Form 3613 PDF Details

The Provider Investigation Report, known formally as Form 3613, serves a critical function within the Home and Community Support Services Agency realm, which includes Home Health, Hospice, and Personal Assistance Services. Crafted to ensure a structured and comprehensive approach to incident reporting, this form is dedicated to providers to facilitate the reporting of allegations related to abuse, neglect, or exploitation. Providers must fax or mail this document to the Texas Department of Aging and Disability Services, aligning with a protocol that emphasizes confidentiality and urgency in addressing potential client or patient vulnerabilities. Detailed in nature, the form requires information ranging from the agency's identification details to specific data on the incident, including the alleged victim and perpetrator's information. Its sections necessitate an exhaustive depiction of the incident, the results of any subsequent investigation, and the actions taken by the agency post-investigation. By mandating a meticulous documentation process, the form acts as a crucial instrument in promoting the safety and rights of clients receiving home and community support services, ensuring that each incident is reviewed comprehensively by the Texas Department of Aging and Disability Services.

QuestionAnswer
Form NameForm 3613
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other nameshhsc 3613 a, texas dads 3613 form, 3613 form dads, how to dads form report

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Provider Investigation Report

For Home and Community Support Services Agency

(Home Health, Hospice and Personal Assistance Services)

Provider Use Only

Fax Cover Sheet

Date:

To: DADS Complaint Intake Unit, Attention: Intake Coordinator

Fax Area Code and Telephone No.: 1-877-438-5827 (if 15 total pages or fewer)

Office Area Code and Telephone No.: – –

Regarding DADS Intake ID No.:

No. of Pages, including cover:

From:

Name of Agency Representative:

 

 

Title of Agency Representative:

 

 

Fax Area Code and Telephone No.:

–

–

Office Area Code and Telephone No.:

–

–

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.

For Home and Community Support Services Agency

(Home Health, Personal Assistance Services and Hospice) Provider Use Only

Form 3613 / 6-2009

Texas Department of Aging

Provider Investigation Report

and Disability Services

 

 

For Home and Community Support Services Agency

 

(Home Health, Hospice and Personal Assistance Services) Provider Use Only

Fax this report to: 1-877-438-5827 (if 15 total pages or fewer)

Mail this report to: Texas Department of Aging and Disability Services, Consumer Rights and Services, Complaint Intake Unit E-249, P.O. Box 149030, Austin, TX 78714-9030

(If more than 15 Attach all documents and pertinent information that might be needed for DADS to complete the review

total pages): of your investigation. Your DADS Regional Office may also contact you to request additional information to complete the review.

Form 3613

June 2009

Note to

reporter:

Do not mail

if faxed.

DADS Intake ID No.

 

Date Reported to DADS 800-458-9858

 

 

Time Reported

 

 

 

 

DFPS Call ID No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

:

 

 

a.m.

p.m.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provider Type

 

 

 

 

 

 

 

 

 

 

 

 

License No.

 

 

Area Code and Telephone No.

 

HCSSA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

–

 

–

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fax Area Code and Telephone No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

–

 

–

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

ZIP Code

 

 

County

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Incident Category

 

 

 

Who made the allegation?

 

 

 

 

 

 

 

 

When?

 

Abuse

Neglect

Exploitation

 

 

Client/Patient

Family

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Incident Date

 

Time

 

 

 

 

 

Location

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

:

 

a.m.

p.m.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Description of the Allegation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Client/Patient Name

 

 

 

 

 

 

 

 

 

 

 

 

Social Security No.

 

 

 

 

Date of Birth

 

 

 

 

 

 

 

 

 

 

 

 

Female

 

Male

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Client/Patient Street Address

Check here if client/patient address below is a residential facility or in-patient hospice

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

State

 

ZIP Code

 

Area Code and Telephone No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

–

 

–

 

Payment Source

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Functional Assistance Needs Status

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total

 

Extensive

Minimal

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If applicable, describe any special supervision required.

 

 

 

 

 

 

 

 

 

Age at the time of the allegation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Services Provided (type, number of hours)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Independently ambulatory:

Yes

No

Interviewable:

Yes

 

No

Capacity to make informed decisions:

Yes

 

 

No

 

Known history of:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Combativeness

 

 

Yes

No

 

 

Similar allegations

 

 

Yes

No

 

Wandering

 

 

 

Yes

No

Sexual misconduct

Yes

No

 

 

Verbal aggression

 

 

Yes

No

 

Physical aggression

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Diagnosis/Pertinent History

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Alleged Perpetrator(s) (AP)

Attach documentation of any criminal history check searches, nurse aide registry searches and employee misconduct registry searches conducted to verify the employability of the alleged perpetrator. Do not send printed copies of actual criminal history reports obtained from the Department of Public Safety (DPS) secure site.

