Form 3613 A PDF Details

The 3613 A form plays a pivotal role in maintaining the high standards of care and safety expected in various residential and day services facilities across the health and care sector. Designed explicitly 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), this form is a vital tool for reporting a range of incidents. These incidents can include, but are not limited to, abuse, neglect, exploitation, missing residents, medication errors, and even environmental emergencies such as fires or power failures. Facility providers are required to fill out this form diligently to report any such occurrences to the Texas Department of Aging and Disability Services. The detailed nature of the form ensures that every aspect of the reported incident is thoroughly documented, including particulars about the involved individuals, the incident's details, and the aftermath and response actions. Furthermore, the inclusion of a fax cover sheet emphasizes the importance of timely and secure communication with the DADS Consumer Rights and Services Section, highlighting the form's role in safeguarding the well-being of vulnerable individuals in care settings. By mandating the use of the 3613 A for the specified facilities, regulatory bodies aim to promote transparency, accountability, and ultimately, optimal care quality and safety.

QuestionAnswer
Form NameForm 3613 A
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other names3613a pdf, form 3613 provider investigation report, texas health and human services for 3613a, 3613a

Form Preview Example

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

SNF, NF, ICF/IID, ALF, ADC, DAHS

and Disability Services

Provider Investigation Report

 

Fax this report to: 1-877-438-5827 (toll free) 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

Form 3613-A

July 2012

Note to reporter:

Do not mail if faxed.

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: Level of Supervision:

Total assistance

No special supervision Within specified distance: Other:

Extensive

Minimal

No assistance

Within eyesight

Within hearing

Within arm’s length

 

Specified observation time frame:

 

 

 

Independently ambulatory

Y

History of

Combativeness

 

 

Wandering

 

Other pertinent history:

N

Interviewable

Y

N

Capacity to make informed decisions

 

Verbal aggression

 

Physical aggression

 

Sexual misconduct

Wearing wander guard at time of incident

Y

N

Similar allegations

Y N

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/Transfer Date

Time

 

 

Treatment provided?

Yes

No

 

:

A.M.

P.M.

 

 

 

Off-site

 

City

 

Treatment location: In-House

Yes

No

 

 

 

 

 

 

 

 

 

 

 

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

Printed Name

Title

Date

How to Edit Form 3613 A Online for Free

Our top rated programmers worked hard to design the PDF editor we are now pleased to present to you. Our software permits you to easily prepare 3613a and will save you valuable time. You need to simply comply with this particular guide.

Step 1: Click the "Get Form Here" button.

Step 2: You are now on the form editing page. You can edit, add information, highlight certain words or phrases, insert crosses or checks, and add images.

Type in the essential material in every segment to create the PDF 3613a

part 1 to filling in hhsc form 3613 a

Indicate the information in Street Address, 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, Use only for Skilled Nursing, and Form A.

part 2 to entering details in hhsc form 3613 a

Note the necessary data in DADS Intake ID No, Date Reported to DADS, Vendor ID No, Time Reported, Telephone No Fax, City, ZIP Code, Drug Diversion Fire Alarm Failure, Fire, Bomb Threat Firearms in the, Provider Type, Name, Street Address, Incident Category, and Abuse field.

hhsc form 3613 a DADS Intake ID No, Date Reported to DADS, Vendor ID No, Time Reported, Telephone No Fax, City, ZIP Code, Drug Diversion Fire Alarm Failure, Fire, Bomb Threat Firearms in the, Provider Type, Name, Street Address, Incident Category, and Abuse fields to complete

The Total assistance No special, Minimal Within hearing Specified, Other, Independently ambulatory History of, Interviewable Verbal aggression, N Capacity to make informed, Physical aggression, Sexual misconduct, Wearing wander guard at time of, Similar allegations, Combativeness Wandering, Other pertinent history, Name, Female, and Male field will be the place to put the rights and obligations of both parties.

Filling out hhsc form 3613 a step 4

Look at the fields Combativeness Wandering, Other pertinent history, Wearing wander guard at time of, and Similar allegations and then complete them.

Entering details in hhsc form 3613 a step 5

Step 3: After you select the Done button, your finished document can be easily transferred to all of your devices or to electronic mail provided by you.

Step 4: To prevent different problems in the long run, be sure to prepare at least several duplicates of the file.

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