Georgia Medicaid PASRR Guide (2026)

When a Georgia family member needs nursing facility care, federal law requires a screening that most families never see and never hear named. It is called PASRR, short for Pre-Admission Screening and Resident Review, and it exists because in 1987 Congress concluded that large numbers of Americans with serious mental illness or intellectual disability had been placed in nursing homes during the long deinstitutionalization wave, often without anyone asking whether a nursing facility was the right setting for them. PASRR is the federal answer to that history. Every applicant to a Medicaid-certified nursing facility in Georgia, and every current resident whose condition changes significantly, must be screened for serious mental illness (SMI) or intellectual disability and developmental disability (ID/DD). If the Level I screen flags either condition, a Level II evaluation determines whether the individual genuinely needs nursing facility services, whether the individual needs Specialized Services for mental health or ID/DD, and whether a community alternative would be more appropriate.

The screening was added to Medicaid by the Omnibus Budget Reconciliation Act of 1987 (OBRA 1987), commonly called the Nursing Home Reform Act, with implementing regulations in the federal Medicaid PASRR rules. The U.S. Supreme Court's decision in Olmstead v. L.C. pulled the entire framework into the broader civil-rights architecture of Title II of the Americans with Disabilities Act. For the operative federal statutory and regulatory citations, the PASRR Technical Assistance Center maintains an updated repository. In Georgia, the Department of Community Health (DCH) contracts with Health Services Advisory Group (HSAG) as the PASRR Level I contractor, while the Department of Behavioral Health and Developmental Disabilities (DBHDD) conducts Level II evaluations as the State Mental Health Authority and Intellectual Disability Authority. A 2010 USDOJ Settlement Agreement that resolved Georgia's Olmstead litigation added a community-integration mandate that runs alongside PASRR. The result is a process that, when it works, prevents inappropriate institutional placement, and when it fails, leaves families without options they were legally entitled to.

This guide translates the PASRR framework for Georgia families. It explains what PASRR is, when it applies, what each step of the Level I and Level II process looks like, what protections exist when a hospital wants to transfer a loved one to a nursing facility, what Specialized Services means and how it differs from nursing facility services, how categorical determinations and exempted hospital discharge work, what the Resident Review obligation requires when a nursing facility resident's condition changes, how the Olmstead community-integration mandate reshaped PASRR in Georgia, who to call when a screening seems wrong or was never done, and how to appeal a PASRR determination through the Office of State Administrative Hearings. Brevy publishes this guide because the families we hear from rarely know the PASRR process exists until something goes wrong, and by then options have narrowed.

By Brevy Care Team · Last verified May 12, 2026

What Georgia Medicaid PASRR is and why it exists

PASRR began as a congressional response to a documented crisis. By the mid-1980s, state psychiatric hospitals across the country had reduced their populations substantially as part of the deinstitutionalization movement that began in the 1960s. Many of the people discharged from state psychiatric hospitals were not returned to families or to community mental health programs but were instead admitted to nursing facilities, often because nursing facilities had open beds, accepted Medicaid, and could not legally refuse a person who met nursing-facility level of care criteria. National disability advocacy organizations documented patterns of nursing facilities housing residents whose primary needs were psychiatric or developmental, not medical, and who received little or no treatment for their underlying conditions while in the facility.

Congress addressed this in the Nursing Home Reform Act, enacted as part of OBRA 1987. The statute requires every state to establish a Pre-Admission Screening and Resident Review program for individuals with serious mental illness or intellectual disability who apply to or reside in a Medicaid-certified nursing facility. CMS issued implementing regulations governing the framework, and subsequent CMS State Medicaid Director Letters have updated guidance on categorical determinations, hospital discharges, and the intersection between PASRR and the ADA. For the current operative text, the PASRR Technical Assistance Center maintains an updated repository of federal regulations, guidance, and state implementation resources.

The statutory purpose of PASRR has two prongs. First, ensure that individuals are not placed in nursing facilities when their primary needs are for mental health or ID/DD services that nursing facilities are not designed or staffed to provide. Second, ensure that when individuals with SMI or ID/DD are appropriately placed in a nursing facility for unrelated medical or functional reasons, they receive the Specialized Services their conditions require. PASRR is not a tool for excluding people with disabilities from nursing facilities; it is a tool for ensuring that placement is appropriate and that services follow the resident wherever the resident lives.

The screening applies to all applicants and residents of Medicaid-certified nursing facilities. This is critical, and it is the source of considerable confusion. PASRR applies regardless of how the resident pays for nursing facility care. A privately paying resident is covered by PASRR if the facility participates in Medicaid. A Medicare-paying resident in a Medicare-certified bed within a dually certified facility is covered. A resident who later applies for Medicaid is covered, and the Level I screen must have been completed at admission, not waited for until a Medicaid application is filed. The trigger is the facility's certification status, not the resident's payer source.

