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The 3613 A form serves as a critical tool for various healthcare facilities, including Skilled Nursing Facilities (SNF), Nursing Facilities (NF), and Assisted Living Facilities (ALF), among others. This form is specifically designed to report incidents that may compromise the safety and well-being of residents. It encompasses a range of incident categories such as abuse, neglect, and even emergencies like fires or natural disasters. Providers must complete the form with detailed information about the incident, including the date, time, and location, as well as the individuals involved. The form also requires a thorough account of the investigation findings, whether confirmed, unconfirmed, or inconclusive. Additionally, it emphasizes the importance of confidentiality, reminding users that the information contained within is privileged. By adhering to these guidelines, facilities can ensure that they maintain compliance with regulatory standards while prioritizing the rights and safety of those they serve.

Form Sample

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
and Disability Services
SNF, NF, ICF/IID, ALF, ADC, DAHS
Provider Investigation Report
Form 3613-A
July 2012
Fax this report to:
1-877-438-5827 (toll free)
Note to reporter:
Do not mail if faxed.
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
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:
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:
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 provided? ............................................
Yes No
Treatment/Transfer Date
Time
:
A.M.
P.M.
Treatment location: In-House ...................................
Yes No
Off-site
City
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
Title
Printed Name
Date
⇩ PDF

Document Specifications

Fact Name Details
Purpose The 3613 A form is designed for use by various types of healthcare facilities, including Skilled Nursing Facilities (SNF) and Assisted Living Facilities (ALF).
Governing Laws This form is governed by Texas Health and Safety Code, Chapter 242 and Chapter 252, which regulate nursing and assisted living facilities.
Confidentiality Notice The form includes a confidentiality notice, emphasizing the privileged nature of the information contained within.
Submission Methods Providers can submit the form via fax to 1-877-438-5827 or mail it to the Texas Department of Aging and Disability Services.
Incident Categories The form categorizes incidents such as abuse, neglect, and drug diversion, allowing for clear reporting of various types of incidents.
Alleged Perpetrator Information It requires detailed information about alleged perpetrators, including their relationship to the victim, if not a staff member.
Investigation Summary At the end of the form, there is a section for summarizing the investigation findings and the actions taken by the provider.

Steps to Filling Out 3613 A

The 3613 A form is essential for reporting incidents involving various types of care facilities. Properly completing this form ensures that all necessary information is communicated effectively to the appropriate authorities. Follow these steps to fill out the form accurately.

  1. Enter the Fax Cover Sheet Date at the top of the form.
  2. Fill in the To section with "DADS Consumer Rights and Services Section" and "Attention: Intake Coordinator."
  3. Provide the Fax Area Code and Telephone No. as 1-877-438-5827.
  4. Complete the Regarding DADS Intake ID No. field.
  5. Indicate the No. of Pages, including the cover sheet.
  6. In the From section, enter the Provider Name and Vendor / ID No..
  7. Fill in the Street Address, City, and Telephone No. for the provider.
  8. Provide the Fax number for the provider.
  9. Complete the Provider Investigation Report Information section, including Agency Name, License No., Street Address, City, State, ZIP Code, and County.
  10. Fill in the Area Code and Telephone No. and the Fax Area Code and Telephone No..
  11. Indicate the Parent Branch/Alternate Delivery Site if applicable.
  12. Mark the Incident Category by checking the appropriate box.
  13. Provide details about Who made the allegation? and the When? fields.
  14. Enter the Incident Date and Time.
  15. Fill out the Location of the incident.
  16. List the Individual(s)/Resident(s) Involved, including their Name, Gender, Social Security No., Date of Birth, and Functional Ability.
  17. Provide the Level of Supervision for each individual involved.
  18. Indicate if each individual is Independently ambulatory, Interviewable, and has the Capacity to make informed decisions.
  19. Document any History of Combativeness or other relevant history.
  20. For the Alleged Perpetrator(s), provide their Name, Date of Birth, and Social Security No..
  21. Indicate how the alleged perpetrator was identified.
  22. Document if the alleged perpetrator denied or confirmed the allegation.
  23. Provide details about any witnesses, including their Name, Address, and Telephone No..
  24. Describe the Allegation in detail.
  25. Indicate if there was any Injury/Adverse Effect and provide a description.
  26. Fill in the Assessment Date and Time, along with the Description of Assessment.
  27. Document the Treatment/Transfer Date and Time, and indicate if treatment was provided.
  28. Complete the Provider Response section.
  29. Summarize the Investigation Findings and mark whether they were confirmed, unconfirmed, inconclusive, or unfounded.
  30. Provide details about any Provider Action Taken post-investigation.
  31. Finally, sign the form with your Printed Name, Title, and Date.

