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Ensuring the safety and rights of individuals in various care facilities is a paramount concern that requires meticulous attention and immediate action when incidents occur. The Form 3613 A serves as a critical tool in this process, specifically designed for use by providers in 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 facilitates a structured approach to reporting and investigating a wide range of incidents including, but not limited to, abuse, neglect, exploitation, unexpected death, and environmental emergencies. With sections dedicated to capturing detailed information about the incident, the individuals involved, and the outcome of the investigation, it underscores the providers' responsibility to safeguard the well-being of their residents. Moreover, its designation as a confidential document emphasizes the sensitivity and importance of handling such reports with the utmost care and discretion. The requirement to fax or mail completed forms to the Texas Department of Aging and Disability Services further ensures that these incidents are recorded and addressed in accordance with regulatory standards, thereby reinforcing the framework of accountability and oversight within these critical care settings.

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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

Provider Investigation Report

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

:

A.M.

P.M.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Individual(s)/Resident(s) Involved, Including Alleged Victim(s) or Alleged Aggressor(s)

Name

 

 

 

 

 

 

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

Y

N Capacity to make informed decisions

Y

N

History of

Combativeness

 

Verbal aggression

 

Physical aggression

 

Sexual misconduct

 

 

 

Wandering

Wearing wander guard at time of incident

Y

N

Similar allegations

 

 

 

Other pertinent history:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

Female

 

Male

Social Security No.

 

Date of Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Functional Ability: Level of Supervision:

Total assistance

No special supervision Within specified distance: Other:

Extensive

Minimal

No assistance

Within eyesight

Within hearing

Within arm’s length

 

Specified observation time frame:

 

 

 

Independently ambulatory

Y

History of

Combativeness

 

 

Wandering

 

Other pertinent history:

N

Interviewable

Y

N

Capacity to make informed decisions

 

Verbal aggression

 

Physical aggression

 

Sexual misconduct

Wearing wander guard at time of incident

Y

N

Similar allegations

Y N

Name

 

 

 

 

 

 

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

Y

N

Capacity to make informed decisions

Y

N

History of

Combativeness

 

Verbal aggression

 

Physical aggression

 

Sexual misconduct

 

 

Wandering

Wearing wander guard at time of incident

 

Y

N

Similar allegations

 

 

 

Other pertinent history:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form 3613-A

Page 2 / 07-2012

DADS Intake ID No.

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.)

Name

Date of Birth

Social Security No.

License/Certificate No.

 

How was the AP identified?

By name

By description

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Perpetrator:

Denied

Confirmed

History of similar allegations?

 

Yes

No

 

 

Did investigation reveal the presence of a witness?

 

 

 

Yes

No

 

 

 

 

 

 

 

Statement attached (signed and notarized, if possible)

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Witness(es) Name

Individual/Patient/Family/Staff/Other

Address

Area Code and Telephone No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Description of the Allegation

....................................................................................................................................................Injury/Adverse Effect?

Yes

No

 

 

 

Description of Injury

 

 

 

 

 

Assessment

Date

Time

:

A.M.

P.M.

Description of Assessment

 

 

 

Treatment/Transfer Date

Time

 

 

Treatment provided?

Yes

No

 

:

A.M.

P.M.

 

 

 

Off-site

 

City

 

Treatment location: In-House

Yes

No

 

 

 

 

 

 

 

 

 

 

 

Provider Response

Form 3613-A

Page 3 / 07-2012

DADS Intake ID No.

Investigation Summary (attach additional sheets, as necessary)

Investigation Findings

Confirmed

Unconfirmed

Inconclusive

Unfounded

Provider Action Taken Post-Investigation

Signature

Printed Name

Title

Date

File Characteristics

Fact Name Detail
Form Purpose The 3613 A form is used by certain care facilities to report investigations to the Texas Department of Aging and Disability Services.
Facilities Covered 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), Day and Activity Health Services Facilities (DAHS).
Incident Categories Categories include death, abuse, neglect, exploitation, missing resident/individual, drug diversion, emergency system failures, and more.
Submission Options Reports can be faxed or mailed to the Texas Department of Aging and Disability Services, with a toll-free fax number provided.
Governing Law Form 3613-A is governed by the regulations of the Texas Department of Aging and Disability Services.