PASRR also applies to a fairly narrow set of facility types. It applies to nursing facilities as defined by federal Medicaid regulations, meaning institutional providers of nursing care that are certified to participate in Medicaid. It does not apply to intermediate care facilities for individuals with intellectual disabilities (ICF/IIDs), which have their own admission standards. It does not apply to assisted living facilities, personal care homes, residential care facilities, group homes, or other community residential settings that are not certified nursing facilities. It does not apply to hospital swing beds used for skilled nursing care under Medicare Part A unless those beds are also Medicaid-certified. The line is the facility's participation in Medicaid as a nursing facility, not the kind of care the resident receives.

The Level I screen in Georgia Medicaid PASRR

The Level I screen is the first PASRR step. It is a paper-based or electronic screening that asks a relatively short series of questions designed to identify whether the applicant or resident may have serious mental illness, intellectual disability, or a related developmental disability. The screen does not diagnose anything; it identifies whether further evaluation is warranted.

In Georgia, the Level I screen is administered by HSAG, under contract with DCH. The screen must be completed before nursing facility admission. A nursing facility cannot lawfully admit a Medicaid-certified resident, regardless of payer source, without a completed Level I screen on file. The screen is typically completed by the hospital discharge planner, by a social worker at a community provider preparing to refer a patient to a nursing facility, or by the nursing facility itself if the referral comes from another community source. HSAG processes the submitted screens, returns a Level I determination, and either clears the resident for nursing facility admission or refers the resident for a Level II evaluation if SMI, ID, or DD indicators are present.

The Level I screen asks about psychiatric history (diagnoses of schizophrenia, mood disorders, paranoid disorders, panic disorder, other psychotic disorders, and any other disorder that may result in chronic disability and significant functional impairment), about intellectual disability as defined in federal PASRR regulations (significantly subaverage general intellectual functioning, concurrent with deficits in adaptive behavior, manifested during the developmental period), and about other developmental disabilities causing impairment comparable to intellectual disability. The screen also asks whether the resident has dementia, because the federal regulations distinguish dementia from SMI in several important ways.

The dementia interaction is one of the most consequential and least understood pieces of PASRR. Under federal PASRR regulations, an individual with a primary diagnosis of dementia (including Alzheimer's disease or a related disorder) is not considered to have serious mental illness for PASRR purposes, even if the dementia is accompanied by behavioral symptoms that look psychiatric. This means that an older adult with advanced dementia and behavioral disturbances who needs nursing facility care will typically clear the Level I screen without a Level II evaluation. However, if the resident has a long-standing SMI diagnosis (for example, schizophrenia) in addition to dementia, the SMI diagnosis controls and a Level II evaluation is required. The order of onset matters. A resident with lifelong schizophrenia who later develops dementia is screened as a person with SMI; a resident who develops dementia in older adulthood without a pre-existing psychiatric history is not screened as a person with SMI.

The Level I screen result is documented in the resident's record at the nursing facility. The facility cannot admit the resident until the screen is complete and the determination is documented. If the screen indicates a possible SMI, ID, or DD condition, the facility cannot admit without a Level II determination, except under the limited circumstances of categorical placements and exempted hospital discharge described below.

When a Level II evaluation is triggered

If the Level I screen identifies indicators of SMI, ID, or DD, the case is referred for a Level II evaluation. In Georgia, Level II evaluations are conducted by DBHDD as the State Mental Health Authority (for SMI cases) and the Intellectual Disability Authority (for ID/DD cases). The Level II evaluation must be completed before the resident is admitted, except where federal regulation explicitly permits admission first, such as for exempted hospital discharges and certain categorical placements.

The Level II evaluation under federal PASRR regulations examines several questions. First, whether the resident has SMI, ID, or DD as defined by federal regulation. Second, whether the resident needs nursing facility level of care. Third, whether the resident needs Specialized Services for the SMI or ID/DD condition. Fourth, whether the resident could be served in an alternative community setting that would meet the resident's needs. The evaluator collects records, interviews the resident when feasible, interviews family members and current caregivers, and produces a written evaluation with a determination.

The Level II is conducted by a professional evaluator who must be independent of the nursing facility (so the facility cannot evaluate its own incoming resident) and who must have the appropriate clinical training. For SMI cases, the evaluator is typically a psychiatrist, psychologist, or other qualified mental health professional. For ID/DD cases, the evaluator is typically a professional trained in evaluating intellectual disability or related developmental disabilities, often a clinical psychologist or developmental specialist. The evaluation involves a face-to-face component when the resident's condition permits, and may also involve records review, collateral interviews, and consultation with current treating providers.

