F-645 PASARR: Tips for Compliance & Success
Insights from Nancy Foss, RN, BSN – Director of Regulatory and Consulting Services
As skilled nursing facilities face rising admissions of younger residents, individuals with complex mental health needs, and those requiring specialized behavioral supports, F645 PASARR compliance has become a leading focus for surveyors nationwide. Yet, many facilities still misunderstand or misapply the regulation—placing them at significant risk.
What PASARR Really Is and Why It Matters
PASARR (Preadmission Screening and Resident Review) is required under federal law for all individuals seeking admission to a Medicaid-certified nursing facility. Its purpose is to identify whether a prospective resident has:
- A serious mental illness (SMI)
- An intellectual disability (ID)
- A related condition (RC)
And to determine whether a nursing facility is the appropriate placement, and the individual requires specialized services beyond what the facility can provide.
PASARR begins with a Level I screen and may trigger a Level II evaluation if concerns are identified. This process ensures that residents receive care in the most integrated, appropriate setting.
Where Facilities Are Struggling
One of the most common and concerning issues is that PASARRs are being completed after the resident arrives, despite clear regulatory requirements stating that PASARR must be completed before admission.
Many staff—particularly newer social workers, admission coordinators, or agency personnel—either misunderstand the mandate or rely on misinformation from hospital discharge planners.
This practice leads to:
- Admissions of residents whose needs exceed the facility’s capacity
- Delays in required Level II evaluations
- Missing specialized service plans
- Survey citations under F645
- Challenges supporting residents with mental health or behavioral needs
What Triggers a Level II?
A positive Level I screen—based on diagnosis, behaviors, medication history, or functional changes—may require a Level II evaluation.
Level II requirements often occur when:
- A resident has a significant mental health condition
- An intellectual disability or related condition is present
- There is a significant change in condition
- Hospital exemptions are incorrectly applied
With more younger residents entering long-term care and more facilities managing behavioral health complexity, Level II triggers are becoming more common.
PASARR is More Than Paperwork
PASARR is not simply a compliance step. It is a resident-centered, safety-focused assessment that ensures proper placement and integrated care, identifies needed specialized services, protects resident rights, and supports quality of life.
Additionally, PASARR also helps prevent facilities from accepting residents whose behavioral, psychiatric, or habilitation needs exceed available staffing or competencies.
Important PASARR Exemptions Leaders Must Understand
PASARR is not required for:
Hospital Readmissions: Residents returning from a hospital stay do not require a new PASARR.
Direct Admissions with a 30-Day Exemption: A physician may certify an anticipated stay of less than 30 days when the admission is for the same condition treated in the hospital.
While these exceptions are in place, facilities often incorrectly apply them, resulting in residents remaining past 30 days without the required Level II review.
Who Provides Specialized Services?
If PASARR identifies the need for specialized services, these must be delivered by external qualified professionals, not the nursing facility. These professionals may include:
- Psychiatrists
- Psychologists
- Behavioral specialists
- Physical, occupational, or speech therapists
- State developmental disability agencies
- Qualified rehabilitation counselors
Facilities must coordinate these services as part of the resident’s ongoing plan of care.
Leadership Considerations
Meeting PASARR requirements is an essential step to ensure facility compliance and enhance care outcomes. Consider the following priorities:
- Make PASARR Truly a Pre-Admission Step: Admissions should not move forward without completed Level I screening and any Level II requirements.
- Build Strong Relationships With Hospital Discharge Planners: Ongoing communication reduces delays and prevents last-minute surprises.
- Educate Admission, Social Services & Clinical Teams: Ensure teams understand what PASARR is, who completes it, how Level II recommendations affect care, and documentation expectations.
- Integrate PASARR into Pre-Admission Screening Systems: PASARR should be as routine as medical necessity reviews, payer confirmations, and clinical eligibility evaluations.
- Incorporate Level II Recommendations into Care Plans: Failure to operationalize Level II findings is a common survey citation.
- Monitor Length of Stay for 30-Day Exemptions: Residents admitted under exemptions must be closely monitored to ensure compliance.
Helpful Resources
Pathway Health Resources:
At Pathway Health, our team brings real-world insight, expertise, and proven education tools to help your organization thrive. Learn more about our resources below:
- PASARR QuickPATH RoP
- Admissions QuickPATH RoP
- The Requirements of Participation – Policy and Procedure Manual (Targeted Sections)
- The Requirements of Participation – Policy and Procedure Manual (Targeted Sections)
- Pathway Health Education Platform
- INTERACT Policy & Procedure Manual
Tune In! New PATHTalks Episode
In our latest PATHTalks episode, Pathway Health’s COO Lisa Thomson connects with Director of Regulatory and Consulting Services, Nancy Foss. She sheds light on the recurring gaps, the importance of PASARR beyond paper compliance, and the leadership actions required to protect residents, mitigate risk, and maintain regulatory compliance.
For deeper insights into the health care continuum and more, explore our other PATHTalks episodes today.
