3613 A Template

3613 A Template

The 3613 A form is a Provider Investigation Report designed specifically for use by various healthcare facilities, including Skilled Nursing Facilities and Assisted Living Facilities. This form is essential for documenting incidents such as abuse, neglect, and other critical events involving residents. For those responsible for completing this form, please ensure accuracy and thoroughness by clicking the button below to get started.

Table of Contents

The 3613 A form serves as a crucial tool for various healthcare facilities, specifically those involved in skilled nursing, intermediate care, assisted living, adult day care, and related services. This form is designed to report incidents that may compromise the safety and well-being of individuals in these facilities. It captures essential details about the incident, including the nature of the allegation—be it abuse, neglect, or other emergencies like fires or power failures. Each report must include information about the individuals involved, such as their functional abilities and level of supervision required. Additionally, the form prompts the reporter to document the alleged perpetrator, any witnesses, and the outcomes of the investigation. This structured approach not only facilitates a thorough investigation but also ensures that appropriate actions are taken in response to the reported incidents. By maintaining confidentiality and adhering to strict guidelines, the 3613 A form plays a vital role in upholding the rights and safety of residents in care facilities across Texas.

3613 A 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
▼ 3613 A PDF Form

Document Attributes

Fact Name Description
Purpose The 3613 A form is used for reporting investigations in various care facilities, including skilled nursing and assisted living facilities.
Governing Law This form is governed by Texas Health and Safety Code, Chapter 260.
Confidentiality The form contains confidential information. Unauthorized disclosure is strictly prohibited.
Submission Methods Reports can be faxed to 1-877-438-5827 or mailed to the Texas Department of Aging and Disability Services.
Incident Categories Incidents reported may include abuse, neglect, exploitation, and various emergencies.
Allegation Reporting Details about the allegation must include who made it and when it occurred.
Investigation Summary The form requires a summary of the investigation findings, which can be confirmed, unconfirmed, inconclusive, or unfounded.
Provider Actions After the investigation, the provider must document actions taken in response to the findings.
Version The current version of the 3613 A form is dated July 2012.

3613 A: Usage Instruction

Filling out the 3613 A form requires careful attention to detail to ensure all necessary information is accurately reported. Once the form is completed, it should be submitted via fax or mail to the appropriate department for processing. Below are the steps to guide you through the completion of the form.

  1. Obtain the Form: Ensure you have the latest version of the 3613 A form.
  2. Fill Out the Fax Cover Sheet: Enter the date, recipient details (DADS Consumer Rights and Services Section, Intake Coordinator), and your contact information.
  3. Provider Information: Complete the provider's name, vendor/ID number, address, city, and contact numbers.
  4. Incident Information: Specify the incident category (e.g., abuse, neglect, etc.), date, time, and location of the incident.
  5. Details of Individuals Involved: List the names, genders, social security numbers, dates of birth, functional abilities, and levels of supervision for each individual involved.
  6. Alleged Perpetrator Information: Provide the name, date of birth, and social security number of the alleged perpetrator, along with how they were identified.
  7. Witness Information: If there are witnesses, include their names, relationships to the incident, and contact details.
  8. Description of the Allegation: Clearly describe the allegation, including any injuries or adverse effects noted.
  9. Assessment Details: Document the assessment date and time, along with treatment information and location.
  10. Investigation Summary: Summarize the findings of the investigation, including whether the claims were confirmed, unconfirmed, inconclusive, or unfounded.
  11. Provider Response: Sign the form and provide your printed name, title, and date of signing.

After completing the form, ensure all sections are filled out accurately. The form can then be faxed to 1-877-438-5827 or mailed to the Texas Department of Aging and Disability Services as indicated. Remember to keep a copy for your records.

Frequently Asked Questions

  1. What is the purpose of the 3613 A form?

    The 3613 A form is a Provider Investigation Report 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). Its main purpose is to document and report incidents such as abuse, neglect, or other emergencies involving residents or individuals in these facilities.

  2. Who should fill out the 3613 A form?

    The form should be completed by authorized personnel within the care facilities mentioned above. This could include administrators, managers, or designated staff members who are responsible for reporting incidents to the Texas Department of Aging and Disability Services (DADS). Accurate and timely completion of this form is essential to ensure the safety and well-being of residents.

