8%)

Exhibit 6: State PASRR Agency Location (n=51)

PASRR Agencies Centralized Decentralized

One agency: (n=7) 7 (14%) —

Two agencies:

–SMHA and Medicaid (n=27) 10 (19%) 17 (33%)

– SMHA or Medicaid and aging/health authority (n=13) 7 (14%) 6 (12%)

Three agencies: (n=4) — 4 (8%)

Total 24 (47%) 27 (53%)
b. How Do States Distribute PASRR

Administrative Functions?

Entity Designated by States To Conduct

PASRR Screens. Exhibit 7 displays the

entities States designate to conduct Level I

and Level II screens. Many States allow

multiple entities to complete screens.

Level I Screens. Federal regulations grant

States considerable flexibility in designating

which entities can conduct Level I

assessments. Level I screens are conducted by

nursing facilities in 12 percent of States and

by referral sources (e.g., acute care facilities,

community-based programs) in 20 percent of

States. Together, the majority (32) of States

allow nursing facilities and referral sources

to complete Level I screens. In States that

allow nursing facilities to complete Level I

screens, respondents typically described this

as being part of the admissions process (i.e.,

nursing facility staff evaluate applicants

before they can be admitted). Eight (16

percent) of States contract out Level I

screening responsibilities, while in 11 States

(22 percent), Level I screens are completed

by State agencies, such as Medicaid and

aging authorities.

Level II Screens. Federal statute stipulates

that Level II assessments must be completed

by an independent entity other than the

SMHA, a nursing facility, or an entity related

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 23

Exhibit 7: Entity Conducting PASRR Screens (n=51)

Entity Conducting Screen (n=51) Level I Level II

Nursing Facility and/or Referring

Agency 32 (63%) 3 (6%)

– Nursing facility only 6 (12%) —

– Referring agency only 10 (20%) 3 (6%)

– Nursing facility and referring

agency 16 (31%) —

Contractor 8 (16%) 44 (86%)

– Private agency/agencies — 17 (33%)

– Individual private practitioners — 9 (18%)

– Community mental health clinics

(CMHCs) or mental health 

authorities

— 18 (35%)

State Agency (e.g., State Medicaid

Agency, SMHA, Aging Authority) 11 (21%) 4 (8%)
to a nursing facility. The majority of States

(44) contract with mental health entities to

conduct Level II assessments. Specifically, 17

States contract with private mental health

agencies (e.g., managed behavioral health

companies), 18 contract with community

mental health clinics or other public mental

health agencies, and 9 contract with

individual mental health practitioners. This

suggests that some SMHAs may be

improperly delegating this function.

Entity Designated by States as Responsible

for Making Level II Determinations. In 43

percent of States, Level II final

determinations are made at the State agency

level based on results from an independent

evaluation. However, in the majority of

States (57 percent), whichever entity

completes the Level II assessment—whether

it is a contracted entity or independent State

agency—is allowed to make the final

determination as to whether an individual

requires nursing facility care and/or

specialized services. This suggests that some

SMHAs may be improperly delegating this

function.

c. How Do States Define and Communicate

PASRR-Related Policies? 

State Definition of Specialized Services.

Federal regulations allow States flexibility in

defining what constitutes specialized mental

health services. The majority (75 percent) of

States have elected to define specialized

services in the most restrictive sense—as 24-

hour intensive care for acute mental health

needs delivered outside the nursing facility,

such as in an inpatient facility. Only 13

States define specialized services more

broadly; for example, as comprehensive

mental health and rehabilitation services

designed to increase individual functioning.

State Use of Advance Determination

Categories. The majority (38) of States allow

advance determinations by category. This

means that States are not required to

conduct PASRR screens on certain groups of

people who are presumed either to meet level

of care requirements for nursing facility care

or to not require specialized mental health

services. The most frequently cited advance

determination category is dementia, followed

by convalescent care (35),

emergency/protective services (26), respite

care (18), severe illness (15), terminal illness

(15), and delirium (11).

State PASRR Training Efforts. States are

responsible for communicating PASRR

policy and regulations to nursing facilities so

that they can comply with their

responsibilities. Exhibit 8 shows the range of

State training activities that respondents

described. Many States employ multiple

training methods that are sponsored by a

variety of PASRR associated agencies (e.g.,

Medicaid, SMHA, aging/health authority).

Most States (30) reported conducting PASRR

trainings for nursing facilities on a regular

basis, but 6 States indicated that they do not

provide any training or outreach. 

24 Special Report
2. PASRR Level I and Level II Screening

Documentation

States were asked to provide data from the

most recent fiscal year available (FY 2001 or

FY 2002) on the number PASRR screens

completed annually. 

Number of Level I and Level II PASRR

Screens Conducted Annually. The average

number of PASRR screens appears to have

remained relatively consistent over the past

decade, suggesting that States continue to

comply with the requirement to administer

PASRR screens. Exhibit 9 compares the

average numbers of Level I and Level II

screens in 1991 and 1993 (as documented in

the Bazelon [1996] study) and 2002. 

Number of Level II Change in Condition

Assessments Conducted Annually. The OIG

(2001) study found that Level II

reassessments as a result of a “change in

condition” rarely occurred. Of the 32 States

providing data in the current study, more

than two fifths (44 percent) reported fewer

than 100 change in condition assessments

were conducted in the previous year (FY

2001 or FY 2002). Coupled with the OIG

study findings and results reported later in

this report, this finding suggests that many

States may not be in compliance with

Federal requirements. 

3. PASRR Level I and Level II Screening

Procedures

Time Frame for Completing PASRR

Screens. Exhibit 10 presents results on State

guidelines for how long Level I and Level II

screening procedures should take.

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 25

Exhibit 8: State PASRR Training for Change in Condition Procedures (n=51)

State PASRR Training (n=50)

Conduct nursing facility trainings on a regular basis 30 (60%)

Conduct nursing facility trainings/phone consultation as needed 27 (54%)

PASRR instruction manual 11 (22%)

No trainings/outreach 6 (12%)

Exhibit 9: Average Number of Level I and Level II Screens 

Conducted Annually

FY 1991 FY 1993 FY 2001/2002

Level I Screen 14,314 19,775 18,916

Level II Screen 1,009 923 972
Level I Screens. While there are no Federal

regulations specifying a time frame for

completing Level I screens, in 22 States,

Level I screens are completed in fewer than

24 hours after the individual is referred to a

nursing facility. Many States require Level I

screens to be submitted concurrently as part

of the nursing facility application. 

Level II Screens. Federal regulations

specify that Level II screens must be

completed within 7–9 business days of

request, on average. In the current survey,

the majority of States (30) complete Level II

screens in less time than Federal regulations

specify. Only three States acknowledged

having difficulty meeting Federal

requirements. 

Professional Qualifications of Screeners.

Exhibit 11 displays State requirements

regarding professional qualifications of

PASRR screeners.

Level I Screens. Federal regulations do not

specify qualifications for Level I screeners,

and a majority of States (36) allow a broad

range of health professionals to complete

them. These health professionals typically

are nurses or social workers, but they may

not necessarily have backgrounds in mental

health.

26 Special Report

Exhibit 10: Time Frame for Completing PASRR Screens (n=51)

Time Frame for Completing Screens

Level I Screens Level II Screens

(n=47) (n=47)

Immediate/less time than 24 hours 22 (47%) —

Fewer than 7 working days 8 (17.0%) 30 (64%)

7–9 working days 4 (8%) 13 (28%)

10 or more working days 5 (11%) 3 (6%)

No specific guidelines 8 (17%) 1 (2%)

Exhibit 11: Professional Qualifications of Level I and 

Level II Screeners (n=51)

Professional Qualifications

Level I Screens Level II Screens

(n=46) (n=51)

Any type of health professional 36 (78%) 1 (2%)

Any type of mental health professional 3 (7%) 45 (88%)

Require physician, psychiatrist,

or doctoral-level psychologist — 5 (10%)

No qualifications specified 7 (15%) —
Level II Screens. Various types of mental

health professionals are allowed to complete

Level II screens in 45 States. Of the 45

States, 29 use specific credentialing

requirements and allow only “qualified

mental health professionals” (QMHPs) to

complete Level II screens. QMHP

designations typically included doctoral-level

mental health professionals, licensed clinical

social workers, and master-level practitioners

with varying levels of experience postdegree.

Regulations require that the Level II function

of making or confirming a diagnosis of

mental illness be performed by a QMHP.

Location of Screens. Exhibit 12 presents

rankings of the locations where PASRR

preadmission and resident review screens are

conducted most frequently. For both Level I

and Level II screens, the majority of States

ranked inpatient hospitals as the most

frequently used screening location, followed

by nursing facilities and community-based

programs. “Other” locations, such as the

applicant’s home, were the least frequently

used locations for conducting both types of

screens. The finding that a significant

percentage of Level II evaluations and

determination are completed in a nursing

facility is difficult to interpret and depends

on the definition of nursing facility. The

Level II process must be completed before

admission to a Medicaid-certified nursing

facility. However, individuals residing in a

nursing home, but in a distinct part of the

facility that is not Medicaid-certified, could

be appropriately evaluated before being

transferred to a part of the institution that is

Medicaid-certified. 

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 27

Exhibit 12: Location of PASRR Preadmission and 

Resident Review Screens (n=51)

Screen Location

Ranking

First Second Third Fourth

Level I (n=46)

Inpatient hospitals 31 (67%) 12 (26%) 1 (2%) 2 (4%)

Nursing facilities 11 (24%) 22 (48%) 7 (15%) 6 (13%)

Community-based programs 2 (4%) 6 (13%) 20 (44%) 18 (39%)

Other; please describe 5 (11%) 2 (4%) 5 (11%) 34 (74%)

Level II

(n=47)

Inpatient hospitals 37 (79%) 5 (11%) 2 (4%) 3 (6%)

Nursing facilities 7 (15%) 21 (45%) 14 (30%) 5 (11%)

Community-based programs 2 (4%) 15 (32%) 15 (32%) 15 (32%)

Other; please describe 4 (9%) 5 (10%) 4 (9%) 34 (72%)
Data Collection Methods. As indicated in

Exhibit 13, the majority of States use

multiple methods to gather data for Level I

and Level II screens, although patient

records and face-to-face interviews are the

most frequently used methods. 

Documentation of PASRR Data. Exhibit

14 shows the methods States use to

document and store PASRR information.

Many States use a combination of paper and

electronic methods to document and store

PASRR data.

Level I Screens. The majority of States (46)

keep PASRR records in paper format. In 22

States, screens are stored in patient records;

however, Level I contractors in 15 States and

agencies with primary oversight

responsibilities in 19 States also keep full

copies. In addition, in 13 States, agencies

with primary oversight responsibilities keep

only partial records, such as summary

statistics on the total number of Level I

screens completed annually. 

Level II Screens. Of the States reporting a

method for PASRR documentation, all use

paper records, and 18 also maintain

electronic databases. In most States (30),

whichever State agency maintains primary

oversight of PASRR keeps full copies of

Level II screens, while one third (17) of

States maintain partial records, such as

28 Special Report

Exhibit 13: Data Collection

Methods for Level I and Level II

Screens (n=51)

Method of Data

Collection

Level I Level II

(n=47) (n=50)

Patient record 46 (98%) 50 (100%)

Face-to-face

interview 38 (81%) 47 (94%)

Family/third

party interviews 36 (77%) 44 (88%)

Written/

electronic data 29 (62%) 27 (56%)

Other source 5 (11%) 10 (20%)

Exhibit 14: Documentation and Storage of PASRR Screens (n=51)

How PASRR Information Is Documented

Level I Level II

(n=48) (n=48)

Paper 46 (96%) 48 (100%)

Electronic database 14 (29%) 18 (37.5%)

How PASRR Records Are Stored (n=44) (n=51)

Level I/II screens and determinations are kept in patient

records in nursing facility 22 (50.0%) 17 (33%)

Level II contractor keeps full copies 15 (34%) 19 (37%)

Full copies kept by SMHA/State Medicaid 

agency/aging authority 19 (43%) 30 (59%)

Determination/summaries/statistics kept by SMHA/State

Medicaid agency/aging authority 13 (30%) 17 (33%)
copies of Level II determination decisions or

summary statistics on the total number of

Level II screens completed annually. 

Use of Standardized Assessment Tools. The

majority of States require the use of

standardized assessment tools for Level I

(n=46) and Level II (n=47) screens, which

promotes consistency of screening within

each State. 

4. PASRR Change in Condition Assessment

Procedures

Annual Resident Reviews. Consistent with

changes in the Federal statute, 43 States no

longer require Level II resident reviews to be

conducted annually. Instead, current statute

requires nursing facilities to report a

significant change in a resident’s mental or

physical condition to the SMHA (or

designated entity) to trigger a Level II change

in condition assessment.

Change in Condition Criteria and

Procedures. When the requirement for

annual resident reviews was eliminated in

1996, States were required to develop

criteria and procedures for identifying when

nursing facility residents experience a

significant change in condition so that

nursing facilities can initiate a Level II

resident review. As shown in Exhibit 15,

while 15 States use the MDS as a change in

condition trigger, most States (26) developed

State-specific behavioral/functional criteria,

such as when a resident receives a new

mental health diagnosis or if a behavior

change persists after a mental health

intervention. Eight States reported using

Level I screening criteria to indicate a change

in condition, which are not appropriate for

this task. More than 40 percent of the States

reported that State policy instructs nursing

facilities to contact the entity designated to

conduct Level II screens. This entity then is

required to notify the SMHA (or designated

entity). One quarter of the States require the

nursing facilities to notify the SMHA

directly, and one quarter require the facilities

to notify another State agency that

subsequently contacts the SMHA. Three

States are not complying with the change in

condition notification requirements.

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 29

Exhibit 15: Change in Condition Criteria and Procedures (n=51)

Change in Condition Criteria (n=49)

Use behavioral/functional criteria developed by State 26 (53%)

Use Minimum Data Set 15 (31%)

Use Level I screen criteria 8 (16%)

SMHA Notification Process for Change in Condition (n=50)

Nursing facility notifies Level II contractor directly; contractor notifies SMHA 21 (42%)

Nursing facility notifies SMHA directly 13 (26%)

Nursing facility notifies other State agency, then agency notifies SMHA 13 (26%)

Not notified systematically 3 (6%)
5. PASRR Oversight Mechanisms

State-Level PASRR Oversight

Responsibilities. From interview responses,

State agencies that were most directly

responsible for ensuring accurate completion

of Level I and Level II screens were identified

and designated as having “primary”

oversight responsibility. As displayed in

Exhibit 16, in most States (n=31), primary

Level I oversight is the responsibility of

Medicaid, and Level II oversight rests with

SMHAs (n=44). In 13 States, the aging or

health authorities assume responsibility for

primary oversight of Level I screens. 

Use of PASRR Data To Monitor State

Policy Goals. Exhibit 17 summarizes how

States use information generated by the

PASRR program. The majority use PASRR

data to monitor various Level II PASRR

outcomes. These include whether or not

someone has a serious mental illness and if

so, whether he/she currently requires

specialized mental health services. Level II

outcomes also determine whether or not an

individual needs nursing facility level of care.