Steps to Writing 3613 A

Filling out the 3613 A form is an essential process that skilled nursing facilities, nursing facilities, intermediate care facilities for individuals with an intellectual disability or related conditions, assisted living facilities, adult day care facilities, and day and activity health services facilities must complete after certain incidents. This form helps in documenting and reporting significant events to the Texas Department of Aging and Disability Services. Once filled, the form can be either faxed or mailed, but it is crucial to choose one method to avoid duplication. Follow these steps carefully to ensure the form is completed accurately.

  1. Start with the Fax Cover Sheet section by entering the current date, the recipient's details as ‘DADS Consumer Rights and Services Section’, the attention line to the ‘Intake Coordinator’, and the fax number 1-877-438-5827. Provide the DADS Intake ID No., number of pages including the cover, and your facility's contact information.
  2. Under Provider Investigation Report Information, fill in your agency's name, license number, complete address including city, state, and ZIP code, along with the county. Add both your area code and telephone number as well as the fax number.
  3. Proceed to DADS Intake ID No. section, input the number and the date you reported to DADS along with the time (specify AM or PM).
  4. Select your Provider Type and input your Vendor / ID No. alongside your telephone and fax numbers.
  5. In the Incident Category area, mark the applicable box(es) for the type of incident being reported, such as Death, Abuse, Neglect, Exploitation, etc.
  6. Specify who made the allegation, when it was made, and provide details about the incident including date, time, and location.
  7. For each involved individual or resident, including alleged victim(s) or aggressor(s), enter their name, gender, social security number, date of birth, functional ability, level of supervision required, and other specified details about their condition and behavior at the time of the incident.
  8. Identify the alleged perpetrator(s) (AP), if applicable, by their name, date of birth, social security number, and how they were identified. Note if the perpetrator denied or confirmed the allegations and if there was a history of similar allegations.
  9. Provide witness(es) information, if any, including their name, relation to the case (Individual/Patient/Family/Staff/Other), address, and contact number.
  10. Detail the Description of the Allegation, and indicate if there was any injury or adverse effect resulting from the incident. Include an injury assessment and details of any treatment or transfer that occurred as a result, specifying date, time, and location.
  11. In the Provider Response section, provide an Investigation Summary including findings (Confirmed, Unconfirmed, Inconclusive, or Unfounded) and any action taken post-investigation. Attach additional sheets if necessary.
  12. Conclude the form with the signature of the person reporting, printed name, title, and date.

After completing the form, verify all information for accuracy before faxing it to 1-877-438-5827 (toll-free) or mailing it to the Texas Department of Aging and Disability Services, Consumer Rights and Services Section, E-249, P.O. Box 149030, Austin, TX 78714-9030. Remember, only choose one method to submit the form to ensure your report is processed efficiently without any duplication.

Important Details about 3613 A

What is the Form 3613-A used for?

Form 3613-A, also known as the Provider Investigation Report, is a document specifically 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). This form is utilized to report and document investigations related to incidents such as abuse, neglect, exploitation, and other critical events affecting the welfare of residents or individuals in these facilities. The purpose is to ensure a systematic approach to handling such incidents, facilitating communication with the Department of Aging and Disability Services (DADS), and promoting the safety and rights of individuals under their care.

How and where should the Form 3613-A be submitted?

The completed Form 3613-A should be submitted either via fax or mail. To fax the report, use the toll-free number 1-877-438-5827. If mailing is preferred, the 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's important to note that if the form is faxed, there's no need to mail it.

What information is required on the Form 3613-A?

The form requires detailed information about the reporting facility, including agency name, license number, address, and contact details. Additionally, it mandates specifics about the incident, such as the category (e.g., death, abuse, neglect), who made the allegation, when and where the incident occurred, and detailed information about the individuals or residents involved, including the alleged victim(s) or aggressor(s). Information about the alleged perpetrator, description of the allegation, any injuries or adverse effects, and the provider's response to the incident is also necessary.

In case of an error in reporting, how should corrections be submitted?

If a mistake is made in the original submission of Form 3613-A, the provider should promptly notify the appropriate contacts at the Department of Aging and Disability Services (DADS). Depending on the nature of the error, the department may accept corrected information over the phone, or they may require a revised form to be submitted with an indication that it supersedes the original report. Clear communication with the department will ensure the correct handling of the updated information.

Who should complete the Form 3613-A?

