Background Pursuant to the Community Mental Health Act of 1963, state psychiatric hospital residents were discharged en masse and moved back home into their communities. In many cases, residents who were over 65 had no home or family to return to, and the newly organized system of community mental health centers was poorly prepared to treat geriatric patients. As such, many of these older adults were transferred into nursing facilities, often without being provided necessary specialized services (Committee of Nursing Home Regulation, 1986; Kahn, 1975). The Institute of Medicine (IOM) defined the unexpected increase in nursing facility residents with psychiatric conditions and the corresponding lack of specialized care as a public-health-policy problem (Institute of Medicine [IOM], 1986). In response, the United States Congress enacted the Nursing Home Reform Act (NHRA) as part of the Omnibus Budget Reconciliation Act of 1987. The goal of the NHRA was to reduce the use of physical restraints and medications as the primary form of care for residents with psychiatric conditions and to increase the use of nonpharmacological therapeutic services (Molinari et al., 2011). To reach this goal, the NHRA required all states to implement the Pre-Admission Screening and Annual Resident Review (PASRR), a process of care designed to prevent individuals with serious psychiatric conditions from being placed in a nursing facility that could not provide specialized services (Timmel, 2005). Operationally, PASRR consists of two steps, and any licensed nursing facility that receives Medicaid reimbursements

meningitis, and from the first he had very active, long delirium. This case was followed by 6 other cases of typhoid fever, 25 mild cases of dysentery, and 28 cases of malarial fever. There was also an average of from twenty-five to thirty general minor ailments per diem, and, with the exception of six cases of typhoid fever, which were through their third week, one case of malaria, and one convalescent from typhoid fever, all were well when we arrived at Plymouth. These eight cases were transferred to the hospital ship at Plymouth. My general opinion of the men was that they were fine specimens of the nationality to which they belong and that the officers were a real good set of fellows. I remain, Sirs, yours very truly,