PASRR Resident Review Says Nursing Facility Not Appropriate? What Now

A Preadmission Screening and Resident Review (PASRR) resident review that says a nursing facility is not appropriate for your parent does not always mean she has to leave.1 Under the federal rule, the answer turns on two things you can check: whether the State found she needs specialized services, and whether she has lived in a nursing facility continuously for at least 30 months before the determination.1 If you just got that letter, or a call from the nursing home about it, it's normal to feel the ground shift. Start with the notice in your hand. It tells you which of three situations she's in, and it has to explain how to appeal.2

In This Guide

• What a PASRR Resident Review Decides
• Why the Review Happened Now
• Three Outcomes When a PASRR Review Says a Nursing Facility Is Not Appropriate
• How the 30 Months Is Counted
• What the State's Written Notice Must Tell You
• How to Appeal a PASRR Determination
• If She Does Have to Move
• Not PASRR? When the Issue Is Medicaid Level of Care
• Who Can Help Right Now
• Frequently Asked Questions

What a PASRR Resident Review Decides

Preadmission Screening and Resident Review (PASRR) is a federal requirement that applies to people with mental illness or an intellectual disability who apply to or live in a nursing facility certified by Medicaid, no matter who pays for the stay.5 So a parent paying privately can be reviewed too.

PASRR runs in two stages. A Level I screen flags anyone suspected of having a serious mental illness or an intellectual disability, and a Level II evaluation then makes two linked decisions: whether she needs the nursing facility level of care, and whether she needs specialized services.5

"Specialized services" has a narrow federal meaning. Under 42 CFR 483.120, they're for residents whose needs call for continuous supervision, treatment and training by qualified mental health or intellectual disability staff, and the State must provide or arrange them. Mental health or intellectual disability services of lesser intensity are the nursing facility's job to provide for residents who need them.5

That distinction matters more than anything else on this page, because it decides which of the three outcomes below applies to your parent.

Why the Review Happened Now

It can feel like this came out of nowhere. Here's what triggers a review under the federal rules.

Under 42 CFR 483.20, a nursing facility must promptly notify the State mental health or intellectual disability authority for a resident review after a significant change in the condition of a resident who has a serious mental disorder, an intellectual disability or a related condition.3 For the facility's assessments, a significant change means a major decline or improvement that won't resolve on its own without staff intervention or standard clinical care, affects more than one area of her health, and calls for an interdisciplinary review or a care-plan revision.3 Notice the word improvement. A parent who has gotten steadier can trigger a review just as a decline can.

The federal statute (section 1919(e)(7)(B)) requires the State to do its review promptly once the facility reports the change.3 And the decision isn't the nursing home's to make. The State and its mental health and intellectual disability authorities can't delegate the review to a nursing facility or to an entity with a direct or indirect affiliation with one.3 If a staff member tells you "PASRR says she has to go," ask to see the State's written determination.

Three Outcomes When a PASRR Review Says a Nursing Facility Is Not Appropriate

This is the heart of it. The federal rule at 42 CFR 483.118 sorts residents found not to need nursing facility level of services into three groups, and what happens next depends entirely on which group your parent is in.1

The three rows above come straight from the federal rule.1

If your parent is in the middle row, the choice is real and it's hers. The State must offer it in consultation with her family or legal representative and her caregivers, tell her about the institutional and noninstitutional alternatives covered under the State Medicaid plan, and explain how leaving would affect her Medicaid eligibility, including if she ever needs to be readmitted.1 If a resident who qualifies for the 30-month choice decides to stay, federal law says the State isn't denied payment for her nursing facility services just because she doesn't need that level of services.1

There's one rare exception. The two specialized-services outcomes can be modified by an alternative disposition plan, but federal law recognizes one only where the State and the federal Secretary reached an agreement on these residents before April 1, 1989, and the State follows it. The first outcome has no such exception.1

How the 30 Months Is Counted

When the line between staying and leaving is 30 months, the count matters. Under 42 CFR 483.118(c)(3), the 30 months is calculated back from the date of the first annual resident review determination that found her not in need of nursing facility level of services.1

Two details work in a family's favor. For the PASRR 30-month rule, temporary absences for a hospital stay or therapeutic leave can count toward the 30 months of continuous nursing facility residence, and so can back-to-back stays in more than one nursing facility.1 If Mom moved from one nursing home to another, or spent a week in the hospital last winter, don't let anyone start the clock over. Write down her admission dates for each facility before you talk to the State.

What the State's Written Notice Must Tell You

The notice is your roadmap, so it's worth holding it up against the federal checklist. Under 42 CFR 483.130, the State authority must send the PASRR determination in writing to your parent and her legal representative, as well as to the nursing facility and her attending physician.2

Every determination notice must say:

• Whether she needs a nursing facility level of services
• Whether she needs specialized services
• The placement options available to her, consistent with those findings
• Her rights to appeal the determination

All four items are required by 42 CFR 483.130(l).2

What comes next on the notice depends on her outcome. If she must be discharged, the notice must explain how, when and by whom she'll be told about the discharge arrangements and about her appeal rights under both the PASRR and the discharge provisions. If she qualifies for the 30-month choice, it must explain how, when and by whom her placement options will be fully explained to her.2 If a notice skips any of this, write down what's missing. That gap is worth raising with the State and with an advocate.

