Free 3613 A PDF Form

How to Fill Out 3613 A

Completing the 3613 A form is a critical process designed to report specific incidents at various care facilities. This form ensures that all necessary details are accurately captured and communicated to the Texas Department of Aging and Disability Services. It is crucial for enhancing the safety and well-being of residents and clients. The information you provide helps in the assessment and improvement of facility operations and care standards. To complete the form, one must follow a structured set of steps, carefully entering all required details to ensure the report is comprehensive and informative.

1. Start with the Fax Cover Sheet. Enter the current Date, the name of the facility and its Vendor/ID No., along with the Street Address, City, Telephone No., and Fax number.
2. On the Provider Investigation Report Information section, fill in the Agency Name, License No., and full address including the Street Address, City, State, ZIP Code, and County.
3. Include both the Area Code and Telephone No. and the Fax Area Code and Telephone No. for the reporting facility.
4. In the section marked DADS Intake ID No., Date Reported to DADS, and Time Reported, provide the specifics of when the incident was initially reported to the Department of Aging and Disability Services, including the Provider Type and Vendor/ID No.
5. Describe the incident thoroughly, starting with the Incident Category (e.g., Death, Abuse, Neglect). Be sure to include Who made the allegation, When it was made, the Incident Date, Time, and Location.
6. For each individual involved (including alleged victims or aggressors), provide their Name, Gender, Social Security No., Date of Birth, and details regarding their Functional Ability, Level of Supervision, and any relevant history that pertains to the incident.
7. If an alleged perpetrator is identified, fill in their details including the Name, Date of Birth, Social Security No., and how they were identified (e.g., By name, By description).
8. Provide a Description of the Allegation, and if there was an Injury/Adverse Effect, give a detailed description of the injury, Assessment Date and Time, and details of any Treatment/Transfer provided.
9. In the Investigation Summary part of the form, briefly summarize the investigation, outlining the Investigation Findings (Confirmed, Unconfirmed, Inconclusive, Unfounded) and any Provider Action Taken Post-Investigation.
10. Lastly, the form must be signed. Include the Signature, Printed Name, Title, and Date.

After completing the form, ensure that all the information provided is accurate and reflective of the incident and investigation. Double-check the document for completeness. Being thorough and precise in your documentation is crucial for a proper review and response. Remember, this form serves as an essential communication tool between care providers and regulatory agencies, playing a vital role in maintaining high standards of care and accountability within the care facility environment.

What is the purpose of the Form 3613 A?

The Form 3613 A is a Provider Investigation Report primarily used by various types of health care facilities like 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). The form is designed to report allegations of abuse, neglect, exploitation, and other significant incidents within these facilities to the Department of Aging and Disability Services (DADS).

Who needs to fill out the Form 3613 A?

This form must be completed by providers operating SNF, NF, ICF/IID, ALF, ADC, and DAHS facilities. It is specifically designed for the use of these facilities in reporting to DADS when a significant incident occurs that requires investigation and documentation.

What types of incidents need to be reported using the Form 3613 A?

The form is used to report a wide range of incidents including, but not limited to, death, abuse, neglect, exploitation, missing residents or individuals, drug diversion, and failure of facility systems like fire alarms, sprinkler systems, heating, and air conditioning during critical temperature conditions. It also covers emergencies such as fires, bomb threats, tornados, floods, and power failures.

How is the form submitted to DADS?

The completed Form 3613 A can be submitted to DADS either by fax at 1-877-438-5827 (toll-free) or by mail 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's important to note that if the form is faxed, it should not be mailed.

What information is required on the Form 3613 A?

The form requires detailed information about the incident including the agency's name, license number, the provider type, incident category, and details about the involved individual(s) or resident(s) such as name, social security number, date of birth, and a description of their functional ability and supervision level. The form also asks for details about the alleged perpetrator, description of the allegation, injury or adverse effect, and investigation findings.

Is the information provided on Form 3613 A confidential?

Yes, the Form 3613 A is considered a confidential document. It contains privileged and/or confidential information intended only for the Department of Aging and Disability Services. Unauthorized disclosure, dissemination, distribution, copying, or other use of the information on this form is strictly prohibited.

What happens after the form is submitted to DADS?

Once the form is submitted, DADS will review the reported incident and the investigation findings. Based on this review, DADS may take further action which could include additional investigation, enforcement actions against the facility if regulatory violations are found, or other measures to ensure the safety and well-being of facility residents.

Can the form be used to report incidents occurring in settings other than those specified?

No, the Form 3613 A is specifically designed for use only by the specified facility types (SNF, NF, ICF/IID, ALF, ADC, and DAHS). Incidents occurring in other settings should be reported through different means or to other appropriate agencies.

Is there a deadline for submitting the Form 3613 A after an incident occurs?

While the form does not specify an exact deadline, it is recommended that the form be submitted as soon as possible after the incident occurs and the internal investigation is completed to ensure timely intervention and response by DADS.

