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Documents
Instructions
Effective Date: 1/2025
Purpose
Form 6102 is used to notify Texas Health and Human Services Commission (HHSC) of an incident and the actions taken by the facility.
Procedure
Submit each form within the required time frame.
Within five working days of becoming aware of the violation, submit all alleged violations that involve mistreatment, neglect or verbal, mental, sexual and physical abuse, including injuries of unknown source, and misappropriation of client property by anyone, including those who furnish services on behalf of the CMHC.
Do not submit multiple incidents in one document.
Explain how the facility will improve care as a result of the incident. Complete the entire form with all requested attachments for HHSC to review the incident without requiring additional information or documents.
Transmittal
Submit each completed form by one of the following:
Email: CII.HCQ@hhs.texas.gov
Fax: 833-709-5735 or 512-206-3985
Mail: Texas Health and Human Services Commission
Complaint and Incident Intake
P.O. Box 149030, Mail Code E-249
Austin, TX 78714-9030
Detailed Instructions
Print or type the information and provide as much information as possible. Use the facility name and license number as listed on your license.
Section 1 – Reportable Incident and Facility Information
Reportable Incident – Select the appropriate option from the following:
- Mistreatment
- Neglect
- Verbal, mental, sexual or physical abuse
- Injuries of unknown source
- Misappropriation of client property by anyone, including those who furnish services on behalf of the center
Date of Report – Enter the report date.
Date of Incident – Enter the date of the incident.
Time of Incident – Enter the time of the incident and check AM or PM
Facility License No. – Enter the facility license number.
Facility Name – Enter the name of the facility.
Facility Address – Enter the street address, city, state, ZIP Code.
Facility Area Code and Phone No. – Enter the area code and phone number.
Reporter Name and Title – Enter the name and title of the contact person the surveyor will ask for should a follow-up phone call be needed.
Primary Area Code and Phone No. – Enter the area code and phone number.
Secondary Area Code and Phone No. – Enter the area code and phone number.
Email – Enter the email address.
Section 2 – Patient and Transfer Facility Information
Patient Name – If the incident involves a patient, enter their first, middle and last name.
Date of Admission – Enter the date the patient was admitted.
Date and Time of Death – Enter the date and time the patient died.
Cause of Death – Enter the suspected cause of death.
Medical and Psychiatric Diagnoses – Enter the diagnoses.
Discharge Disposition – Select either home, hospital, psych facility or other. If other, enter the other disposition.
Transfer Facility Name – Enter the name of the facility.
Transfer Facility City – Enter the name of the transfer facility city.
Section 3 – Alleged Perpetrator Information
Alleged Perpetrator First, Middle, Last Name – Enter the alleged perpetrator’s name and title. List only alleged perpetrators who are not patients. List alleged perpetrators who are patients in the Patient section.
Relationship to Patient – If the alleged perpetrator is not a patient or a staff member, indicate this person’s relationship to the patient. Examples are friend or family member.
License No. – Enter the alleged perpetrator’s license number.
Social Security No. – Enter the alleged perpetrator’s Social Security number.
Area Code and Phone No. – Enter the alleged perpetrator’s area code and phone number.
Address – Enter the alleged perpetrator’s street address, city, state and ZIP Code.
Alleged Perpetrator Similar History – Select yes or no.
Section 4 – Physician Information
Name of Treating Physician, PA or NP – Enter the first and last name of the physician, physician assistant (PA) or nurse practitioner (NP).
Title – Enter the title of the physician, PA or NP.
Section 5 – Witness Information
Witness First, Middle, Last Name – Enter the witness’s first, middle and last name. Witnesses can include other patients, staff members, family members or friends.
Title – Enter the witness's title if the witness is a staff member.
Area Code and Phone No. – Enter the witness's area code and phone number.
Section 6 – Summary
When did you first learn of the incident? – Enter the date and time.
Provide a summary – Enter what happened, who was involved such as an RN, LVN, PCT, MD, other and the action taken at the time of the incident.
Did the patient sustain injuries? – Select yes or no. If yes, explain the injuries.
Were restraints used? – Select yes or no. If yes, provide the type of restraint and explain how and why they were used.
Did the patient receive treatment at the CMHC? – Select yes or no. If yes, explain the treatment provided. Attach pertinent treatment documentation if necessary.
Provide the outcome of the hospital transfer including hospital diagnosis, treatment details and diagnostic test results.
Does the patient have a history of elopements, suicidal ideations or attempts, self-harming behaviors, or other? Select yes or no. If yes, explain.
Was a psychiatric assessment performed? Select yes or no. If yes, provide psychiatric assessment results.
Provide a narrative report of the investigation – Explain how you handled the incident and what actions you will take to reduce the potential for similar incidents in the future.
Section 7 – Referrals
Referrals – Check all boxes that apply and the report number for each.
For Office Use Only
Actions to be taken as a result of this incident. – Check all boxes that apply.
Printed Name – Enter the name of the supervising authority.
Signature – Signature of supervising authority.
Date – Date of the signature.