How to Appeal a PASRR Determination

You may be thinking the State got it wrong. Maybe Mom's good months came because of the support she has where she is. You can challenge that.

Under 42 CFR 483.204, every State must have a system that lets a person adversely affected by a PASRR determination appeal it, and a separate system for a resident to appeal a nursing facility's notice that it intends to discharge or transfer her.2 The Medicaid fair-hearing rule at 42 CFR 431.220 lists them as different grounds for a hearing: a belief that the State made an erroneous PASRR determination is one, and a belief that a nursing facility erroneously decided a resident must be transferred or discharged is another.4

So you may have two appeals, not one:

1. The PASRR determination itself. This challenges the State's finding about her need for nursing facility care or specialized services. The notice must tell her about her right to appeal, so start there for your State's process. The federal provisions that require the appeal don't set a deadline, so ask the State what its deadline is and act quickly.2
2. The nursing home's discharge notice, if one comes. The hearing body and filing deadline for a discharge appeal vary by state, but the federal rule caps the window at no more than 90 days from the date the notice is mailed, and the facility's notice must name the entity that receives appeal requests.6

When a resident appeals a facility's transfer or discharge notice, federal rules say the facility may not discharge her while the appeal is pending, unless failing to discharge her would endanger her health or safety or that of others in the facility, and the facility must document that danger.7 If you appeal the PASRR determination, ask the State whether her nursing facility payment continues while the appeal is pending, and get the answer in writing.

If She Does Have to Move

If the review stands and she's in one of the discharge groups, the move still has to be safe. Our guide to nursing home discharge rights covers the discharge rules in full; here's how they touch this situation.

• The improved-health ground needs a doctor's documentation. One of the six federal grounds for a facility discharge is that the resident's health has improved enough that she no longer needs the facility's services.7 When a nursing facility discharges a resident because her health has improved enough that she no longer needs its services, her own physician must document that in her medical record.7
• Notice timing can be shorter. A facility's written discharge notice is generally due at least 30 days ahead, but it can come as soon as practicable when the resident's health improves enough to allow a quicker discharge, and a copy goes to the long-term care ombudsman.7
• The destination has to fit her. The notice must name where she's going, and CMS surveyor guidance says the discharge destination must meet her health and safety needs and her preferences.7
• You belong in the planning. The facility must involve the resident and her representative in building the discharge plan, and if she wants information about returning to the community, it must document any referral to a local contact agency.8
• Payment source doesn't change the rules. A participating facility must keep identical transfer and discharge policies for all residents, regardless of who pays.9

If the nursing home pushes her out before the State's process has run, see our guide to being pressured into a nursing home discharge. If she has the 30-month choice and decides she wants to move, our guide to leaving a nursing home walks through the community-transition route.

Not PASRR? When the Issue Is Medicaid Level of Care

PASRR only reaches people with mental illness or an intellectual disability.5 If your parent has neither, and someone has told you she no longer qualifies for nursing home care, you're most likely dealing with a Medicaid coverage decision, and the steps are different.

A Medicaid coverage dispute is its own fair-hearing ground under 42 CFR 431.220, separate from both PASRR and a facility discharge.4 If her care comes through a Medicaid managed care plan, the plan must send a written notice of its adverse benefit determination explaining the reasons, her right to appeal and to a State fair hearing, and her right to have benefits continue while the appeal is resolved, including when she might have to pay for those services.10

Timing matters here. Under 42 CFR 431.230, if the State sends the required advance notice and she requests a hearing before the date of action, the agency may not end or reduce her services until a decision is made after the hearing. The one exception needs both of two things: the hearing finds the only issue is one of federal or state law or policy, and the agency promptly tells her in writing that services will stop or be reduced pending the decision. If the decision goes against her, the State may try to recover the cost of services she received only because of that rule.11 Our guide to discharge when rehab coverage ends or Medicaid is pending covers the coverage side of a discharge in more detail.

Who Can Help Right Now

You don't have to read these notices alone. The Long-Term Care Ombudsman Program has an office in every state, its services are free and confidential, and it represents the resident and follows her direction, so expect the ombudsman to ask what your parent wants.12 The federal Administration for Community Living points people to the state directory run by the National Consumer Voice for Quality Long-Term Care to find their state's program.12 Our long-term care ombudsman guide explains what else the program does.

It also helps to have her records in hand. A nursing home resident has the right to access her personal and medical records within 24 hours of an oral or written request, excluding weekends and holidays, and to get copies with 2 working days' advance notice.13 Our guide to nursing home residents' rights covers the rest.

Learn More

Find personalized help reading a PASRR determination notice at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.