Although Nursing Facilities (NFs) are primarily responsible for helping individuals transition to the community, PASRR can play a vital role in helping NFs develop individualized plans of care that support successful transition. The “common ground” of NFs and State PASRR programs is the well-being of the individual.
The Code of Federal Regulations (CFR) at §483.21 defines NF requirements for comprehensive person-centered care planning, including establishing initial baseline care plans, comprehensive care plans, and an effective discharge planning process. The capacity of the NF to develop a baseline care plan, and a comprehensive care plan, can be greatly influenced by the information detailed in the PASRR Level II report and determination.
The PASRR evaluation criteria at §483.128, and the criteria for determining the need for mental health (§483.134) or intellectual disability (§483.136) specialized services, all focus on ensuring that the PASRR findings are as person-centered as possible. Those findings and recommendations, detailed in the Level II report help ensure that the NF is aware of the need for services unique to the individuals PASRR condition, and the information can help the NF identify appropriate personnel for providing those services.
Also see PTAC Webinar, April 2018: Discharge Planning and Transitions into the Community