The determination is binary in some respects and multidimensional in others. The evaluator determines whether the resident has the qualifying condition (yes or no), whether the resident needs nursing facility services (yes or no), whether the resident needs Specialized Services (yes or no, and if yes, what kind), and whether community placement is appropriate (yes or no). The combination of these answers shapes the placement decision. A resident who needs nursing facility services and Specialized Services may be admitted with Specialized Services attached. A resident who does not need nursing facility services but needs Specialized Services should be diverted to a community setting where those services can be provided. A resident who needs neither nursing facility services nor Specialized Services should not be placed in a nursing facility at all.

DBHDD must complete the Level II evaluation within the timeframe specified in federal regulations and the DCH-DBHDD memorandum of understanding, with shorter windows for hospital discharges that qualify for expedited review. Delays in the Level II process are a chronic source of complaints from Georgia hospitals and families because hospital discharge planning runs on tight clinical and reimbursement timelines, and a Level II delay can mean a hospitalized patient remains in an acute care bed when neither the patient nor the hospital benefits from the prolonged stay.

Categorical determinations and exempted hospital discharge

Federal regulation recognizes that requiring a full Level II evaluation in every case would produce delays that harm residents in some circumstances. Federal PASRR regulations authorize categorical determinations, which are streamlined determinations made by the state without a full individualized Level II evaluation for certain narrow categories. A separate category, the exempted hospital discharge, applies to residents transferring from a hospital to a nursing facility under specific conditions.

Federal regulations recognize a limited set of categorical determinations. Common categories include convalescent care (a short-term post-hospital stay unrelated to the SMI/ID/DD diagnosis), terminal illness (short life expectancy), severe medical illness (where Specialized Services would be clinically inappropriate), and respite care for primary caregivers. For the operative list of categories, the duration limits, and the specific conditions on each, consult the current PASRR Technical Assistance Center guidance or DCH PASRR policy directly, because the regulatory text and the state's adopted categorical determinations evolve.

These categorical determinations do not eliminate the screening obligation. The Level I screen is still required, and the categorical determination is documented as the state's answer to the question of what kind of evaluation was conducted. The state retains the authority to convert a categorical placement to a full Level II evaluation if circumstances change, particularly if the resident's stay extends beyond the period originally contemplated by the category.

The exempted hospital discharge is a separate and frequently invoked path. Under federal PASRR regulations, an individual being discharged from a hospital to a nursing facility may be admitted under a presumptive Level II determination if the hospital discharge meets specific conditions: the individual must be admitted from a hospital after a multi-day inpatient stay, the attending physician must certify that the individual is likely to require a short-term nursing facility stay, the individual must require nursing facility services for the condition treated in the hospital, and the screening process must include a referral to the state for a full Level II evaluation if the stay extends beyond the regulatory short-stay window. The exempted hospital discharge is intended to handle the common scenario of an older adult hospitalized for a fall, stroke, or other acute event who needs short-term rehabilitation and is expected to return to the community.

For Eleanor, a 78-year-old in Macon hospitalized after a stroke, the exempted hospital discharge path may apply. Her primary care physician certifies that she needs short-term rehabilitative nursing facility services. Her Level I screen indicates no history of SMI or ID/DD. She is admitted to a Bibb County nursing facility on an exempted hospital discharge with the understanding that if her recovery extends past the regulatory short-stay window, the nursing facility must refer her for a full Level II evaluation. In Eleanor's case, the Level I screen identified no concerns, so the exempted hospital discharge path serves as a streamlined administrative path rather than a substantive Level II determination, and the entire process resolves quickly.

When the exempted hospital discharge path is used for a resident who does have a possible SMI or ID/DD condition, the protections of the path are heightened. The short-stay clock is firm. If the resident remains in the facility beyond the regulatory window, the facility must refer the resident to DBHDD for a full Level II evaluation, and DBHDD has the same obligation to determine the appropriate level of care and Specialized Services that it would have had if the resident had been screened pre-admission. Facilities that fail to refer at the cutoff are out of compliance with PASRR and exposed to surveyor citations and potential payment recoupment.

Specialized Services under Georgia Medicaid PASRR

Specialized Services are the services that an individual with SMI or ID/DD may need beyond what a nursing facility ordinarily provides. Federal regulations distinguish Specialized Services from nursing facility services in important ways. Nursing facility services are the room, board, nursing care, basic rehabilitation, basic activities, and supportive social services that every nursing facility resident receives. Specialized Services are clinical or programmatic services targeted to the resident's underlying mental health or developmental condition: active treatment for an ID/DD condition, psychiatric care for an SMI condition, occupational and behavioral programming designed for the resident's diagnostic profile, and other services that are not within the standard nursing facility scope.

The state is responsible for ensuring that Specialized Services are delivered when the Level II determination calls for them. This responsibility does not transfer to the nursing facility; the state may arrange for Specialized Services through community providers, through DBHDD-contracted providers, or through other mechanisms. In Georgia, DBHDD typically arranges Specialized Services through its community mental health and developmental disability network, with services delivered to the resident at the nursing facility or, in some cases, through structured visits to community settings.

