Form 1012, Mental Illness/Dementia Resident Review

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Effective Date: 1/2020


Updated: 1/2020


Form 1012 assists nursing facilities (NF) in determining whether a resident with a negative Preadmission Screening and Resident Review (PASRR) Level I (PL1) Screening form submitted into the Long-Term Care (LTC) Portal, needs further evaluation for Mental Illness (MI).

This form is used to determine whether the individual has a primary dementia diagnosis or if the individual has a mental illness diagnosis. This form also serves as the NF’s documentation for the individual’s medical record as to why further evaluation was or was not completed.

Only a physician, which includes a psychiatrist, can complete Section D this form. A Nurse Practitioner or Physician’s Assistant cannot complete Section D.


When to Prepare

The NF completes Form 1012 following:

   • A determination that a resident with a negative PL1 screening form submitted into the LTC Portal needs further evaluation for MI.
   • An individual’s diagnosis is changed.

Detailed Instructions

Always complete Sections A, B, D, and E. Complete section C when the question in Section B is answered “No.”  

Section A. Resident and Nursing Facility Identifying Information – Complete each field and make sure the information is accurate and legible.

Section B. Dementia Review

  1. Review the definition of dementia in this section.
  2. Check “No” if the individual does not have a diagnosis of dementia or has a dementia diagnosis, but it is not primary. Complete Section C of the form.
  3. Check “Yes” if the individual has a primary diagnosis as defined on the form. The NF physician signs and dates the form and records the date the dementia diagnosis was assigned.  
  4. Complete Sections D and E of the form. Maintain the completed form in the individual’s medical record.

Section C. Mental Illness (MI) Indication – Complete this section only if the response in section B is “No.”

  1. Review the medical record for a diagnosis of MI and indicate “No” or “Yes” for each MI listed.

    Examples of MI are:

    • Schizophrenia
    • Mood Disorder (Bipolar Disorder, Major Depression or other mood disorder)
    • Paranoid Disorder
    • Somatoform Disorder
    • Schizoaffective Disorder
    • Panic or other disorder that may lead to a chronic disability diagnosable under the current Diagnostic and Statistical Manual of Mental Disorders (DSM)

Many common signs and symptoms caused by dementia (i.e., Alzheimer’s disease, vascular dementia, Lewy body dementia, frontotemporal dementia) may be confused with an MI diagnosis. Examples of what is not MI:

Dementia symptoms vary depending on the cause, but common signs and symptoms include:

Cognitive changes

  • Memory loss, which is usually noticed by a spouse or someone else
  • Difficulty communicating or finding words
  • Difficulty with visual and spatial abilities, such as getting lost while driving
  • Difficulty reasoning or problem-solving
  • Difficulty handling complex tasks
  • Difficulty with planning and organizing
  • Difficulty with coordination and motor functions
  • Confusion and disorientation

The following are psychological changes that can co-occur with dementia:

  • Personality changes
  • Depression
  • Anxiety
  • Inappropriate behavior
  • Paranoia
  • Agitation
  • Hallucinations

Unless the individual had a mental illness prior to their dementia diagnosis, these changes are caused by their dementia; therefore, a new positive PL1 is not needed because the individual does not have MI, just symptoms of their dementia.

Examples of medical conditions not considered a mental illness are:

  • Huntington’s Disease
  • Traumatic Brain Injury
  • Parkinson’s

Depression, unless diagnosed as major depressive disorder in the medical record by the physician, is not considered a mental illness.

  1. If yes is checked and if this is a new diagnosis, include the date of onset for the diagnosis.
  2. If any of the responses in section C are “yes”, the NF needs to complete a new PL1 and Sections D and E of the form.
  3. If all the responses to section C are “no,” the NF does not need to complete a new PL1.
  4. The NF physician signs and dates Section C of the form attesting to the accuracy of the MI diagnosis information.
  5. Complete Sections D and E of the form.

Section D. Nursing Facility Action – Complete this section based on the information completed in Section C.

Check either:

  • The PL1 on file remains negative.  The resident does not need a new PL1 or further evaluation at this time.
  • A new PL1 is needed at this time. A full PASRR Evaluation will be conducted after the NF submits a new positive PL1. After form submission on the LTC Online Portal, include the date of submission and the positive PL1 document locator number (DLN) on this form.

Section E. Staff Completing the Form – The NF staff completing Form 1012 will complete this section with their name, title, signature, and the date the form was signed.

Maintain the completed 1012 form in the individual’s medical record.