Form 6109, Special Care Facility Incident Report

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Documents

Effective Date: 10/2024

Instructions

Effective Date: 10/2024

Purpose

A facility uses Form 6109 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:

  • As soon as possible:
    • Abuse or neglect of a child
    • Abuse, neglect or exploitation of an elderly or disabled person
  • As soon as possible, but not later than 10 calendar days following the occurrence:
    • Fire
  • Within 24 hours of the incident:
    • Fire causing injury or death to a resident

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 may 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.

Reportable Incident  Check the appropriate box from the following:

  • Abuse or neglect of a child
  • Abuse, neglect or exploitation of an elderly or disabled person
  • Fire occurrence
  • Fire causing injury or death to a resident

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.

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  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.  Enter the area code and phone numbers.

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

Email  Enter the email address.

Patient First, Middle, Last Name  If the incident involves a patient, enter their 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.

All Diagnoses  Enter the diagnoses.

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

Name of Procedure  Enter the name of the procedure.

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

Was the patient receiving home health or hospice services? If yes, provide the name, physical address, area code and phone number of the agency.

Medical Provider Name  Enter the name of the medical provider who 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. Alleged perpetrators who are patients should be listed 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.

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, other, and the action taken at the time of the incident.

Did the patient receive any treatment at the Special Care Facility?  Check Yes or No. If yes, explain.

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

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.

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.

Printed Name, Signature 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 provided above under Transmittal.