This form should be completed by an authorized representative of the facility where the incident occurred or was discovered. Typically, this responsibility falls to individuals in roles such as administrators, directors of nursing, or other management-level staff who have been delegated the authority to handle such reports. It's crucial that the person filling out the form has access to all necessary information and understands the details of the incident to ensure accurate and comprehensive reporting.

Is the Form 3613-A considered a confidential document?

Yes, the Form 3613-A is considered a confidential document. It contains sensitive information about individuals and incidents that may involve legal and privacy issues. The form itself explicitly states that the communication, including any attached document, contains privileged and/or confidential information. Unauthorized disclosure, dissemination, distribution, copying, or other use of this form and any attached documents is strictly prohibited.

What should be done if the Form 3613-A is received by mistake?

If you receive Form 3613-A and you are not the intended recipient, you must take several steps to comply with confidentiality requirements. Immediately notify the sender of the error, refrain from disclosing any of the information contained within the document, and promptly destroy all copies of the form and any attached documentation. Taking these actions helps protect the privacy and rights of the individuals involved and ensures compliance with regulatory standards.

Common mistakes

Filling out the Form 3613 A, meant for Provider Investigation Reports, demands attention to detail and thoroughness. Often, individuals responsible for completing this form encounter pitfalls that could affect the integrity and outcome of their submissions. Recognizing these common errors can enhance the quality of reporting and ensure the necessary actions are taken promptly.

One major mistake involves inaccuracies or omissions in reporting Incident Details, such as the incident date, time, and location. Accurately recording these elements is crucial for a robust investigation. Failure to provide precise information may lead to delays or inaccuracies in the assessment of the incident, affecting the overall quality of care and potentially leading to non-compliance with regulations.

Another area often overlooked is providing complete information about Individual(s)/Resident(s) Involved, including the alleged victim(s) or aggressor(s). Essential details such as functional ability, level of supervision needed, and any pertinent history are sometimes inadequately reported. This omission can severely impact the investigation's direction and outcomes, as these details offer insight into the individuals' needs and may highlight systemic issues or specific vulnerabilities.

Incorrect or incomplete details about the Alleged Perpetrator(s) (AP) can also hinder the investigation process. It is not uncommon for reports to vaguely identify the AP or miss crucial information such as the relationship of the AP to the resident or their history of similar allegations. Precise identification and comprehensive background details are pivotal for conducting a thorough investigation and for implementing measures to prevent future incidents.

Lastly, the Investigation Summary is a section that frequently suffers from being too generic or lacking in detail. This summary should encapsulate the investigation's findings, confirming or refuting the allegations, and stating actions taken. A well-drafted summary provides clear understanding and documentation of the investigative process and outcomes, serving as a critical reference for future assessments and care planning.

In each of these instances, the errors revolve around a common theme: the need for detailed, accurate, and comprehensive documentation. Recognizing the importance of these elements in the Form 3613 A will not only support the immediate need for a thorough investigation but also reinforce the commitment to providing a safe, responsive, and caring environment for all residents.

Documents used along the form

When dealing with matters addressed in Form 3613 A, it's not uncommon for various other forms and documents to play critical roles throughout the process. These documents are essential in ensuring that all factors and incidents are accurately reported and that the necessary follow-up actions are taken in compliance with regulatory requirements. Below is a list of eight forms and documents often used alongside Form 3613 A, each with a brief description of their significance.

  • Incident Report Form: Used by facilities to document any incident that occurs, providing a detailed account of events, individuals involved, and immediate actions taken.
  • Medical Evaluation Report: A document completed by a healthcare provider, detailing the medical assessment and treatment of the individual involved in the incident.
  • Staff Witness Statement Form: Allows staff members who witnessed the incident to provide their account, ensuring all perspectives are considered during the investigation.
  • Resident or Family Statement Form: Provides a platform for the resident involved in the incident or their family to share their perspective and any complaints formally.
  • Corrective Action Plan: Outlines the steps the facility intends to take to address the issues identified in the investigation, aiming to prevent future occurrences.
  • Risk Assessment Form: Assesses the level of risk to residents or individuals following an incident, helping to implement measures to mitigate identified risks.
  • Follow-up Investigation Report: A subsequent report detailing the findings of any follow-up investigations, including interviews, environmental assessments, or other inquiry methods.
  • Regulatory Compliance Checklist: A document used by facilities to ensure that all necessary regulatory requirements are met in the handling, reporting, and responding to incidents.

