PASRR and Person-Centered Behavioral Health Services

Notifying the Department of Mental Health, promptly after a significant change in the mental or physical condition of a resident who has mental illness or intellectual disability for resident review, is key to ensuring individuals with a mental disorder or intellectual disabilities receive the care and services they need in the most appropriate setting, when a significant change in their status occurs. A significant change for purposes of PASRR may or may not trigger a significant change in status assessment in the RAI/MDS process.

For behavioral health services, a “significant change” is a major decline or improvement in a resident’s status that

  • will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; the decline is not considered “self-limiting” (NOTE: Self-limiting is when the condition will normally resolve itself without further intervention or by staff implementing standard clinical interventions to resolve the condition.);
  • impacts more than one area of the resident’s health status; and
  • requires interdisciplinary review and/or revision of the care plan.

Examples of such changes include, but are not limited to:

  • A resident who demonstrates increased behavioral, psychiatric, or mood-related symptoms.
  • A resident with behavioral, psychiatric, or mood-related symptoms that have not responded to ongoing treatment.
  • A resident who experiences an improved medical condition—such that the residents’ plan of care or placement recommendations may require modifications.
  • A resident whose significant change is physical, but has behavioral, psychiatric, or mood-related symptoms, or cognitive abilities, that may influence adjustment to an altered pattern of daily living.
  • A resident whose condition or treatment is or will be significantly different than described in the resident’s most recent PASARR Level II evaluation and determination.
  • A resident who indicates a preference to leave the facility. (This preference may be communicated verbally or through other forms of communication, including behavior.)

Referral to DMH should be made as soon as the criteria indicative of a significant change are evident – the facility should not wait until the significant change in status assessment is complete. To notify DMH of a change in status related to disability or mental illness, providers can access the Notification to DMH for CIS and Resident Review Referral Form on DMH’s webpage:

  • Provide ID/MI diagnosis. Describe change in condition or status and the it meets the criteria for reporting the change to DMH.
  • Did the facility access the Behavioral Health Crisis Line for assistance with unsafe behaviors?
  • Date of most current PASRR evaluation and description of how the previous PASRR evaluation differs from the individual’s current condition.

The referral form and questions related to the resident review process should be emailed to:

Are you survey ready? Review CMS’ Behavioral and Emotional Status Critical Element Pathway at