Form 6110, Ambulatory Surgical Center Facility Incident Report

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Documents

Effective Date: 6/2021

Instructions

Updated: 6/2021

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 as soon as possible for abuse/neglect or unethical conduct. Submit each form separately within 10 days of incident. 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 that HHSC may review the incident without requiring additional information or documents.

Transmittal

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

Email: cii.hcq@hhsc.state.tx.us
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:

  • Death of Patient While Under the Care of the Ambulatory Surgical Center (ASC)
  • Transfer of Patient to Hospital
  • Any Theft of Drugs and/or Diversion of Controlled Drugs
  • Patient Stay Exceeding 23 Hours
  • Illegal, Unprofessional or Unethical Conduct Related to Operation of Facility or Services
  • Abuse and Neglect
  • Patient Development of Complication Within 24 Hours of Discharge from the ASC Resulting in Admission to Hospital
  • Fire

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 A.M. or P.M.

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 Name – Enter the name of the facility.

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

Telephone – Enter the area code and telephone number.

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

Primary Phone No. and Secondary Phone No. – Enter the area code and telephone 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 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 (all) – Enter the diagnoses.

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.

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.

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 neither a patient nor a staff member, indicate the relationship of this person to the patient (example: friend, family member, etc.).

License No. – Enter the alleged perpetrator’s license number.

Social Security No. – Enter the alleged perpetrator’s Social Security number.

Telephone – 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 brief summary – Enter what happened, who was involved (e.g., RN, LVN, PCT, MD, other), and the action taken at the time of the incident.

Did the patient receive any treatment? – Check Yes or No and if yes, provide 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.

What was the hospital outcome and diagnosis? – 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.

Action you will take as a result of this incident – Check all boxes that apply.

Signature, Printed Name and Date – The supervising authority signs, prints his/her name and enters the date. Then, email, fax or mail the completed incident form to the number or address provided above under Transmittal.