The 3613 A form is a Provider Investigation Report specifically designed for use by various care facilities, including Skilled Nursing Facilities, Nursing Facilities, and Assisted Living Facilities. This form serves as a critical tool for documenting incidents such as abuse, neglect, or other emergencies that may occur within these facilities. By providing a structured format for reporting, the 3613 A form helps ensure that all necessary information is collected and communicated effectively to the appropriate authorities.
The 3613 A form serves a crucial role in the realm of healthcare facilities, specifically designed for use by Skilled Nursing Facilities (SNF), Nursing Facilities (NF), Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions (ICF/IID), Assisted Living Facilities (ALF), Adult Day Care Facilities (ADC), and Day and Activity Health Services Facilities (DAHS). This form is essential for reporting incidents that may compromise the safety and well-being of residents. It encompasses a wide range of incidents, from allegations of abuse and neglect to emergencies like fires and power failures. The form requires detailed information about the incident, including the individuals involved, the nature of the allegation, and any actions taken in response. Additionally, it ensures that all sensitive information remains confidential, emphasizing the importance of privacy in these serious matters. As a vital communication tool, the 3613 A form must be accurately completed and promptly submitted to the Texas Department of Aging and Disability Services (DADS) to facilitate timely investigations and ensure the protection of vulnerable individuals in care facilities.
What is the purpose of the 3613 A form?
The 3613 A form is designed for use by various types of care facilities, including Skilled Nursing Facilities (SNF), Nursing Facilities (NF), Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions (ICF/IID), Assisted Living Facilities (ALF), Adult Day Care Facilities (ADC), and Day and Activity Health Services Facilities (DAHS). Its primary purpose is to report investigations into incidents that may involve abuse, neglect, or other serious concerns affecting residents or individuals in these facilities.
Who should complete the 3613 A form?
The form should be completed by authorized personnel within the facilities mentioned above. This typically includes staff members responsible for reporting incidents or overseeing investigations. The individual filling out the form must ensure that all relevant information is accurately documented to facilitate a thorough investigation by the Texas Department of Aging and Disability Services (DADS).
How should the 3613 A form be submitted?
The 3613 A form can be submitted either by fax or by mail. If faxing, it should be sent to the toll-free number 1-877-438-5827. If mailing, the completed form should be sent to the Texas Department of Aging and Disability Services, Consumer Rights and Services Section, E-249, P.O. Box 149030, Austin, TX 78714-9030. It is important to note that if the form is faxed, it should not be mailed.
What types of incidents must be reported using the 3613 A form?
Incidents that require reporting include a range of serious issues such as death, abuse, neglect, exploitation, missing residents, drug diversion, and various emergencies like fire or severe weather. Each incident category is specified on the form, and it is crucial for the reporter to accurately classify the nature of the incident to ensure appropriate follow-up and investigation.
What information is required on the 3613 A form?
The form requires comprehensive details about the incident, including the date, time, and location of the occurrence. Information about the individuals involved, including alleged victims and aggressors, must also be documented. This includes personal details like names, dates of birth, and social security numbers, as well as descriptions of the incident and any injuries sustained. Additional sections cover the identification of witnesses and the findings of the investigation.
What happens after the 3613 A form is submitted?
Once the form is submitted, the Texas Department of Aging and Disability Services will review the report and initiate an investigation if necessary. The agency will assess the information provided to determine the validity of the allegations and decide on appropriate actions. The facility that submitted the report may be required to cooperate with the investigation and provide further documentation or clarification as needed.
Is the information on the 3613 A form confidential?
Yes, the information contained in the 3613 A form is considered confidential. It is intended only for the use of the designated authorities involved in the investigation. Unauthorized disclosure or distribution of this information is strictly prohibited. If someone receives the form in error, they should notify the sender immediately and destroy any copies to maintain confidentiality.
The 3613 A form is specifically designed for use by various types of facilities, including Skilled Nursing Facilities and Assisted Living Facilities, to report incidents involving residents.
When filling out the form, ensure that all sections are completed accurately, including details about the incident, individuals involved, and any actions taken.
It's important to submit the form promptly. You can either fax it to the designated number or mail it to the Texas Department of Aging and Disability Services.
Confidentiality is crucial. The form contains sensitive information, so it should only be shared with authorized personnel and handled with care.
This form is used for a variety of incidents, not just severe cases. It covers everything from minor issues to serious allegations like abuse or neglect.
While the form is primarily for skilled nursing and similar facilities, any facility under the Texas Department of Aging and Disability Services (DADS) guidelines may need to report incidents using this form.
