Nursing Home Pre-Admission Screening in Washington State

Before a parent can be admitted to a Medicaid-funded nursing home in Washington, they need to clear a pre-admission screening process. This isn't just a formality — it determines whether nursing home placement is medically necessary, whether there's a community-based alternative that could meet their needs, and whether any mental health or intellectual disability conditions require specialized services that a standard nursing facility isn't equipped to provide.

What the Screening Evaluates

Washington's pre-admission screening has two main components:

Nursing Facility Level of Care (NFLOC) determination. This is handled through the CARE assessment, administered by a DSHS case manager. The assessment evaluates the parent's functional abilities across activities of daily living — bathing, dressing, eating, transferring, toileting, and medication management. To meet the NFLOC threshold, the parent must need extensive assistance with at least two ADLs, or some help with three or more. Alternatively, a person with cognitive impairment who requires supervision and needs extensive help with at least one ADL may qualify.

The CARE assessment classifies the applicant into one of 17 classification groups, which determines both the level of care the state will authorize and the daily reimbursement rate paid to the nursing facility. If the assessment doesn't place the parent at nursing facility level, Medicaid won't pay for nursing home placement — the case manager will recommend community-based alternatives like home care through CFC or an adult family home.

PASRR screening. The Preadmission Screening and Resident Review (PASRR) is a federally mandated process that applies to every individual seeking admission to a Medicaid-certified nursing facility, regardless of payment source. PASRR has two levels:

• Level I is an initial screen, typically completed by the hospital discharge planner or referring provider, that identifies whether the person has a serious mental illness, an intellectual disability, or a related condition.
• Level II is a more detailed evaluation triggered when Level I identifies one of these conditions. A qualified evaluator assesses whether the person needs the specialized services that a nursing home alone cannot provide — and whether nursing home placement is appropriate or whether they should be served in a community setting with specialized supports.

The PASRR process exists to prevent people with mental illness or intellectual disabilities from being inappropriately placed in nursing homes when their needs could be better met elsewhere. It's a protection, even though it can feel like another bureaucratic hurdle when you're in a crisis.

What Families Need to Prepare

The pre-admission process goes faster and produces a more accurate result when you arrive with documentation:

• Medical records showing current diagnoses, medication lists, and recent hospitalizations or rehab stays
• A written description of the parent's daily functional limitations — not how they perform on a good day, but their typical worst-day reality. The "good day" reporting pitfall is one of the most common reasons families end up with an inaccurate assessment.
• Five years of financial records if Medicaid will be the payment source — bank statements, real estate deeds, tax returns, life insurance policies. Washington enforces a 60-month lookback on asset transfers.
• Any existing Durable Power of Attorney documents — the nursing home will need to verify who has legal authority to sign the admission agreement and make healthcare decisions.

Timing Considerations

If your parent is being discharged from a hospital, the timeline can feel compressed. Hospital discharge planners typically work toward a 48-hour placement window. The CARE assessment and PASRR Level I are separate screening steps; if Level II is triggered, allow additional time for that evaluation.

If a hospital is pressuring you to choose a facility before screening is complete, know that Washington law protects patients from unsafe discharges. You can request a discharge appeal through Medicare's Beneficiary and Family Centered Care Quality Improvement Organization if you believe the discharge plan is premature.

What Happens After Placement

The screening doesn't end at admission. DSHS conducts periodic reassessments to verify that the resident still meets nursing facility level of care and that the facility is meeting their assessed needs. For residents who entered through PASRR Level II, specialized services must be documented and monitored on an ongoing basis.

For a full walkthrough of how nursing home placement fits alongside home care, assisted living, and adult family homes in Washington — including cost comparisons, Medicaid eligibility, and the complete CARE assessment process — our Washington care decision guide covers the entire landscape.

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