Form 6106, Private Psychiatric Hospital and Crisis Stabilization Unit Incident Report

Instructions for Opening a Form

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Documents

Effective Date: 11/2024

Instructions

Effective Date: 11/2024

Purpose

Form 6106 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 separately within the required time frame of the incident:

  • Report  as soon as possible:
    • Abuse, neglect or exploitation
    • Illegal, unethical or unprofessional conduct that relates to the operation of the facility or mental health or chemical dependency services provided in the facility
    • Abuse or neglect of a child
    • Abuse, neglect or exploitation of an elderly or disabled person
    • Abuse or neglect of a person with a mental illness
  • As soon as possible, but not later than 10 calendar days following the occurrence: all fire occurrences.

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 so HHSC can review the incident without requiring additional information or documents.

Transmittal

Submit each completed form by ONE of the following (email, fax or mail):

Submit each completed form by one of the following:

Email: CII.HCQ@hhs.texas.gov
Fax: 1-833-709-5735 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.
Reportable Incident – Check the appropriate box from the following:

  • Illegal, unethical or unprofessional conduct
  • Abuse, including abuse of a child, an elderly or disabled person or person with mental illness
  • Neglect, including neglect of a child, an elderly or disabled person or person with mental illness
  • Exploitation of an elderly or disabled person or person with mental illness
  • Fire occurrence

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.

Address – Enter the street address, city, state, ZIP Code.

Area Code and Phone No. – Enter the area code and phone number.

Area of Specialty – Enter the area of specialty.

Reporter Name and Title – Enter the contact person and title the surveyor will ask for should a follow-up phone call be needed.

Primary Area Code and Phone No. and Secondary Area Code and Phone No. – Enter the area code and phone numbers.

Email – Enter the email address.

Patient Name – If the incident involves a patient enter the first, middle and last name.

Date of Birth – Enter the patient’s date of birth.

Date of Admission – Enter the date the patient was admitted.

Date of Discharge – Enter the date the patient was discharged.

Mental and Psychiatric Diagnoses (all) – Enter the diagnoses.

Level of Supervision – Enter the patient’s level of supervision at the time of the incident

Discharge Disposition – Check the box for home, hospital or other. If other enter the other disposition.

Facility Name and City – Enter the name of the facility and city.

Medical Provider Name- Enter the name of the medical provider that provided medical services to the patient

Title- Enter the title of the medical provider

License No – Enter the license number of the medical provider

Witness Name – Enter the name of the witness. Witnesses can include other patients, staff members, family members or friends.

Title - Enter the title of the witness if the witness is a staff member

Area Code and Phone No. – Enter the phone number of the witness

Alleged Perpetrator Name and Title – 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. If the alleged perpetrator is not a patient or a staff member indicate the relationship of this person to the patient, such as friend or family member.

Alleged Perpetrator 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.

Alleged Perpetrator Address – Enter the alleged perpetrator’s street address, city, state and ZIP code.

Summary

When did you first learn of the incident? – Enter the date and time.

On what shift did the incident occur? – Check the box for day, evening or night.

Provide a summary – Enter what happened, who was involved such as an RN, LVN, PCT, MD or other, and the action taken at the time of the incident.

Did the patient sustain any injuries? – Check Yes or No. If yes provide an explanation of the injuries.

Did the patient receive any treatment? – Check Yes or No. If yes provide an explanation of the treatment provided. Attach pertinent treatment documentation if necessary.

Were any diagnostic tests performed such as X-ray, CT scan, MRI, ultrasound, PET scan, blood work or other? – Check Yes or No. If yes provide diagnostic test results.

Does the patient have a history of elopements, suicidal ideations or attempts, self-harming behaviors, or other? Check Yes or No. If Yes explain.

Was a psychiatric assessment performed? Check Yes or No. If yes, provide psychiatric assessment results.

Is the patient under an emergency detention order? Check Yes or No.

Did the patient transfer to another facility? Check Yes or No. If yes provide the name and address of the facility.

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.

Referrals – Check all boxes that apply and the report number for each.

Actions to be taken as a result of this incident – Check all boxes that apply.

Signature, Printed Name and Date – The supervising authority signs, prints their name and enters the date. Email, fax or mail the completed incident form to the number or address under Transmittal.