Each of these documents plays a pivotal role in the comprehensive handling of incidents in facilities regulated under Form 3613 A. They ensure a thorough investigation process, proper medical and staff attention, and compliance with regulatory standards, thus safeguarding the health, safety, and rights of the individuals in care. Familiarity and compliance with these forms and documents are essential for maintaining the highest standards of care and accountability.

Similar forms

The Incident Report Form, used across various healthcare settings, bears resemblance to the Health Insurance Portability and Accountability Act (HIPAA) Violation Report Form. Both require detailed information regarding the nature of the incident, including the individuals involved and the specific outcome or impact. They emphasize confidentiality and the protection of personal information, underscoring the criticality of privacy within healthcare and related services. The focus on secure handling of sensitive data underscores the overarching theme of safeguarding individual rights within these environments.

The OSHA Form 300, which is utilized for recording work-related injuries and illnesses, shares similarities with the 3613 A form in terms of documenting specific incidents. Both forms collect data on the individuals involved, details of the incident including timing and location, and the outcomes such as injury or other adverse effects. This parallel highlights the universal need across sectors to meticulously record and analyze incidents for future prevention and compliance with regulations aimed at ensuring safety and well-being.

Another example includes the Medication Error Reporting Form used in healthcare facilities to document any incidents related to medication administration errors. Like the 3613 A form, it requires detailed information on the incident's circumstances, including the affected individuals and the error's nature. Both forms play a crucial role in quality control and the continuous improvement of care standards by identifying patterns that could lead to systemic changes, emphasizing the importance of accuracy and vigilance in patient care.

The Child and Adult Protective Services Reporting Forms, designed for reporting suspected abuse or neglect, also share similarities with the 3613 A form. Both require reporters to provide detailed accounts of the incident, including information about the alleged perpetrator and victim. This focus on detailed documentation underlines the commitment to protecting vulnerable populations through thorough investigation and remediation efforts, which are instrumental in ensuring the safety and welfare of individuals in care environments.

The Fire Safety Inspection Report, though primarily focused on structural and safety standards within facilities, has parallels with the 3613 A form concerning the documentation of facilities-related incidents like fires or system failures. Both forms contribute crucial data that informs the need for improvements or modifications in policies or physical structures, ensuring a safer environment for inhabitants and complying with regulatory standards focused on minimizing risks.

Adverse Event Reporting Forms used in clinical trials to document any unexpected or harmful effects experienced by participants during the study closely align with the 3613 A form's intention to record adverse incidents. The structured documentation on these forms ensures a rigorous approach to monitoring and mitigating risks, highlighting the overarching goal of safety within both research and care provision contexts.

The Facility Complaint Form, which allows residents or their families to report concerns or issues within a care facility, parallels the 3613 A form in its emphasis on capturing detailed information about potential problems. Both forms serve as essential tools for oversight and accountability, ensuring that facilities adhere to standards of care and address any issues that could compromise resident well-being or safety.

Finally, the Vulnerable Adult Maltreatment Reporting Form captures information on abuse, neglect, or exploitation of vulnerable adults, drawing parallels with the 3613 A form's focus on similar incident categories within care facilities. Both forms are crucial in ensuring responsive action and intervention to protect vulnerable individuals from harm, reflecting a broader commitment to uphold the dignity and safety of those within care settings.

Dos and Don'ts

Filling out the Form 3613 A properly is crucial for skilled nursing facilities, nursing facilities, and other specific residential care facilities to report incidents accurately. The list below outlines ten essential dos and don'ts to help ensure the report is filled out correctly and effectively.

  • Do thoroughly read all the instructions before starting to fill out the form to ensure a clear understanding of the required information.
  • Don't leave any sections blank unless specifically instructed to do so; if a question does not apply, write “N/A” to indicate this.
  • Do use clear, concise language to describe the incident, avoiding overly technical terms or jargon that might confuse the reader.
  • Don't include subjective opinions or unverified facts; stick to objective, factual information supported by evidence whenever possible.
  • Do ensure that all names, social security numbers, and other personal identifiers are accurately reported to respect privacy and assist in the investigation.
  • Don't forget to specify the incident category accurately by checking the appropriate box that best describes the nature of the event being reported.
  • Do double-check the form for accuracy, completeness, and legibility before submitting it to avoid delays in the investigation process.
  • Don't disregard the confidentiality notice; ensure that the form and any accompanying documents are transmitted securely to protect sensitive information.
  • Do provide detailed information about the incident, including dates, times, and locations, to paint a clear picture of what occurred.
  • Don't delay in filing the report; ensure it is completed and submitted in a timely manner according to the guidelines provided.

