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Outline

The 3613 A form serves as a crucial tool for reporting incidents within various healthcare facilities, including Skilled Nursing Facilities, Nursing Facilities, and Assisted Living Facilities. This form is designed specifically for use by providers in the Texas Department of Aging and Disability Services (DADS) system. It encompasses a wide range of incidents, such as abuse, neglect, and emergency situations, ensuring that all critical information is documented and communicated effectively. The form requires detailed information about the incident, including the date, time, and location, as well as the individuals involved. Additionally, it prompts the reporter to outline the nature of the allegation, any injuries sustained, and the actions taken by the provider in response to the incident. Confidentiality is paramount, as the form contains privileged information that must be handled with care. Timely submission is essential, with options for faxing or mailing the report to DADS, highlighting the urgency of addressing such matters. Understanding the components and requirements of the 3613 A form is vital for ensuring compliance and safeguarding the well-being of residents in these facilities.

Sample - 3613 A Form

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
Click for PDF

Form Information

Fact Name Fact Description
Form Purpose The 3613 A form is used for reporting investigations by various types of care facilities, including skilled nursing and assisted living facilities.
Applicable Facilities This form is specifically for 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).
Confidentiality Notice The form contains a confidentiality notice, indicating that the information is privileged and should not be shared with unauthorized individuals.
Fax Submission The completed report should be faxed to the Texas Department of Aging and Disability Services at 1-877-438-5827.
Mailing Address If faxing is not possible, the form can be mailed to the Texas Department of Aging and Disability Services, Consumer Rights and Services Section, E-249, P.O. Box 149030, Austin, TX 78714-9030.
Incident Categories Incidents reported can include death, abuse, neglect, exploitation, missing residents, drug diversion, and various emergencies like fire or flooding.
Reporting Timeline Providers must report incidents to DADS as soon as possible, including the date and time of the report.
Investigation Findings The form allows for multiple outcomes of the investigation, such as confirmed, unconfirmed, inconclusive, or unfounded.
Provider Information Providers must include their name, license number, and contact information on the form for identification and follow-up.
Governing Law This form is governed by Texas state laws regarding the reporting and investigation of incidents in care facilities.

Detailed Guide for Filling Out 3613 A

Completing the 3613 A form requires careful attention to detail. This document is essential for reporting incidents related to various care facilities. Once the form is filled out, it should be faxed to the appropriate department or mailed as specified. Below are the steps to accurately complete the form.

  1. Begin by entering the Date at the top of the form.
  2. Fill in the To section with "DADS Consumer Rights and Services Section Attention: Intake Coordinator."
  3. Provide the Fax Area Code and Telephone No. as 1-877-438-5827.
  4. Enter the Regarding DADS Intake ID No. in the designated space.
  5. Indicate the No. of Pages, including the cover sheet.
  6. Complete the From section with the Provider Name and Vendor / ID No..
  7. Fill in the Street Address, City, and Telephone No..
  8. In the Provider Investigation Report Information section, provide the Agency Name and License No..
  9. Complete the Street Address, City, State, ZIP Code, and County.
  10. Provide the Area Code and Telephone No. and Fax Area Code and Telephone No..
  11. Indicate the Provider Type and Vendor / ID No..
  12. Fill in the Incident Category by selecting one from the list provided.
  13. Document who made the allegation and the date it was made.
  14. Record the Incident Date and Time.
  15. Provide the Location of the incident.
  16. List the Individual(s)/Resident(s) Involved, including their names, gender, Social Security No., and Date of Birth.
  17. For each individual, indicate their Functional Ability and Level of Supervision.
  18. Note any history of combativeness or other pertinent history for each individual.
  19. Fill in details for the Alleged Perpetrator(s), including their name and how they were identified.
  20. Indicate whether the alleged perpetrator denied or confirmed the allegations and if there is a history of similar allegations.
  21. Document if there were any witnesses and provide their details.
  22. Describe the Allegation and any Injury/Adverse Effect that occurred.
  23. Fill in the Assessment Date and Time, along with a description of the assessment.
  24. Indicate whether treatment was provided and the treatment location.
  25. Summarize the Investigation Findings and any actions taken by the provider.
  26. Finally, sign and print your name, title, and date at the bottom of the form.

Obtain Answers on 3613 A

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

    The 3613 A form serves as a Provider Investigation Report specifically designed for various types of 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 document incidents that may involve abuse, neglect, or other significant events affecting residents or individuals in these facilities.