Direct Oversight of PASRR in Nursing

Facilities. As presented in Exhibit 18, when

asked which State agency has primary

responsibility for directly overseeing the

PASRR process in nursing facilities, very few

respondents mentioned agencies involved in

administering PASRR, such as Medicaid

agencies (22 percent), SMHAs (8 percent), or

aging authorities (14 percent). Instead, 75

percent of respondents indicated that the

entity responsible for conducting nursing

facility survey and certification is responsible

for including PASRR as part of its overall

quality review process. These findings are

consistent with those of the 2001 OIG

30 Special Report

Exhibit 16: Primary PASRR Oversight Responsibilities (n=51)

PASRR Activity Medicaid SMHA Aging/Health

Authority

Level I Screens 31 (61%) 7 (14%) 13 (25%)

Level II Screens 3 (6%) 44 (86%) 4 (8%)

Exhibit 17: How States Use 

PASRR Data (n=51)

Purposes of PASRR Data Yes

Monitor PASRR outcomes 46 (90%)

SMI diagnosis 33 (65%)

– Need for nursing facility care 42 (82%)

– Need for specialized services 41 (80%)

Monitor need for alternative 

placements 27 (53%)

Monitor nursing facility

quality of care 12 (24%)

Exhibit 18: Primary Responsibility

for Direct Oversight of PASRR in

Nursing Facilities (n=51)

Direct Oversight of PASRR in

Nursing Facilities (n=49)

Handled by entity that does

survey/licensing of nursing facilities

37

(76%)

Handled by Medicaid agencies 11

(22%)

Handled by aging/elderly authorities 7 (14%)

Handled by SMHA 4 (8%)
report. In four out of five OIG case study

States, Medicaid agencies and SMHAs

reported relying on State surveyors to

monitor the PASRR process. None of the

surveyors interviewed in these States,

however, considered monitoring PASRR

screens to be his/her responsibility.

State-Level Monitoring Systems. Also

consistent with the OIG study findings, very

few respondents described comprehensive

State-level monitoring systems. As displayed

in Exhibit 19, only nine States routinely

monitor Level I outcomes (e.g., referred for

Level II screen, meets criteria for dementia or

some other categorical determination) as

part of an overall quality improvement

system. Even fewer States (seven) monitor

Level II outcomes (e.g., has a serious mental

illness, requires specialized mental health

services, appropriate for nursing facility

care). In addition, fewer than half of the

States review individual Level I and Level II

screens for accuracy and completeness of

information. 

B. PASRR Impact on Policy Goals

This section presents survey results that

address the impact of PASRR on intended

policy goals. At the State level, input

centered primarily on the overall

effectiveness of PASRR and availability and

receipt of mental health services in nursing

facilities. 

1. Overall Effectiveness of PASRR

Prior to the enactment of PASARR in 1987,

only eight States reported having an

assessment process in place to evaluate the

mental health needs of nursing facility

residents. Today, all 50 States and the

District of Columbia have implemented

PASRR programs intended to address three

main policy goals. These goals include

identifying individuals with serious mental

illness, screening their appropriateness for

nursing facility care, and ensuring provision

of specialized and other mental health

services.

Level II Preadmission Screening

Outcomes. States were asked to provide

annual data from the most recent fiscal year

available on the outcomes of Level II

preadmission screens. The most frequently

reported outcomes were as follows: 45

percent of States found 90–100 percent of

individuals to have a serious mental illness,

58 percent of States found 90–100 percent of

individuals to be appropriate for nursing

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 31

Exhibit 19: State-Level Monitoring Systems (n=51)

Description of Monitoring System

Level I Screen Level II Screen

(n=46) (n=48)

Review each individual screen 19 (41%) 23 (48%)

Sample percentage of individual screens 5 (11%) 7 (15%)

Review aggregated screens 14 (30%) 19 (40%)

Monitor PASRR outcomes as part of quality improvement 9 (20%) 7 (15%)

No monitoring system in place 4 (9%) 5 (10%)

Other: e.g., regular interagency meetings 2 (4%) 1 (2%)
facility level of care, and 38 percent of States

found 0–9 percent of individuals to require

specialized services. 

These very low rates of false positives from

the Level I screen call into question whether

the broad and rudimentary Level I screen is

functioning as intended to identify all

individuals who may have mental illness. It

appears that in some States, the Level I

screen only passes on to Level II those

individuals who obviously require treatment

planning for their mental illness. This

practice is economical for States but is out of

compliance with regulation, eliminating from

evaluation those persons whose mental

illness can only be determined by more

sophisticated evaluation.

These findings are consistent with other

studies, which report that average diversion

rates (those found to be inappropriate for

nursing facility care) tend to be less than 10

percent (SSWLHC, 1995; Bazelon, 1996).

The results are consistent with the Bazelon

findings that an average of 7–8 percent of

nursing facility applicants need specialized

services. 

Perceived Effectiveness of PASRR

Programs. Exhibit 21 compares Medicaid

and SMHA ratings of the effectiveness of

PASRR in achieving intended policy

outcomes. Agreement between Medicaid and

SMHA respondents was strong, with the

majority rating PASRR as doing a “good”

job of identifying individuals with serious

mental illness, screening their

appropriateness for nursing facility care, and

ensuring provision of specialized services.

Nearly half of the Medicaid and SMHA

respondents reported that PASRR positively

affected the type or amount of mental health

services provided in their State. Both

Medicaid and SMHA respondents were also

32 Special Report

Exhibit 20: Level II Preadmission Screening Outcomes

Descriptive

Statistics

Percentage Diagnosed

With Serious Mental

Illness (n=38)

Percentage Found

Appropriate for Nursing

Facility (n=40)

Percentage Found To

Need Specialized Mental

Health Services (n=39)

Mean 71.9% 82.9% 11.6%

Median 71.0% 94.0% 2.8%

Frequencies

0–9% 2 (5%) 2 (5%) 15 (38%)

10–19% 0 (0%) 0 (0%) 9 (23%)

20–29% 0 (0%) 0 (0%) 6 (15%)

30–59% 8 (21%) 3 (7%) 4 (10%)

60–89% 11 (29%) 12 (30%) 0 (0%)

90–100% 17 (45%) 23 (58%) 5 (13%)
likely to indicate that PASRR positively

affected the quality of mental health services

in their State. 

2. Availability and Receipt of Mental Health

Services

Provision of Specialized Services. As

described earlier, 75 percent of States define

specialized services as 24-hour acute care

provided in inpatient facilities. By this

definition, nursing facility applicants who

require specialized services to treat their

mental illness would not be admitted to a

nursing facility. Of the 13 States that define

specialized services more broadly, definitions

varied but included such services as

psychosocial rehabilitation, case

consultation, medication management, and

crisis intervention. Most noted that while

these specialized services were often provided

by community mental health centers,

rehabilitation agencies, nursing facilities, and

individual practitioners are also eligible to

provide them. 

State respondents described a variety of

funding sources. Use of the Medicaid

rehabilitation option and State general funds

were mentioned most frequently. Some States

indicated that specialized services were

included in the per diem rate paid to nursing

facilities and mental health providers. This

statement is difficult to interpret since

specialized services by regulatory definition

are services over and above those provided

in the nursing facility benefit. States may

contract with nursing facilities to provide

specialized services, but such services would

be reimbursed over and above the nursing

facility per diem payment.

Provision of Mental Health Services of a

Lesser Intensity by Nursing Facilities.

Federal statute requires nursing facilities to

provide mental health services (of a lesser

intensity than specialized services) to

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 33

Exhibit 21: Perceived Effectiveness of PASRR Programs (n=51)

State Medicaid Respondents Poor Fair Good Excellent

Identifying individuals with serious mental

illness (n=51) 1 (2.0%) 11 (22%) 22 (43%) 17 (33%)

Screening appropriateness for nursing

facility care (n=49) 3 (6%) 6 (12%) 29 (59%) 11 (22%)

Ensuring provision of specialized services

(n=42) 9 (21%) 12 (29%) 15 (36%) 6 (14%)

SMHA Respondents Poor Fair Good Excellent

Identifying individuals with serious mental

illness (n=50) 1 (2%) 5 (10%) 24 (48%) 20 (40%)

Screening appropriateness for nursing

facility care (n=47) 2 (4%) 3 (6%) 27 (57%) 15 (32%)

Ensuring provision of specialized services

(n=47) 2 (4%) 3 (6%) 27 (57%) 15 (32%)
residents with mental illness; that is, services

provided as part of the standard Medicaid

nursing facility per diem payment, without

additional reimbursement. Thirty-nine of 42

responding States indicated that Medicaid

includes certain mental health services

provided in the nursing facility benefit but

does not cover others. 

Provision of Other Mental Health Services.

In addition to mental health services

provided by nursing facilities and specialized

services (in 13 States), other mental health

services may be available from the Medicaid

State plan or other sources. Most States

reported that Medicaid covers psychiatric

consultation (for example, medication

monitoring, individual therapy, assessments)

in their State plans, while fewer than half of

State Medicaid plans cover rehabilitation

services (for example, intensive case

management, psychosocial rehabilitation).

Exhibit 22 presents further detail on the

availability of mental health services and the

type of practitioner providing the service.

The majority of States (69 percent) reported

that these services are most often provided

by private independent practitioners. 

Quality of Access to Mental Health

Services in Nursing Facilities. Thirty-seven of

the respondents completing either the State

Medicaid or SMHA interview provided their

perspectives on the quality of access to

mental health services in nursing facilities

throughout their State. Many respondents

characterized access to mental health care as

either being insufficient (30–32 percent) or

varying considerably from facility to facility

(22–30 percent) (see Exhibit 23). For

example, one SMHA respondent highlighted

Medicaid reimbursement as a barrier to

receiving mental health services in nursing

facilities, stating “Our Medicaid agency has

very strict rules. If the person is in a nursing

facility, Medicaid won’t pay for any

additional services outside of the per diem.

So community mental health centers don’t

get paid for any services they provide for

nursing facility residents.”

Others highlighted the problem of

variability in mental health service access

that exists across nursing facilities,

particularly by geographic region. Despite

these largely negative characterizations,

many respondents characterized overall

34 Special Report

Exhibit 22: Mental Health Services

in Nursing Facilities (n=51)

Medicaid-Covered Services (n=42)

Psychiatric consultation services 38 (91%)

Rehabilitation option services 18 (42.9%)

Who Provides Mental Health

Services in Nursing Facilities? (n=35)

Private independent practitioners 24 (69%)

CMHC staff 14 (40%)

Contract with private behavioral

health agency to provide mental

health services

3 (9%)

Exhibit 23: Access to Mental Health

Services in Nursing Facilities

(n=51)

Quality of Access of

Mental Health

Services in Nursing

Facilities

State

Medicaid SMHA

(n=37) (n=37)

Good access to mental

health services 18 (49%) 18 (49%)

Not enough mental

health services are

being provided in

nursing facilities

11 (30%) 12 (32%)

Varies from 

facility to facility 11 (30%) 8 (22%)
access as good. A typical Medicaid agency

response was, “I don’t think we have a

problem. . . . Medicaid does get a significant

number of claims for mental health services

for nursing facility residents, so I think it is

working okay.” 

C. PASRR Issues Identified at the State

Level 

The following section describes issues that

State respondents identified as important to

the PASRR process, including how PASRR

relates to broader State system issues, such

as Olmstead and the availability of

community-based alternatives to institutional

care. Also reported are additional State

respondent perceptions about PASRR and

recommendations to CMS, State PASRR

agencies, and nursing facilities for improving

the PASRR process. 

1. How PASRR Relates to Broader System

Issues

Relationship Between PASRR and

Olmstead Planning. In response to the 1999

Olmstead decision, many States are

reexamining their decisionmaking process

for institutional and community-based

placements for disabled populations,

including people with psychiatric disabilities.

As illustrated in Exhibit 24, the majority of

States (34) indicated active consideration or

some consideration of PASRR within the

broader context of their Olmstead planning. 

Use of Home and Community-Based

Services (HCBS) Waivers. In 38 States,

HCBS waivers cannot be used to move

individuals with serious mental illness from

institutional settings, such as psychiatric

hospitals and nursing facilities, into

community placements. Many respondents

explained that the HCBS waiver statute

requires States to demonstrate the costeffectiveness of care provided in communitybased programs relative to care provided in

institutional settings. However, because

Medicaid does not pay for care of

individuals residing in institutes for mental

disease (IMDs), many States reported that

they are unable to generate the appropriate

cost comparisons needed to demonstrate cost

neutrality, a requirement of HCBS waivers.

For example, one State Medicaid agency

representative explained, “Because you have

to prove cost effectiveness and Medicaid

doesn’t pay for IMDs, it is hard to make the

comparison to determine cost-effectiveness.”

Similarly, a mental health authority

respondent from another State said, “It’s

hard for us to make the waiver math work!”

Effect of PASRR on Acute Care

Discharges. Some stakeholder organizations

have raised concerns about PASRR’s effect

on State acute care systems. A 1995 survey

by the Society of Social Work Leadership in

Health Care described concerns on the part

of hospitals and nursing facilities that the

complexities of the PASRR screening process

can create costly delays in discharges. In this

study, when asked directly about PASRR’s

impact on acute care discharges, almost

three quarters of the States responding

highlighted negative effects, such as delays in

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 35

Exhibit 24: PASRR and 

Olmstead (n=51)

Consideration of PASRR as

Part of Olmstead Planning (n=50)

Active consideration of PASRR

as part of Olmstead planning 14 (28%)

Some consideration of PASRR as

part of Olmstead planning 20 (40%)

No consideration of PASRR as

part of Olmstead planning 16 (32%)
discharge and additional costs incurred.

However, more than a third noted PASRR’s

positive effects, such as preventing

inappropriate discharges and making

hospital staff more aware of individual

mental health needs. 

Alternatives to Nursing Facility Placement.

When individuals are determined through

the PASRR screening process to not require

nursing facility level care, States must

arrange for some type of alternative

placement. Exhibit 25 presents information

on what kinds of alternative placements and

funding sources are available in the States.

The majority of State respondents (39)

indicated that their State provides some type

of community-based mental health

residential or intensive support programs

(e.g., group homes, board/care, supported

apartments, assertive community treatment).

Less than a third specifically mentioned

inpatient psychiatric facilities as an

alternative to nursing facility placement.

Regarding funding mechanisms, most

respondents reported that their States use a

combination of funding streams, such as

State funds, Medicaid, and other sources

(e.g., Medicare, private insurance, county

grants).

2. State Respondent Perceptions of PASRR

Strengths of PASRR Screening Process. As

presented in Exhibit 26, when asked to

describe the strengths of the PASRR

program, both SMHA and Medicaid agency

respondents most often reported a specific

policy goal, such as preventing the

inappropriate admission of people with

serious mental illness to nursing facilities,

ensuring that people with serious mental

illness are identified, and ensuring access to

specialized services. One Medicaid agency

respondent stated, “PASRR has forced

people to be concerned about the seriously

mentally ill population . . . the program has

helped ensure no dumping in institutions.”

Nearly one third of Medicaid agency and 14

percent of SMHA respondents also described

PASRR as helping to increase nursing facility

resident access to nonspecialized mental

health services. One SMHA respondent

indicated, “PASRR has improved the quality

of care [in nursing facilities] by educating

staff about different diagnoses.” 

Weaknesses of PASRR Screening Process.

Exhibit 27 reports findings regarding

perceived PASRR program weaknesses. State

agencies most commonly highlighted

oversight issues, such as how there is

comparatively little energy or resources

devoted to follow-up and that States often

lack a “stick” (punitive disincentive) to

enforce nursing facility compliance with

PASRR. As one SMHA respondent noted,

“Enforcement of PASRR is nonexistent in

terms of people getting services they need or

being placed in alternative settings. It can

36 Special Report

Exhibit 25: Alternative 

Placements (n=51)

Alternative Placements (n=47)

Community-based mental

health residential programs 39 (83%)

State psychiatric facility or

other IMD 15 (32%)

Assisted living facility or

other senior residential programs

17 (36%)

Funding Mechanisms for

Alternative Placements (n=45)

State funds 28 (62%)

Medicaid 34 (76%)

Other payers 21 (47%)
turn into a paper shuffle and nothing ever

happens.”

