How to Fill Out and Submit the PASRR Level 1 Screening Form

The PASRR Level 1 screening form is a short federal checklist that must be completed for every person seeking admission to a Medicaid-certified nursing facility, no matter who is paying.¹ To complete it, you pull the applicant’s medical, psychiatric, and developmental records, fill out the demographics section and the two clinical screens (mental illness and intellectual disability or related conditions), then submit the signed form to your state’s PASRR agency before the person is admitted.² Whoever handles the transfer usually does the paperwork: a hospital discharge planner, a social worker, or nursing facility intake staff.

Who the Form Applies To

Federal law requires a Level 1 screen for every applicant to a Medicaid-certified nursing facility, including private-pay and Medicare residents.³ It also has to be repeated for current residents when they experience a significant change in condition, meaning a major decline or improvement that will not resolve on its own, affects more than one area of health, and calls for changes to the care plan.⁴ If a setback that first looked short-term hasn’t cleared within about two weeks, treat it as significant and start a new screen.

Documents to Gather Before You Start

Incomplete records are the most common reason screenings stall. Before you open the form, pull:

A current medication list, with attention to psychiatric drugs (antipsychotics, mood stabilizers, anxiolytics) and medications for seizures or other neurological conditions. An active psychiatric prescription is often the first sign the mental illness section needs a closer look.
Psychiatric and behavioral health history for the past two years, including any inpatient stays, partial hospitalization, or crisis stabilization.
Developmental disability records: diagnoses, functional assessments, or service plans from a state intellectual or developmental disability agency. Documentation showing onset before age 22 is essential for related-condition determinations.
The hospital discharge summary if the person is transferring from acute care. It confirms diagnosis, treatment, and the physician’s estimate of how long nursing facility care will be needed.
The physician’s statement of the primary diagnosis, particularly whether dementia is listed as primary, because that changes how the mental illness section is scored.

If the person transferred from another facility or has a fragmented care history, contact prior providers before completing the form rather than leaving clinical questions blank or guessing.

The Demographics Section

Each state designs its own Level 1 form, and you can typically download it from your state Department of Health or Medicaid agency website.⁵ The demographics section is the same in spirit everywhere: full legal name, date of birth, Social Security number, and current address. Most versions also ask for the referral source (hospital name, attending physician), the anticipated admission date, and the expected payer. This information ties the screening to the person’s Medicaid record and lets the state agency track the case.

The Mental Illness Screen

The mental illness section walks through three criteria drawn from 42 CFR 483.102. All three must be present for the person to meet the federal definition of serious mental illness:⁶

A qualifying diagnosis, such as schizophrenia, a mood disorder, a severe anxiety or panic disorder, a somatoform disorder, a personality disorder, or another psychotic disorder that may lead to chronic disability.
Functional impairment: the disorder has caused significant difficulty in at least one major life area within the past three to six months, such as trouble interacting with others, inability to sustain concentration on routine tasks, or serious difficulty adapting to change.
Recent treatment history: within the past two years, the person received psychiatric care more intensive than outpatient (such as inpatient or partial hospitalization), or experienced a major disruption to their living situation that required support services or intervention by law enforcement or housing officials.

The form will also ask whether dementia is the primary diagnosis. This matters. A primary diagnosis of dementia, including Alzheimer’s disease, excludes the person from the serious mental illness category under PASRR even if a mental health condition co-exists.⁶ If the person has both dementia and a major mental disorder, the mental illness must be the more serious of the two for the section to screen positive.²

The Intellectual Disability and Related Condition Screen

The second clinical section asks whether the person has an intellectual disability at any level (mild, moderate, severe, or profound) or a related developmental condition.⁶ A “related condition” under federal Medicaid rules is a disability that:⁴

Is caused by cerebral palsy, epilepsy, or another condition (other than mental illness) that impairs intellectual functioning or requires services similar to those provided for intellectual disability
First appeared before age 22
Is expected to continue indefinitely
Causes substantial functional limitations in three or more major life activities: self-care, language, learning, mobility, self-direction, or capacity for independent living

Check the medical history for any prior diagnosis of intellectual disability, autism, cerebral palsy, spina bifida, or similar developmental conditions. Records from childhood developmental services, school-based individualized education programs, or adult disability service agencies are the most useful documentation. If the person has a known related condition, record it even if the current reason for seeking nursing facility care is purely physical. The screening looks at the full diagnostic picture, not just the presenting complaint.