Completing the Provider Investigation Report, commonly referred to as Form 3613-A, is crucial for reporting incidents at healthcare and activity facilities. However, this process is fraught with potential errors. Below is a discussion of six common mistakes made while filling out this form.

1. Incorrect or Incomplete Provider Details: Often, the form is submitted with missing or inaccurate information regarding the provider's name, address, or ID number. This essential data ensures proper identification and follow-up.

2. Failure to Accurately Classify the Incident: One of the key components is correctly identifying the incident category (e.g., abuse, neglect, exploitation). Misclassification can lead to inappropriate handling of the report.

3. Omitting Details of Individuals Involved: Not providing comprehensive details about the individuals or residents involved, including their level of supervision needed or functional ability, undermines the ability to assess the incident accurately.

4. Inadequate Description of the Incident: Submitting a vague or incomplete description of what happened, who was involved, and the outcomes observed negates the form's purpose. Specificity is key to a thorough investigation.

5. Not Including Pertinent History: Failing to mention any relevant history or patterns related to the individual or resident involved, such as a history of combativeness or wandering, can obscure potential contributing factors to the incident.

6. Neglecting to Indicate Witness Information or Attachments: Witnesses can provide invaluable insights into the incident. Not listing witnesses or attaching their statements (if available) is a missed opportunity for a more comprehensive understanding of the events.

When completing Form 3613-A, attention to detail and thoroughness are paramount. Understanding and avoiding these common mistakes can significantly enhance the quality of the information provided, facilitating a more effective investigation and ensuring proper care and response by the facilities involved.

When handling matters related to the Form 3613 A, a variety of supplementary documents often play crucial roles in ensuring comprehensive compliance and thorough investigation. These documents support different aspects of the procedures for Skilled Nursing Facilities, Nursing Facilities, Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions, Assisted Living Facilities, Adult Day Care Facilities, and Day and Activity Health Services Facilities.

• Incident Report Forms: These forms record details of any incidents that occur within a facility, providing a structured way to document the what, when, who, and how of an event that may lead to an investigation.
• Consent Forms: Used to obtain permission from residents or their legal representatives for various actions, including participation in certain programs or sharing of personal information during investigations.
• Personal Data Sheets: Collect essential information about residents, including contact information, medical history, and personal preferences, aiding facilities in personalizing care and conducting thorough investigations.
• Medical Records: Critical for investigations involving claims of abuse, neglect, or inadequate care, medical records document the resident's health status before and after the incident.
• Staff Rosters and Schedules: Help identify which caregivers were present at the time of an incident, thereby narrowing down potential witnesses or individuals involved in the situation.
• Training Logs: Show the training history of staff members, which can be relevant in investigations to determine if the incident was related to a lack of knowledge or training.
• Surveillance Footage: In facilities equipped with cameras, footage can provide invaluable objective evidence regarding the circumstances of an incident.
• Witness Statements: Written accounts from residents, staff, or visitors who witnessed an incident can provide perspectives and details that are crucial for a thorough investigation.
• Correction and Prevention Plans: Following an investigation, these documents outline the steps a facility will take to correct identified issues and prevent future occurrences, ensuring ongoing compliance and safety.

Effective management and coordinated use of these forms and documents are essential for facilities to address incidents comprehensively and maintain compliance with regulatory standards. They not only support the investigation process but also contribute to the ongoing effort to provide safe, respectful, and quality care to all residents.

• The Incident Report form used in hospitals is quite similar to the 3613 A form. Both documents require detailed information about an incident, including the date, time, location, and individuals involved. The primary difference lies in their application settings, with the Incident Report form being more general for hospital use, while the 3613 A is specific to care facilities.

• Home Health Care Incident Reporting form shares similarities with the 3613 A form, particularly in documenting adverse events or incidents in home care settings. It captures specific details like incident category, involved individuals, and the outcome, akin to the structured reporting required by the 3613 A form for facility-based incidents.

• The Complaint Intake Form used by regulatory bodies also mirrors aspects of the 3613 A form. While it's used to record complaints rather than provider-reported incidents, both forms gather detailed information about the involved parties, the nature of the complaint or incident, and the actions taken in response.

• Medication Error Reporting Form in pharmacies and hospitals somewhat aligns with the 3613 A form's purpose. Both forms are designed to document specific occurrences - medication errors on one hand and various incidents in care facilities on the other. Each requires reporting on the immediate and subsequent actions taken to address the incident.

• The Adult Protective Services (APS) Report Form, which is used to report abuse, neglect, or exploitation of vulnerable adults, shares its core objective with the 3613 A form. Both forms serve to protect individuals by ensuring incidents are formally recorded and investigated, although the APS form is broader, encompassing any setting where an adult may be at risk.

• Facility Emergency Incident Report form, used for documenting emergency situations like fires or natural disasters within institutional settings, parallels the 3613 A form regarding the structure and detail of reportage. Although focusing on emergency incidents, it similarly collects data on the event, the response, and the outcome to ensure safety and compliance.