Many also expressed frustration with the

lack of clarity surrounding many of the

Federal regulations. As articulated by one

Medicaid respondent, “PASRR rules and

regulations are complicated, and it takes a

lot of effort to get the details down—

especially for people who don’t deal with it

every day.” A small number of Medicaid

respondents also noted that PASRR does not

appropriately address the needs of people

with Alzheimer’s or dementia. For example,

one respondent explained, “PASRR doesn’t

properly recognize dementia and

Alzheimer’s. They get admitted to nursing

facilities with all sorts of problems. It’s a

gray area—I can see why they are excluded

[from PASRR], but there needs to be a better

way to get them recognized and treated.” 

3. Recommendations for Improving PASRR

■ Increase guidance to States,

clarify/modify certain regulations. The

top suggestion among State agency

respondents was to request that CMS

provide additional guidance on the

PASRR process. This recommendation

was often framed as needing more

clarification regarding PASRR’s overall

intent. For example, one Medicaid

respondent explained, “CMS needs more

resources to support State efforts to

implement PASRR. Their intent was

good, but what’s the point if they aren’t

following it up. It shouldn’t be me

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 37

Exhibit 26: PASRR Strengths (n=51)

Strengths of the PASRR Screening Process

State Medicaid SMHA

(n=40) (n=51)

Prevents inappropriate admission of people with serious mental

illness to nursing facilities 23 (58%) 18 (35%)

Ensures that people with serious mental illness are identified 16 (40%) 16 (31%)

Ensures that people get specialized services 10 (25%) 15 (29%)

Increases access to nonspecialized mental health services 12 (30%) 7 (14%)

Exhibit 27: PASRR Weaknesses (n=51)

Weaknesses of the PASRR Screening Process

State Medicaid SMHA

(n=35) (n=38)

No “stick” for enforcing compliance with any part of PASRR 21 (60%) 20 (53%)

Federal regulations unclear, complicated 12 (34%) 18 (47%)

Delays admissions, even when necessary 7 (20%) 8 (21%)

Does not appropriately deal with Alzheimer's/dementia patients 4 (11%) 1 (3%)
determining how it’s implemented

without clarification from CMS.” In

fact, many respondents specifically called

for CMS to establish a Federal definition

of specialized services that accurately

reflects the intent of the original

legislation.

■ Strengthen oversight. Along with the

request for increased CMS guidance,

almost one quarter of the States called

for increased oversight from CMS to

help guide and shape State PASRR

programs. For example, one Medicaid

respondent indicated, “We don’t have

much to do with CMS. They should get

to know how these processes work [in

our State] and get more involved.” Many

respondents articulated a desire for CMS

to mandate and provide support for

monitoring systems so that their agency

could strengthen oversight of nursing

facilities and discharge entities. A typical

comment included, “I wish that CMS

were more active in giving States ‘some

teeth’ to make folks comply. Maybe

legislate it. There is a long history in this

State of noncompliance.” 

■ Establish Federal definition of specialized

services.” Although PASRR regulations

mandate that States arrange for the

provision of specialized mental health

services, CMS allows each State to create

its own requirements for the kinds of

services that qualify as “specialized.”

This latitude allows States’ variations

and flexibility, but may create some

confusion from one State to another.

■ Address funding issues with

Medicaid/PASRR. States also appear to

have many specific financing questions

(e.g., what Medicaid does and does not

cover) and are also concerned about

what they perceive as a lack of financial

incentives for nursing facilities to provide

mental health services. This particular

sentiment was echoed by an SMHA

respondent: “Payment for psychiatric

services in nursing facilities is so low,

they really have to kick in some of their

own money for payments to

psychiatrists. I think they do a pretty

good job considering this resource

limitation.” A Medicaid respondent

added that CMS needs to “expand what

Medicaid/Medicare can bill for mental

health services and broaden the resources

available.”

Recommendations for State Agencies. As

shown in Exhibit 29, respondents also were

asked to provide suggestions for how their

own agencies might improve PASRR

effectiveness. 

38 Special Report

Exhibit 28: Recommendations to CMS for the PASRR Process (n=51)

Recommendations for CMS

State Medicaid SMHA

(n=41) (n=42)

Increase guidance to States, clarify/modify regulations 22 (54%) 22 (52%)

Strengthen oversight activities 8 (20%) 12 (29%)

Establish Federal definition of specialized services 4 (10%) 9 (21%)

Address funding issues with Medicaid program and PASRR 5 (12%) 6 (14%)
■ Strengthen oversight. Similar to

recommendations for CMS, many

respondents underscored the relative

weakness of existing State oversight

mechanisms and the corresponding need

to improve this process to meet the goal

of “ensuring” that nursing facility

residents have access to appropriate

mental health services. One Medicaid

respondent went so far as to suggest that

Medicaid “reinstitute the annual resident

review. . . . [This] would make

[oversight] a tighter process. . . . We

need to ensure that quality of care is

improved in nursing facilities and the

Department of Public Health going in

once a year is not enough.” 

■ Increase efforts to coordinate and

communicate with other PASRR

agencies. Data from the national survey

show that States often involve multiple

agencies in administering PASRR, which

necessitates regular communication and

coordination to ensure successful

program administration. Nearly a

quarter of the respondents—Medicaid,

SMHA, or a third agency—made this

recommendation to their own agency.

For example, one Medicaid respondent

highlighted the complexity of her State’s

system: “There are at least four

departments that are responsible for

PASRR—Medicaid, Elder Affairs,

Health, and the Department of Mental

Health. Just by having so many State

agencies involved, not to mention the

local level, it is inherent that there will

be snags.” 

■ Make PASRR and PASRR populations

more of a priority. Several respondents

urged their agency to make PASRR and

PASRR target populations a greater

priority. For Medicaid and aging and

health authorities, this often meant

expanding agency focus to include

individuals with serious mental illness,

while for SMHAs, the needs of

aging/geriatric populations were

perceived as taking a backseat to

populations of individuals with serious

mental illness. An SMHA respondent

focused on the need to educate health

care professionals, remarking that

“within the State, we need to have more

training on how to do PASRR, as well as

more education about the elderly and

mental illness for general health

practitioners. Care is often fragmented

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 39

Exhibit 29: Recommendations to State Agencies 

for the PASRR Process (n=51)

Recommendations to State Agencies

State Medicaid SMHA

(n=37) (n=36)

Strengthen oversight 11 (30%) 13 (36%)

Increase coordination with other PASRR agencies 5 (14%) 9 (25%)

Make PASRR and PASRR population more of a priority 5 (14%) 7 (19%)

Educate nursing facilities and discharge agencies on PASRR 7 (19%) 3 (8%)

Increase monetary resources that are available 4 (11%) 6 (17%)

Improve Medicaid billing process, rules, and/or technology 2 (5%) 2 (6%)
for people with serious mental illness,

and now that we are trying to address

aging needs, there needs to be a lot of

education for people in general health

care about how to identify people with

mental health needs.” 

■ Educate nursing facilities and discharge

agencies on PASRR. A gap highlighted

by the national survey is the number of

States that do not provide regular or

even “as needed” PASRR training to

nursing facilities. Recognizing this

problem, several survey respondents also

recommended expanding their training

and outreach to nursing facilities.

Nursing facility staff turnover issues

were underscored as an issue by one

Medicaid respondent: “Nursing facility

staff turn over so quickly that we need to

figure out how to do continuing

education—other than the four yearly

trainings—and give them the same

message every time.” 

■ Increase monetary resources that are

available.

■ Improve Medicaid billing process, rules,

and/or technology.

Recommendations for Nursing Facilities.

As presented in Exhibit 30, State

respondents also provided suggestions for

how nursing facilities might improve their

PASRR responsiveness. Key

recommendations appear below.

■ Increase training in PASRR for nursing

facility staff. Respondents recommended

that nursing facilities should devote more

training to PASRR. In a joint interview,

Medicaid and mental health agency staff

in one State summarized the issue as

follows: “Training new staff is key . . .

turnover is a big problem. Nursing

facilities have a great burden to fully

understand the needs of new residents

and staff doesn’t always understand

that.” 

■ Increase training in mental health issues

for nursing facility staff. Respondents

recommended that nursing facility staff

receive more training in mental health

issues generally.

■ Make PASRR more of a priority.

Respondents also framed training issues

in terms of nursing facilities needing to

make PASRR and residents with mental

illness more of a priority by recognizing

how information collected through the

PASRR process might be incorporated

into overall treatment planning, rather

than viewed as a burdensome paperwork

requirement.

40 Special Report

Exhibit 30: Recommendations to Nursing Facilities 

for the PASRR Process (n=51)

Recommendations to Nursing Facilities

State Medicaid SMHA

(n=30) (n=31)

Increase training in PASRR for nursing facility staff 18 (60%) 11 (35%)

Increase training in mental health issues for nursing facility staff 7 (23%) 6 (19%)

Make PASRR more of a priority 8 (27%) 3 (10%)

Provide additional mental health services in nursing facilities 2 (7%) 5 (16%)
■ Provide additional mental health services

in nursing facilities. Among some Statelevel respondents, there was a perception

that many nursing facilities could do

more to improve resident access to

mental health services—either by

increasing the number of providers

available or offering a wider array of

service options. While advocating this

point, one SMHA respondent was also

sensitive to nursing facility resource

constraints: “Nursing facilities need to

provide more mental health services

within their own resources; however, this

is a difficult demand to place on nursing

facilities, particularly given the increasing

geriatric population and the diversity of

needs.”

Barriers to Changing PASRR Process.

Respondents were asked about perceived

barriers to making the recommended

changes above. As Exhibit 31 shows, the

majority of respondents indicated that

barriers existed, the most common of which

was an overall lack of State resources—

financial, infrastructure, and personnel—to

dedicate toward strengthening the PASRR

process. One Medicaid respondent

highlighted financial difficulties: “Money is

the biggest one . . . but time will force them

to rethink things, because more and more

people will need services.” Others noted the

lack of political will and State agency

resistance to change. As one SMHA

respondent succinctly stated, “PASRR is a

low priority for everyone, so this is a

barrier—nobody is paying attention.” A

Medicaid respondent highlighted resistance

issues: “We have gotten used to using

PASRR in a certain way, so it is hard to

change. It’s a burden when you’ve got your

system in place and then the Federal rules

change.” 

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 41

Exhibit 31: Barriers to Changes in the PASRR Process (n=51)

Barriers to Changes in the PASRR Process

State Medicaid SMHA

(n=43) (n=46)

Yes 35 (81%) 33 (72%)

No 8 (19%) 13 (28%)

If yes, please describe (n=35) (n=32)

Lack of resources (financial and nonfinancial) 21 (48%) 23 (52%)

Lack of political will; resistance to change 12 (27%) 7 (16%)

Federal government must initiate change 9 (26%) 5 (16%)

Lack of coordination across agencies 3 (9%) 3 (9%)

A. In-Depth Study Samples

1. State Sample

Exhibit 32 presents national survey results

on key organizational and structural

characteristics of the States selected for indepth study. 

State Agencies Involved in PASRR/Primary

Oversight Responsibilities. States 1 and 2 fit

the typical profile of having two State

agencies involved in PASRR: Medicaid (for

Level I) and the SMHA (for Level II). State 3

is one of only four States that have three

State agencies involved in PASRR—the State

Medicaid, mental health, and aging

authorities. In State 4, the State aging

authority plays a primary role in Level I

administration, while the SMHA is

responsible for Level II PASRR functions. It

appears that in this State, the Medicaid

agency does not perform its required

functions. 

State Agency Centralization Versus

Decentralization. As discussed in Section V

of this report, the degree of centralization

between Medicaid, the SMHA, and other

related agencies is different across the States

and may influence the level of coordination

among these agencies in administering

PASRR programs. Within the four selected

States, PASRR agencies in three States are

distinct entities that are physically separated

from one another. Only in State 4 are

PASRR agencies subsumed under a single

umbrella agency. 

Entity Designated To Conduct PASRR

Screens. Level I screens are conducted by

nursing facilities and/or referral sources in

three out of four States. As a primary

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 43

VI. In-Depth State 

Study Findings

I

n-depth case studies were conducted in four States to gain a better

understanding of the experiences of nursing facility administrators, staff,

and residents regarding how the PASRR process works at local levels.

Results of these in-depth studies are limited and not generalizable to the State

or national levels. Instead, they are considered exploratory in nature and

intended to identify topics where SAMHSA and CMS can provide further

guidance to SMHAs, Medicaid agencies, and nursing facilities.

Section A describes State, nursing facility, medical record, and clinical

interview samples. Sections B–D synthesize findings across these different data

sources to address the following core research questions:

1. How are nursing facilities implementing PASRR? (Section B)

2. How has PASRR affected its intended policy goals? (Section C)

3. What issues have nursing facilities identified throughout PASRR

implementation? (Section D)
stratification variable in selecting in-depth

study States, however, each of the four States

designates a different entity as responsible

for conducting Level II screens, including the

aging authority, private behavioral health

vendors, local public mental health

authorities, and individual practitioners.

Number of PASRR Screens Completed

Annually. Findings on the number of Level I

and Level II screens conducted annually for

the four in-depth study States are in keeping

with national survey results (see Exhibit 33).

States 1 and 4 completed fewer than 10,000

Level I screens annually, while State 3

44 Special Report

Exhibit 32: Organizational and Structural Characteristics of 

In-Depth Study States (n=4)

State 1 State 2 State 3 State 4

State Agencies Involved in PASRR

Medicaid, SMHA Medicaid, SMHA Medicaid, SMHA,

aging authorities

SMHA, aging

authorities

Primary Oversight Responsibilities

Level I Medicaid Medicaid Medicaid Aging authorities

Level II SMHA SMHA SMHA SMHA

Degree of Centralization

Two separate 

agencies

Two separate 

agencies

Three separate

agencies

Two agencies

under umbrella

agency

Entity Designated To Conduct PASRR Screens

Level I Nursing facility or

referral source

Nursing facility or

referral source

Nursing facility or

referral source Aging authorities

Level II

Individual 

practitioners,

aging authorities

Private vendor

Community mental health clinics,

local mental health

authorities

Individual 

practitioners

Exhibit 33: Annual PASRR Screens Completed by 

In-Depth Study States (n=4)

Number of PASRR Screens Completed Annually State 1 State 2 State 3 State 4

Level I Screens 3,725 n/a 70,248 1,870

Level lI Screens

– Preadmission 202 450 2,330 500

– Change in condition 447 56 555 124
conducted well over 20,000 Level I screens

in the sample year. Annual Level II screens

(both preadmission and change in condition)

were also high for State 3, while figures for

States 1, 2, and 4 were consistent with

national survey results.

2. Nursing Facility Sample

a. Nursing Facility Characteristics

As presented in Exhibit 34, a total of 24

facilities were selected from the four States

(six per State). To capture urban and rural

variation within each State, three facilities

from a rural county and three from an urban

county were selected. In addition, in each

area (urban or rural), nursing facilities were

stratified according to size (small, medium,

and large), based on the number of available

beds. Average small facilities ranged from 35

to 49 beds, medium-sized facilities from 60

to 78 beds, and large facilities from 104 to

168 beds. In States 1, 2, and 3, a majority of

facilities sampled were for-profit, under the

auspices of a corporation or a partnership.

In State 4, however, most nursing facilities

held nonprofit status as a corporation or

faith-based entity. Of the 24 facilities

sampled, 17 operated autonomously, while 7

belonged to a multi-nursing-home

ownership. Additionally, only one of the

facilities sampled was located within a

hospital.

b. Nursing Facility Quality Performance 

Participating nursing facilities submitted

summary statistics on MDS quality

indicators. Because these indicators are

framed as negative events, higher facility

percentages and percentiles are seen to

indicate poorer performance. MDS

aggregates 24 individual indicators into the

following 11 categories: accidents,

behavior/emotional patterns, clinical

management, cognitive patterns,

elimination/incontinence, infection control,

nutrition/eating, physical functioning,

psychotropic drug use, quality of life, and

skin care. 