The Specialized Services obligation is one of the most frequently litigated and least consistently implemented pieces of PASRR. Across the country, states have been cited for failing to deliver Specialized Services to Level II-positive residents, and several Olmstead settlements (including Georgia's 2010 Settlement Agreement) explicitly addressed the Specialized Services gap. For Georgia families, the practical implication is that a resident with an SMI or ID/DD condition who is appropriately placed in a nursing facility for unrelated medical reasons should be receiving documented Specialized Services targeted to the mental health or developmental condition. If the resident is not, the family or an advocate can request a PASRR review, contact the Georgia Long-Term Care Ombudsman, or contact Disability Rights Georgia.

The Resident Review obligation

PASRR is not only a pre-admission screening. Federal Medicaid law and the PASRR regulations require an additional Resident Review whenever a nursing facility resident experiences a significant change in physical or mental condition. The Resident Review is not the routine Minimum Data Set (MDS) assessment that every resident receives quarterly. It is a separate, condition-triggered review designed to determine whether the resident's new condition warrants a fresh Level I screen, a fresh Level II evaluation, a change in Specialized Services, or a change in placement.

A significant change in condition is defined by federal guidance and includes events such as a new psychiatric diagnosis, a new behavioral manifestation that suggests an underlying psychiatric or developmental condition, a sudden onset of psychotic symptoms, a marked decline in functioning that may indicate a previously undiagnosed condition, or any change that would have triggered a Level II evaluation if it had been present at admission. The nursing facility must initiate the Resident Review process by referring the resident to HSAG for a fresh Level I screen, with the same downstream process applying as for pre-admission cases.

For Diana, an 84-year-old long-term resident in a rural Georgia nursing facility, the Resident Review obligation may be triggered if she begins experiencing late-onset psychotic symptoms that the facility's medical director identifies as inconsistent with her pre-existing dementia profile. The facility refers Diana to HSAG for a fresh Level I screen. The screen identifies a possible SMI condition warranting Level II evaluation. DBHDD conducts the Level II, determines that Diana has late-onset psychosis requiring psychiatric services beyond standard nursing facility care, and adds Specialized Services to her care plan. Diana remains in the facility but with documented psychiatric services targeted to her condition. The Resident Review process protected her access to appropriate care; without it, her psychotic symptoms might have been managed only with sedating medications and behavioral interventions without underlying treatment of the psychiatric condition.

The Resident Review obligation often fails in practice. Nursing facilities may interpret a significant change in condition narrowly, focusing on medical changes that affect the MDS rather than psychiatric or developmental changes that would warrant PASRR re-screening. Family members and the Long-Term Care Ombudsman are often the parties who identify a missed Resident Review trigger. The Ombudsman Program can request a Resident Review on a resident's behalf, and Disability Rights Georgia has used Resident Review failures as the basis for advocacy intervention.

Olmstead and the community-integration mandate

The Supreme Court's decision in Olmstead v. L.C. transformed the legal landscape in which PASRR operates. Olmstead held that under Title II of the ADA, public entities must administer services, programs, and activities in the most integrated setting appropriate to the needs of individuals with disabilities. The decision did not invalidate institutional placement, but it required that states justify institutional placement when a community alternative would meet the individual's needs and the individual does not oppose community placement.

For PASRR, Olmstead has two main consequences. First, the Level II evaluation must consider community alternatives, not just the appropriateness of nursing facility placement. If a community placement with appropriate supports would meet the resident's needs and the resident does not oppose it, that placement should be offered. Second, the state's obligation to deliver Specialized Services intersects with its Olmstead obligation: a resident receiving Specialized Services in a nursing facility may be entitled to receive equivalent services in a community setting if the community setting is appropriate.

Georgia's 2010 USDOJ Settlement Agreement explicitly addressed PASRR and nursing facility placement of individuals with disabilities. The settlement required Georgia to expand community-based services, reduce nursing facility placement of individuals with ID/DD, and improve coordination between PASRR Level II determinations and community placement options. The Olmstead Hotline is the state's mechanism for individuals to request community placement when they believe they have been inappropriately institutionalized or are at risk of inappropriate institutionalization; verify the current Olmstead Hotline contact details on the DBHDD website.

For Tasha's father, a 70-year-old in Atlanta whom a hospital discharge planner is preparing to transfer to a nursing facility after a hospitalization for a urinary tract infection that complicated his pre-existing schizophrenia, the PASRR Level II evaluation should consider whether community placement with Assertive Community Treatment (ACT), supportive housing, or other DBHDD-funded community services would meet his needs. The evaluator interviews him; he expresses a strong preference for returning to his own apartment with services. DBHDD identifies an ACT team with capacity to serve him, coordinates a transition plan with the hospital, and the nursing facility transfer is averted. Tasha's father returns home with community-based mental health services rather than entering institutional care. The Olmstead-grounded community alternative is not always available, and DBHDD capacity constraints are real, but the PASRR Level II is the trigger that opens the inquiry.

