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 that helps investigate incidents or complaints in 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). This form is used to document incidents and track progress in resolving issues.

The report requires specific information, including the provider's name, address, and contact details. It also includes a cover sheet that provides space for reporting the incident or complaint, as well as any relevant follow-up actions or procedures. The form is designed for use by providers who need to document incidents and track their resolution.

Key features of this report include:

• The report is used to investigate incidents or complaints in various types of facilities, including SNF, NFs, ICF/IIDs, ALFs, DAHS, ISS providers, and PPECCs.
• The form requires specific information from the provider, including their name, address, and contact details.
• The report includes a cover sheet for reporting incidents or complaints and tracking follow-up actions or procedures.