Exhibit 1 in Appendix A provides average

facility-specific percentages and percentile

rankings for each State. All facilities appear

to be in the normal/average range across the

full range of quality indicators. Regarding

specific quality indicators relating to mental

health, all States were in the average range

for resident behavior and emotional patterns

(none above 57th percentile). Similarly,

among the sampled facilities, on average, 8

percent of the residents were cognitively

impaired, placing no State above the 62nd

percentile. Indicators relating to the use of

psychotropic drugs measured the prevalence

of antipsychotic, antianxiety, and hypnotic

use. Across all four States, scores ranged

from the 42nd to the 65th percentile. 

c. Nursing Facility Residents’ Diagnoses

Across all States, of the nursing facility

resident records reviewed, primary diagnoses

(e.g., first diagnosis listed in medical record)

for the majority of residents indicated a

physical (versus mental) health condition.

This was true at initial admission and

currently. Within States 1 and 2, there were

roughly equivalent percentages of individuals

with primary diagnoses of

dementia/Alzheimer’s or mental illness,

comparing initial admission to “currently.”

In States 3 and 4, however, there were higher

numbers of Alzheimer’s/dementia diagnoses

at initial admission and currently (see

Exhibit 35).

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 45
46 Special Report

Exhibit 34: Characteristics of Nursing Facility Sample (n=24)

State 1 State 2 State 3 State 4

(n=6) (n=6) (n=6) (n=6)

Nursing Facility Location

Urban 3 3 3 3

Rural 3 3 3 3

Nursing Facility Size

Small 49 36 39 35

Medium 61 60 78 82

Large 156 130 104 168

Profit Status

For profit—corporation 3 2 4 2

For profit—partnership 1 2 0 0

Nonprofit—corporation 1 1 1 3

Nonprofit—faith-based 1 1 1 1

Multi-Nursing-Home Ownership

Yes 1 1 4 1

No 5 5 2 5

Located Within a Hospital

No 6 6 6 5
Physical Health Diagnoses. Nearly all

records reviewed indicated a physical health

diagnosis, ranging from 93–98 percent upon

admission to 97–99 percent currently. Across

all four States, disorders of the nervous

system (e.g., dementia/Alzheimer's,

dysphagia) were the most frequently

diagnosed conditions both at time of initial

admission and currently. This was followed

by disorders of the circulatory system (e.g.,

atrial fibrillation, hypertension). Other

commonly diagnosed medical disorders

included: musculoskeletal/connective tissue

(e.g., arthritis, osteoporosis);

endocrine/nutritional/metabolic (e.g.,

diabetes, hypothyroidism); and digestive

(e.g., hernia, peptic ulcer disease). In all four

States, there were typically increases in

diagnosis of physical health conditions over

time from initial admission to the current

record review (see Exhibit 36).

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 47

Exhibit 35: Primary Diagnoses of Nursing Facility Resident 

Record Review Sample (n=786)

Primary Diagnosis 

State 1 State 2 State 3 State 4

(n=215) (n=213) (n=177) (n=181)

Upon Admission (n=215) (n=212) (n=177) (n=181)

Physical 150 (70%) 182 (86%) 112 (63%) 117 (65%)

Mental 25 (12%) 11 (5%) 19 (11%) 21 (12%)

Substance abuse 2 (1%) 0 (0%) 0 (0%) 2 (1%)

Alzheimer’s, dementia 38 (18%) 20 (9%) 46 (26%) 41 (23%)

Currently (n=215) (n=213) (n=177) (n=181)

Physical 151 (70%) 176 (83%) 97 (55%) 106 (59%)

Mental 24 (11%) 19 (9%) 23 (13%) 23 (13%)

Substance abuse 0 (0%) 0 (0%) 0 (0%) 2 (1%)

Alzheimer’s, dementia 40 (19%) 18 (8%) 57 (32%) 50 (28%)
48 Special Report

Exhibit 36: Physical Health Conditions of Nursing Facility Resident Sample (n=786)

State 1 State 2 State 3 State 4

Initial

(n=215)

Current

(n=215)

Initial 

(n=212)

Current

(n=213)

Initial

(n=177)

Current

(n=177)

Initial

(n=181)

Current

(n=181)

Major Disease

Categories* for

Physical Health

Conditions

206

(96%)

209

(97%)

206

(97%)

207

(97%)

165

(93%)

176

(99%)

178

(98%)

180

(99%)

Nervous system 140 (65%) 160 (74%) 157 (74%) 159 (75%) 120 (68%) 148 (84%) 142 (78%) 153 (85%)

Circulatory 147 (68%) 160 (74%) 135 (64%) 151 (71%) 112 (63%) 134 (76%) 121 (67%) 133 (73%)

Musculoskeletal 82 (38%) 82 (38%) 113 (53%) 109 (51%) 79 (45%) 95 (54%) 81 (45%) 93 (51%)

Endocrine/nutritional/

metabolic 89 (41%) 106 (49%) 72 (34%) 85 (40%) 62 (35%) 79 (45%) 80 (44%) 85 (47%)

Digestive 68 (32%) 84 (39%) 57 (27%) 71 (33%) 34 (19%) 62 (35%) 59 (33%) 64 (35%)

Respiratory 56 (26%) 61 (28%) 47 (22%) 52 (25%) 43 (24%) 47 (27%) 38 (21%) 38 (21%)

Kidney/urinary tract 42 (20%) 55 (26%) 36 (17%) 38 (18%) 36 (20%) 43 (24%) 41 (23%) 38 (21%)

Blood/immunological 40 (19%) 48 (22%) 23 (11%) 35 (17%) 14 (8%) 24 (14%) 32 (18%) 37 (20%)

Skin/breast 31 (14%) 35 (16%) 23 (11%) 30 (14%) 15 (8%) 19 (11%) 29 (16%) 37 (20%)

Eye 22 (10%) 37 (17%) 17 (8%) 18 (8%) 17 (10%) 33 (19%) 12 (7%) 18 (10%)

Infections/parasitic

diseases 10 (5%) 11 (5%) 9 (4%) 10 (5%) 1 (1%) 0 (0%) 5 (3%) 4 (2%)

Ear/nose/mouth/throat 3 (1%) 11 (5%) 4 (2%) 7 (3%) 5 (3%) 7 (4%) 9 (5%) 9 (5%)

Hepatobiliary/pancreas 11 (5%) 12 (6%) 6 (3%) 7 (3%) 4 (2%) 6 (3%) 10 (6%) 12 (7%)

Male reproductive 9 (4%) 11 (5%) 10 (5%) 9 (4%) 3 (2%) 6 (3%) 8 (4%) 9 (5%)

Female reproductive 7 (3%) 10 (5%) 3 (1%) 1 (0%) 3 (2%) 4 (2%) 3 (2%) 3 (2%)

Myeloproliferative/

neoplasms 6 (3%) 5 (2%) 4 (2%) 1 (0%) 0 (0%) 1 (1%) 1 (1%) 1 (1%)

Injury/poisoning/

toxic drugs 2 (1%) 3 (1%) 5 (2%) 2 (1%) 1 (1%) 0 (0%) 2 (1%) 1 (1%)

Burns 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)

Multiple significant 

trauma 2 (1%) 3 (1%) 7 (3%) 8 (4%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)

HIV 2 (1%) 1 (0%) 0 (0%) 1 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)

* 2001 DRG Guide (2000)
Number of Physical Health Conditions per

Resident. In States 1, 2, and 3, the average

nursing facility resident in the medical record

sample had between four and six medical

diagnoses at the time of initial admission.

This number was slightly higher (seven to

nine diagnoses) for State 4. For current

diagnoses, these numbers generally remained

at the same levels (see Exhibit 37).

3. Medical Record Review Sample

Nursing facility residents with potential

mental illness were randomly selected based

on criteria described in Section IV. An

average of 30–40 medical records were

reviewed at each nursing facility in all four

States, for a total of 786 records. 

a. Background Characteristics 

Exhibit 38 presents background

characteristics of the nursing facility resident

medical record sample. The average age for

nursing facility residents whose medical

records were sampled in States 1 and 2 was

80–90; for States 3 and 4, the average age

was slightly younger at 65–79. Overall, there

were relatively low percentages of nursing

facility residents under 65 across all 4 States,

with numbers ranging from 6 percent (State

2) to 20 percent (State 4). In all four States,

the majority of records sampled were female,

widowed, and White.

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 49

Exhibit 37: Number of Physical Health Diagnoses per 

Resident for Nursing Facility Resident Record Review Sample (n=786)

Number per

Resident

State 1 State 2 State 3 State 4

(n=215) (n=213) (n=177) (n=181)

Upon Admission

1–3 diagnoses 31 (14%) 57 (27%) 45 (25%) 15 (8%)

4–6 diagnoses 106 (49%) 82 (39%) 76 (43%) 59 (33%)

7–9 diagnoses 70 (33%) 58 (27%) 39 (22%) 87 (48%)

10+ diagnoses 9 (4%) 15 (7%) 17 (10%) 20 (11%)

Currently

1–3 diagnoses 13 (6%) 48 (23%) 8 (5%) 3 (2%)

4–6 diagnoses 88 (41%) 73 (34%) 39 (22%) 35 (19%)

7–9 diagnoses 72 (33%) 67 (31%) 86 (49%) 94 (52%)

10+ diagnoses 42 (20%) 25 (12%) 44 (25%) 49 (27%)
b. Admissions Information

Exhibit 39 presents admissions information

for the sample of 786 nursing facility

residents whose medical records were

reviewed. Across all four States, most

residents were referred to nursing facilities

from hospitals or acute care settings. The

next highest percentage of referrals came

from other nursing facilities and assisted

living facilities. Many nursing facility

residents in State 3 were also referred from

their private residences. State 1 had a much

higher percentage of referrals from

psychiatric facilities (13 percent) as

compared to other States (2 percent). 

50 Special Report

Exhibit 38: Demographics of Nursing Facility Resident 

Record Sample (n=786)

Demographics

State 1 State 2 State 3 State 4

(n=215) (n=213) (n=177) (n=181)

Age (n=204) (n=209) (n=177) (n=181)

35–49 2 (1%) 4 (2%) 6 (3%) 14 (8%)

50–64 12 (6%) 9 (4%) 14 (8%) 21 (12%)

65–79 45 (22%) 48 (23%) 69 (39%) 56 (31%)

80–84 52 (25%) 51 (24%) 30 (17%) 42 (23%)

85–90 49 (24%) 55 (26%) 37 (21%) 25 (14%)

>90 44 (22%) 42 (20%) 21 (12%) 23 (13%)

Gender (n=212) (n=207) (n=176) (n=181)

Female 167 (79%) 167 (81%) 125 (71%) 124 (69%)

Male 45 (21%) 40 (19%) 51 (29%) 57 (31%)

Marital Status (n=214) (n=208) (n=177) (n=181)

Single/never married 27 (13%) 17 (8%) 35 (20%) 32 (18%)

Married 24 (11%) 57 (27%) 33 (19%) 26 (14%)

Divorced/separated 25 (12%) 13 (6%) 33 (19%) 34 (19%)

Widowed 138 (64%) 121 (58%) 76 (43%) 89 (49%)

Other 0 (0%) 0 (0%) 0 (0%) 0 (0%)

Race/Ethnicity (n=210) (n=204) (n=177) (n=181)

White 203 (97%) 193 (95%) 137 (77%) 173 (96%)

African American 3 (1%) 8 (4%) 39 (22%) 2 (1%)

Asian American/Pacific Islander 0 (0%) 1 (0.5%) 1 (1%) 1 (1%)

American Indian/Alaska Native 1 (0.5%) 0 (0%) 0 (0%) 1 (1%)

Hispanic/Latino(a) 3 (1%) 1 (0.5%) 0 (0%) 4 (2%)
In all four States, nursing facilities most

frequently recorded a specific physical or

psychiatric diagnosis as the reason for

admission. Other commonly cited admission

reasons included: individual needs nursing

facility level of care; individual needs

assistance with activities of daily living or

indirect activities of daily living; and

individual has multiple, complex medical

conditions (see Exhibit 2 in Appendix A).

4. Clinical Interview Sample

To conduct clinical interviews in States 1 and

2, a sample of residents was drawn from the

larger medical record sample. If residents

refused to participate (n=21–26) or screened

positive for dementia (n=43–48), they were

replaced with another record from the larger

sample in order to interview an average of

7–9 residents per facility. A total of 93

clinical interviews were conducted across

both States. 

As illustrated in Exhibit 48 (and in

Appendix A, Exhibits 3 and 4), data on

background characteristics and admissions

information are comparable generally

between clinical interview and medical

record samples. Demographically, the clinical

interview sample tended to be slightly

younger, although this may be attributable in

part to having screened out participants with

dementia, who tended to be slightly older.

No other background characteristics (e.g.,

gender, marital status, and race/ethnicity)

appeared to differ substantially across the

two samples. Admissions information reveals

there are slight differences between clinical

interview and medical record samples in

both States. In State 1, a larger percentage of

the clinical interview sample was referred

from nonpsychiatric hospitals and fewer

from private residences. In State 2, there

were fewer clinical interview participants

who had been referred from nursing and

assisted living facilities and more referred

from private residences. 

B. PASRR Implementation at the

Nursing Facility Level

One primary goal of the current study was

to gather information about implementation

of PASRR at the nursing facility level.

Throughout this section of the report, data

and qualitative evidence are integrated from

nursing facility staff interviews (n=24) and

resident record reviews (n=786). 

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 51

Exhibit 39: Referral Source for Nursing Facility Resident 

Record Review Sample (n=786)

State 1 State 2 State 3 State 4

Referral Source (n=210) (n=208) (n=161) (n=180)

Nonpsychiatric hospital 83 (40%) 118 (57%) 86 (53%) 123 (68%)

Psychiatric hospital/psychiatric ward 28 (13%) 5 (2%) 3 (2%) 4 (2%)

Nursing facility/assisted living facility 55 (26%) 51 (25%) 26 (15%) 37 (21%)

Private residence 43 (20%) 34 (16%) 43 (27%) 14 (8%)

Other 1 (0.5%) 0 (0%) 3 (2%) 2 (1%)
1. PASRR Level I and Level II documentation

a. Are Level I and Level II Screens Being

Completed?

Evidence of PASRR Level I and Level II

Screens in Medical Records. The extent to

which PASRR Level I and Level II screens

are appropriately documented in nursing

facility charts is an indicator of how well

referring agencies and nursing facilities are

implementing PASRR programs. Exhibit 40

presents medical record review findings on

Level I and Level II documentation. 

Level I Screens. Across the four States,

percentages of Level I screens found in

medical records ranged from 71 percent in

State 3 to 93 percent in State 4. While not

specifically required to be documented in the

patient record, PASRR regulations require

100 percent of individuals admitted to a

Medicaid nursing facility to have Level I

screens regardless of resident funding source.

While the documentation in our sample did

not reach 100 percent, it is higher than rates

of documentation in the 2001 OIG report

findings, which indicated that only 88 of 187

(47 percent) reviewed charts contained Level

I screens in five case study States.

Level II Screens. States are required to

conduct Level II screens on nursing facility

applicants suspected of having a serious

mental illness based on Level I screening

results. In the current sample, 0–14 percent

of individuals who received a Level I screen

subsequently were administered a Level II

screen, as evidenced in their patient record.

According to Linkins et al. (2001), previous

studies have found rates in the 6–7 percent

ranges (Borson et al., 1997; Bazelon, 1996).

States 2 and 4 appear to be in this range,

while results suggest that State 1 nursing

facilities in the sample administered Level II

screens to a greater proportion of applicants.