  2. Who is required to use the 3613 A form?

    Only designated facilities, such as SNFs, NFs, ICF/IIDs, ALFs, ADCs, and DAHS, are required to use this form. It is crucial for these providers to accurately report incidents to ensure the safety and well-being of their residents.

  3. How should the 3613 A form be submitted?

    The completed form can be submitted via fax or mail. To fax the report, send it to the toll-free number 1-877-438-5827. Alternatively, it can be mailed 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 report is faxed, it should not be mailed.

  4. What types of incidents must be reported using the 3613 A form?

    Incidents that fall under various categories must be reported, including:

    • Death
    • Abuse
    • Neglect
    • Exploitation
    • Missing resident/individual
    • Drug diversion
    • Emergency situations (e.g., fire, flood, power failure)
    • System failures (e.g., sprinkler system, fire alarm)

    Facilities must assess the nature of the incident to determine if it requires reporting.

  5. What information is required on the 3613 A form?

    The form requires detailed information, including:

    • The name and contact details of the provider.
    • The date and time of the incident.
    • A description of the allegation.
    • Details about the individuals involved, including alleged victims and perpetrators.
    • Witness information, if applicable.
    • Results of the investigation and any actions taken by the provider.

  6. What happens if the 3613 A form is filled out incorrectly?

    Filling out the form incorrectly can lead to delays in investigation or miscommunication regarding the incident. It is essential for the reporting party to ensure that all information is accurate and complete. If errors are discovered after submission, it is advisable to submit a corrected report as soon as possible.

  7. What is the confidentiality status of the 3613 A form?

    The 3613 A form is classified as a confidential document. It contains sensitive information regarding individuals involved in incidents. Unauthorized disclosure, dissemination, or distribution of the form is strictly prohibited. Recipients must handle the document with care and ensure that it is only shared with authorized personnel.

Common mistakes

Filling out the 3613 A form can be straightforward, but many people make common mistakes that can lead to delays or complications. One frequent error is neglecting to include the DADS Intake ID No.. This number is crucial for tracking the report and ensuring it reaches the correct department. Without it, the form may be considered incomplete.

Another common mistake is providing inaccurate or incomplete contact information. This includes the provider's name, address, and telephone number. If any of this information is wrong, it can hinder communication and follow-up actions. Always double-check these details before submitting the form.

Many individuals also fail to specify the incident category clearly. The form lists various categories such as abuse, neglect, and exploitation. Choosing the wrong category or leaving it blank can lead to misinterpretation of the incident, impacting the investigation process.

In addition, some people do not provide adequate details about the individuals involved. It's essential to include complete names, dates of birth, and social security numbers when applicable. Omitting this information can complicate the investigation and delay necessary actions.

Another mistake is not documenting the alleged perpetrator's information accurately. If the alleged perpetrator is not a staff member, their relationship to the resident should be clearly indicated. This helps investigators understand the context of the allegation better.

People often overlook the importance of detailing the description of the allegation. A vague description can lead to misunderstandings and insufficient investigations. Be specific about what occurred, including any relevant circumstances or behaviors.

Additionally, many fail to attach necessary witness statements or documentation. If there are witnesses to the incident, including their statements can provide valuable insight. Not having this information may weaken the case and affect the outcome of the investigation.

Lastly, some individuals forget to sign and date the form. This step is crucial for validating the report. A missing signature can lead to the form being rejected, causing unnecessary delays in the investigation process.

Documents used along the form

The 3613 A form is an essential document used primarily by various healthcare facilities to report incidents involving residents. When completing this form, you may also need to use several other related documents. Here’s a brief overview of six common forms that often accompany the 3613 A form.

  • Incident Report Form: This form provides detailed information about the incident, including the date, time, and nature of the event. It serves as a foundational document for further investigation and reporting.
  • Witness Statement Form: This document collects testimonies from individuals who witnessed the incident. It helps to gather different perspectives and can be crucial for the investigation.
  • Medical Assessment Report: If there are any injuries or medical concerns resulting from the incident, this report outlines the medical evaluation and any treatment provided to the affected individuals.
  • Provider Response Form: After the investigation, this form allows the facility to outline the actions taken in response to the incident. It reflects the facility's commitment to addressing issues and improving care.
  • Follow-Up Action Plan: This plan details the steps the facility will take to prevent similar incidents in the future. It may include staff training, policy changes, or additional safety measures.
  • Confidentiality Agreement: This document ensures that all parties involved in the investigation understand the importance of keeping sensitive information private. It protects the rights of residents and staff alike.

