Blank 3613 A PDF Form

What is the purpose of the 3613 A form?

The 3613 A form serves as a Provider Investigation Report specifically designed for use by various types of 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). Its primary purpose is to document incidents such as abuse, neglect, or other emergencies involving residents or individuals within these facilities. This form ensures that appropriate actions are taken in response to allegations and that relevant information is communicated to the Texas Department of Aging and Disability Services (DADS).

Who is required to fill out the 3613 A form?

The 3613 A form must be completed by staff members or administrators within the relevant facilities mentioned above. This includes anyone who is responsible for reporting incidents that may affect the safety and well-being of residents or individuals. It is crucial that the person filling out the form has accurate and comprehensive information regarding the incident to ensure proper reporting and follow-up.

How should the 3613 A form be submitted?

Once the 3613 A form has been completed, it should be submitted either by fax or by mail. The fax number for submission is 1-877-438-5827, which is toll-free. If opting for mail, the form should be sent 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 is important to note that if the form is faxed, it should not be mailed.

What types of incidents should be reported using the 3613 A form?

The form is intended for a wide range of incidents, including but not limited to death, abuse, neglect, exploitation, missing residents, drug diversion, and various emergencies such as fires, tornadoes, and power failures. Each incident category is clearly outlined on the form, allowing the reporter to specify the nature of the incident accurately.

What information is needed to complete the 3613 A form?

Completing the 3613 A form requires detailed information about the incident, including the date, time, and location of the event, as well as the individuals involved. This includes the names and relevant details of the alleged victim(s) and alleged perpetrator(s), if applicable. Additionally, the form asks for a description of the allegation, any injuries or adverse effects, and the response taken by the facility. Gathering this information is essential for a thorough investigation.

What happens after the 3613 A form is submitted?

After submission, the Texas Department of Aging and Disability Services will review the report. They may conduct further investigations based on the information provided. The facility is expected to take appropriate actions in response to the findings of the investigation. Documentation of these actions, along with the investigation summary, should be maintained for future reference and compliance purposes.

Is the information on the 3613 A form confidential?

Yes, the information contained within the 3613 A form is considered confidential. The form includes a statement indicating that the communication may contain privileged and/or confidential information. If someone receives the form in error, they are advised to notify the sender immediately and destroy all copies. This confidentiality is crucial to protect the privacy of individuals involved in the incidents reported.

1. Failing to provide the DADS Intake ID No. at the top of the form can lead to delays in processing the report.

2. Not including the incident date and time accurately can result in confusion about when the event occurred.

3. Omitting the provider type can hinder the ability of the Department of Aging and Disability Services (DADS) to categorize the report correctly.

4. Using incorrect or outdated contact information for the facility may prevent DADS from reaching out for follow-up questions.

5. Failing to specify the incident category can make it difficult for DADS to understand the nature of the report.

6. Not providing a clear description of the allegation can lead to misunderstandings about the situation being reported.

7. Neglecting to include the names and details of individuals involved may result in incomplete investigations.

8. Forgetting to attach any witness statements can weaken the credibility of the report.

9. Submitting the form without a signature from the reporting individual can render the report invalid.

The 3613 A form is an essential document used by various healthcare facilities to report incidents and investigations. Alongside this form, several other documents often accompany it to ensure thorough communication and compliance. Below are some commonly used forms and documents that may be relevant in this context.

• Incident Report Form: This document provides a detailed account of the incident that occurred, including the date, time, location, and individuals involved. It serves as a foundational record for any further investigation or follow-up actions.
• Witness Statement Form: This form collects testimonies from individuals who witnessed the incident. It is crucial for establishing facts and understanding the context surrounding the event.
• Provider Response Form: After an investigation, this form outlines the actions taken by the facility in response to the incident. It may include corrective measures and any changes implemented to prevent future occurrences.
• Follow-Up Report: This document is used to summarize the outcomes of the investigation and any ongoing actions or support provided to affected individuals. It ensures that all parties are informed of the resolution process.

These documents collectively support the investigation process and help maintain transparency and accountability within healthcare facilities. Utilizing them effectively can enhance the quality of care and ensure the safety of residents.