By contrast, in State 3, no Level II screens

were found in the medical records of

individuals with Level I screens. These

findings cannot be compared to those in the

OIG report’s investigation because the

current study did not purposively sample

nursing facilities with high percentages of

residents with mental illness. 

2. PASRR Change in Condition Documentation

and Procedures

When the requirement for annual resident

review was eliminated in 1996, nursing

facilities were given the responsibility of

identifying when residents experience a

significant “change in physical or mental

condition” to trigger a Level II screen. This

section reports on nursing facility staff

interview and medical record data to assess

the extent to which nursing facilities in our

sample appropriately documented change in

52 Special Report

Exhibit 40: Presence of PASRR Documentation in 

Medical Records (n=786)

State 1 State 2 State 3 State 4

(n=215) (n=213) (n=176) (n=181)

Level I 175 (81%) 167 (78%) 125 (71%) 168 (93%)

Individuals received Level I screen (n=175) (n=167) (n=125) (n=168)

Also received Level II screen 24 (14%) 6 (4%) 0 (0%) 14 (8%)
condition assessments in medical records and

have developed specific policies and

procedures in this area. 

a. Are Nursing Facilities Completing Change in

Condition Assessments?

Evidence of Change in Condition

Assessments in Medical Records. In the

medical records in all four States, very few

change in condition assessments were found

(10 percent in one State, 1 percent in the

other three States). There is no objective

standard in the literature against which to

compare these numbers. 

b. Are Nursing Facilities Familiar With Change

in Condition Criteria and Procedures?

Change in Condition Criteria. The extent

to which nursing facilities have developed

policies and procedures for change in

condition assessments can also contribute to

our understanding of the quality of

documentation in medical records. OIG

(2001) found that 16 out of 19 nursing

facilities sampled in five case study States

were unclear as to change in condition

criteria. In our sample, many nursing facility

staff in States 2 and 3 appeared unfamiliar

with the 1996 PASRR-related change in

condition criteria (see Exhibit 41). In State 2,

no respondents described specific criteria,

while in State 3, the percentage of staff

reporting specific “change in condition”

criteria was 33 percent. Respondents from

these two States typically explained that

their nursing facility had very little

experience with Level II screens and they

were “unaware” of this requirement. One

facility in State 3 further explained: “We

don’t have anything specific—it’s based on

clinical judgment. If someone’s mental status

changes, we follow up with this. I don’t

know what the State considers to be a

‘change in condition.’”

By contrast, nursing facility staff in States

1 and 4 appeared more familiar with change

in condition criteria, with 67 percent of

facilities in each State reporting established

criteria. It is important to mention, however,

that many of these nursing facilities

indicated that change in condition criteria

were developed to meet their MDS rather

than PASRR requirements. For example, a

nursing facility in State 4 responded, “We do

monitor resident change in condition—

positive or negative—because of MDS. We

do take mental health into consideration as

well.” For those nursing facilities with

established change in condition criteria, these

criteria were most often described as changes

in nursing facility resident behavior or

cognitive status, such as suicidal ideation,

aggressive outbursts, and confusion (see

Exhibit 15).

Change in Condition Procedures. When

asked to describe their protocol for handling

the psychiatric decompensation of nursing

facility residents, the most frequent response

in States 2, 3, and 4 was to consult with a

mental health professional. Discharging

someone to a mental health treatment facility

was the most common response for nursing

facility staff in State 1. Less frequently,

nursing facilities reported seeking

consultations with nonmental-health–specific

medical professionals and family (see Exhibit

41). 

3. PASRR Oversight Mechanisms 

The extent to which States have developed

direct oversight systems to monitor PASRR

implementation in nursing facilities can

affect PASRR’s impact on intended policy

goals. 

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 53
Nursing Facility Coordination and

Communication With State. In States 1 and

4, nursing facility staff respondents typically

described some familiarity with procedures

for communicating with States about PASRR

requirements as well as knowledge of the

State’s role in providing specialized services.

In States 2 and 3, however, nursing facility

staff respondents described much less

familiarity in these areas (see Exhibit 42).

State Oversight of PASRR Screens. As

presented in Exhibit 43, in States 1 and 4,

the majority of nursing facility staff

respondents reported that the State regularly

monitors Level I and/or Level II screens and

that State surveyors review PASRR

documentation. This was particularly true in

State 4. Respondents in States 2 and 3 were

much less familiar with State monitoring

activities, frequently responding “I don’t

know.” 

54 Special Report

Exhibit 42: Coordination and Communication With State (n=24)

State 1 State 2 State 3 State 4

State Communication Procedures (n=6) (n=6) (n=6) (n=6)

Some procedures 3 0 1 5

No procedures 3 6 5 1

Knowledge of State Role in Providing

Specialized Services (n=6) (n=6) (n=6) (n=6)

Some familiarity described 4 0 0 4

Do not know how State handles this 2 6 6 2

Exhibit 41: Change in Condition Issues for Nursing Facility 

Resident Record Review Sample (n=24)

Change in Condition Criteria

State 1 State 2 State 3 State 4

(n=6) (n=6) (n=6) (n=6)

Yes 4 (67%) 0 (0%) 2 (33%) 4 (67%)

No 2 (33%) 6 (100%) 4 (67%) 2 (33%)

Change in Condition Procedures (n=6) (n=5) (n=6) (n=6)

Seek mental health consultation 3 (50%) 4 (80%) 6 (100%) 6 (100%)

Discharge to mental health treatment facility 6 (100%) 2 (40%) 5 (83%) 3 (50%)

Consult with primary care physician/medical staff 2 (33%) 1 (20%) 4 (67%) 2 (33%)

Consult with family 0 (0%) 1 (20%) 0 (0%) 1 (17%)
Effectiveness of State Oversight of PASRR

Screens. In State 1, staff respondents most

frequently described the current oversight

system as effective and not needing

improvement. In State 2, the majority of

nursing facility staff respondents described

PASRR oversight as effective, but also

indicated room for improvement. In States 3

and 4, the majority of respondents described

their State’s oversight system as not effective

and needing improvement (see Exhibit 44).

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 55

Exhibit 43: State Oversight of PASRR Screens (n=24)

State 1 State 2 State 3 State 4

Does State Regularly Monitor 

Level I or II Screens? (n=6) (n=6) (n=6) (n=6)

Yes 5 0 3 5

No 0 1 0 0

Do not know 1 5 3 1

Do State Surveyors Review PASRR

Documentation? (n=6) (n=6) (n=6) (n=6)

Yes 3 0 2 4

No 1 2 0 0

Do not know 2 4 4 2

Exhibit 44: Effectiveness of State Oversight of PASRR Screens (n=24)

State 1 State 2 State 3 State 4

Is Current PASRR Oversight System Effective? (n=6) (n=3) (n=6) (n=5)

Yes 3 2 2 0

No 2 1 4 3

Don’t know 1 0 0 2

Could Current Oversight System Be Improved? (n=5) (n=3) (n=6) (n=5)

Yes 2 1 5 2

No 3 1 1 2

Do not know 0 1 0 1
C. PASRR Impact on Policy Goals

This section presents findings on the impact

of PASRR on three important policy goals:

■ Determining the extent to which PASRR

assists in identifying serious mental

illness in nursing facility applicants and

residents

■ Facilitating the availability and receipt of

mental health services in nursing facilities

■ Screening applicants and residents to

ensure their appropriateness for nursing

facility care

1. Overall Effectiveness of PASRR

Effectiveness of PASRR Programs. Exhibit

45 presents nursing facility staff ratings, by

State, on the effectiveness of PASRR in

achieving the policy goals enumerated above.

In all four States, very few facility

56 Special Report

Exhibit 45: Nursing Facility Staff Perceptions of 

PASRR Effectiveness (n=24)

Poor Fair Good Excellent

State 1

Identifying individuals with serious 

mental illness (n=6) 2 1 3 0

Screening appropriateness for 

nursing facility care (n=6) 2 3 1 0

Ensuring provision of specialized services (n=6) 2 2 2 0

State 2

Identifying individuals with serious 

mental illness (n=6) 1 4 1 0

Screening appropriateness for 

nursing facility care (n=6) 1 4 1 0

Ensuring provision of specialized services (n=5) 3 2 0 0

State 3

Identifying individuals with serious 

mental illness (n=6) 0 1 4 1

Screening appropriateness for 

nursing facility care (n=5) 0 3 1 1

Ensuring provision of specialized services (n=5) 1 4 0 0

State 4

Identifying individuals with serious 

mental illness (n=6) 3 1 2 0

Screening appropriateness for 

nursing facility care (n=4) 2 1 1 0

Ensuring provision of specialized services (n=4) 1 0 3 0
respondents rated PASRR as doing an

“excellent” job achieving various outcomes.

In States 1 and 3, the majority of nursing

facility respondents rated PASRR in the

“good” to “fair” range for various

outcomes. Ratings in States 2 and 4 were

slightly lower, with most respondents rating

PASRR in the “fair” to “poor” range.

Ratings on PASRR’s ability to ensure the

provision of specialized services tended to be

lower, with State 4 being a notable

exception. 

2. Identification of Serious Mental Illness 

To evaluate the extent to which PASRR has

led to improved identification of serious

mental illness among nursing facility

applicants and residents, data are presented

from both the larger sample of resident

medical record reviews (n=786) and the

subsample of clinical interviews (n=93).

a. Are Level II Screens Administered To

Identify Nursing Facility Applicants With

Primary Serious Mental Health Diagnoses?

Level II Screens and Nursing Facility

Residents With Primary Mental Health

Diagnoses Upon Admission. Exhibit 46

displays data on the subsample of

individuals in each State who were given

primary diagnoses of mental illness on

admission. Examining their receipt of Level

II screens and comorbid physical health

diagnoses addresses PASRR’s effectiveness in

meeting intended policy goals of (a)

identifying individuals with serious mental

illness and (b) screening individuals who

may not require nursing facility level of care,

respectively. While States are expected to

administer Level II screens to all nursing

facility applicants with primary diagnoses of

mental illness, data from the four-State

sample indicate low levels of administration

overall and considerable variation across

States. No Level II screens were administered

to individuals with primary mental health

diagnoses in State 3, while State 1

administered Level II screens to 60 percent

of individuals with primary mental health

diagnoses. 

It is also important to note that in our

sample, most individuals with primary

mental health diagnoses were also diagnosed

with comorbid physical health conditions.

Therefore, in our sample, even though Level

II screens may not be administered

consistently to individuals with primary

diagnoses of mental illness, these individuals

appear to have significant physical health

conditions and are likely to meet nursing

facility level of care requirements in the

absence of mental health evaluations. 

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 57

Exhibit 46: Nursing Facility Residents With 

Primary Mental Health Diagnoses at Admission (n=786)

State 1 State 2 State 3 State 4

(n=215) (n=213) (n=177) (n=181)

Primary Diagnosis of Mental Illness at

Admission (n=25) (n=11) (n=19) (n=21)

Received Level II screen 15 (60%) 3 (27%) 0 (0%) 2 (10%)

Also diagnosed with physical health condition 23 (92%) 11 (100%) 15 (79%) 20 (95%)
b. Prevalence of Co-Occurring

Dementia/Mental Health Conditions

PASRR Level II screens are not required for

people diagnosed as having a primary

diagnosis of dementia (unless mental

retardation is present). However, a large

proportion of the residents sampled had

primary diagnoses of Alzheimer’s/dementia

and secondary diagnoses of mental health

conditions (State 1=29 percent, State 2=40

percent, State 3=59 percent, and State 4=49

percent). This finding illustrates that PASRR

cannot be considered to address all mental

illness in nursing facilities.

c. Prevalence of Mental Illness (Severe and

Less Severe) in Medical Chart Sample

Psychiatric Diagnoses. The percentage of

individuals diagnosed with psychotic

disorders upon admission ranged from 8

percent in State 2 to 17 percent in State 4.

Therefore, these data suggest that nursing

facilities in this sample are not admitting

excessively high numbers of individuals with

serious mental illness (that would meet the

criteria of severity covered under PASRR).

However, as shown in Exhibit 47, a

significant number of residents do have

psychiatric diagnoses that do not necessarily

meet the PASRR severity criteria.

Exhibit 47 presents psychiatric diagnosis

information across nursing facility resident

records reviewed at two points in time:

initial admission and currently (i.e., time of

record review). In all four States, at initial

admission and currently, the most frequently

diagnosed psychiatric conditions were

depressive disorders (e.g., major depression,

dysthymia), followed by either psychotic

disorders (e.g., schizophrenia, schizoaffective

disorder) or anxiety disorders (e.g.,

obsessive-compulsive disorder, phobias).

There appear to be relatively low numbers of

individuals diagnosed with bipolar, substance

abuse, and personality disorders in all four

States. There was an increase in all

psychiatric diagnoses (except for substance

abuse and personality disorders) from initial

admission to currently, which does suggest

that many residents experienced significant

changes in their mental condition over time.

This could signal a problem in compliance

with the statute since 1996 that requires a

Level II screen whenever there is a significant

change in the resident’s physical or mental

condition. 

At the time of admission, between 42 and

61 percent of the resident records indicated a

psychiatric diagnosis of any type. These

numbers increased to between 53 and 81

percent at the time of the record reviews.

These numbers are consistent with estimates

from the National Nursing Home Survey

(NNHS), which showed 66 percent of

nursing facility residents have some type of

mental disorder (Strahan & Burns, 1991).

Further, 6–24 percent are estimated to have

major depression, a particular serious mental

illness that can respond to treatment (Cohen

et al., 2003). In addition, some research

indicates that close to two thirds of nursing

facility residents are likely to have a mental

disorder, although these figures include

individuals with dementia as well as those

with serious mental illnesses such as

schizophrenia and major depression (Burns

et al., 1993).

Dementia. Because they are excluded from

statutory definitions of serious mental illness,

individuals with a primary diagnosis of

dementia, including Alzheimer’s disease and

related conditions, are not required to

receive Level II screens. Across all four

States, diagnoses of dementia-related

58 Special Report
conditions at initial admission were found in

40–53 percent of the records reviewed (it

was not possible to determine whether these

were primary or secondary diagnosis). By the

time of the record review, these numbers

increased to between 43 and 61 percent of

sampled residents (see Exhibit 47). These

findings are consistent with literature

indicating that roughly 50 percent of nursing

facility residents have dementia on admission

(Emerson Lombardo, 1994; Strahan &

Burns, 1991).

3. Availability and Receipt of Mental Health

Services

a. What Mental Health Services Are Available

to Nursing Facility Residents? 

Mental Health Services Available in

Nursing Facilities. All participating nursing

facilities across the four study States offered

psychotropic medications, medication

management, and consultation with mental

health professionals (typically psychiatrists).

Individual therapy/counseling was another

frequently reported mental health service.

Less frequently available services included

developing behavior management plans,

providing family education, and offering

psychosocial rehabilitation services (see

Exhibit 48).

Prescription of Psychotropic Medications.

As presented in Exhibit 49, across all four

States, 39–50 percent of residents were

prescribed antidepressants upon initial

admission, increasing to 62–65 percent at

the time of the current record review.