Using these forms in conjunction with the 3613 A form can help ensure a thorough and effective reporting process. Each document plays a vital role in maintaining the safety and well-being of residents in care facilities.

Similar forms

  • Incident Report Form: Similar to the 3613 A form, an incident report form documents specific incidents within a facility. It captures details such as the nature of the incident, individuals involved, and actions taken, ensuring accountability and compliance with regulatory requirements.
  • Patient Safety Report: This report focuses on incidents affecting patient safety. Like the 3613 A form, it emphasizes the importance of documenting occurrences that may harm residents and outlines measures taken to prevent future incidents.
  • Quality Assurance Report: This document reviews the quality of care provided in facilities. It shares similarities with the 3613 A form in that it identifies issues and recommends improvements to enhance service delivery and resident safety.
  • Compliance Report: A compliance report evaluates adherence to regulatory standards. Much like the 3613 A form, it highlights areas of concern and outlines corrective actions taken by the facility to maintain compliance with state and federal regulations.
  • Accident Report Form: This form captures details of accidents occurring on facility premises. It parallels the 3613 A form by documenting the incident, assessing its impact, and detailing the response, thus aiding in risk management and prevention strategies.

Dos and Don'ts

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

  • Do provide accurate information about the incident, including dates and times.
  • Do ensure that all required fields are completed before submission.
  • Do include the correct contact information for the provider and any involved individuals.
  • Do attach any relevant documentation or evidence to support your report.
  • Don't submit the form if you have faxed it; follow the instructions regarding mailing and faxing.
  • Don't include unnecessary personal opinions or speculations about the incident.
  • Don't forget to sign and date the form to validate the submission.

Following these guidelines will help ensure that your report is processed smoothly and effectively. Pay attention to detail, and do not hesitate to seek clarification if you are unsure about any part of the form.

Misconceptions

Understanding the 3613 A form is crucial for various facilities, including skilled nursing and assisted living facilities. However, several misconceptions exist that can lead to confusion. Below is a list of common misunderstandings about this form, along with clarifications to help clear the air.

  • Misconception 1: The 3613 A form is only for reporting severe incidents.

    • This form is not limited to serious incidents like abuse or neglect. It is designed to report a wide range of occurrences, including minor incidents that may still require documentation.

  • Misconception 2: Only licensed professionals can fill out the form.

    • While it is important for trained staff to complete the form accurately, anyone involved in the incident, such as family members or other witnesses, can provide information for the report.

  • Misconception 3: The form must be submitted immediately after an incident.

    • While prompt reporting is encouraged, there may be specific time frames within which the form must be submitted. Always check the guidelines to ensure compliance.

  • Misconception 4: The 3613 A form is confidential and cannot be shared with anyone.

    • While the form contains confidential information, it may be shared with appropriate parties involved in the investigation or care of the individuals affected.

  • Misconception 5: Only the incident's outcome needs to be reported.

    • It is essential to document the entire process, including the investigation findings and any actions taken by the facility. This comprehensive approach ensures accountability and transparency.

  • Misconception 6: The form can be faxed or mailed interchangeably.

    • It is important to note that if the report is faxed, it should not be mailed. This helps avoid duplicate submissions and potential confusion in processing.

  • Misconception 7: The 3613 A form is only relevant to the facility where the incident occurred.

    • The form may have implications beyond the immediate facility. It can inform broader regulatory or compliance issues within the state’s health and safety systems.

By addressing these misconceptions, facilities can better navigate the reporting process and ensure that they are complying with necessary regulations. Understanding the purpose and requirements of the 3613 A form can ultimately enhance the care and safety of individuals in these facilities.

Key takeaways

When filling out and using the 3613 A form, there are several important points to keep in mind:

  • Purpose of the Form: This form is specifically designed for use by various types of care facilities, including Skilled Nursing Facilities, Nursing Facilities, and Assisted Living Facilities. Ensure that you are part of an eligible facility before proceeding.
  • Confidentiality: The document contains privileged information. If you receive it in error, do not disclose or use it. Notify the sender immediately and destroy any copies.
  • Accurate Reporting: It is crucial to provide accurate and complete information regarding incidents. This includes details about the individuals involved, the nature of the incident, and any actions taken following the event.
  • Submission Guidelines: After completing the form, you have the option to either fax it to the designated number or mail it to the Texas Department of Aging and Disability Services. If you fax the report, do not send a hard copy by mail.