Why resident reviews matter
As states look to strengthen Medicaid oversight and improve long-term services and supports (LTSS) outcomes, PASRR resident reviews are drawing renewed attention for their roles in both resident protection and Medicaid accountability.
The perspective that PASRR compliance works best when it is proactive, interdisciplinary, and clearly understood across roles was a prominent theme in recent conversations with state leaders and providers at the South Dakota Healthcare Association (SDHCA) Spring Institute, where Maximus clinical experts participated in a PASRR session with representatives from the South Dakota Department of Social Services, Division of Medical Services.
Resident reviews apply to individuals already residing in a Medicaid-certified nursing facility, regardless of payor source, diagnosis, or admission setting. These event-driven reviews occur when there is a change that could affect an individual’s PASRR determination, care needs, or appropriate placement. This may include changes in clinical or psychiatric condition, psychotropic medication changes, missing PASRR history, or the expiration of time-limited approvals.
That distinction is important because resident reviews are what keep PASRR current over time. A person’s condition may evolve after admission. Diagnoses may become clearer. Service needs may increase, decrease, or shift. Without a process for updating those determinations, care planning can fall out of sync with the individual’s needs. Resident reviews help prevent that gap by ensuring that PASRR continues to reflect the person’s current situation rather than just the information available at admission.
The connection to Medicaid program integrity
Resident reviews help ensure that nursing facility placement remains appropriate, that PASRR-identified services are reflected in care planning, and that required documentation is current and complete. In practical terms, that means Medicaid payments are supported by evidence that federal PASRR requirements have been met.
When resident reviews are delayed, missed, or based on incomplete information, the risk extends beyond compliance paperwork. States may have difficulty demonstrating that an individual is in the right setting, receiving the right services, and supported by a current PASRR determination. That creates exposure to audit findings, survey issues, and improper payment risk. In this way, Resident Reviews are not separate from program integrity — they are one of the mechanisms that enable it.
Support for better, person-centered care
Resident reviews also support person-centered care by ensuring that PASRR recommendations are integrated into care planning as resident needs change. When conducted effectively, resident reviews help assess whether an individual continues to require nursing facility level of care, whether specialized services are needed, and whether another setting may now be more appropriate.
This is especially important for states seeking to prevent unnecessary or prolonged institutional stays. A strong resident review process can help surface opportunities for more appropriate services and settings while reinforcing the expectation that care plans should reflect the full picture of the resident’s needs. That alignment benefits both the individual and the Medicaid program.
Shared accountability for improved compliance
Although PASRR involves multiple parties, nursing facilities play a central role in ensuring compliance with resident review. They are the ongoing point of contact for monitoring changes in a resident’s condition, maintaining current documentation, and recognizing when a review is warranted. At the same time, effective resident reviews depend on coordination across hospitals, referring providers, facility staff, and the clinical services vendors responsible for PASRR determinations.
One of the strongest themes to emerge at the SDHCA Spring Institute was the drive for greater alignment across stakeholders. PASRR works best when administrators, nursing staff, care coordinators, social services personnel, and compliance teams operate from a shared understanding of triggers, responsibilities, and timelines. Without that alignment, avoidable delays and rework can undermine both care planning and compliance.