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 59

Exhibit 47: Psychiatric Diagnoses of Nursing Facility Resident Sample (n=786) 

All Nursing Facility

Residents 

State 1 (n=215) State 2 (n=213) State 3 (n=177) State 4 (n=181)

Initial Current Initial Current Initial Current Initial Current

(n=215) (n=215) (n=212) (n=213) (n=177) (n=177) (n=181) (n=181)

Psychiatric Diagnoses 100

(47%)

127

(59%)

89

(42%)

113

(53%)

82

(46%)

136

(77%)

110

(61%)

146

(81%)

Depressive disorders 51 (24%) 81 (38%) 63 (30%) 85 (40%) 57 (32%) 109

(62%) 77 (43%) 113(62%)

Psychotic disorders 23 (11%) 28 (13%) 17 (8%) 20 (9%) 24 (14%) 36 (20%) 31 (17%) 36 (20%)

Anxiety disorders 14 (7%) 26 (12%) 16 (8%) 19 (9%) 12 (7%) 39 (22%) 26 (14%) 38 (21%)

Bipolar disorders 12 (6%) 12 (6%) 3 (1%) 5 (2%) 4 (2%) 10 (6%) 12 (7%) 15 (8%)

Personality disorders 1 (0%) 0 (0%) 0 (0%) 0 (0%) 2 (1%) 1 (1%) 3 (2%) 5 (3%)

Substance use disorders 6 (3%) 4 (2%) 3 (1%) 5 (2%) 8 (5%) 9 (5%) 20 (11%) 19 (10%)

Dementia-Related

Conditions

Alzheimer’s

disease/dementia 89 (41%) 105(49%) 90 (42%) 92 (43%) 71 (40%) 100(56%) 96 (53%) 111(61%)
Significant percentages of residents were

prescribed antipsychotics or anxiolytics at

the time of initial admission (ranging from

22 to 38 percent) and currently (ranging

from 24 to 43 percent). Mood stabilizers

were less frequently prescribed across all

four States. 

In all four States, there was an increase in

prescriptions of all types of psychotropic

medications (except for traditional

antipsychotics) from the time of initial

admission to the current record review.

Percentage increases from admission to the

current time period were generally

comparable across all States:

■ State 1 percentage increase:

antidepressants (19 percent), atypical

antipsychotics (7 percent), anxiolytics (2

percent)

■ State 2 percentage increase:

60 Special Report

Exhibit 48: Mental Health Services Available in Nursing Facilities (n=24)

State 1 State 2 State 3 State 4

Available Mental Health Services (n=6) (n=6) (n=6) (n=6)

Psychotropic medications/medication management 6 6 6 6

Consultation with mental health professionals 6 6 6 6

Individual psychotherapy/counseling 0 4 6 6 

Behavior management/token economy 2 0 2 2

Family education 0 0 0 1

Socialization/recreation activities 2 0 1 2

Quality review/care team meetings 2 1 1 1

Day treatment/rehabilitation 0 1 0 2

Exhibit 49: Prescription of Psychotropic Medications for 

Nursing Facility Resident Record Review Sample (n=786) 

Psychotropic

Medications

State 1 State 2 State 3 State 4

Initial Current Initial Current Initial Current Initial Current

(n=209) (n=215) (n=205) (n=213) (n=79) (n=177) (n=160) (n=181)

Antidepressants 93

(44%)

135

(63%)

103

(50%)

137

(64%)

31

(39%)

109

(62%)

80

(50%)

117

(65%)

Antipsychotics 80

(38%)

92

(43%)

60

(29%)

71

(33%)

24

(30%)

77

(29%)

47

(29%)

70

(39%)

Anxiolytics 45

(22%)

51

(24%)

57

(28%)

85

(40%)

20

(25%)

71

(40%)

39

(24%)

49

(27%)

Mood stabilizers 21

(10%)

22

(10%)

7 

(3%)

8 

(4%)

14

(18%)

35

(20%)

18

(11%)

29

(16%)
antidepressants (14 percent), atypical

antipsychotics (7 percent), anxiolytics

(12 percent), and mood stabilizers (1

percent)

■ State 3 percentage increase:

antidepressants (23 percent), atypical

antipsychotics (14 percent), anxiolytics

(15 percent), and mood stabilizers (2

percent)

■ State 4 percentage increase:

antidepressants (15 percent), atypical

antipsychotics (14 percent), anxiolytics

(3 percent), and mood stabilizers (5

percent)

b. Are Nursing Facility Residents Receiving

Mental Health Services?

Mental Health Services Ordered and

Received. Based on an assessment of

treatment activity over the previous 30 days,

the most commonly ordered mental health

services across all four States were

psychotropic medication management and

case consultation. There also was evidence in

progress notes that ordered mental health

services were actually received. In State 3,

individual therapy was another commonly

ordered and received mental health service,

and in States 1 and 2, psychological

testing/evaluation was received by a small

number of residents (see Exhibit 50).

Mental Health Services and Medications by

Psychiatric Diagnosis. As Exhibit 51 shows,

when examined by specific type of

psychiatric diagnosis, it is clear that the

primary services that residents with mental

health issues receive in all four States are

medication review and case consultation.

Residents with mental health issues in State

3 also received individual therapy (primarily

those diagnoses with psychotic disorders,

major depression, and anxiety).

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 61

Exhibit 50: Mental Health Services Ordered and Received for 

Nursing Facility Resident Record Review Sample (n=786)

State 1 (n=215) State 2 (n=213) State 3 (n=177) State 4 (n=181)

Mental Health

Services Ordered Received Ordered Received Ordered Received Ordered Received

Medication

review

78

(36%)

110

(51%)

94

(44%)

123

(58%)

45

(25%)

45

(25%)

145

(80%)

147

(81%)

Psychological

testing/ 

evaluation

0 

(0%)

3 

(1%)

9 

(4%)

7 

(3%)

0 

(0%)

0 

(0%)

0 

(0%)

0 

(0%)

Case management1 

(0%)

0 

(0%)

0 

(0%)

1 

(0%)

0 

(0%)

0 

(0%)

0 

(0%)

0 

(0%)

Case 

consultation

90

(42%)

99

(46%)

89

(42%)

82

(38%)

16 

(9%)

16 

(9%)

56

(31%)

56

(31%)

Individual

therapy

0 

(0%)

0 

(0%)

7 

(3%)

7 

(3%)

32

(18%)

33

(19%)

0 

(0%)

0 

(0%)

Other mental

health services

2 

(1%)

13 

(6%)

5 

(2%)

18 

(8%)

0 

(0%)

0 

(0%)

1 

(1%)

1 

(1%)
62 Special Report

Exhibit 51: Type of Service Received by Psychiatric Diagnosis

Current Diagnoses

State 1 State 2 State 3 State 4

(n=215) (n=213) (n=177) (n=181)

Psychiatric Diagnoses (n=129) (n=117) (n=138) (n=149)

Psychotic Disorders (n=28) (n=20) (n=36) (n=36)

Medication review 19 (68%) 15 (75%) 15 (42%) 31 (86%)

Psychological testing/evaluation 1 (4%) 1 (5%) 0 (0%) 0 (0%)

Case management 0 (0%) 1 (5%) 0 (0%) 0 (0%)

Case consultation 16 (57%) 6 (30%) 8 (22%) 8 (22%)

Individual therapy 0 (0%) 1 (5%) 8 (22%) 0 (0%)

Other mental health services 2 (7%) 1 (5%) 0 (0%) 0 (0%)

Bipolar Disorders (n=12) (n=5) (n=10) (n=15)

Medication review 8 (67%) 5 (100%) 4 (40%) 12 (80%)

Psychological testing/evaluation 0 (0%) 1 (20%) 0 (0%) 0 (0%)

Case management 0 (0%) 0 (0%) 0 (0%) 0 (0%)

Case consultation 8 (67%) 2 (40%) 3 (30%) 6 (40%)

Individual therapy 0 (0%) 0 (0%) 2 (20%) 0 (0%)

Other mental health services 2 (17%) 0 (0%) 0 (0%) 0 (0%)

Major Depressive Disorders (n=81) (n=85) (n=109) (n=113)

Medication review 40 (49%) 58 (68%) 29 (27%) 96 (85%)

Psychological testing/evaluation 0 (0%) 3 (4%) 0 (0%) 0 (0%)

Case management 0 (0%) 0 (0%) 0 (0%) 0 (0%)

Case consultation 38 (47%) 40 (47%) 8 (7%) 44 (39%)

Individual therapy 0 (0%) 4 (5%) 25 (23%) 0 (0%)

Other mental health services 3 (4%) 9 (11%) 0 (0%) 1 (1%)
c. What Mental Health Professionals Are

Available to Nursing Facility Residents?

Availability of External Mental Health

Specialists. As presented in Exhibit 52, some

nursing facility staff respondents (about 38

percent) in States 1, 2, and 4 described some

level of reluctance on the part of external

mental health professionals (i.e., not on staff

at the facility) to serve residents. Reasons for

reluctance included not wanting to make

visits outside their professional offices and a

lack of specialized training in mental health

issues. For example, one nursing facility in

State 2 explained, “None are happy to come.

. . . They are hesitant to leave their offices

and sometimes have the perception that they

cannot change older people.” 

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 63

Exhibit 51 (Continued): Type of Service Received by Psychiatric Diagnosis

Current Diagnoses

State 1 State 2 State 3 State 4

(n=215) (n=213) (n=177) (n=181)

Psychiatric Diagnoses (n=129) (n=117) (n=138) (n=149)

Anxiety Disorders (n=26) (n=19) (n=39 (n=38)

Medication review 8 (31%) 13 (68%) 6 (15%) 28 (74%)

Psychological testing/evaluation 1 (4%) 1 (5%) 0 (0%) 0 (0%)

Case management 0 (0%) 0 (0%) 0 (0%) 0 (0%)

Case consultation (38%) 7 (37%) 0 (0%) 16 (42%)

Individual therapy 0 (0%) 2 (11%) 7 (18%) 0 (0%)

Other mental health services 2 (8%) 1 (5%) 0 (0%) 0 (0%)

Personality Disorders (n=0) (n=0) (n=1) (n=5)

Medication review 0 (0%) 0 (0%) 0 (0%) 5 (100%)

Psychological testing/evaluation 0 (0%) 0 (0%) 0 (0%) 0 (0%)

Case management 0 (0%) 0 (0%) 0 (0%) 0 (0%)

Case consultation 0 (0%) 0 (0%) 0 (0%) 1 (20%)

Individual therapy 0 (0%) 0 (0%) 0 (0%) 0 (0%)

Other mental health services 0 (0%) 0 (0%) 0 (0%) 0 (0%)

Substance Use Disorders (n=4) (n=5) (n=9) (n=19)

Medication review 2 (50%) 4 (80%) 3 (33%) 14 (74%)

Psychological testing/evaluation 0 (0%) 1 (20%) 0 (0%) 0 (0%)

Case management 0 (0%) 0 (0%) 0 (0%) 0 (0%)

Case consultation 2 (50%) 1 (20%) 1 (11%) 6 (32%)

Individual therapy 0 (0%) 2 (40%) 3 (33%) 0 (0%)

Other mental health services 0 (0%) 1 (20%) 0 (0%) 0 (0%)
Availability of Mental Health

Professionals in Nursing Facilities.

As illustrated in Exhibit 53,

across the four States, there

appear to be few mental health

professionals on staff in the

nursing facilities sampled. When

on-staff mental health

professionals are available, they

are typically clinical social

workers. Participating nursing

facilities in all four States contract

with a full range of mental health

professionals, including

psychiatrists, psychologists, and

clinical social workers. In States 1

and 2, nursing facilities most

frequently contract with

psychiatrists, while in State 3, the

most commonly contracted

mental health professionals are

psychologists. In State 4, a high

percentage of nursing facilities

also contract with clinical social

workers.

64 Special Report

Exhibit 52: Availability of Mental Health Specialists (n=24)

State 1 State 2 State 3 State 4

Are Mental Health Specialists Reluctant To Serve

Nursing Facility Residents? (n=6) (n=6) (n=6) (n=6)

Yes 3 3 0 3

Reasons for Reluctance (n=2) (n=3) (n=0) (n=3)

Do not want to see people outside their office 0 3 0 0

Do not have special training with geriatric populations 0 1 0 2

Medicaid/Medicare reimbursement issues 1 1 0 0

Overall scarcity of mental health professionals 1 0 0 1

Exhibit 53: Availability of Mental Health

Professionals in Nursing Facilities (n=24)

Staff Contractors

State 1 (n=6)

Psychiatrist 0 6 

Psychologist 0 1 

Clinical social worker 1 1

Other mental health professionals 0 3

State 2 (n=6)

Psychiatrist 0 6

Psychologist 0 1

Clinical social worker 2 2

Other mental health professionals 1 1

State 3 (n=6)

Psychiatrist 0 3

Psychologist 0 5

Clinical social worker 1 2

Other mental health professionals 0 0

State 4 (n=6)

Psychiatrist 1 4

Psychologist 0 1

Clinical social worker 2 3

Other mental health professionals 1 3
Mental Health Training in Nursing

Facilities. The majority of nursing facility

staff respondents in all four States reported

that staff received some level of mental

health training, ranging from 5 out of 6

facilities in States 2 and 4, to 100 percent of

participating facilities in States 1 and 3.

Trainings were typically offered in-house and

covered various topics, including recognizing

and treating specific mental illnesses like

depression, how to manage difficult

behaviors, and working with residents with

dementia or other cognitive impairments (see

Exhibit 8 in Appendix A).

Challenges Faced by Nursing Facilities in

Treating Individuals With Mental Illness. As

presented in Exhibit 54, nursing facility staff

in all four States most often highlighted

difficult behaviors (e.g., aggressive outbursts,

suicidality) as the most challenging aspect of

treating residents with mental illness. In the

words of one nursing facility respondent in

State 4, “The challenge is to get people

stable and have a normal-type resident. . . .

It can take a long time to get appropriate

medications.” Nursing facility staffing and

resource issues (e.g., lack of resources to

provide mental health services within nursing

facilities, understaffing, etc.) were also

frequently reported challenges in all States.

Respondents in States 2, 3, and 4 also

mentioned the role that stigma can play in

serving residents with mental illness. One

facility in State 3 described attempting to

address this issue proactively, noting that “[it

is important] to educate family members

about dementia, depression, and anxiety in

regard to the disease process and how to

deal with behavior changes.”

D. PASSR Issues Identified From the

Clinical Interview Sample

A further goal of the in-depth four-State

study was to obtain a subsample of nursing

facility residents from the medical chart

sample in two States and conduct clinical

interviews with a total of no more than 100

of those residents. Several objectives were

achieved: 

■ Identification of those with the most

severe illness in the clinical interview

subsample

■ Assessment of performance of Level I

and II screens in sample

■ Assessment of mental health services

ordered and received for sample

■ Assessment of diagnoses and

psychotropic drug medications in sample

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 65

Exhibit 54: Nursing Facility Staff Perceptions of 

Challenges to Treating Residents With Mental Illness (n=24)

Challenges Treating Residents With Mental Illness

State 1 State 2 State 3 State 4

(n=6) (n=6) (n=6) (n=6)

Resident behavior 5 5 2 5

Nursing facility staffing/resource issues 2 2 3 3

Stigma/lack of understanding among family, staff 0 2 2 2

Lack of specialized providers 1 2 1 3

Difficult to coordinate mental health care 

with nonmental-health-care providers 2 1 1 0
1. Reviewing Method of Obtaining Interview

Sample

The clinical interview sample was pulled

from the two States’ medical chart sample to

yield a total of 93 residents. The clinical

interview sample selection (a subset of the

medical chart sample) is described in more

depth on pages 18 and 51. Briefly, the 93

interviewed residents were selected randomly

from two States in the larger medical record

chart sample, previously described on pages

17–18. In those two States, about 7–9

interviewees per facility were pulled

randomly from the medical chart sample.

It should be noted the original, larger

medical record sample in all four States, of

which 786 charts were examined (almost 40

from each of 6 facilities in each of 4 States),

was purposively biased to identify and

capture those residents most likely to have

mental illness. The purpose was to evaluate

if those with mental illness were receiving

the Level II screen as required and services

they needed, and to determine if they were

appropriately placed in nursing facilities.

To draw the larger medical chart sample,

first all charts of residents who received a

Level II screen were pulled; then, those

currently prescribed psychotropic

medications; and lastly, those positive for

any primary or secondary diagnosis on any

mental illness. From this group, up to 40

charts per facility were pulled randomly for

the medical chart review (n=786). From the

chart review group, a subset to clinically

interview was randomly selected (n=93).