When a Level 2 Isn’t Required Even After a Positive Screen

Some admissions still get a Level 1 but skip or defer the deeper Level 2 evaluation. The exempted hospital discharge covers a direct transfer from an acute-care hospital when the person needs nursing facility services for the same condition treated in the hospital and the physician certifies the stay will likely last fewer than 30 days. If the stay exceeds 30 days, the state must complete the Level 2 within 40 calendar days of admission.⁷

States can also set categorical determinations for preset situations: convalescent care after hospitalization, terminal illness with a prognosis of six months or less, severe physical illness such as coma or ventilator dependence, provisional admission during delirium, emergency protective services for up to 7 days, and short respite stays.⁸ Each category carries a time limit; if the stay runs past it, a full Level 2 has to be started before the stay can continue.

Submitting the Completed Form

The discharging hospital or the receiving nursing facility submits the completed Level 1 form to the state agency that administers PASRR, usually the Department of Health, the Medicaid agency, or a designated contractor. Most states accept submissions through a secure online portal or health information exchange; some still allow fax or registered mail. Your state Medicaid agency website lists the exact method and address.

When the screen identifies a person as potentially having a serious mental illness or intellectual disability, the state must send written notice to the individual (or their legal representative) that they are being referred to the state mental health or intellectual disability authority for a Level 2 evaluation.⁵ Keep a copy of the completed form and any confirmation receipt in the resident’s permanent medical record. Facilities need that documentation to demonstrate compliance during audits.

What Happens After You Submit

A negative screen means no indicators of serious mental illness, intellectual disability, or a related condition were found. Admission can proceed. Retain the completed form as proof the federal screening requirement was met at admission.

A positive screen triggers a Level 2 evaluation by the state mental health authority or the state intellectual disability authority, depending on the finding.¹ The Level 2 is a comprehensive, individualized assessment answering two questions: does the person genuinely need nursing facility-level care, and do they need specialized services for their mental illness or intellectual disability? Federal regulations require the state to issue its written determination within an annual average of 7 to 9 working days after receiving the Level 2 referral.⁹ Admission is usually held until the determination comes through, so stay in close contact with the state agency during this window to avoid bed-hold costs.

The Level 2 comes back one of three ways: nursing facility care is appropriate and no specialized services are needed, in which case admission proceeds; nursing facility care is appropriate and specialized services are required, in which case the facility must build those services into the care plan; or nursing facility care is not appropriate, in which case the person should be directed toward community-based services or another residential setting.

Notice and Appeal Rights

The state authority must send written notice of the Level 2 determination to the individual and their legal representative, the nursing facility, the attending physician, and the discharging hospital (unless the person entered under an exempted hospital discharge).¹⁰ That notice must state whether nursing facility services are needed, whether specialized services are needed, what placement options are available, and the right to appeal. An adverse determination, whether it denies nursing facility placement or denies specialized services, can be appealed through the state’s fair hearing process. Make sure the individual or their representative knows the appeal is available before accepting the outcome.

What’s at Stake for Getting It Wrong

Facilities that admit residents without completing the PASRR screening face federal enforcement. CMS can impose civil money penalties under 42 CFR 488.438, deny payment for new admissions, require a directed plan of correction, or in the most serious cases terminate Medicare and Medicaid participation.¹¹¹² Inaccurate screening carries the same risk as no screening: if an auditor finds a pattern of negative screens for residents whose records clearly show a qualifying condition, the compliance history is treated as if the screening never happened.

1
Medicaid. Preadmission Screening and Resident Review
2
PASRR Technical Assistance Center. PASRR in Plain English
3
eCFR. 42 CFR 483.102 – Applicability and Definitions
4
NC Medicaid. Pre-Admission Screening and Resident Review (PASRR)
5
eCFR. 42 CFR 483.128 – Level I Identification of Individuals With MI or IID
6
eCFR. 42 CFR 483.102 – Applicability and Definitions
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eCFR. 42 CFR 483.106 – Basic Rule
8
eCFR. 42 CFR Part 483 Subpart C – Preadmission Screening and Annual Resident Review
9
eCFR. 42 CFR 483.112 – Preadmission Screening of Applicants for Admission to NFs
10
eCFR. 42 CFR 483.130 – PASARR Determination Criteria
11
eCFR. 42 CFR 488.438 – Civil Money Penalties Amounts
12
Centers for Medicare and Medicaid Services. Civil Money Penalty Reinvestment Program