DCH, HSAG, and DBHDD: the Georgia Medicaid PASRR roles

Three Georgia entities operate the PASRR program, and understanding their respective roles is essential for any family or advocate seeking to navigate the process. The current operational structure is summarized below; confirm specific contact details and current responsibilities on each agency's website.

The Department of Community Health (DCH) is Georgia's Medicaid agency. DCH holds the federal PASRR contract obligation, administers nursing facility certification, contracts with HSAG as the PASRR Level I contractor, and maintains the memorandum of understanding (MOU) with DBHDD that allocates Level II responsibilities. DCH's Long-Term Care Bureau is the policy lead on PASRR within DCH, and DCH Medicaid Member Services is the general entry point for member inquiries; verify the current member-services contact details on dch.georgia.gov.

Health Services Advisory Group (HSAG) is the DCH-contracted PASRR Level I administrator. HSAG receives Level I screen submissions from hospitals, community providers, and nursing facilities; processes them; returns determinations; and refers qualifying cases to DBHDD for Level II evaluation. HSAG's Georgia PASRR contact details are published on the HSAG Georgia PASRR page; verify the current line before submitting a screen or status check. HSAG also handles certain administrative functions related to categorical determinations and exempted hospital discharges.

The Department of Behavioral Health and Developmental Disabilities (DBHDD) is Georgia's State Mental Health Authority and Intellectual Disability Authority. DBHDD conducts Level II evaluations through its contracted evaluator network, oversees Specialized Services delivery for residents with positive Level II determinations, and coordinates community placement options for residents whom Level II determinations identify as appropriate for community settings. DBHDD intake and the DBHDD Office of Behavioral Health Quality (which handles PASRR program inquiries) are accessible through the DBHDD website; verify current phone numbers there.

The DCH-DBHDD MOU allocates operational responsibility for PASRR between the two agencies. DCH retains overall program responsibility and pays for PASRR administration; DBHDD operates as the State Mental Health Authority and Intellectual Disability Authority and is responsible for Level II evaluations and Specialized Services. The Olmstead Hotline sits at the intersection of the two agencies' work and handles community-placement inquiries; the current Olmstead Hotline number is posted on the DBHDD website.

Georgia Medicaid PASRR nursing facility responsibilities

Federal regulation places several specific obligations on nursing facilities themselves. Under the federal Medicaid nursing facility requirements, nursing facilities cannot admit a resident without a completed Level I screen, must refer for Level II evaluation when the Level I indicates a concern, must implement the care plan including Specialized Services when a Level II determination requires them, must identify and refer for Resident Review when a resident experiences a significant change in condition, and must cooperate with state PASRR program audits and Olmstead-related inquiries.

Facilities that fail to comply with PASRR are exposed to several consequences. CMS surveyors operating under the CMS nursing facility survey framework cite facilities for PASRR non-compliance during annual surveys and complaint investigations. The Georgia State Survey Agency conducts the surveys on CMS's behalf. Citations for PASRR violations can result in plans of correction, civil money penalties, denial of payment for new admissions, and in serious cases termination of the Medicaid provider agreement. Repeated failure to deliver Specialized Services to Level II-positive residents has been the basis for federal enforcement actions in several states.

Facilities also face the financial risk of payment recoupment for residents who were admitted without proper PASRR screening. CMS can deny Medicaid payment for the period during which a resident was inappropriately housed in the facility without a Level II determination, and DCH has audit authority to identify such cases in Georgia.

How families navigate Georgia Medicaid PASRR

The PASRR process is largely invisible to families until it goes wrong. Most Georgia families never see a Level I screen submitted on their behalf, never hear that a Level II evaluation was triggered (or not triggered), and never know that the resident has a right to community placement when a Level II identifies a community alternative as appropriate. The following family scenarios illustrate how PASRR shapes nursing facility placement decisions in Georgia.

Eleanor, 78, Macon: post-stroke admission and the Level I screen

Eleanor is hospitalized at Atrium Health Navicent in Macon after a stroke that has left her with right-sided weakness and dysphagia. Her physician determines that she needs three to four weeks of rehabilitative skilled nursing care before she can return home. The hospital discharge planner identifies a Medicaid-certified nursing facility in Bibb County and prepares the referral. As part of the referral, the discharge planner completes a Level I screen and submits it to HSAG. The screen asks about Eleanor's psychiatric history (none), about intellectual disability (none), and about other developmental disabilities (none). The screen also notes Eleanor's age and asks about dementia; Eleanor has no dementia diagnosis. HSAG processes the screen, returns a negative Level I determination, and clears Eleanor for admission. The discharge planner uses the exempted hospital discharge category given Eleanor's multi-day hospital stay and the physician's certification that her nursing facility stay is expected to be short. Eleanor is admitted to the nursing facility, receives rehabilitative care, and is discharged home after a few weeks. The PASRR process operated as a brief administrative step that confirmed Eleanor did not have an underlying SMI, ID, or DD condition that would warrant deeper evaluation.

