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 and Prescribed Pediatric Extended Care Centers (PPECCs).
The purpose of this form is to furnish a standardized format for long-term care (LTC) providers to document their self-reported incident investigation summary, analysis and finding(s) in accordance with regulatory requirements.
After making an oral report to 1-800-458-9858, submit Form 3613-A, Provider Investigation Report, with statements and other relevant documentation, within the applicable regulatory time frame:
- five working days for NFs, SNFs and all ICF/IIDs;
- five calendar days for ALFs and PPECCs.
ICF/IIDs facilities must submit a status report within five working days and a copy of the Texas Department of Family and Protective Services (DFPS) final investigation report upon receipt
If Form 3613-A, with statements and other relevant documentation, is 15 pages or fewer, email email@example.com or fax the report and attachments toll-free to HHSC at 1-877-438-5827. 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.
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. Indicating the total number of pages, including any attachments, enables HHSC to verify receipt of all pages of the provider's investigation report. The cover sheet must be signed and dated by the facility representative completing the report form.
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 at the time of oral report for a crisis of an immediate nature, such as death under unusual circumstances or an incident of a sexual nature. An HHSC program specialist will contact 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/service type and identifying/contact information.
Incident Category — Identify the type of allegation being 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.
Individual(s)/Resident(s) Involved in the Incident — List all individuals/residents involved in the incident, including 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 an individual/resident is not the alleged victim, describe the individual's/resident's relationship to this person (example: witness, relative, etc.) in the investigation summary.
Alleged Perpetrator(s) (AP) — List only alleged perpetrators who are not individuals/residents. Alleged perpetrators who are residents should be listed under "Individual(s)/Resident(s) Involved in the Incident" above. If the alleged perpetrator is neither a resident nor a staff member, indicate the relationship of this person to the individual/resident (example: friend, family member, etc.).
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.
Injury/Adverse Effect — Provide a brief description of the injury or adverse effect to the individual/resident as a result of the incident.
Assessment — Describe any physical or emotional assessment performed as a result of the incident.
Treatment Provided — Describe any treatment provided as a result of the incident.
Provider Response — Describe immediate actions taken to protect the individual's/resident's health and safety as a result of the allegation. Include who was notified of the allegation (example: doctor, family/guardian, ombudsman, etc.), if applicable. If the provider notified DFPS, include the call/case identification number issued by this agency. If the provider notified the police, include the case/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 regarding the allegation, the investigator's conclusion regarding 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).
Investigation Findings — Check the term that best describes the findings.
- Confirmed: The allegation is supported by a preponderance of the evidence (evidence that best accords with reason and probability, i.e., the facts are more probably one way than another).
- Unconfirmed: It is reasonable to conclude that 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 as a result of the investigative findings. Indicate who the provider notified of the investigative findings, if applicable.
Signature Section — This section must be completed and signed by the reporter.