Form 6104, Freestanding Emergency Medical Care Facility Incident Report

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Effective Date

1/2025
6104.pdf

Instructions

Effective Date: 1/2025

Purpose

Form 6104 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:

  • Immediately:
    • Abuse, neglect and exploitation
  • As soon as possible:
    • Illegal, unethical or unprofessional conduct
  • Within one business day:
    • Fire that causes injury to a person
  • No later than the 10th business day after the incident:
    • Death of a patient while under the care of the facility
    • Fire
    • A patient stay exceeds 23 hours
    • 911 activation or the emergency transfer of a patient from the facility to a hospital by ambulance

Do not submit multiple incidents in one document.

Explain how the facility will improve care because of the incident. Complete the entire form with all requested attachments for HHSC to review the incident without requiring more 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  

Mark the appropriate incident from the following:

  • Abuse
  • Neglect
  • Exploitation
  • Illegal, unprofessional or unethical conduct
  • Fire that causes injury to a person
  • Death of patient while under the care of the freestanding emergency medical care facility
  • Fire
  • Patient stay exceeds 23 hours
  • 911 activation or the emergency transfer of a patient from the facility to a hospital by ambulance

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 Provider No. – Enter the facility provider number, which is your Medicare six-digit number.

Facility Name – Enter the name of the facility.

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

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

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

Title – Enter the 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 Information

Patient Name – If the incident involves a patient, enter their 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.

Chief Complaint – Enter the patient’s chief complaint.

All Acute Diagnoses – Enter the diagnoses.

Name of Procedure – Enter the name of the procedure.

Discharge Disposition – Select an option 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.

Section 3, Medical Provider Information

Medical Provider Name – Enter the name of the provider who provided medical services to the patient.

Title – Enter the medical provider's title.

License No. – Enter the medical provider's license number.

Section 4, Witness Information

Witness Name – Enter the witness’s 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 phone number.

Section 6, Alleged Perpetrator Information

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 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.

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

Section 7, Summary

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

Time of Triage or Assessment: Enter time triage or assessment was conducted.

On what shift did the incident occur? – Check button 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 treatment at the FEMC? – Mark yes or no. If yes, explain the treatment provided. Attach pertinent treatment documentation if necessary.

Provide the condition of the patient upon discharge – Explain the patient’s medical condition at the time of discharge.

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 8, Referrals

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

For Office Use Only

Actions to be taken because of this incident – Check all boxes that apply.

Printed Name – The printed name of staff.

Signature – The signature of staff.

Date – The date of signature.