The form should be submitted as soon as an incident is reported, regardless of whether an investigation is ongoing. Timeliness is crucial in these situations.
The 3613 A form contains confidential information. It’s important to handle it with care to protect the privacy of all individuals involved.
While mailing is an option, the form is designed to be faxed to ensure quicker processing. If you fax it, do not mail it.
The form allows for reporting any individual involved in an incident, including visitors or family members. It’s essential to document all relevant parties.
Filing the 3613 A form is a requirement for facilities when certain incidents occur. Failing to do so can lead to regulatory issues and affect the facility’s compliance status.
Provider Investigation Report
For use only by Skilled Nursing Facilities (SNF), Nursing Facilities (NF), Intermediate Care Facilities for Individual with an Intellectual Disability or Related Conditions (ICF/IID), Assisted Living Facilities (ALF), Adult Day Care Facilities (ADC), and Day and Activity Health Services Facilities (DAHS).
Fax Cover Sheet
Date:
To: DADS Consumer Rights and Services Section
Attention: Intake Coordinator
Fax Area Code and Telephone No.: 1-877-438-5827
Regarding DADS Intake ID No.:
No. of Pages, including cover:
From:
Provider Name:
Vendor / ID No.:
Street Address:
City:
Telephone No.:
–
Fax:
Provider Investigation Report Information
Agency Name
License No.
Street Address
City, State, ZIP Code
County
Area Code and Telephone No.
Fax Area Code and Telephone No.
Parent
Branch/Alternate Delivery Site
Confidential Document:
This communication (including any attached document) contains privileged and/or confidential information. If you are not an intended recipient of this communication, please be advised that any disclosure, dissemination, distribution, copying or other use of this communication or any attached document is strictly prohibited. If you have received this communication in error, please notify the sender immediately and promptly destroy all copies of this communication and any attached documents.
Use only for Skilled Nursing Facilities (SNF), Nursing Facilities (NF),
Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions (ICF/IID),
Assisted Living Facilities (ALF), Adult Day Care Facilities (ADC),
and Day and Activity Health Services Facilities (DAHS).
Form 3613-A/ 07-2012
Texas Department of Aging
SNF, NF, ICF/IID, ALF, ADC, DAHS
and Disability Services
Fax this report to: 1-877-438-5827 (toll free) or
Mail this report to: Texas Department of Aging and Disability Services, Consumer Rights and Services Section, E-249, P.O. Box 149030, Austin, TX 78714-9030
Form 3613-A
July 2012
Note to reporter:
Do not mail if faxed.
DADS Intake ID No.
Date Reported to DADS 800-458-9858
Time Reported
:
A.M.
P.M.
Provider Type
Vendor / ID No.
Telephone No.
Name
Fax
City
ZIP Code
Incident Category
Death
Abuse
Neglect
Exploitation
Missing Resident/Individual
Drug Diversion
Fire
Bomb Threat
Tornado
Flood
Emergency Power Failure
Sprinkler System Failure
Fire Alarm Failure
Firearms in the Building
Air Conditioning Failure if Outdoor Temperature is or will be 90 Degrees or Above
Heating System Failure if Outdoor Temperature is 65 Degrees or Below
Others, specify
Who made the allegation?
When?
Individual /Resident
Family
Other
Incident Date
Time
Location
Individual(s)/Resident(s) Involved, Including Alleged Victim(s) or Alleged Aggressor(s)
Female
Male
Social Security No.
Date of Birth
Functional Ability:
Total assistance
Extensive
Minimal
No assistance
Level of Supervision:
No special supervision
Within eyesight
Within hearing
Within arm’s length
Within specified distance:
Specified observation time frame:
Other:
Independently ambulatory
Y
N
Interviewable
N Capacity to make informed decisions
History of
Combativeness
Verbal aggression
Physical aggression
Sexual misconduct
Wandering
Wearing wander guard at time of incident
Similar allegations
Other pertinent history:
Functional Ability: Level of Supervision:
No special supervision Within specified distance: Other:
Capacity to make informed decisions
Y N
Page 2 / 07-2012
Alleged Perpetrator(s) (AP)
(If alleged perpetrator is somebody other than a staff member, indicate this individual’s relationship to the person. Example: relative, visitor, etc.)
License/Certificate No.
How was the AP identified?
By name
By description
Perpetrator:
Denied
Confirmed
History of similar allegations?
Yes
No
Did investigation reveal the presence of a witness?
Statement attached (signed and notarized, if possible)
Witness(es) Name
Individual/Patient/Family/Staff/Other
Address
Description of the Allegation
....................................................................................................................................................Injury/Adverse Effect?