More About 3613 A

What is the purpose of the 3613 A form?

The 3613 A form is used to report incidents that occur in various types of care facilities, including Skilled Nursing Facilities, Nursing Facilities, Intermediate Care Facilities, Assisted Living Facilities, Adult Day Care Facilities, and Day and Activity Health Services Facilities. It serves to document allegations of abuse, neglect, exploitation, and other incidents affecting residents.

Who is required to complete the 3613 A form?

Staff members at the designated facilities are responsible for completing the 3613 A form when an incident occurs. This includes administrators, nurses, and other personnel who are aware of the situation and can provide the necessary details.

How should the completed form be submitted?

The completed 3613 A form can be submitted via fax to 1-877-438-5827 or mailed to the Texas Department of Aging and Disability Services. If faxing the report, it should not be mailed afterward.

What types of incidents must be reported using this form?

Incidents that require reporting include, but are not limited to, death, abuse, neglect, exploitation, missing residents, drug diversion, and emergencies such as fires or natural disasters. Each incident category must be clearly indicated on the form.

What information is needed about the individuals involved?

The form requires detailed information about all individuals involved, including their names, dates of birth, social security numbers, functional abilities, and levels of supervision. This helps provide a comprehensive view of the incident and the individuals affected.

What should be included in the description of the allegation?

The description of the allegation should include specific details about what occurred, the context of the incident, and any relevant history. This information is crucial for the investigation process.

Is it necessary to include witness information?

Yes, if there are witnesses to the incident, their names and contact information should be included. This can help substantiate claims and provide additional perspectives during the investigation.

What happens after the form is submitted?

Once submitted, the Texas Department of Aging and Disability Services will review the report. They may conduct an investigation based on the information provided. The facility may also be required to take specific actions in response to the findings.

What should be done if the form is filled out incorrectly?

If there are errors on the form, it is important to correct them before submission. If the form has already been submitted, contact the appropriate department to inform them of the mistake and provide the correct information if necessary.

Are there any confidentiality concerns with the 3613 A form?

Yes, the 3613 A form contains confidential information. It is crucial to handle the form and any attached documents with care to protect the privacy of individuals involved. Unauthorized disclosure is strictly prohibited.

Common mistakes

  1. Incomplete Information: Many people forget to fill out all required sections of the form. Missing information can lead to delays in processing the report. Always double-check that every field is completed.

  2. Incorrect Incident Category: Selecting the wrong incident category can confuse the review process. Make sure to choose the category that best describes the situation. This helps ensure the report is directed to the appropriate department.

  3. Failing to Include Contact Information: Omitting contact details can hinder communication. It's crucial to provide accurate phone numbers and addresses for follow-up questions or clarifications.

  4. Not Keeping a Copy: Some individuals neglect to keep a copy of the submitted form. Retaining a copy is important for your records and can assist in any future inquiries regarding the report.

Documents used along the form

The 3613 A form serves as a crucial document for reporting incidents within various care facilities. However, it is often accompanied by other essential forms and documents that support the investigation process and ensure compliance with regulatory standards. Understanding these additional documents can help streamline reporting and improve the overall quality of care provided in these facilities.

  • Incident Report Form: This document details the specifics of an incident, including the nature of the event, individuals involved, and immediate actions taken. It serves as a preliminary record that may inform further investigations and is vital for tracking patterns of incidents over time.
  • Witness Statement Form: This form is used to collect firsthand accounts from individuals who witnessed the incident. Witness statements can provide critical insights into what occurred and help corroborate or refute claims made in the initial report.
  • Provider Response Form: After an investigation, facilities must complete this form to outline their response to the incident. It includes actions taken to address the situation and any measures implemented to prevent future occurrences. This demonstrates accountability and a commitment to improving care standards.
  • Follow-Up Assessment Form: Following an incident, a follow-up assessment may be necessary to evaluate the ongoing needs of the affected individuals. This form documents the outcomes of any interventions and assesses whether further action is required to support the individuals involved.

Utilizing these forms in conjunction with the 3613 A form enhances the thoroughness of incident reporting and ensures that all relevant information is captured. This comprehensive approach not only aids in investigations but also fosters a culture of safety and transparency within care facilities.

