Requirements Reminder for Individualized Discharge Care Planning for PASRR Purposes

February 25, 2013

Dear Nursing Home Administrator:

The purpose of this letter is to remind providers of the requirements for individualized discharge care planning for Preadmission Screen and Resident Review (PASRR) purposes. PASRR Level II Evaluation Report recommendations must be incorporated into the resident's discharge plan of care.

Specifically, nursing homes are reminded that for all completed PASRR Level II Adult Mental Health Evaluation Reports containing the recommendation, "The individual's total needs are such that his or her needs can be met in the appropriate community setting," the nursing home must immediately develop, implement, facilitate and coordinate an active discharge plan in accordance with the individual's needs and desires. This includes the safe and orderly discharge of the resident to the most integrated, appropriate Community Housing with appropriate Community Services.

"Community Housing" means the most integrated setting appropriate to the needs of a person with serious mental illness, where the setting is designed to promote independence in daily living, economic self-sufficiency and the ability to interact with non-disabled persons to the fullest extent possible. Community Housing includes, but is not limited to:

  • Supportive Housing, including Community Residence Single Room Occupancy (CR/SRO), Apartment Treatment, and Family Care;
  • Supported Housing, including Scattered Site Apartments and Single Site Apartments;
  • Independent housing with the person's family or friends;
  • Independent housing not owned or operated by a social service entity;
  • Senior Housing; and
  • Such other housing alternatives as are clinically appropriate for the needs of the particular person.

"Community Services" means services and supports provided in New York State that assist individuals with serious mental illness to live in the community. Such services and supports include, but are not limited to:

  • Assertive Community Treatment (ACT);
  • Intensive Case Management (ICM);
  • Case Management;
  • Personalized Recovery Oriented Services (PROS);
  • Continuing Day Treatment (CDT); and
  • Medicaid benefits for which the individual is eligible, including home and community based services (HCBS) waivers, clinic services, certified home health care, personal care assistance, nursing and rehabilitative services.

For purposes of PASRR, no adult home in New York City and no impacted adult home outside of New York City shall be considered to be Community Housing. For purposes of this letter, an impacted adult home is an adult home in which at least 25% of the resident population or 25 residents, whichever is less, are persons with mental disabilities who have been released or discharged from facilities operated or certified by an Office of Mental Health. Notwithstanding this definition, an individual may make an informed choice to live in housing that is not Community Housing.

For all nursing home residents, the discharge planning process must include direct communication with the resident and, as appropriate, families, guardians and legally authorized representatives. Residents must be provided access to information that allows them to make informed decisions regarding discharge and the nursing home must maintain documentation to support the informed decision making process.

The Department remains committed to ensuring the highest quality of life in the most integrated setting for all New York State residents and will continue to review the nursing home's compliance with federal PASRR requirements. Questions regarding this letter may be directed to the Community Transition Unit at (518) 408-1272 or via email at


Valerie A. Deetz, Director
Community Transition Unit
Center for Health Care Quality & Surveillance