All persons needing admission to a nursing facility must first be screened (Preadmission Screening) for possible mental illnesses (Level I). If a mental illness or intellectual disability appears to exist, the person must be referred for further evaluation (Level II) before being admitted to a nursing facility. For mental illnesses, persons are referred for assessment to the Florida Department of Children and Families contracted PASRR provider. For intellectual disabilities, persons are referred to the Agency for Persons with Disabilities (opens in a new window) .

All persons who already reside in a nursing facility are subject to Resident Review if there is a substantial change in their mental status. This warrants a referral for a Level II evaluation to either the Florida Department of Children and Families contracted PASRR provider (opens in a new window) , or the Agency for Persons with Disabilities (opens in a new window) .

Persons may not be admitted to a nursing facility until the Level I screening is completed. If a mental illness or intellectual disability is suspected, admission must wait until the Level II evaluation is also completed.

Each referral must be evaluated to determine whether

• a serious mental illness exists or not,
• the appropriateness of nursing facility level of services for that person; and
• Specialized Services that are needed beyond what the nursing facility can provide.

When a complete PASRR/MI referral packet is received, licensed clinical evaluators will review the documentation and medical records.

If there is not sufficient documentation to make a determination of whether the person has a serious mental illness, the referral source may be asked for additional information and in some cases, a face-to-face evaluation with the individual being referred will be completed.

Face-to-face evaluations typically take 1-2 hours to complete. The evaluator will contact the referring agency, the individual seeking admission and family members, as appropriate, to schedule the date/time/location of the evaluation.

Evaluators are licensed Florida clinicians and include Registered Nurses, Mental Health Professionals and Licensed Clinical Social Workers.

The results of the evaluation and determination will be sent to CARES, CMAT, the hospital and/or the nursing facility, as appropriate, and must be filed in the individual’s medical record. A notice of the decision will also be sent to the client and his/her legal representative.

In the context of the PASRR process, a serious mental illness (SMI) consists of:

1. A diagnosis: The individual has a major mental disorder diagnosable under the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev., 2000). The manual is accessible on the American Psychiatric Association website (opens in a new window) .

a. Schizophrenia, Mood Disorder, Panic or other severe anxiety disorder; Somatoform Disorder; Personality Disorder; Other Psychotic Disorder; or another mental disorder that may lead to a chronic disability; but

b. excludes a primary diagnosis of Dementia, including Alzheimer's disease or a related disorder, or a non-primary diagnosis of dementia unless the primary diagnosis is a major mental disorder as defined in this rule.

2. A level of impairment: the disorder, and not dementia, results in functional limitations in major life activities within the past three to six months that would be appropriate for the individual’s developmental stage; an individual typically has at least one of the following characteristics on a continuing or intermittent basis, or is likely to exhibit the following characteristics without continued treatment or intervention: 

• interpersonal functioning: the individual has serious difficulty interacting appropriately and communicating effectively with other persons, has a possible history of altercations, evictions, firing, fear of strangers, avoidance of interpersonal relationships and social isolation;
• concentration, persistence, and pace; the individual has serious difficulty in sustaining focused attention for a long enough period to permit the completion of tasks commonly found in work settings or in work-like structured activities occurring in school or home settings, manifests difficulties in concentration, inability to complete simple tasks within an established time period, makes frequent errors, or requires assistance in the completion of these tasks; and
• adaptation to change: the individual has serious difficulty in adapting to typical changes in circumstances associated with work, school, family, or social interaction, manifests agitation, exacerbated signs and symptoms associated with the illness, or withdrawal from the situation, or requires intervention by the mental health or judicial system.

3. Recent treatment: the treatment history indicates that the individual has experienced at least one of the following:

• psychiatric treatment more intensive than outpatient care more than once in the past two years (e.g., partial hospitalization or inpatient hospitalization); or
• within the last two years, due to the mental disorder, experienced an episode of significant disruption to the normal living situation, for which supportive services were required to maintain functioning at home, or in a residential treatment environment, or which resulted in intervention by housing or law enforcement officials.

Specialized Services are services provided in a nursing facility including psychiatric consultation, evaluation and psychotropic medication management, and individual and group psychotherapy for an acute episode of mental illness, at levels required to avert or eliminate the need for acute inpatient psychiatric care. These services are provided at the nursing home by a mental health provider.

If Specialized Services are needed, the DCF contracted PASRR provider will develop a recommended Plan of Care which will be sent to the referring facility. It is the responsibility of the Nursing Facility admitting the person to notify the DCF contracted PASRR provider of the pending admission so that Specialized Services may be arranged. Services will be arranged with local mental health providers.

The applicant or resident is notified of their appeal rights when they are notified of the outcome of the Level II determination. Any applicant who is dissatisfied with the determination can appeal the decision by requesting a hearing verbally or in writing to the Department’s contractor. Hearings are conducted by DCF's Office of Appeals and Hearings.