Effective Date: 



Updated: 9/2018


Form 1012 assists Nursing Facilities (NF) in determining if a previously negative Preadmission Screening and Resident Review (PASRR) Level I (PL1) Screening form, that has already been submitted to the Long Term Care (LTC) Portal, needs to be changed to a positive PL1 for Mental Illness (MI). This form confirms if the individual meets the Code of Federal Regulations (CFR) definition of MI, if there is a dementia diagnosis  and if the individual’s dementia is the primary diagnosis.    This form also provides NFs documentation for the medical record as to why a new positive PL1 was not completed.


When to Prepare

The NF completes Form 1012 following:

   •  A determination that the PL1 was filled out incorrectly.
   •  An individual’s diagnosis is changed.
   •  A survey determines the PL1 is incorrect or needs review


Sections A, B, C and E are completed by the NF. Section D is completed by the local mental health authority (LMHA)/local behavioral health authority (LBHA).

Section A. Resident and Nursing Facility Identifying Information – Complete all required information in each field and make sure the information is legible. Forms will be denied and returned to the NF if information is not complete or legible. Include an accurate area code and telephone number, fax number and email address for the primary contact, along with the Document Locator Number (DLN) of the current PL1.

Section B. Mental Illness (MI) Review – Review the CFR definition of MI and determine if the individual has an MI diagnosis that meets this definition. 

If yes, indicate whether or not this is a new diagnosis and, if so, the diagnosis and date of diagnosis is needed.  Then proceed to complete Section C. 

If no, the NF has the physician sign and date the form. The NF completes Section E and files the completed form in the resident’s chart.

Section C. Dementia Review – The NF completes this section only if the answer in Section B was yes, the individual meets the CFR definition of MI. Review the definition of Primary Diagnosis Dementia. 

If no, the individual does not have a diagnosis of dementia or has a dementia diagnosis but it is not primary, the NF has the physician sign and date the form. The NF enters a positive PL1 and a PE will be conducted. The NF completes Section E of the form as instructed. 

If yes, the individual has a primary diagnosis as defined on the form, record the date the diagnosis was assigned. The physician signs and dates the form.  The NF faxes the form to the LMHA/LBHA for further review.  Supporting documentation should be included to support the primary diagnosis of dementia.  An example of appropriate supporting documentation includes a copy of the medical record confirming a primary diagnosis of dementia by the physician.

Section D. LMHA/LBHA Review – The NF faxes the form to the LMHA/LBHA for a review by a Qualified Mental Health Professional – Community Services (QMHP-CS) associated with the LMHA/LBHA. After the QMHP-CS reviews the form and supporting documentation, the QMHP-CS makes a recommendation for one of the following:

    • Dementia is indicated as the primary diagnosis.  The LMHA/LBHA finds that the documentation supports the diagnosis. The negative PL1 on file stands as correct.  No further evaluation or new PL1 is needed at this time. 

The LMHA/LBHA signs and dates the form and faxes it back to the NF to be included in the medical record.  

    • Further evaluation is needed at this time. A full evaluation will be conducted after the NF submits a new positive PL1.

The LMHA/LBHA signs and dates the form, then faxes the form to the NF.  The NF submits a new positive PL1 and then completes Section E. 

Section E. Nursing Facility PL1 Entry – If Section B is no, the individual does not have a diagnosis of MI that meets the definition, or Section C is no, the individual does not have a dementia diagnosis or has a dementia diagnosis but it is not primary, or after the LMHA/LBHA faxes the form to the NF, the NF selects one of the following:

    •  A new positive PL1 was submitted on [date] according to the instructions in Section C with DLN [document locator number].
    •  A new positive PL1 was submitted on [date] according to the instructions in Section D with [document locator number].
    •  The PL1 remains negative according to the instructions in Section B or D.

The NF files the completed form in the resident’s medical record chart.

Additional Guidance

Can a Nurse Practioner or Physician’s Assistant complete this form? 
      No, only a physician, which includes a psychiatrist, can complete this form.

How much time does the LMHA/LBHA have to return the form once we fax it? 
       The LMHA/LBHA has 7 days to review and complete Section D which includes faxing Form 1012 back to the NF.

What happens if the NF does not receive Form 1012 within the 7 days of faxing the form?

       Contact the LMHA/LBHA to follow up and document these call(s) – who you spoke with, date, time, results of call, etc.

       If NF does not receive completed Form 1012 within 14 days, send email to PASRR.MentalHealth@hhsc.state.tx.us with the following information:

          • Copy of form and of the faxed receipt showing when the original form was faxed and received
          • Documented attempts to contact LMHA/LBHA
          • NF Contact information

Examples of MI, as per Section C0300 of the PASRR evaluation form are: 

    • Schizophrenia
    • Mood Disorder (Bipolar Disorder, Major Depression or other mood disorder)
    • Paranoid Disorder
    • Somatoform Disorder
    • Other Psychotic 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) 

Examples of what is not MI:

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.  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 since the PASRR evaluation would be negative 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, is not considered a mental illness.  

For questions regarding this form, contact PASRR.MentalHealth@hhsc.state.tx.us.

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