PASRR Level I and Level II Documentation

Pre-admission screening form to document PASRR Level I completion and, when indicated, Level II review for mental illness or intellectual disability prior to skilled nursing admission.

Submission Overview

• Submission Type
• Facility Name
• Screening Date
• Screening Completed By
• Anonymous submission
  Select only if your workflow allows anonymous submission. Do not include patient-identifying details if anonymous is selected.

Resident Screening Details

• Resident Initials
  Use initials or your facility-approved identifier if full name is not required.
• Date of Birth
  Collect only if required by your PASRR workflow or state process.
• Medicaid ID Last 4 Digits
  If needed, enter only the last 4 digits to minimize PII exposure.
• Admission Type
• Planned Admission Date

Level I Screening

• Was Level I screening completed?
• Level I Completion Date
• Suspected mental illness present?
• Suspected intellectual disability present?
• Basis for Level I determination
  Select all that apply to support the screening decision.

Level II Review

• Was Level II referral made?
• Referral Date
• Reviewing Entity
  Enter the state-designated review entity or contractor name if applicable.
• Level II Review Status
• Level II Outcome Summary
  Summarize the outcome and any admission restrictions, recommendations, or next steps.

Admission Disposition

• Admission Disposition
• Follow-up Actions
  Select all actions that apply.
• Next Review Date

Attestation and Consent

• Attestation
  I attest that the information provided is accurate to the best of my knowledge and collected in accordance with applicable privacy and documentation requirements.
• Signature
• Signature Date