Form 6110, Ambulatory Surgical Center Facility Incident Report

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Documents

Effective Date: 11/2024

Instructions

Updated: 11/2024

Purpose

Form 6110 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 to HHSC within the required time frame of incident:

  • Not later than the next business day: Any fire occurrence that caused injury to a person.
  • Within two business days: Occurrences of surgical suite fires if flammable germicides, including alcohol-based products, are used for preoperative surgical skin preparation.
  • Within 10 business days of the incident:
    • The death of a patient while under the care of the ASC
    • The transfer of a patient to a hospital
    • Any theft of drugs, diversion of controlled drugs or both
    • A patient stay exceeding 23 hours
    • Abuse, neglect or exploitation
    • Fire occurrence
    • Patient developed complications within 24 hours of discharge from the ASC, which resulted in admission to a hospital

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 email, fax or mail to:

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:

  • Fire causing injury to a person
  • Occurrence of surgical fires if flammable germicides, including alcohol-based products, are used for preoperative surgical skin preparation
  • Death of patient while under the care of the ambulatory surgical center (ASC)
  • Transfer of patient to hospital
  • Any theft of drugs, diversion of controlled drugs or both
  • Patient stay exceeding 23 Hours
  • Abuse  
  • Neglect
  • Exploitation
  • Fire occurrence
  • Patient developed complication within 24 Hours of discharge from the ASC, which resulted in admission to hospital

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 Name – Enter the name of the facility.

Facility License No. – Enter the facility license number.

Facility Provider No. (CCN) – Enter the facility provider number, which is the Medicare six-digit number.

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

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

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 number.

Email – Enter the email address.

Patient Information  – If the incident involves a patient complete the following:

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 and Time of Admission – Enter the date the patient was admitted and the time.

Date of Discharge and Time of Discharge – Enter the date the patient was discharged and the time.

Diagnoses – Enter the diagnoses.

Level of Supervision – Enter the patient’s level of supervision.

Does the patient have a history of similar incidents? – Check Yes or No. If yes explain in detail. Include dates the previous similar incidents took place.

Post-Surgical Diagnoses – Enter the patient’s post-surgical diagnoses.

Pre-surgical ASA Score – Select the patient’s pre-surgical ASA score of I, II, III, IV, V or Other.

Was a Cardiac Clearance Obtained? – Select Yes or No.

Name of Procedure – Enter the name of the procedure.

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

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

Name of Physician Performing Procedure – Enter the first and last name of the physician.

License No. – Enter the physician’s license number.

Name of Anesthesia Provider – Enter the first and last name of the anesthesia provider.

License No. – Enter the anesthesia provider’s license number.

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 area code and 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 must 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.

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 receive any treatment at the facility? – Check Yes or No. If yes provide the outcome of the hospital transfer with an explanation of the treatment provided. Attach pertinent treatment documentation if necessary.

If the patient was transferred to a hospital what was the hospital discharge date? – Enter the discharge date the patient was transferred to a hospital.

Provide the outcome of the hospital transfer and any treatment provided – Enter the patient outcome result from the hospital and the patient diagnosis upon discharge.

Provide a narrative report of your 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.

Action to be Taken as a Result of this Incident

Check all boxes that apply.

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