Form 3726, Notification of Adverse Change in Financial Condition

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Documents

Effective Date: 9/2007

Instructions

Updated: 9/2007

Purpose

Use the Notification of Adverse Change in Financial Condition form to report any significant adverse changes in financial condition to the Texas Health and Human Services Commission (HHSC) in accordance with Title 40 Texas Administrative Code (TAC) §19.1925(b)-(f), Financial Condition.

Procedure

Who Must Report

All licensed nursing facilities must notify HHSC of significant adverse changes in financial condition, in accordance with Title 40 TAC §19.1925(b)-(f).

When to Report

The license holder must notify HHSC in writing of a significant adverse change in its financial condition, as required by Title 40 TAC §19.1925(b)-(f), within 72 hours after the license holder becomes aware of or should have become aware of the change.

Where to Report

This form must be faxed to 512-438-2730 or 512-438-2728.

What to Report

Adverse changes in financial condition include changes in financial position, cash flow or operation results, or other events that could adversely affect the delivery of essential care and services such as nursing or dietary services or utilities, as required by Title 40 TAC §19.1925(b)-(f).

Detailed Instructions

  • Print or download the blank form.
  • Complete the form by entering the required information in the spaces provided.
  • The completed form must be legible.
  • Enter the Nursing Facility Name, Facility ID Number and Name of License Holder.
  • Check the applicable rule section(s) corresponding with the reported event(s).
  • Check "Other" if the reported event is not listed on the form.
  • Complete the description of the event:
    • Enter the TAC section number or enter "Other," if applicable, for the reported event. Describe each event clearly, include all the relevant facts and identify the impact on the facility's ability to deliver essential care and services (Title 40 TAC §19.1925(d)(1)(2)). Identify the action(s) taken to address the adverse change in financial condition (Title 40 TAC §19.1925(d)(3)).
  • Enter the TAC section number and the description of additional changes, if applicable, in the spaces provided.
  • Copy and paste new rows, if necessary, to describe more than three events.
  • Sign and complete the contact information.
  • Fax the form to Regulatory Services at either 512-438-2730 or 512-438-2728.
  • Contact the Provider Licensing Enforcement Unit at 512-438-4860 if you have any questions regarding this issue.

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