  3. How do I submit the 3613 A form?

    Once you have filled out the 3613 A form, you have two options for submission:

    • Fax: Send the completed form to the toll-free fax number 1-877-438-5827.
    • Mail: Alternatively, you can mail the report 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, if you choose to fax the report, do not mail a copy, as this could lead to duplicate reports being filed.

  4. What types of incidents should be reported using this form?

    The 3613 A form is intended for a variety of incidents, including but not limited to:

    • Death
    • Abuse
    • Neglect
    • Exploitation
    • Missing residents or individuals
    • Drug diversion
    • Natural disasters such as floods or tornadoes
    • Emergency power failures

    Each incident must be carefully documented to ensure appropriate action can be taken.

  5. What happens after I submit the 3613 A form?

    After submission, the report will be reviewed by the Consumer Rights and Services Section at DADS. They will assess the information provided and may initiate further investigation if necessary. It is crucial to ensure that all details are accurate and comprehensive, as this will aid in any follow-up actions or investigations that may occur.

Common mistakes

Filling out the 3613 A form can be a straightforward process, but there are common mistakes that can lead to delays or complications. One frequent error is leaving out essential information. For example, not providing the Provider Name or Vendor ID No. can cause the report to be incomplete. Ensure that all required fields are filled in accurately to avoid any unnecessary back-and-forth.

Another mistake is failing to include the correct DADS Intake ID No.. This number is crucial for tracking the report within the system. Double-check that you have the right ID before submitting the form. If you submit a report without this number, it may not be processed in a timely manner.

People often misinterpret the Incident Category section as well. Selecting the wrong category can lead to miscommunication and may affect how the incident is addressed. For instance, if the incident involved abuse, but the category selected was neglect, it could hinder the response needed for resolution.

Another common oversight involves the Incident Date and Time. It’s important to be precise here. Entering the wrong date or time can create confusion and may impact the investigation. Always verify the details before finalizing the form.

Many individuals also overlook the Alleged Perpetrator(s) section. This part requires clear identification of the alleged perpetrator, including their relationship to the individual involved. Incomplete or vague information can complicate the investigation process.

Additionally, neglecting to attach supporting documents can be a significant error. If there are witness statements or other evidence, make sure these are included with the report. Omitting these documents can weaken the case and delay resolution.

Lastly, signing and dating the form is often forgotten. A report that is not signed may be considered invalid. Ensure that the Provider Response section is completed, including the signature, printed name, title, and date, to confirm that the report is official.

Documents used along the form

The 3613 A form is crucial for reporting incidents in various types of care facilities, including Skilled Nursing Facilities and Assisted Living Facilities. Alongside this form, several other documents may be required to ensure a comprehensive understanding of the situation and to facilitate proper follow-up actions. Below is a list of related forms and documents that may be used in conjunction with the 3613 A form.

  • Incident Report Form: This document provides a detailed account of the incident, including what happened, when it occurred, and who was involved. It serves as an initial record for internal investigations and may be required by regulatory agencies.
  • Witness Statement Form: This form collects testimonies from individuals who witnessed the incident. These statements can be critical for corroborating details and understanding the context of the event.
  • Provider Response Form: After an incident is reported, this document outlines the actions taken by the facility in response. It may include corrective measures and any changes implemented to prevent future occurrences.
  • Assessment and Treatment Report: This report details any medical assessments or treatments provided to individuals involved in the incident. It is essential for documenting injuries and ensuring that proper care was administered.
  • Follow-Up Investigation Report: After the initial investigation, this document summarizes findings, conclusions, and any further actions taken. It helps ensure accountability and transparency in handling the incident.

These documents work together with the 3613 A form to create a thorough record of incidents in care facilities. Having all relevant paperwork completed and submitted can significantly improve the response to incidents and enhance the overall safety and care provided to residents.