When filling out the 3613 A form for reporting incidents in various care facilities, it's important to keep in mind a set of do's and don'ts to ensure accurate and compliant submission. Below are six essential points to consider:

• Do verify that the form is being used for the correct facility type, as it's designed specifically 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 Activity and Health Services Facilities (DAHS).
• Do fill out all sections accurately, providing detailed information about the incident, including the date, time, location, individuals involved, and a detailed description of the allegation and any injuries or adverse effects.
• Do include a comprehensive investigation summary, along with your findings and the actions taken by the provider post-investigation.
• Don't disregard the importance of confidentiality. Remember, this document is confidential and should be handled as such at all times.
• Don't submit the form without reviewing it for completeness and accuracy. Missing or inaccurate information can lead to delays or complications in the investigative process.
• Don't forget to include the Provider Name, Vendor/ID No., and the DADS Intake ID No. if available. These are key details that connect the report to your facility and the specific incident being reported.

By adhering to these guidelines, providers can ensure that their reports are both compliant with regulations and effective in contributing to the safety and well-being of the individuals in their care.

When navigating the complexity of the Form 3613 A, several misconceptions can emerge, leading to confusion. It's vital to debunk these myths for a clear understanding of its purpose and utilization in healthcare settings. Below are some common misconceptions and explanations.

• Only for Reporting Abuse and Neglect: A misconception is that Form 3613 A is exclusively for reporting abuse and neglect. In reality, it covers a wider range of incidents including death, exploitation, missing residents, drug diversion, and various facility failures such as power or fire alarm system failures, indicating its broad application for ensuring resident safety.
• Exclusively for Hospitals: Another misunderstanding is that Form 3613 A is solely for hospital use. However, it's explicitly designed for a range of care 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). This wide spectrum underscores its relevance across different care settings.
• Public Document: There's a belief that Form 3613 A is a public document due to its importance in reporting significant incidents. Yet, it is considered a confidential document, containing sensitive information about individuals and incidents. Unauthorized disclosure or misuse of this information is strictly prohibited, emphasizing the need for discretion and security in handling the form.
• Optional Submission: Some may consider submission of Form 3613 A to be optional. Contrary to this belief, prompt and mandatory reporting through this form is critical for compliance with regulatory requirements and ensuring the safety and rights of residents in care facilities. Failure to report can have serious legal and regulatory repercussions.
• Only Accepts Fax Submissions: While faxing is a common method of submitting Form 3613 A, thinking it's the only way to submit is incorrect. The form can also be mailed to the Texas Department of Aging and Disability Services, providing flexibility to facilities in how they choose to submit their reports.
• Limited to Certain Incident Types: It's a misconception that the form is limited to reporting only specific types of incidents. In fact, the form allows for the reporting of a "Other" category, which can include any significant event that doesn't fall neatly into the pre-listed categories. This catch-all category ensures that facilities can report any incident they believe is significant and impacts the safety and well-being of their residents.

Understanding these misconceptions about Form 3613 A is pivotal for healthcare administrators and staff in various facilities. Clearing up these misunderstandings can lead to better compliance, more accurate reporting, and ultimately, enhanced care for individuals in these settings.

When it comes to handling and utilizing Form 3613 A, it's essential to grasp its purpose, requirements, and correct procedures to ensure accurate and effective reporting. Here are key takeaways that should be kept in mind:

• Intended Use: This form is specifically designed 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).
• Confidentiality: All information provided in Form 3613 A, including any attached documents, is considered confidential. Disclosure, dissemination, distribution, copying, or any other use of this information by unintended recipients is strictly prohibited. If received in error, notify the sender immediately and destroy all copies.
• Submission Options: You can submit the completed report either via fax to 1-877-438-5827 or mail it to the Texas Department of Aging and Disability Services, Consumer Rights and Services Section, E-249, P.O. Box 149030, Austin, TX 78714-9030.
• Dual Submission Not Required: If you choose to fax the report, there's no need to mail it, thus avoiding duplicate submissions.
• Incident Reporting: The form captures detailed information about various incident types such as death, abuse, neglect, exploitation, and more, emphasizing the importance of accurate incident categorization.
• Victim and Perpetrator Details: Provide comprehensive details regarding both the alleged victim(s) and perpetrator(s), including their names, genders, social security numbers, dates of birth, and specific details regarding the incident and their backgrounds.
• Investigation Reporting: It requires information about whether an alleged perpetrator was identified, the presence of any witnesses, and the inclusion of witness statements which should be signed and notarized if possible.
• Outcome Recording: The form necessitates documenting the investigation findings, indicating whether the allegations were confirmed, unconfirmed, inconclusive, or unfounded, and detailing any actions taken by the provider post-investigation.
• Provider Responsibility: It's the responsibility of the reporting provider to ensure that all information is accurate and that the form is filled out in its entirety, reflecting an understanding of the seriousness of the reported incidents and the welfare of those involved.

By adhering to these key takeaways, providers can ensure they fulfill their reporting obligations comprehensively and ethically, contributing to the safety and well-being of individuals in care facilities.