• Incident Report Form: Similar to the 3613 A form, an incident report form captures details about specific events that occur within a facility, including allegations of abuse or neglect. Both documents require information about the individuals involved, the nature of the incident, and the response taken.
• Accident Report Form: This form documents accidents that occur on facility premises. Like the 3613 A form, it outlines the circumstances surrounding the incident, the individuals affected, and any injuries sustained. Both serve to ensure accountability and facilitate investigations.
• Patient Care Incident Report: This document focuses on incidents that impact patient care, similar to the 3613 A form. It records details about the incident, the patient involved, and the actions taken by staff to address the situation, ensuring that patient safety remains a priority.
• Abuse Reporting Form: This form is specifically designed for reporting allegations of abuse within care facilities. It parallels the 3613 A form in that it collects information about the alleged victim, the perpetrator, and the circumstances of the incident, emphasizing the need for immediate action.
• Quality Assurance Report: A quality assurance report evaluates the services provided by a facility. While it differs in focus, it shares similarities with the 3613 A form by assessing incidents that may affect service quality, including any allegations of misconduct or neglect.

When filling out the 3613 A form, it's essential to follow certain guidelines to ensure accuracy and compliance. Here are seven things you should and shouldn't do:

• Do provide complete and accurate information. Double-check all entries to avoid mistakes.
• Don't leave any sections blank unless instructed. Missing information can delay processing.
• Do use clear and concise language. Avoid jargon or complex terms that may confuse the reader.
• Don't submit the form without reviewing it. Take a moment to read through your responses.
• Do ensure that all required signatures are included. Missing signatures can result in rejection.
• Don't use correction fluid on the form. If you make a mistake, cross it out neatly and write the correct information.
• Do keep a copy of the completed form for your records. This can be helpful for future reference.

Following these tips can help streamline the submission process and ensure that your report is processed efficiently.

Understanding the 3613 A form can be challenging, and several misconceptions often arise. Here are eight common misunderstandings about this important document:

• The form is only for skilled nursing facilities. While it is commonly associated with skilled nursing facilities (SNF), the 3613 A form is also applicable to nursing facilities (NF), intermediate care facilities for individuals with intellectual disabilities (ICF/IID), assisted living facilities (ALF), adult day care facilities (ADC), and day and activity health services facilities (DAHS).
• It can be used for any type of incident. The form is specifically designed for reporting certain incidents such as abuse, neglect, exploitation, and other critical situations. It is not a general reporting form for all types of complaints.
• Filing the form is optional. For the facilities mentioned, submitting the 3613 A form is a requirement when certain incidents occur. It is crucial for compliance with regulations set forth by the Texas Department of Aging and Disability Services (DADS).
• The form is only for internal use. This misconception overlooks the fact that the form must be sent to the DADS Consumer Rights and Services Section. It serves an external purpose in ensuring accountability and transparency.
• Any staff member can fill out the form. While staff may report incidents, the form should ideally be completed by someone in a managerial or supervisory role who has a thorough understanding of the incident and its implications.
• It does not require supporting documentation. The 3613 A form often necessitates additional information, including witness statements and descriptions of the incident. Supporting documents enhance the credibility of the report.
• Once submitted, the form cannot be amended. While it is important to ensure accuracy before submission, if new information arises, it is possible to provide updates or amendments to the DADS after the initial filing.
• Confidentiality is not a concern. On the contrary, the form contains sensitive information. Proper handling and confidentiality must be maintained throughout the reporting process to protect the individuals involved.

By addressing these misconceptions, individuals and facilities can better navigate the requirements and responsibilities associated with the 3613 A form.

Filling out the 3613 A form is an essential process for various facilities, including Skilled Nursing Facilities and Assisted Living Facilities. Here are some key takeaways to keep in mind:

• Purpose: The 3613 A form is specifically designed for reporting incidents in facilities like SNFs, NFs, and ALFs.
• Confidentiality: This form contains confidential information. If you receive it by mistake, do not share it and notify the sender immediately.
• Submission Method: You can either fax the completed form to 1-877-438-5827 or mail it to the Texas Department of Aging and Disability Services.
• Incident Categories: Clearly identify the type of incident being reported, such as abuse, neglect, or emergencies like fire or flooding.
• Involved Individuals: Include detailed information about all individuals involved, including alleged victims and aggressors.
• Allegation Details: Provide a thorough description of the allegation, including any injuries or adverse effects experienced.
• Investigation Findings: After the investigation, indicate whether the findings are confirmed, unconfirmed, inconclusive, or unfounded.
• Provider Action: Document any actions taken by the provider following the investigation to address the incident.
• Signature Requirement: Ensure that the form is signed and dated by the appropriate personnel to validate the report.

By keeping these points in mind, facilities can ensure that they complete the 3613 A form accurately and efficiently, fostering a safer environment for all residents.