Thus, all those 93 residents interviewed

would be expected to have some level of

mental illness.

2. Exhibits Overview

The five exhibits (Exhibits 55–59) describing

the clinical interview sample show composite

data for 93 residents from two States and

are displayed in each exhibit as two separate

groups: 

■ Those 61 residents who scored below the

cutoff scores for significant symptoms of

mental illness based on any of the three

clinical screening instruments: Brief

Symptom Inventory (BSI), the Geriatric

Depression Scale (GDS), and the ShortForm Health Survey (SF-12), and 

■ Those 32 residents who scored above the

cutoff score on any of the three clinical

tests 

Due to the method of obtaining the

medical chart sample and the subsample of

those selected to interview, all participants in

the clinical interview would be expected to

have a likelihood of mental illness. Those 32

individuals scoring beyond the cutoff were

judged likely to have serious

psychopathology. Nevertheless, this

judgment emanated from scores on these

screening instruments and was not validated

by an independent, formal clinical

assessment.

3. Validity and Reliability for the Three Clinical

Screening Instruments To Identify Residents

With Significant Mental Illness

The residents were given five mental health

screens, described on page 20. Based on a

review of the psychometric properties of

these screens, scores on three of these

instruments were used to identify residents

showing significant symptoms consistent

with diagnoses of mental illness: the Brief

Symptom Inventory (BSI), the Geriatric

Depression Scale (GDS), and the Short-Form

Health Survey (SF-12).

To be consistent with a cutoff score across

all three measures, a percentile rank of 90

(equivalent to a T-score of 63) was identified

as the statistical marker of significant mental

66 Special Report
illness. Residents who scored in the top 10th

percentile on any of these three measures of

psychiatric symptoms were identified as

scoring above the cutoff and were considered

to have the highest probability of serious

mental illness. The specific cutoff scores for

each measure were identified as— 

1. A BSI T-score greater than or equal to 63,

or 

2. An SF-12 Transformed Mental Score less

than or equal to 37, or 

3. A GDS score of 10 or above.

Of the 32 residents judged to have serious

psychopathology, 30 scored above the cutoff

on 2 or more screening instruments.

a. Brief Symptom Inventory

The BSI T-score cutoff of 63 or above was

based on the definition provided in studies

and established by the BSI Procedures

Manual (Derogatis, 1993):

The operational rule for caseness

provided above states that if the

respondent has a GSI score (on Norm

B, the adult nonpatient norm) greater

than or equal to a T score of 63, or if

any two primary dimension scores are

greater than or equal to a T score of

63, then the individual will be

considered a positive diagnosis or a

case (Derogatis, page 32).

b. Short Form-12

The SF-12 asks 12 questions: 6 questions are

on the individual’s physical health, and 6

questions are on the mental health of the

individual. The SF-12 uses norms developed

on noninstitutionalized adults and has one Tscore that combines the 6 mental health

items into a single normed score called the

“Transformed Mental Score.” A T-score of

37 or lower on the Transformed Mental

Score is at the 90th percentile, corresponding

to the extreme 10 percent of the normal

population on a bell curve. In this screen, the

lower the score, the more likely there is an

illness. 

c. Geriatric Depression Scale

The GDS uses T-scores to divide respondents

into three categories of “normal,” “mild

depression,” and “severe depression.” A

positive case was defined as “severe

depression” in the clinical interview sample.

The Interview Sample and Exhibits

All 93 interviewees were from the

purposively biased sample, identified by the

medical chart review sample as more likely

to have a mental illness. The 32 residents

with the most severe symptoms identified

from the interviews are represented in the 5

following exhibits as those “equal to or

above the cutoff.” Thus, one would expect

those individuals to be the most likely to

have severe mental illness and receive the

highest rate of Level I and Level II screens,

as well as mental health services.

4. Demographics of the Clinical Interview

Sample

Exhibit 55 shows the demographics of the

clinical interview sample. The group as a

whole was relatively similar to the larger

medical chart sample from which the

interview sample was pulled (see Exhibit 

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 67
68 Special Report

Exhibit 55: Demographics of Clinical Interviewees

Demographics

Both States n=93

Composite Score*

< cutoff ≥ cutoff

(n=61) (n=32)

Age (n=59) (n=32)

18–64 7 (11.9%) 6 (18.8%)

65–79 14 (23.7%) 9 (28.1%)

80–84 13 (22%) 0 (31.3%)

85–90 17 (28.8%) 4 (12.5%)

>90 8 (13.6%) 3 (9.4%)

Gender (n=61) (n=32)

Female 40 (65.6%) 28 (87.5%)

Male 21 (34.4%) 4 (12.5%)

Marital Status (n=61) (n=32)

Single/Never Married 6 (9.8%) 7 (21.9%)

Married 12 (19.7%) 7 (21.9%)

Divorced/Separated 5 (8.2%) 6 (18.8%)

Widowed 38 (62.3%) 12 (37.5%)

Race/Ethnicity (n=58) (n=31)

White 56 (96.6%) 29 (93.5%)

Non-White 2 (3.4%) 2 (6.4%)

* Individuals considered more likely to have mental illness if they have—

1. A BSI t-statistic greater than or equal to 63,

2. An SF-12 “transformed mental” score less than or equal to 37, or

3. A GDS score of 10 or above.
38). The age spread included a significant

number of individuals over 80 years of age

(53–64 percent); mainly female in gender;

and more predominantly widowed, rather

never married/divorced. In ethnicity, the

sample was over 93 percent White.

5. PASRR Level I and II Screens

All admissions to a nursing facility should

have received the Level I screen for potential

mental illness, but our clinical sample

received a rate between 72 and 79 percent.

Those scoring above the cutoff were

clinically very symptomatic; thus, all should

have received the Level II PASRR screens as

well. However, less than 10 percent had

evidence in their charts of receiving a Level II

screen. Exhibit 56 shows that 76 percent of

those interviewed got a Level I screen, and

only 7 percent of all those interviewed

received a Level II screen—an inexplicably

low PASRR screening rate.

6. Current Diagnoses of Clinical Interviewees

Within the sample, only 64 percent of the 93

residents interviewed were identified in their

charts as having a current psychiatric

diagnosis. As shown by Exhibit 57, at least

34 per cent had no mental illness diagnosis,

even though this sample was from the most

severe mentally ill residents; yet all were on

some type of psychotropic medication. 

Among those with a diagnosis, major

depressive disorders were the most common

in both groups. Only 16 percent had a

diagnosis of Alzheimer’s or dementia.

Psychiatric History of Clinical Sample.

About one third of the residents clinically

interviewed reported previous contact with

mental health professionals; less than one

quarter reported previous inpatient

hospitalization (see Exhibit 7 in Appendix

A).

7. Current Psychotropic Medications

Nearly all of the residents clinically

interviewed received psychotropic

medication, but 34 percent did not have a

psychiatric diagnosis. Although Exhibit 57

shows 60–70 percent overall rate in

identified psychiatric diagnoses, the rate of

current psychotropic medications was

virtually at 100 percent in the more

symptomatic clinical group, and over 95

percent for the rest of the clinical sample

(Exhibit 58). Antidepressant medication rate

was above 70 percent in both clinical

groups, yet exhibit 57 shows a diagnosis of

major depression at a rate of only 37–52

percent. 

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 69

Exhibit 56: PASRR Level I and II of

Clinical Interviewees

Both States n=93

Composite Score*

< cutoff ≥ cutoff

PASRR Screens (n=61) (n=32)

Level I 48 (78.7%) 23 (71.9%)

Level II 4 (6.6%) 3 (9.4%)

* Individuals considered more likely to have mental illness if they have—

1. A BSI t-statistic greater than or equal to 63,

2. An SF-12 “transformed mental” score less than

or equal to 37, or

3. A GDS score of 10 or above.
8. Mental Health Services Currently Ordered

and Received in Last Month for

Interviewees

Exhibit 59 shows that in this sample of 93

residents with probable mental illness and on

psychotropic medications, a significant

percent received no mental health services in

the previous 30 days—not even medication

review. Of those individuals receiving

services, the services were almost entirely

limited to medication review and case

consultation. No psychosocial rehabilitation

services, no individual or group therapy, no

behavior therapy, and no crisis intervention

were being delivered to this subsample of

residents with a high likelihood of having

mental illness.

9. Summary of Clinical Interview Sample

A subset of nursing facility residents from

two States, purposively drawn to select those

more likely to have mental illness, was

interviewed using clinical screening tests. Of

93 residents interviewed, about one third

(32) scored on clinical screening instruments

as most definitely having psychopathology.

Yet, few of those interviewed appeared to

have received a mandated Level II PASRR

screen (less than 10 percent of those above

the cutoff). Nearly all were receiving

70 Special Report

Exhibit 57: Major Categories of Diagnoses of Clinical

Interviewees,Currently

Demographics

Both States n=93

Composite Score*

< cutoff ≥ cutoff

Currently (n=61) (n=32)

Psychiatric Diagnoses 41 (67.2%) 19 (59.4%)

Psychotic disorders 7 (11.5%) 5 (15.6%)

Bipolar disorders 3 (4.9%) 2 (6.3%)

Major depressive disorders 32 (52.5%) 12 (37.5%)

Anxiety disorders 6 (9.8%) 3 (9.4%)

Personality disorders 0 (0%) 0 (0%)

Substance use disorders 1 (1.6%) 1 (3.1%)

Dementia-Related Conditions

Alzheimer’s disease/dementia 11 (18%) 4 (12.5%)

Note: Categories are not mutually exclusive

* Individuals considered more likely to have mental illness if they have—

1. A BSI t-statistic greater than or equal to 63,

2. An SF-12 “transformed mental” score less than or equal to 37, or

3. A GDS score of 10 or above..
psychotropic medications, yet barely half

had a mental diagnosis, and virtually none

was receiving any mental health services

other than some limited medication review

and case consultation. In fact, a significant

portion had received no mental health

service in the previous 30 days, not even

medication review.

E. PASRR Issues Identified at the

Nursing Facility Level

A final goal of the in-depth State studies was

to identify key issues and concerns regarding

actual implementing PASRR at the nursing

facilities. Throughout this section, data and

qualitative evidence are integrated from

nursing facility staff interviews (n=24).

1. Nursing Facility Staff Respondent

Perceptions of PASRR

Administrative Burden. In all four States,

the majority of nursing facility respondents

said that PASRR did not increase

administrative burden—with States 1 and 3

at 67 percent, and States 2 and 4 at 100

percent (see Exhibit 10 in Appendix A). 

Use of PASRR. To assess how nursing

facilities are using PASRR, nursing facility

staff respondents were asked to describe the

purpose of PASRR in their facility. Exhibit

56 presents data on nursing facility staff

responses to the question, “How is PASRR

used at your facility?” In States 1 and 3,

most respondents described PASRR as a

required screening tool that assists them in

making admissions decisions. For example, a

typical response included, “[PASRR is used]

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 71

Exhibit 58: Current Psychotropic Medications of Clinical Interviewees

Psychotropic Medications

Both States n=93

Composite Score*

< cutoff ≥ cutoff

Currently (n=61) (n=32)

Traditional antipsychotics 3 (4.9%) 0 (0%)

Atypical antipsychotics 6 (9.8%) 10 (31.3%)

Antidepressants 44 (72.1%) 23 (71.9%)

Anxiolytics 18 (29.5%) 14 (43.8%)

Mood stabilizers 4 (6.6%) 3 (9.4%)

Other medications 6 (9.8%) 2 (6.3%)

Any Psychotropic Medications 58 (95.1%) 32 (100%)

* Individuals considered more likely to have mental illness if they have—

1. A BSI t-statistic greater than or equal to 63,

2. An SF-12 “transformed mental” score less than or equal to 37, or

3. A GDS score of 10 or above.
to determine whether or not placement is

appropriate. We do have some residents with

mental retardation/developmental disabilities

or mental illness, but there have to be other

complex medical issues going on. The

PASRR process determines this.”

By contrast, all six respondents in State 2

and half of State 4 respondents did not

consider PASRR to be useful, viewing it as a

mandatory paperwork requirement. In the

words of one nursing facility staff in State 3,

“PASRR is simply a piece of paper—a

72 Special Report

Exhibit 59: Mental Health Services Currently Ordered and Received in

Last 30 Days of Clinical Interviewees

Mental Health Services

< Cutoff* – Both States ≥ Cutoff* – Both States

Composite Score* Composite Score*

Ordered Received Ordered Received

Currently (n=61) (n=61) (n=32) (n=32)

Medication review 26 (42.6%) 29 (47.5%) 10 (31.3%) 18 (56.3%)

Psychological testing/evaluation 4 (6.6%) 3 (4.9%) 0 (0%) 1 (3.1%)

Case management 1 (1.6%) 0 (0%) 0 (0%) 0 (0%)

Case consultation 27 (44.3%) 24 (39.3%) 13 (40.6%) 10 (31.3%)

Psychiatrist 15 (24.6%) 10 (16.4%) 10 (31.3%) 6 (18.8%)

Psychologist 0 (0%) 0 (0%) 0 (0%) 0 (0%)

Other mental health professional 13 (21.3%) 15 (24.6%) 3 (9.4%) 4 (12.5%)

Psychosocial rehabilitation services 0 (0%) 0 (0%) 0 (0%) 0 (0%)

Individual therapy 0 (0%) 0 (0%) 0 (0%) 0 (0%)

Group/Family therapy 0 (0%) 0 (0%) 0 (0%) 0 (0%)

Behavior management/therapy 0 (0%) 0 (0%) 0 (0%) 0 (0%)

Psychoeducation 0 (0%) 0 (0%) 0 (0%) 0 (0%)

Outpatient services 0 (0%) 0 (0%) 0 (0%) 0 (0%)

Day treatment/partial hospitalization 0 (0%) 0 (0%) 0 (0%) 0 (0%)

Crisis intervention 0 (0%) 0 (0%) 0 (0%) 0 (0%)

Other mental health services 1 (1.6%) 5 (8.2%) 1 (3.1%) 1 (3.1%)

* Individuals considered more likely to have mental illness if they have—

1. A BSI t-statistic greater than or equal to 63,

2. An SF-12 “transformed mental” score less than or equal to 37, or

3. A GDS score of 10 or above.
requirement. We already know what the

history is because we get this as part of our

admissions packet.” Despite conflicting

views of PASRR’s overall purpose and utility,

the majority of nursing facilities have

incorporated PASRR into overall facility

operations by assigning PASRR

responsibility to a designated staff member,

typically the admissions nurse or a social

worker (see Exhibit 5 in Appendix A).

PASRR and Nursing Facility Admissions.

As presented in Exhibit 57, in nursing

facility staff interviews, the majority of

respondents from States 1, 3, and 4

described PASRR’s impact on the admissions

process as one that primarily involves

ensuring that PASRR paperwork is

completed. One respondent in State 1

highlighted payment issues as an incentive

for completing paperwork: “The PASRR

screen needs to be completed in order to

receive payment from Medicaid.” A majority

of respondents in States 3 and 4 also

reported that special attention is paid to

whether or not the nursing facility can

handle the needs of residents with mental

illness. For example, in State 3, one staff

person described PASRR as important for

their facility because staff lack mental health

expertise: “If the PASRR form indicates

mental illness, we try to understand what

they have to see if we can handle it, since we

are not a strong mental health facility.” In

State 2, the majority of respondents

described their nursing facilities as reluctant

to accept individuals with mental illness. A

typical response was that “they are really at

the end of the waiting list in terms of

acceptance to the facility.” Across all four

States, the majority of nursing facility staff

respondents reported that the admissions

process does not differ substantially

depending on age and that individuals with

mental illness are not physically separated

from other residents in any way (see Exhibit

9 in Appendix A).

