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

Form 3613-A is an official Provider Investigation Report used in Texas to document and report incidents, allegations, and investigation findings involving individuals receiving care in regulated healthcare and long-term care settings. This form is submitted to the Texas Health and Human Services Commission (HHSC) and plays a critical role in regulatory oversight, resident protection, and compliance with state reporting requirements.

The form is designed to ensure that serious incidents such as abuse, neglect, exploitation, injuries, or other adverse events are properly investigated, documented, and communicated to HHSC in a consistent and verifiable manner.

Who Must Use This Form

Form 3613-A is intended only for the following Texas-regulated provider types:

• Skilled Nursing Facilities (SNFs)
• Nursing Facilities (NFs)
• Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions (ICF/IIDs)
• Assisted Living Facilities (ALFs)
• Day Activity and Health Services (DAHS), including Individualized Skills and Socialization (ISS) providers
• Prescribed Pediatric Extended Care Centers (PPECCs)

The form must be completed by authorized facility representatives, administrators, or designated reporters responsible for incident reporting and compliance.

When Form 3613-A Is Required

This form must be submitted when a reportable incident occurs involving a resident, client, or individual receiving services. Submission is required whether the allegation is substantiated or still under investigation.

Common situations requiring this form include:

• Allegations of abuse, neglect, or exploitation
• Injuries or adverse health effects
• Incidents involving alleged perpetrators, including staff or third parties
• Events requiring medical treatment, transfer, or law enforcement notification
• Incidents involving individuals receiving ISS services

If no reportable incident has occurred, this form should not be submitted.

Legal and Regulatory Background

Form 3613-A is required under Texas Health and Safety Code and HHSC regulatory rules governing provider reporting obligations. HHSC uses this form to:

• Assess compliance with state care standards
• Ensure resident safety and protection
• Review provider investigations
• Determine whether further regulatory or enforcement action is needed

Failure to submit this form accurately or on time may result in regulatory action, penalties, or increased oversight.

Explanation of Key Sections

Fax Cover Sheet

The cover sheet identifies the provider, contact information, intake ID, number of pages, and method of submission. It also includes a confidentiality notice protecting sensitive resident and investigation data.

Provider and Facility Information

This section captures the provider name, license number, address, phone number, and provider type. Accuracy here is essential for HHSC to correctly associate the report with the licensed facility.

Incident Details

Providers must describe when and where the incident occurred, who made the allegation, the category of the incident, and the individuals involved. This includes residents, alleged victims, and alleged aggressors.

Resident Information

Information such as date of birth, functional ability, supervision level, interviewability, and cognitive capacity is used to assess vulnerability and risk factors.

Alleged Perpetrator Information

If applicable, this section documents details about the alleged perpetrator, their relationship to the resident, prior history, and how they were identified.

Assessment and Injury Details

Facilities must document injuries, adverse effects, assessments performed, treatments provided, and any transfers to outside medical facilities.

Provider Response and Investigation Summary

This section explains immediate protective actions taken, investigation steps, findings, notifications made, and corrective actions implemented after the investigation.

Practical Tips for Completing the Form

• Submit the report only once by fax, email, or mail, as instructed.
• Attach all supporting documentation at the time of submission.
• Use clear, factual language and avoid assumptions.
• Ensure dates, times, and names are consistent across all sections.
• Keep copies of the completed form and attachments for facility records.

Common Mistakes to Avoid

• Leaving required fields blank
• Submitting the report multiple times using different methods
• Failing to attach investigation summaries or medical records
• Providing vague or incomplete incident descriptions
• Omitting follow-up actions taken to protect residents

Real-Life Examples

• A nursing facility reports an allegation of staff misconduct involving a resident injury.
• An assisted living facility documents an unexplained fall requiring hospital transfer.
• An ISS provider submits an investigation after a third-party allegation of neglect.

Documents Commonly Attached

• Investigation summaries and interview notes
• Clinical records and assessments
• Hospital or emergency room reports
• Law enforcement or incident reports
• Photographs or diagrams, if applicable

Frequently Asked Questions

How should Form 3613-A be submitted?

The form may be faxed, emailed, or mailed to HHSC. Only one submission method should be used.

Is notarization required?

Notarization is not required for the form itself, but signed statements may be included if available.

What happens after submission?

HHSC reviews the report and may request additional information or conduct further investigation.

Who signs the form?

An authorized facility representative or investigator completes and signs the report.

Are residents or families notified?

Yes, notifications to families, physicians, or ombudsmen must be documented when required.

Related Forms

• HHSC Incident and Complaint Intake Forms
• Provider Corrective Action Plan Forms
• Facility Licensing and Compliance Reports

Form Details

• Form Name: Provider Investigation Report
• Form Number: 3613-A
• Issuing Agency: Texas Health and Human Services Commission (HHSC)
• Region: Texas
• Revision Date: April 2024