Staff Name (includes family if employed by, volunteering with or contracted to the agency)

Date of Birth

Social Security No.

License/Certificate No.

 

 

 

 

 

 

 

 

 

 

 

 

DADS Intake ID No.

Agency Name

Form 3613

Page 2 / 06-2009

License No.

How was the AP identified?

The AP.....................................

By Name Denied

By Description

Other:

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

Client/Patient/Family/Staff/Other

Address

 

 

Area Code and Telephone No.

 

 

 

 

 

 

 

 

 

–

–

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Assessment Date

 

 

 

Time

 

 

Injury or adverse effect?

Yes

No

 

 

 

 

 

:

a.m.

p.m.

 

 

 

 

 

 

 

 

 

 

 

 

Description of Injury/Assessment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Treatment/Transfer Date

 

 

Time

 

 

Treatment provided?

Yes

No

 

 

 

 

 

 

:

a.m.

p.m.

 

 

 

 

 

 

 

 

 

 

 

Treatment Location (name and complete address)

 

 

 

 

 

 

 

 

In-House?

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

Yes

No

Agency Immediate Response

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Investigation Summary (attach additional sheets as necessary)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Investigation Findings

 

 

 

 

 

 

 

 

 

 

 

 

Confirmed

Unconfirmed

Inconclusive

Unfounded

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Agency Action Post-Investigation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Note: DADS does not accept this report as complete until the reporter’s signature, printed name, title and date have been entered below.

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature

 

 

 

 

 

 

Title

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Printed Name

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

How to Edit Form 3613 Online for Free

Handling PDF forms online is actually very easy with our PDF editor. Anyone can fill out hhsc form 3613 here and use several other functions we provide. The editor is constantly maintained by us, receiving useful features and growing to be much more convenient. Getting underway is simple! Everything you need to do is follow these basic steps down below:

Step 1: First, access the pdf editor by pressing the "Get Form Button" at the top of this webpage.

Step 2: The editor offers you the capability to customize your PDF form in many different ways. Improve it with any text, correct original content, and include a signature - all at your convenience!

Completing this PDF calls for attention to detail. Make sure that all mandatory blanks are filled in correctly.

1. Fill out your hhsc form 3613 with a selection of necessary blank fields. Note all of the important information and ensure there is nothing left out!

3613 completion process described (part 1)

2. The third part is usually to fill out the next few blanks: City State ZIP Code, County, Area Code and Telephone No, Fax Area Code and Telephone No, Parent, BranchAlternate Delivery Site, Confidential Document, This communication including any, For Home and Community Support, Home Health Personal Assistance, and Form.

Ways to prepare 3613 part 2

3. Through this step, examine DADS Intake ID No, Date Reported to DADS, Time Reported, DFPS Call ID No, License No, Area Code and Telephone No, Fax Area Code and Telephone No, City, ZIP Code, Who made the allegation, County, When, Provider Type, HCSSA, and Name. All these need to be filled in with highest accuracy.

A way to complete 3613 step 3

4. This next section requires some additional information. Ensure you complete all the necessary fields - If applicable describe any special, Age at the time of the allegation, Services Provided type number of, Independently ambulatory, Yes, No Interviewable, Yes, No Capacity to make informed, Yes, Known history of, Combativeness, Sexual misconduct, Yes Yes, No No, and Similar allegations - to proceed further in your process!

Learn how to complete 3613 step 4

5. To finish your document, the particular area includes a few extra blanks. Filling in DADS Intake ID No, Agency Name, License No, How was the AP identified, By Name, By Description, Other, The AP, Denied, Confirmed, History of similar allegations, Yes, Did investigation reveal the, Statement attached signed and, and Yes should finalize everything and you can be done in no time!

3613 conclusion process clarified (stage 5)

In terms of Yes and License No, be certain that you do everything right here. Both these are the key fields in the file.

Step 3: Before moving forward, check that all blanks have been filled out the correct way. As soon as you determine that it's correct, press “Done." Sign up with us right now and immediately access hhsc form 3613, set for download. All changes made by you are saved , meaning you can modify the pdf at a later point if necessary. FormsPal guarantees safe form completion devoid of personal data recording or distributing. Rest assured that your details are secure with us!

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