2. Recommendations for Improving PASRR

Recommendations for Improving State

Oversight. Few facilities offered suggestions

for ways to improve State oversight of the

PASRR process (see Exhibit 58). Those

responding frequently highlighted the need

for increased State training on PASRR policy

and procedures. In State 1, the majority of

respondents also advocated the need for

increased funding and resources for nursing

facilities to treat mental illness among

residents. 

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 73

Exhibit 60: Nursing Facility Staff Perceptions of 

Usefulness of PASRR (n=24)

Purpose/Utility of PASRR

State 1 State 2 State 3 State 4

(n=6) (n=6) (n=6) (n=6)

Not useful, mandatory paperwork 2 6 0 3 

Useful, required screening tool 4 0 6 3
74 Special Report

Exhibit 61: PASRR Impact on Admissions Process (n=24)

PASRR’s Impact on Admissions Process 

for Individuals With Mental Illness

State 1 State 2 State 3 State 4

(n=6) (n=6) (n=6) (n=6)

Make sure PASRR paperwork is complete 6 2 4 4

Special attention to assessing whether nursing facility can

meet mental health service needs 2 2 4 5

Reluctant to accept individuals with serious mental illness or

difficult-to-manage behaviors 1 4 1 0

Exhibit 62: Recommendations for Improving 

State Oversight of PASRR (n=63)

Recommendations for Improving 

State Oversight of PASRR

State 1 State 2 State 3 State 4

(n=5) (n=1) (n=5) (n=2)

PASRR screens should provide more detailed

information about mental illness 1 1 0 0 

Reinstate annual review requirement 1 0 2 0 

Require State surveyors to review PASRR documentation 1 0 2 0 

More State training on PASRR 2 0 3 1 

More funding/resources for treatment of 

mental illness in nursing facilities 3 0 0 1
PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 75

A. Summary of National Survey

Findings

1. PASSR Policies and Procedures at the State

Level

There is significant State variation in the

administration and implementation of

PASRR. States vary in the way they organize

and distribute PASRR responsibilities among

agencies. Although considerable flexibility is

afforded to States in organization and

delegation of functions, Federal law and

regulations specifically delineate PASRR

roles for Medicaid agencies and SMHAs.

However, only 27 States reported dividing

PASRR responsibilities between these two

agencies. The entities responsible for

conducting PASRR screening also vary

considerably across States. For Level I

screens, most States allow referral sources

(e.g., acute care facilities, rehabilitation

hospitals) and nursing facilities to complete

evaluations. In 20 percent of the States,

however, this function is completed by a

State agency, while 16 percent of the States

contract with various public and private

entities to complete these screens. For Level

II screens, most State agencies contract with

an independent entity, but the type of

contracted entity ranges from private mental

health organizations to local public mental

health authorities to individual practitioners.

In addition, there are several States that

allow a State agency other than the SMHA

to make PASRR determinations.

Change in condition criteria and

notification procedures also vary across

States. With the elimination of the annual

resident review requirement in 1996, States

were required to develop criteria and

procedures for identifying when nursing

facility residents experience a significant

change in condition to trigger a Level II

review. While all States have developed

procedures for identifying significant changes

in condition (for example, use of the MDS

[53 percent], specific behavioral/functional

criteria, requirements for nursing facilities to

notify the State), some, such as use of Level I

criteria are inappropriate for this purpose.

There is evidence that rates of compliance

with the change in condition requirement

may be low, which is consistent with the

finding of the PASRR study conducted by

OIG (2001).

2. PASRR Impact on Intended Policy Goals

While most State Medicaid agencies cover

the cost of providing basic mental health

services in nursing facilities, many

respondents expressed concerns about access

to and quality of mental health services. In

38 of 42 States, the Medicaid nursing facility

benefit covers basic psychiatric consultation

services, such as medication monitoring by a

psychiatrist or individual counseling by a

social worker, but few cover more intensive

mental health rehabilitation services that are

effective for people with serious mental

illness. Furthermore, up to one third of State

75

VII. Conclusions
respondents reported that nursing facility

resident access to mental health services is

limited and of variable quality. This calls

into question whether determinations of

need for nursing facility services are facilityspecific, as required (that is, that the

admitting nursing facility offers the specific

services the individual requires).

PASRR agencies are minimally involved in

monitoring of PASRR outcomes.

Respondents at State PASRR agencies

involved with PASRR rarely described their

agency as having responsibility for

overseeing nursing facility implementation of

PASRR evaluations and determinations and

recommendations. Instead, over three

quarters of States reported that oversight

was handled by the State entity that

conducts survey and certification of nursing

facilities (which is not one of their

functions). Very few States have developed

quality review processes to ensure that

PASRR screens are completed accurately.

Community-based alternatives to

institutional care are available in most

States. Over 80 percent of States reported

the availability of community-based mental

health residential programs, and 36 percent

mentioned assisted living with mental health

services and other senior residential

programs as alternatives to nursing facility

care. Nevertheless, most survey respondents

emphasized that demand for such

alternatives tends to outpace current

availability of these alternative options.

States are not offering home and

community-based (waiver) mental health

services for the 21–65-year-old population

because Medicaid rules forbid using

institutions for mental illnesses as the

institutional alternative. Interestingly, PASRR

data could help to establish nursing facilities

76 Special Report

as the institutional basis for mental health

waiver services, but States did not describe

doing so.

PASSR is underutilized in Olmstead

planning. Perhaps reflecting the fact that the

Olmstead ruling has been applied more

consistently to younger populations, only

about a quarter of States actively consider

PASRR as part of their planning to serve

individuals with disabilities in the most

community-integrating setting.

3. State-Level Issues Identified Through

PASRR Implementation

PASRR is considered effective and generally

meets policy goals. Most respondents rated

PASRR as doing a “good” job of meeting its

main policy goals of identifying individuals

with serious mental illness, screening

appropriateness for nursing facility care, and

ensuring provision of specialized services.

About half also reported that it has

positively affected the type, amount, and

quality of mental health services in their

State.

Lack of State oversight is highlighted as

main PASRR weakness. When identifying

specific weaknesses of their State PASRR

programs, respondents most frequently cited

gaps in oversight, which included limited

State activity related to PASRR enforcement

and the absence of punitive disincentives for

enforcing nursing facility compliance. Lack

of agency coordination was also cited.

Survey respondents generated

recommendations on how to improve

PASRR for CMS, State PASRR agencies, and

nursing facilities. Respondents called for

more guidance and involvement by CMS,

particularly in clarifying various regulations

and payment issues. They highlighted the

need for both CMS and State PASRR

agencies to strengthen oversight, and they
stressed the need to expand educational

activities at the State level and within

nursing facilities to improve knowledge

of PASRR programs and mental

health/behavioral issues.

Lack of resources are perceived as

biggest barrier to change. Nearly all

States are currently experiencing budget

difficulties that necessitate hard decisions

about where agencies can trim back to

save money. Most respondents felt that

improving PASRR would require more

financial (as well as nonfinancial)

resources than States are willing or able

to provide. 

B. Summary of In-Depth State

Study Findings

1. PASRR Policies and Procedures at the

Nursing Facility Level 

Many nursing facilities do not consider

PASRR to be a useful tool. Nursing

facility staff respondents were equivocal

in their views of the utility of the PASRR

process. Nearly half (46 percent) viewed

the process as mandatory paperwork

that does not enhance the admissions

process. This is not surprising since

Level II evaluations and determinations

that should guide care were often not

even present in the resident’s record.

However, the other half described the

process as a valuable approach for

determining the appropriateness of a

nursing home placement. The nursing

facilities were also mixed in their views

regarding State oversight of the PASRR

process, with a third of the staff viewing

the oversight process as effective and

more than 40 percent indicating the

oversight system could be improved.

Only a third of the nursing facilities

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 77

reported regular State monitoring of Level I

and Level II screens.

Level I screens are well documented in

charts. Compared to the OIG study that

found Level I documentation in fewer than

50 percent of the charts reviewed, relatively

high percentages of Level 1 screens were

found in the charts reviewed, ranging from

71 to 93 percent across the four States. 

Nursing facility staff in many facilities are

unfamiliar with change in condition criteria

for triggering a PASRR Level II resident

review. More than half (58 percent) of the

nursing staff respondents were unfamiliar

with the change in condition requirement

and could not describe the criteria used in

their States to trigger a PASRR review. Levels

of awareness and knowledge of the change

in condition criteria varied across and within

the four States; however in one State, no

respondents could describe the specific

criteria used. Few Level II change in

condition resident reviews were documented

in medical records.

Investments in Level II evaluations are

variable and underutilized. In the sample

states and in the national survey, states

demonstrate the capacity to perform Level II

evaluations. However, Level II preadmission

evaluations and determinations are not being

adequately completed for those with mental

illness, as required (Exhibits 46 and 56).

Even when they are done, the information is

used less frequently to guide ongoing

treatment and services for individuals after

they become nursing facility residents. Level

II evaluations (as required by the Balanced

Budget Act [BBA] of 1996) are performed or

documented even less frequently when

needed to reassess residents who experience

a change in condition or mental or physical

status. 
Nursing facility workers and state

respondents indicate that these deficits are

the result of the lack of clear policy, little

oversight or training, and insufficient

resources. However, since Level II

evaluations for resident review are identical

to preadmission screenings (PAS) (which are

being performed), it appears that there is

existing capacity to perform resident review

that is underutilized by nursing facilities. The

process apparently missing is the integration

of available PAS information by nursing

facilities into their treatment planning and

reassessment process. 

Developing a PASRR tracking system for

nursing facilities would be burdensome, and

possibly unnecessary, if the MDS (Minimum

Data Set) process can include PASRR.

Nursing facilities are invested in and

compliant with the MDS, which is a

comprehensive process for evaluating and

tracking resident condition, changes in

condition, and needed services. Federal

regulations encourage closely linking PASRR

to the MDS, and 53 percent of states refer to

the MDS in their PASRR change of

condition procedures. Further study is

indicated to determine whether there is a

means to connect the existing state

investments in Level II PAS, the apparent

available capacity to perform Level II RR,

and nursing facility investment in the

ongoing MDS process as a cost-effective

means to correct the observed deficiencies in

PASRR.

2. PASRR Impact on Intended Policy Goals

The ability of the PASRR screening process

to effectively identify individuals with serious

mental illness varies across the four study

States. Averaged across all 4 States, 50

percent of records reviewed indicated some

type of psychiatric diagnosis at the time of

78 Special Report

admission, most of which were depressive

(60 percent) or psychotic (24 percent)

disorders. Fewer records (12 percent or less

across all four States) identified individuals

with a primary diagnosis of mental illness

upon admission, yet not all of these

individuals received PASRR Level II screens.

Of great concern is the considerable

variability across study States in the extent

to which Level II screens were administered

to individuals with primary diagnoses of

mental illness, ranging from 0 percent in one

State to a high of 60 percent in another

State. 

In the medical records reviewed, diagnoses

of mental illness increased over the course of

stay in the nursing facility, indicating that

levels of depression and

psychiatric/behavioral problems are

associated with length of stay. Clinical

interviews indicated serious psychopathology

among 34 percent of those interviewed and

few of those who needed it got a Level II

(PASRR) screen or mental health services. 

Nearly half of nursing facility residents

had diagnoses of dementia. At time of

admission, 18 percent of residents on

average had a primary diagnosis of

dementia, but almost half were diagnosed

with a nonprimary dementia-related

condition at admission. Federal guidelines

exclude many individuals with dementia

from the PASRR process, missing significant

mental health needs. This policy bears

further examination.

In the four study States, the PASRR

process appears effective in identifying

individuals who do not require nursing

facility level of care. Medical record data

from our sample indicate that nearly all

nursing facility admissions (96 percent) had

a primary or secondary physical health

diagnosis. In addition, most people had
PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 79

multiple medical conditions—between four

and nine in all four States, with the most

common diagnoses including disorders of the

nervous, circulatory, and musculoskeletal

systems. Health status data also indicate that

individuals from the clinical sample currently

experience significant physical health

impairments. Furthermore, of those

individuals with primary mental health

diagnoses, 91 percent had additional

physical health diagnoses upon admission

across all four States. 

In the four study States, the PASRR

process alone does not ensure that people

receive mental health services. While all 24

nursing facilities studied provide some

mental health services (primarily medication

monitoring and psychiatric consultation

services), the availability of other mental

health services, such as individual counseling

or behavior management plans, varies across

States and facilities. Only 20 percent of the

facilities offer quality review and care team

meetings for mental illness treatment. The

majority (62 percent) of the nursing facilities

indicate that treating persons with mental

illness is challenging, primarily because of

behavioral issues, and cited a lack of

resources, including staff, as barriers to

dealing effectively with this population.

These findings suggest that PASRR

determinations are not facility-specific, as

required; that is, a judgment that a particular

nursing facility can provide the exact services

an applicant requires. In one State, the

majority of nursing facilities indicate a

reluctance even to admit persons with

serious mental illness because of their

behavioral issues.

3. PASRR Implementation Issues at the

Nursing Facility Level

Procedures for communicating PASRR

outcomes are unclear to many nursing

facilities. Nursing facilities in most of the

States studied indicate a lack of familiarity

with how to communicate to State agencies

about PASRR outcomes and change in

condition criteria. Many facilities are not

aware of State oversight procedures. 

There appear to be issues with notification

of significant change in condition. Nursing

facility staff appear less familiar with the

requirement to perform a Level II resident

assessment whenever there is a change in a

resident’s mental or physical condition. More

training, oversight by CMS, and linkage with

the MDS would be helpful.

Nursing facility staff ratings of PASRR

effectiveness are low compared to State-level

administrators. The majority of nursing

facility staff rate the effectiveness of PASRR

as fair to poor in three areas: identifying

individuals with serious mental illness,

screening appropriateness for nursing facility

level of care, and ensuring the provision of

specialized services. However, the majority

did not find PASRR to be an administrative

burden.

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 81

VIII.

BBA – Balanced Budget Amendment

BOMC – Blessed Orientation-Memory-Concentration Test (screens for dementia)

BSI – Brief Symptom Inventory (test to rate emotional distress)

CMS – Centers for Medicare & Medicaid Services

CMHS – Center for Mental Health Services

DHHS – Department of Health and Human Services

DQoL – Dementia Quality of Life instrument

DSM – Diagnostic and Statistical Manual of Mental Disorders

GAO – General Accounting Office

HCBS – Home and Community-Based Services (Medicaid waivers)

IMD – Institute for Mental Disease

IOM – Institute of Medicine

Level I PAS Screen – Identifies, prior to admission, nursing facility applicants who might have

serious mental illness

Level II PAS Screen – More extensive screen, prior to admission, for nursing facility

applicants who are suspected of having a serious mental illness

MDS – Minimum data set

MSA – Metropolitan statistical area

OBRA – Omnibus Budget Reconciliation Act

OIG – The Office of the Inspector General

Olmstead – The Olmstead Supreme Court decision mandates that States “provide

community-based treatment for persons with mental disabilities when the State’s

treatment professionals determine that such placement is appropriate.”

PAS – Preadmission Screening

PASARR – Preadmission Screening and Annual Resident Review (prior to 1996)

PASRR – Preadmission Screening and Resident Review (sometimes referred to in parts as PAS

and RR)

QMHP – Qualified mental health professionals

RR – Resident Review

SAMHSA – Substance Abuse and Mental Health Services Administration

SF-12 – Short-Form Health Survey (test to assess perceived health)

SMHA – State Mental Health Authorities

SSWLHC – Society for Social Work Leadership in Health Care

Glossary

PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 83

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84 Special Report
PASRR Screening for Mental Illness in Nursing Facility Applicants and Residents 85

X. Appendices