Similar forms

The 3613 A form is a crucial document used primarily by various healthcare facilities to report incidents involving residents. It shares similarities with several other documents in the healthcare and regulatory field. Here are four documents that are comparable to the 3613 A form:

  • Incident Report Form: Like the 3613 A form, an incident report form is utilized to document any incidents that occur within a facility. It captures details about the event, individuals involved, and actions taken, ensuring proper follow-up and accountability.
  • Patient Safety Report: This report focuses on incidents that may compromise patient safety. Similar to the 3613 A form, it outlines the nature of the incident, contributing factors, and corrective measures taken to prevent future occurrences.
  • Abuse Reporting Form: Used to report suspected abuse in healthcare settings, this form shares the same purpose of documenting allegations and ensuring that appropriate investigations are conducted. It emphasizes the importance of safeguarding residents.
  • Quality Assurance Report: This report evaluates the quality of care provided in facilities. It often includes incident data, much like the 3613 A form, to assess trends and implement improvements to enhance patient care and safety.

Dos and Don'ts

When filling out the 3613 A form, it’s essential to be thorough and accurate. Here are some dos and don'ts to keep in mind:

  • Do double-check all entries for accuracy before submitting.
  • Don't leave any sections blank; provide as much detail as possible.
  • Do ensure that the correct contact information is provided for follow-up.
  • Don't use abbreviations or shorthand that may confuse the reader.
  • Do include all relevant incident details, including dates and times.
  • Don't submit the form without a thorough review of the information provided.
  • Do follow the submission guidelines, whether faxing or mailing the form.

By adhering to these guidelines, you can help ensure that your report is processed smoothly and effectively.

Misconceptions

Understanding the 3613 A form is essential for facilities involved in care services. However, several misconceptions often arise regarding its purpose and use. Here are ten common misunderstandings:

  • It is only for reporting abuse. Many believe the form is solely for abuse cases. In reality, it covers a wide range of incidents, including neglect, drug diversion, and emergency situations.
  • Only licensed facilities can use it. Some think that only licensed skilled nursing facilities can submit the form. However, it is applicable to various types of facilities, including assisted living and adult day care facilities.
  • Reports must always be mailed. There is a misconception that the form must be mailed to the Texas Department of Aging and Disability Services. Faxing the report is also an acceptable method of submission.
  • Confidentiality is not a concern. Some individuals underestimate the importance of confidentiality. The form contains sensitive information, and unauthorized disclosure is strictly prohibited.
  • Only staff members can be alleged perpetrators. A common belief is that only employees can be identified as perpetrators. In fact, family members or visitors can also be named in allegations.
  • The form can be filled out by anyone. There is a misconception that anyone can complete the form. It is intended to be filled out by authorized personnel within the facility.
  • Incidents must be reported immediately. Some believe that all incidents require immediate reporting. While prompt reporting is encouraged, certain situations may allow for a more measured approach.
  • All reports will lead to investigations. There is a belief that every submitted form will trigger an investigation. However, the Department evaluates each report and determines the appropriate course of action.
  • Incomplete forms will still be accepted. Some individuals think that submitting an incomplete form is acceptable. In reality, missing information can delay the processing of the report.
  • It is not necessary to keep copies of submitted forms. A misconception exists that keeping copies of submitted forms is unnecessary. Retaining a copy is important for record-keeping and follow-up purposes.

Clarifying these misconceptions can help ensure that the 3613 A form is used correctly and effectively by all relevant parties.

Key takeaways

Filling out the 3613 A form is a critical process for various healthcare facilities. Understanding the key elements can ensure compliance and effective communication with the Texas Department of Aging and Disability Services (DADS). Here are four essential takeaways:

  • Accuracy is Crucial: Ensure all information, including dates, times, and incident details, is accurately recorded. Inaccuracies can lead to delays in processing and potential legal issues.
  • Confidentiality Matters: The form contains sensitive information. It is essential to handle it with care, ensuring that only authorized personnel have access to the document.
  • Timeliness is Key: Submit the form promptly after an incident occurs. Delayed reporting can hinder investigations and may violate regulatory requirements.
  • Follow Submission Guidelines: Whether faxing or mailing, adhere strictly to the instructions provided. This includes ensuring that the cover sheet is filled out correctly and that the report is sent to the appropriate DADS contact.

By keeping these points in mind, facilities can navigate the reporting process more effectively and maintain compliance with state regulations.