Description of Injury
Assessment
Date
Description of Assessment
Treatment/Transfer Date
Treatment provided?
Off-site
Treatment location: In-House
Provider Response
Page 3 / 07-2012
Investigation Summary (attach additional sheets, as necessary)
Investigation Findings
Unconfirmed
Inconclusive
Unfounded
Provider Action Taken Post-Investigation
Signature
Printed Name
Title
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Incomplete Information: One common mistake is failing to fill out all required sections of the form. Each part of the form is important for a complete understanding of the incident.
Incorrect Contact Details: Providing wrong contact information can lead to delays in communication. Double-check the phone numbers and addresses to ensure accuracy.
Missing Incident Date and Time: Omitting the date and time of the incident can create confusion during the investigation. Always include this information to provide a clear timeline.
Not Specifying the Allegation: Failing to clearly describe the nature of the allegation can hinder the investigation. Be as specific as possible about what occurred.
Forgetting Witness Information: If there are witnesses, neglecting to include their details can limit the investigation's effectiveness. Always list any witnesses and their contact information.
Inaccurate Incident Category: Selecting the wrong category for the incident can mislead the investigation process. Review the categories carefully to ensure the right one is chosen.
Not Following Submission Instructions: Some individuals may not follow the specific instructions for submitting the form, whether by fax or mail. Adhering to these guidelines is crucial for timely processing.
When filling out the 3613 A form, it's important to follow specific guidelines to ensure accuracy and compliance. Here’s a helpful list of dos and don’ts:
The Incident Report Form is a document used by various facilities to record specific incidents involving residents or clients. Like the 3613 A form, it captures essential details such as the nature of the incident, individuals involved, and any actions taken. Both forms aim to ensure accountability and transparency in the care provided to vulnerable populations. The Incident Report Form typically includes sections for incident description, witness statements, and follow-up actions, similar to the structured approach found in the 3613 A form.
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The Abuse Reporting Form serves as a critical tool for documenting allegations of abuse within care facilities. This document, much like the 3613 A form, is designed to collect information regarding the alleged victim, the perpetrator, and the circumstances surrounding the incident. Both forms emphasize the importance of timely reporting and detail the necessary steps to ensure the safety and well-being of individuals involved. The Abuse Reporting Form may also include a section for facility response and corrective actions taken, paralleling the investigation summary found in the 3613 A form.
The Quality Assurance Report is utilized by healthcare facilities to assess and improve the quality of care provided. Similar to the 3613 A form, it collects data on incidents, complaints, and outcomes to identify trends and areas needing improvement. Both documents serve a dual purpose: documenting events and guiding future actions to enhance service delivery. The Quality Assurance Report typically includes recommendations for training or policy changes, aligning with the post-investigation actions outlined in the 3613 A form.
The Patient Safety Incident Report is specifically focused on incidents that may affect patient safety within healthcare settings. This document, akin to the 3613 A form, gathers comprehensive details about the incident, including the time, location, and individuals involved. Both forms aim to promote a culture of safety and accountability. The Patient Safety Incident Report often includes a section for root cause analysis and preventive measures, similar to the investigation summary and provider action sections of the 3613 A form.
The Client Grievance Form allows residents or their families to formally express concerns or complaints about care. Like the 3613 A form, it serves as a mechanism for documentation and resolution of issues. Both forms prioritize the rights of individuals receiving care and outline processes for reporting and addressing grievances. The Client Grievance Form typically includes a timeline for resolution and follow-up, paralleling the investigative components of the 3613 A form.
The Staff Incident Report is used to document incidents involving staff members within care facilities. This document shares similarities with the 3613 A form in that it captures essential details about the incident, including witnesses and actions taken. Both forms emphasize the importance of thorough documentation to ensure accountability and compliance with facility policies. The Staff Incident Report may also include recommendations for staff training or policy revisions, similar to the action items noted in the 3613 A form.
The Medical Incident Report is a document that records incidents related to medical care or treatment errors. Much like the 3613 A form, it collects detailed information about the incident, including the individuals involved and the nature of the medical error. Both forms are designed to ensure that incidents are properly documented and addressed to improve patient safety and care quality. The Medical Incident Report often includes follow-up actions and recommendations for preventing similar incidents in the future, echoing the structure of the 3613 A form.
The Compliance Report is utilized by facilities to ensure adherence to regulatory standards and best practices. This document, similar to the 3613 A form, collects information about compliance-related incidents and actions taken to address them. Both forms are essential for maintaining accountability and transparency within care settings. The Compliance Report typically includes sections for corrective actions and timelines for implementation, akin to the post-investigation actions outlined in the 3613 A form.