By following these dos and don'ts, facilities can contribute to a more efficient and effective investigation process, helping to ensure that appropriate actions are taken in response to reported incidents.

Misconceptions

There are several common misconceptions about the Form 3613 A, often due to misunderstanding its purpose and requirements. Below are nine misconceptions explained to provide clearer insight:

  • It’s only for reporting abuse. While abuse is a significant category, Form 3613 A covers a range of incidents, including neglect, exploitation, missing residents, and emergency situations like fires or power failures. It's an all-encompassing report for various critical events in care facilities.
  • Any healthcare facility can use it. This form is specifically designed for use by Skilled Nursing Facilities (SNF), Nursing Facilities (NF), Intermediate Care Facilities for Individuals with an Intellectual Disability (ICF/IID), Assisted Living Facilities (ALF), Adult Day Care Facilities (ADC), and Day and Activity Health Services Facilities (DAHS). It’s not for hospitals or private clinics.
  • Personal information isn't necessary. The form requires detailed personal information about the individuals involved, including social security numbers and dates of birth. This information is critical for proper identification and follow-up.
  • You can delay reporting until after an internal investigation. Immediate reporting to the Department of Aging and Disability Services (DADS) is required once an incident is known, even if the facility plans to conduct its investigation.
  • Email is an acceptable method of submission. The form must be faxed or mailed to the specified address. Email submissions are not accepted, as stated clearly on the form instructions for security and confidentiality reasons.
  • All sections must be completed for every report. Some sections may not be relevant to every incident. It's important to read instructions carefully and provide information that is applicable to the specific event being reported.
  • It’s a public document. The Form 3613 A contains confidential information. It's intended for the Department of Aging and Disability Services and should be handled as a confidential communication to protect individual privacy.
  • Complaints about staff behavior don’t belong on this form. Allegations against staff, including abuse, neglect, or exploitation, are exactly what this form is designed to report. It includes sections for detailing allegations against both staff and non-staff individuals.
  • Once submitted, no further action is required. The facility may need to provide additional information or take corrective action as a result of the investigation findings. Submission is the beginning of the process, not the end.

Understanding these misconceptions is crucial for ensuring that care facilities report incidents accurately and promptly, complying with state regulations and safeguarding the welfare of residents and individuals in their care.

Key takeaways

When it comes to filling out and using the 3613 A form, which is essential for provider investigation reports in facilities like Skilled Nursing Facilities (SNF), Nursing Facilities (NF), and others, there are several key takeaways to keep in mind to ensure the process is handled correctly and effectively.

  • Understand the purpose: This form is specifically designed for use by various care facilities to report incidents to the Texas Department of Aging and Disability Services. It's important to understand that it's not a general-purpose form but targeted for specific incident reporting within the outlined care environments.
  • Confidentiality is key: The 3613 A form contains sensitive information. It's a confidential document intended for the eyes of designated recipients only. This means extra care should be taken in its handling, ensuring that privacy and confidentiality are maintained at all times.
  • Complete all sections accurately: Accuracy is paramount when filling out the form. This includes detailed information about the incident being reported, such as the nature of the incident (e.g., abuse, neglect, exploitation), the individuals involved, and the specific details of what happened. Incomplete or inaccurate information can lead to delays or issues in the investigation process.
  • Documentation is crucial: Along with the form, any relevant documentation (e.g., witness statements, medical records) should be attached if available. This could help provide a clearer picture of the incident and support a thorough investigation.
  • Timely reporting: Incidents should be reported as soon as possible. Delays in submitting the 3613 A form can impact the response time and effectiveness of the investigation, potentially jeopardizing the safety and well-being of residents.
  • Follow-up: After submitting the form, be prepared for possible follow-up by the Texas Department of Aging and Disability Services. They may require additional information or clarification as part of their investigation. Keeping detailed records and being responsive to inquiries can facilitate a more efficient review process.

By keeping these key takeaways in mind, staff and administrators of the relevant facilities can ensure they are meeting their obligations in reporting incidents, contributing to the safety and well-being of those in their care.

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