Marcus, 52, Albany: psychiatric hospitalization to nursing facility transfer

Marcus is a 52-year-old in Albany with a long-standing diagnosis of schizoaffective disorder. He has been hospitalized at the state psychiatric hospital after an acute episode involving suicidal ideation. As his acute symptoms resolve, his treatment team identifies that he also has poorly controlled diabetes that requires more medical management than community supports in Dougherty County can immediately provide. The hospital discharge planner explores nursing facility placement to address his medical needs and submits a Level I screen to HSAG. The screen identifies Marcus's SMI history. HSAG refers Marcus to DBHDD for a Level II evaluation. The DBHDD evaluator, a psychiatrist, meets with Marcus, reviews his records, and consults with his current psychiatric treatment team. The evaluator concludes that Marcus has SMI and currently needs nursing facility-level medical services for his diabetes management, but also needs Specialized Services for his schizoaffective disorder while in the nursing facility. The evaluator also considers community alternatives: with intensive case management, supportive housing, and DBHDD-coordinated medical services, Marcus could potentially be served in the community. Marcus expresses interest in eventually returning to the community but acknowledges he needs medical stabilization first. The evaluator's determination is that Marcus is appropriate for short-term nursing facility placement with Specialized Services attached, and that DBHDD will coordinate a transition to community placement. Marcus is admitted, the nursing facility provides medical care, DBHDD coordinates with a contracted psychiatric provider to deliver weekly therapy and medication management at the facility, and Marcus's case manager works on his community transition plan during his stay.

Jamil, 32, Columbus: ID/DD individual placed in nursing facility

Jamil is a 32-year-old in Columbus with moderate intellectual disability who has lived with his mother throughout his life. His mother has recently been diagnosed with terminal cancer and can no longer care for him. The family does not have other relatives able to take him in, and a hospital social worker preparing for his mother's discharge to hospice has been unable to identify a community placement on a same-day basis. As a stopgap, the social worker refers Jamil to a Muscogee County nursing facility and submits a Level I screen. The screen identifies Jamil's intellectual disability. HSAG refers him to DBHDD for a Level II evaluation. The evaluator, a developmental specialist, conducts an in-person evaluation and concludes that Jamil does not need nursing facility-level services. He is medically stable, ambulatory, and does not require skilled nursing care. He does need extensive supports for activities of daily living, supervision, and structured programming targeted to his developmental level. The evaluator determines that a community placement with COMP (Comprehensive Supports) Waiver services would be appropriate and that Jamil opposes nursing facility placement. DBHDD's regional office identifies that Jamil is already on the COMP waiver waiting list (or eligible for crisis priority given his mother's terminal illness) and coordinates an emergency placement. Within days, DBHDD identifies a Muscogee County host-home provider with COMP waiver capacity and Jamil is transitioned directly from the hospital to the host-home placement without ever being admitted to the nursing facility. The Level II determination opened a community pathway that would not have been available without PASRR.

Aisha, 65, Savannah: depression and dementia complicating nursing facility placement

Aisha is a 65-year-old in Savannah who has been treated for major depressive disorder for over 20 years, with two prior psychiatric hospitalizations. She has also been recently diagnosed with mild-to-moderate Alzheimer's disease. After a fall and hip fracture, her orthopedic surgeon recommends a short-term skilled nursing facility stay for rehabilitation. The hospital discharge planner submits a Level I screen to HSAG. The screen notes both Aisha's longstanding depression (which qualifies as SMI under federal definitions) and her dementia diagnosis. Because her SMI predated her dementia, the SMI controls for PASRR purposes, and HSAG refers Aisha to DBHDD for a Level II evaluation. The DBHDD evaluator concludes that Aisha has SMI and currently needs short-term nursing facility services for hip rehabilitation. The evaluator determines that Aisha would benefit from Specialized Services for her depression while at the nursing facility, particularly given that her dementia and recent injury have placed her at elevated risk for depressive decompensation. The evaluator's determination triggers DBHDD's arrangement of weekly psychotherapy and medication management visits during Aisha's nursing facility stay. Aisha is admitted with Specialized Services attached, completes her rehabilitation in five weeks, and returns home with continued community-based mental health services. Without PASRR, Aisha's depression might have gone untreated during her nursing facility stay, with documented risk of poor recovery outcomes.

