PASRR Level 2 HELP!!!


I'm an MDS Coordinator and have been at my current job for 7 years. During those 7 years we have never had a PASRR level 2 and now we do. I'm kinda confused on what I need to have on this residents care plan? I received a care plan for this resident from PASRR some of the items seem strange like meals on wheels and house keeping this resident is in a long term care facility and these things are provided with that being said do I need to add it to the care plan? They want on the care plan her psychiatric services which I can figure that out, but then in ASCEND there is a Service matters that has to be filled out and it asks about a Behavioral Health Advanced Directive which I have no idea what that is. I feel stupid that I don't know these things. So if there is anyone out there that could help a girlfriend out I would so appropriate it.