Form 3613-A, SNF, NF, ICF/IID, ALF, DAHS including ISS providers and PPECC Provider Investigation Report with Cover Sheet

Instructions

Updated: 4/2024

For use only by skilled nursing facilities (SNFs), nursing facilities (NFs), intermediate care facilities for individuals with an intellectual disability or related conditions (ICF/IIDs), assisted living facilities (ALFs), day and activity health services (DAHS) facilities including individualized skills and socialization (ISS) providers and prescribed pediatric extended care centers  (PPECCs).

Purpose

This form furnishes a standardized format for long-term care (LTC) providers to document their self-reported incident investigation summary, analysis and finding(s) per regulatory requirements.

Procedure

After making a verbal report to 800-458-9858, submit Form 3613-A, Provider Investigation Report. Include  statements and other relevant documentation, within the applicable regulatory time frame:

• five working days for NFs, SNFs, ISS and all ICF/IIDs;
• five calendar days for ALFs, PPECCs and DAHS providers without ISS services.

If Form 3613-A, with statements and other relevant documentation, is 15 pages or less, email ciiprovider@hhs.texas.gov or fax the report and attachments toll-free to HHSC at 877-438-5827. If the form, with statements and other relevant documentation, is 16 pages or more, email or mail the report and attachments to:

Texas Health and Human Services Commission
Regulatory Services Complaint and Incident Intake, Mail Code E-249
ATTN: Intake Coordinator
P.O. Box 149030
Austin, TX  78714-9030

Do not fax and mail. Either fax the report and any attachments or mail the report and any attachments, based on the length of the report.

A separate Form 3613-A must be completed and submitted for each incident reported.

Detailed Instructions

Fill out the form completely. Check each appropriate option or fill in each applicable blank.

Investigation Report Fax Cover Sheet

Use this cover sheet for any investigation report faxed to HHSC. Fill out the cover sheet completely. Indicate the total number of pages, including any attachments, so HHSC can verify receipt of all pages of the provider's investigation report. The facility representative who completes the report form must sign and date the cover sheet.

HHSC Intake ID No. — Mark the HHSC Intake ID No. on each page of your report, including the cover sheet and each page of any attachments.  An HHSC program specialist will provide the Intake ID number when a verbal report is made for a crisis of an immediate nature, such as death under unusual circumstances or an incident of a sexual nature. An HHSC program specialist contacts the reporter within two working days to verify correct spelling of names, to confirm details of the incident and to provide the Intake ID No. if the incident was reported to the incident voice mail box system.

Provider Type — Note the provider's program or service type and identifying or contact information.

Incident Category — Identify the type of allegation reported, who made the allegation and when the allegation was reported to facility staff.

Incident Date, Time and Location — Document the date, time and location of the incident.

Person(s) or Resident(s) Involved in the Incident — List all people or residents involved in the incident. Include alleged victims or alleged aggressors. Describe their functional ability, level of supervision required and other characteristics listed on the form by checking all items that apply. If a person or resident is not the alleged victim, describe the person's or resident's relationship to this person in the investigation summary. The person could be a witness or relative. 

Alleged Perpetrator(s) (AP) — List only alleged perpetrators who are not individuals or residents. Alleged perpetrators who are residents should be listed under "Person(s) or Resident(s) Involved in the Incident" above. If the alleged perpetrator is not a resident or staff member, indicate this person’s relationship to the person or resident, such as friend or family member. 

Witness(es) — List all witnesses who have knowledge of the incident.

Description of the Allegation — Provide a brief description of the allegation that identifies the alleged victim(s), alleged perpetrator(s), any witness(es), the date and time the alleged incident occurred, when the allegation was initially reported to the provider, and how the incident was discovered.

Assessment — Describe any physical or emotional assessment performed because of the incident.

Treatment Provided — Describe any treatment provided because of the incident.

Provider Response — Describe immediate actions taken to protect the person’s or resident's health and safety because of the allegation. Include who was notified of the allegation, such as a doctor, family member or guardian, or ombudsman, if applicable. If the provider notified the police, include the case or reference number issued after the report was made.

Investigation Summary — Summarize the provider's investigative procedures concisely, factually and objectively. Summarize the investigator's analysis of supporting documents, such as interviews, witness statements, injury reports, diagrams, life satisfaction surveys, observations and other appropriate evidence. Clearly state the investigator's conclusion about the allegation and any contributing facility practice(s) and the investigator's recommendation(s). Summarize how the investigator arrived at these conclusions and recommendation(s). Include the name(s) and position(s) of the investigator(s).

Facility Investigation Findings — Check the term that best describes the facility’s investigation.

• Confirmed: The allegation is supported by the strength of the evidence that best concurs with reason and probability, for example, the facts are more probably one way than another.
• Unconfirmed: It is reasonable to conclude the allegation did not occur or is unlikely to have occurred.
• Inconclusive: There is insufficient evidence to support or refute the allegation.
• Unfounded: The allegation is untrue or patently without factual basis.

Provider Action Post-Investigation — Describe actions taken by the provider because of the investigative findings. Indicate who the provider notified of the investigative findings, if applicable.

Signature Section — The reporter must complete and sign this section.