Diana, 84, rural Georgia: Resident Review for change in condition

Diana is an 84-year-old long-term nursing facility resident in a rural Georgia county. She was admitted three years ago after a hip fracture and has remained in the facility because she has no family able to provide community-based supports. Her Level I screen at admission was negative; she had no SMI, ID, or DD history, and her dementia diagnosis at admission did not trigger Level II evaluation under the dementia exemption. Over the past four months, the facility's medical director has noted that Diana has begun experiencing what appear to be psychotic symptoms: persistent paranoid beliefs, occasional hallucinations, and behavioral disturbances that are not typical for her dementia trajectory. The medical director suspects late-onset psychosis or a previously undiagnosed psychiatric condition. Under the federal PASRR Resident Review requirement, this constitutes a significant change in condition warranting Resident Review. The facility refers Diana to HSAG for a fresh Level I screen. The screen now identifies the new psychiatric symptoms, and HSAG refers to DBHDD for Level II evaluation. The Level II evaluator confirms a psychotic disorder warranting psychiatric care and determines that Diana now needs Specialized Services that were not required at admission. DBHDD coordinates with a contracted geriatric psychiatrist to provide consultation and ongoing medication management at the facility, and the facility revises Diana's care plan to incorporate the Specialized Services. The Resident Review obligation under PASRR ensured that Diana's emergent psychiatric condition received targeted treatment rather than being managed only with non-specific sedating medications.

Tasha's father, 70, Atlanta: Olmstead-grounded nursing facility diversion

Tasha is the daughter of a 70-year-old Atlanta resident with longstanding schizophrenia who has lived in his own apartment for many years with weekly community mental health visits. He has recently been hospitalized at Grady Memorial for a complicated urinary tract infection that exacerbated his psychiatric symptoms. As he stabilizes medically, the hospital discharge planner is preparing to transfer him to a nursing facility because the planner is uncertain whether his community supports can handle his return. Tasha objects and asks for a PASRR Level II evaluation before any nursing facility transfer. The Level I screen is submitted, identifies his SMI history, and triggers a Level II evaluation. The DBHDD evaluator interviews Tasha's father, his apartment landlord, and his current community mental health team. The evaluator concludes that Tasha's father does not need nursing facility services, that with intensified community supports (an Assertive Community Treatment team or expanded case management) he could return to his apartment, and that he strongly opposes nursing facility placement. The evaluator's determination, combined with the Olmstead community-integration mandate, leads DBHDD to coordinate a transition plan that returns Tasha's father to his apartment with an ACT team taking over his community supports. The nursing facility transfer never happens. Without PASRR and without Olmstead, the hospital discharge would almost certainly have ended in nursing facility placement, and Tasha's father would have lost the apartment he had lived in for over a decade.

Common failure modes and how families respond

PASRR's effectiveness depends on every actor in the chain doing their job, and the process fails in several recognizable patterns.

Missed Level I screens at admission are the most fundamental failure. A nursing facility that admits a resident without completing the Level I screen is in clear violation of federal regulation. Families typically discover this only when reviewing the resident's medical record or when a surveyor citation reveals it. The Georgia Long-Term Care Ombudsman and the State Survey Agency are the primary mechanisms for reporting and correcting missed screens.

Level II referrals that should have been made but were not are a more subtle failure. A Level I screen may identify SMI, ID, or DD indicators but the case may not be referred to DBHDD, or the referral may be made but never acted on. Tracking individual cases through the HSAG-DBHDD handoff is difficult for families, and the family's best protection is to request, in writing, copies of any Level I and Level II screening documents from the nursing facility and to follow up with HSAG and DBHDD directly.

ID/DD residents placed in nursing facilities without Specialized Services are a population that Olmstead settlements across the country have repeatedly targeted. Federal regulation requires Specialized Services for any resident with a positive Level II determination, but states have struggled to deliver these services consistently. If a Georgia family member with ID/DD is in a nursing facility, families should ask explicitly whether Specialized Services have been arranged, request documentation, and contact Disability Rights Georgia or the Georgia Advocacy Office if the services are not being delivered.

Missed Resident Reviews when a resident's condition changes are common because the facility may interpret significant change narrowly. Family members are often the first to notice psychiatric or behavioral changes, and a written request to the facility for a Resident Review (with a copy to HSAG) creates a documented basis for triggering the process.

Olmstead-grounded community alternatives that the Level II identifies as appropriate but that DBHDD does not arrange are a separate category of failure. The Level II determination is supposed to open the community-placement pathway, but DBHDD capacity constraints may delay or prevent the placement. The Olmstead Hotline is the state's mechanism for escalating these cases, and legal services organizations (Georgia Legal Services Program, Atlanta Legal Aid Society) can support families when administrative escalation has not produced a placement.

Appealing a Georgia Medicaid PASRR determination

A PASRR determination can be appealed. Under the federal PASRR appeal-rights provision, the resident or applicant has the right to appeal a Level II determination through the state fair hearing process. In Georgia, PASRR appeals are heard through the Office of State Administrative Hearings (OSAH), with appeal rights set out in the resident's notice of determination. The notice itself is supposed to explain the determination, the basis for it, the resident's right to appeal, and the deadline for filing the appeal; consult the notice and the OSAH website for the operative filing deadline.

