Form 3613, Provider Investigation Report with Fax Cover Sheet (Home Health, Hospice and Personal Assistance Services Provider Use Only)
Effective Date: 6/2009
The purpose of this form is to furnish a standardized format for Home and Community Support Services Agencies (HCSSAs) to document their self-reported incident investigation summary, analysis and finding(s) in accordance with regulatory requirements. This form is for reporting abuse, neglect or exploitation by HCSSA employees as required by 40 Texas Administrative Code, §97.249. This form is for Home and Community Support Services Agency (that is, Home Health, Hospice and Personal Assistance Services) provider use only.
After making an oral report to 1-800-458-9858, submit Form 3613 with statements and other relevant documentation within the applicable regulatory time frame of no later than the 10th day after reporting the alleged act to DADS.
If Form 3613, with statements and other relevant documentation, is 15 pages or fewer, fax the report and attachments toll-free to DADS at 1-877-438-5827. If the report is 16 pages or more, mail the report and attachments to DADS at the address shown on Form 3613. A report sent by mail must be postmarked by the 10th day after the oral report.
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.
Attach all documents and pertinent information that may be needed for DADS to complete the review of your investigation. Your DADS Regional Office also may contact you to request additional information needed to complete the review.
Complete the form entirely; check each appropriate option or fill in each applicable blank.
Provider Investigation Report Fax Cover Sheet (If Applicable)
Use this cover sheet for any investigation report faxed to DADS. Specifying the total number of pages, including any attachments, enables DADS to verify receipt of all pages of the agency's investigation report. The cover sheet must be signed and dated by the agency representative completing the report form. To confirm DADS received the form and attachments, the agency may print a confirmation that the fax was successfully sent.
No cover sheet is required if the report and attachments are mailed.
Provider Investigation Report
DADS Intake ID No. — Mark the DADS Intake ID number on each page of the report, including the cover sheet and each page of any attachments. (A DADS intake specialist will provide the intake identification number at the time of the oral report. If the reporter left a voice mail statement, a DADS intake specialist will contact the reporter to verify correct spelling of names, confirm details of the incident and provide the intake ID number.)
All form fields are self-explanatory with the following exceptions:
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 agency and how the incident was discovered.
Alleged Perpetrator(s) (AP) — The alleged perpetrator is someone who is a current or former employee (includes contractors and volunteers) of the agency. Include family members who are paid by the agency to provide services to the individual. If the individual does not know the person's name and the agency cannot identify the person, provide a description of the alleged perpetrator. Attach documentation of any criminal history searches, nurse aide registry searches and employee misconduct registry searches conducted to verify the employability of the alleged perpetrator.
Description of Injury/Assessment — Describe any physical and/or emotional assessment as a result of the incident.
Treatment provided?, Treatment/Transfer Date, Time, Treatment Location — Enter information in the spaces provided.
Agency Immediate Response — Describe immediate actions taken to protect the individual's health and safety as a result of the allegation. Include who was notified of the allegation (Example: doctor, family/guardian, etc.), if applicable. If the agency notified DFPS, include the call/case identification number. If the agency notified the police, include the case/reference number.
Investigation Summary — Summarize the agency'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/or other appropriate evidence. Clearly state the investigator's conclusion regarding the allegation; clearly state the investigator's conclusion regarding any contributing agency practice(s); and clearly state 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).
Confirmed: The allegation is supported by a preponderance of the evidence (evidence that best accords with reason and probability; the facts are more probable 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.
Agency Action Post-Investigation — Describe actions taken by the agency as a result of the investigative findings. Include who the agency notified of the investigative findings, if applicable.
Signature section must be completely filled out and signed by the reporter.