Similar forms

The Incident Report is a document that serves a similar purpose to the 3613 A form. It is used by various healthcare facilities to document any incidents that occur within their premises. Like the 3613 A form, the Incident Report captures essential details such as the date, time, and nature of the incident. Both documents require the identification of individuals involved, including alleged victims and aggressors. The focus on confidentiality and the need for accurate reporting are paramount in both forms, ensuring that sensitive information is handled appropriately.

The Patient Safety Report is another document that parallels the 3613 A form. This report is specifically designed to track and analyze safety incidents affecting patients in healthcare settings. Much like the 3613 A form, it emphasizes the importance of documenting incidents that could lead to harm. The Patient Safety Report collects data on the circumstances surrounding each incident, including contributing factors and outcomes. Both documents aim to improve overall safety by identifying trends and areas needing attention within the facility.

The Abuse Reporting Form is closely related to the 3613 A form in that it specifically addresses allegations of abuse within healthcare facilities. This form requires detailed information about the alleged abuse, including the individuals involved and the nature of the allegations. Similar to the 3613 A form, it mandates prompt reporting to the appropriate authorities. Both documents are crucial for protecting vulnerable populations and ensuring that allegations are taken seriously and investigated thoroughly.

The Quality Assurance Report also shares similarities with the 3613 A form, as both are utilized to ensure compliance with safety and quality standards in healthcare facilities. This report evaluates the effectiveness of care and identifies areas for improvement. Like the 3613 A form, it requires comprehensive documentation of incidents and responses, helping to maintain a high standard of care. Both documents contribute to the ongoing effort to enhance the quality of services provided to residents.

Lastly, the Compliance Investigation Report mirrors the 3613 A form in its focus on documenting investigations into potential violations of regulations or standards. This report collects information about the nature of the complaint, the investigation process, and the findings. Both forms emphasize the importance of thorough and accurate reporting, ensuring that any issues are addressed promptly and effectively. They both serve as vital tools for maintaining accountability and transparency within healthcare facilities.

Dos and Don'ts

When filling out the 3613 A form, it’s important to follow certain guidelines to ensure accuracy and compliance. Here are four things you should and shouldn't do:

  • Do ensure all information is accurate. Double-check names, dates, and other details before submission to avoid confusion or delays.
  • Do use clear and concise language. Avoid overly complex sentences. Clarity helps prevent misunderstandings.
  • Don't leave any required fields blank. Incomplete forms can lead to processing issues. Fill out every section as required.
  • Don't submit without reviewing the entire form. A thorough review can catch mistakes that may have been overlooked initially.

By adhering to these guidelines, the process of submitting the 3613 A form can be smoother and more efficient.

Misconceptions

Misconceptions about the 3613 A form can lead to confusion among providers and stakeholders. Here are five common misunderstandings, along with clarifications for each:

  • The 3613 A form is only for serious incidents. Many believe that this form is only necessary for severe incidents like abuse or neglect. In reality, it is also used for reporting less severe issues, such as operational failures or minor incidents that could impact resident safety.
  • Only nursing facilities need to use the 3613 A form. Some think that only skilled nursing facilities are required to fill out this form. However, it is designed for a variety of facilities, including assisted living and adult day care facilities, ensuring comprehensive reporting across the board.
  • The form can be submitted via mail only. A common misconception is that the 3613 A form must be mailed to the Texas Department of Aging and Disability Services. In fact, it can be faxed, which allows for quicker reporting and response times.
  • Confidentiality is not a concern with the 3613 A form. Some individuals underestimate the importance of confidentiality when filling out this form. It contains sensitive information, and any unauthorized disclosure can lead to serious legal consequences. Therefore, it must be handled with care.
  • Completing the form is optional. Many providers mistakenly believe that filling out the 3613 A form is optional. In truth, it is a mandatory requirement when certain incidents occur, and failure to report can result in penalties or loss of licensure.

Key takeaways

Here are some key takeaways for filling out and using the 3613 A form:

  • Purpose and Audience: This form is specifically designed for use by various types of facilities, including Skilled Nursing Facilities (SNF) and Assisted Living Facilities (ALF). Ensure your facility type is eligible to use this form.
  • Submission Process: The completed form can be faxed to 1-877-438-5827 or mailed to the Texas Department of Aging and Disability Services. If you fax the report, do not mail it.
  • Incident Details: Clearly document all relevant incident details, including the date, time, and nature of the incident. Accurate information helps in the investigation process.
  • Confidentiality: Remember that this document contains confidential information. Handle it with care and only share it with authorized individuals.