TX HHS Form 3613-A. SNF. NF. ICF/IID. ALF. DAHS including ISS providers and PPECC Provider Investigation Report with Cover Sheet

The TX HHS Form 3613-A is a report used by skilled nursing facilities (SNF), nursing facilities (NFs), intermediate care facilities for individuals with an intellectual disability or related conditions (ICF/IIDs), assisted living facilities (ALFs), day and activity health services facilities (DAHS) including Individualized Skills and Socialization (ISS) providers, and prescribed pediatric extended care centers (PPECCs) to document investigations into incidents or complaints. This form helps facilities identify and address issues promptly, ensuring the well-being of residents and clients.

The report includes a cover sheet that requires essential information such as the provider's name, address, phone number, and email address, as well as the date, intake ID number, and number of pages in the report. The form also specifies confidential reporting procedures to ensure sensitive information is protected.

This form should be used by facilities when investigating incidents or complaints related to their services. It provides a standardized framework for documenting findings and recommendations, helping facilities maintain compliance with regulatory requirements and improve overall quality of care.