The grounds for appeal include disagreement with the Level II evaluator's clinical determination, disagreement with the placement recommendation, disagreement with the Specialized Services determination, and procedural challenges (such as a screening that was conducted without proper notice or that did not include the resident's records). Families should keep copies of all PASRR documentation, including the Level I screen, the Level II evaluation report, the determination notice, and any related correspondence with HSAG, DBHDD, or the nursing facility.

Appeals are heard by an OSAH administrative law judge. The resident may be represented by an attorney, a family member, an Ombudsman, a Disability Rights Georgia advocate, or another representative. Legal services organizations may be able to provide free representation depending on the resident's income and the nature of the appeal. The OSAH hearing is on the record and the ALJ's decision can be further appealed through the state administrative process and into state court.

Beyond the formal appeal, families have other escalation paths. Complaints to the State Survey Agency can result in surveyor investigations of facility-level compliance. Complaints to CMS Region IV in Atlanta can trigger federal-level review. Complaints to the HHS Office for Civil Rights Region IV are appropriate when the underlying issue involves discrimination or violations of Section 504 or the ADA.

A few more common questions:

What is the difference between PASRR and the routine MDS assessment? The MDS (Minimum Data Set) is the federally required functional assessment that every nursing facility resident receives at admission and quarterly thereafter, used primarily for care planning and Medicare/Medicaid reimbursement classification. PASRR is a separate screening focused specifically on SMI, ID, and DD conditions. The two processes overlap but are not interchangeable, and a completed MDS does not satisfy the PASRR requirement.

What does "Specialized Services" mean and who pays for them? Specialized Services are clinical or programmatic services targeted to a resident's underlying SMI or ID/DD condition that go beyond what a nursing facility ordinarily provides. The state, through DBHDD, is responsible for arranging Specialized Services and bears the cost. Specialized Services may be delivered at the nursing facility (for example, weekly psychiatric visits) or through community arrangements.

What is the exempted hospital discharge category? An individual being discharged from a hospital to a nursing facility may be admitted under a presumptive Level II determination if the hospital stay meets the federal multi-day inpatient threshold, the attending physician certifies that the nursing facility stay is expected to be short-term, and the resident requires nursing facility services for the condition treated in the hospital. If the stay extends beyond the regulatory short-stay window, the facility must refer the resident for a full Level II evaluation.

What is a Resident Review and when is it triggered? A Resident Review is a fresh PASRR screening of a current nursing facility resident, triggered by a significant change in physical or mental condition. Significant change includes a new psychiatric diagnosis, new behavioral manifestations suggesting an undiagnosed condition, sudden onset of psychotic symptoms, or any change that would have triggered a Level II evaluation if present at admission. The nursing facility is obligated to identify and refer such cases.

How does Olmstead affect Georgia Medicaid PASRR? The Supreme Court's Olmstead decision under Title II of the ADA requires that public entities serve individuals with disabilities in the most integrated setting appropriate to the individual's needs. The Level II evaluation must consider whether a community alternative would meet the resident's needs and whether the resident opposes community placement. Georgia's 2010 USDOJ Settlement Agreement specifically addressed nursing facility placement of individuals with disabilities and required expansion of community-based services. The Olmstead Hotline handles community-placement requests; verify the current line on the DBHDD website.

What should I do if my family member was admitted to a nursing facility without a Georgia Medicaid PASRR Level I screen? Contact the Georgia Long-Term Care Ombudsman and the State Survey Agency. Request copies of the resident's medical record and any PASRR documentation in writing from the facility. If the screen was not done, request that it be completed immediately. Missed Level I screens are clear violations of federal regulation, and survey citations and payment recoupment may apply.

What if my family member is in a nursing facility but has ID/DD and is not receiving Specialized Services? Contact DBHDD directly and request documentation of the Level II determination and the Specialized Services plan. If Specialized Services were determined to be needed but are not being delivered, contact Disability Rights Georgia or the Georgia Advocacy Office. Failure to deliver Specialized Services is a basis for federal enforcement and for legal advocacy.

Key Georgia Medicaid PASRR contacts

For current phone numbers and contact details, consult the official websites:

• Georgia Department of Community Health (DCH Medicaid Member Services, Aged Blind Disabled / Long-Term Care, member inquiries)
• Health Services Advisory Group (HSAG Georgia PASRR Level I contractor; submit Level I screens and check status)
• Georgia Department of Behavioral Health and Developmental Disabilities (DBHDD Intake, Office of Behavioral Health Quality for PASRR program inquiries, Olmstead Hotline)
• Georgia Long-Term Care Ombudsman
• Georgia Aging and Disability Resource Connection (ADRC)
• Georgia Legal Services Program
• Atlanta Legal Aid Society
• Disability Rights Georgia
• Georgia Advocacy Office
• HHS Office for Civil Rights Region IV
• 211 Georgia (community-resource referral)

Find personalized help navigating Georgia Medicaid PASRR at brevy.com.