Effective Date
Instructions
Effective Date: 1/2025
Purpose
Form 6108 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:
Chemical Dependency Treatment Facilities (CDTFs):
- Abuse
- Neglect
- Exploitation
- Illegal, unprofessional or unethical conduct that relates to the operation of the facility or its services
Note: Must report as soon as possible or within two business days.
Narcotic Treatment Programs (NTP):
- Knowledge of patient death must report with two weeks.
- Theft, break-in or drug diversion from the clinic must report within 48 hours of discovery.
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 for HHSC to review the incident without requiring more information or documents.
Transmittal
Submit each completed form by one of the following:
Email: cii.sa@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
Select the appropriate incident from the following:
Chemical Dependency Treatment Facilities
- Abuse
- Neglect
- Exploitation
- Illegal, unprofessional or unethical conduct that relates to the operation of the facility or its services
Narcotic Treatment Programs
- Knowledge of patient death
- Theft, break-in or drug diversion from the clinic
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.
Area Code and Phone No. – Enter the facility's area code and phone number.
Facility Address – Enter the street address.
City – Enter city of facility.
State – Enter state of facility.
ZIP Code – Enter ZIP code of facility.
Reporter Name – Enter the name 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 primary area code and phone number.
Secondary Area Code and Phone No. – Enter the secondary area code and phone number.
Title – Enter the title of the contact person.
Email – Enter the email address.
Section 2 – Client Information
Client Name – If the incident involves a client, enter their first, middle and last name.
Date of Birth – Enter the client’s date of birth.
Date of Admission – Enter the date the client was admitted.
Date of Discharge – Enter the date the client was discharged.
Level of Care – Select the patient’s level of care as Inpatient, Outpatient, Sober Living or Other, specify.
Admitting and Acute Diagnoses – Enter the diagnoses.
Discharge Disposition – Check the radio button for home, hospital or other. If other, enter the other disposition.
Transfer Facility Name – Enter the name of the transferring facility.
City – Enter the name of the transferring city.
Section 3 – Medical Provider Information
Medical Provider Name – Enter the name of the medical 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 First, Middle and Last Name – Enter the witness's full 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 area code and phone number.
Alleged Perpetrator First, Middle and Last Name – Enter the alleged perpetrator’s full name.
Title – Enter the alleged perpetrator’s title.
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 – Enter the city of the alleged perpetrator.
State – Enter the state of the alleged perpetrator.
ZIP Code – Enter the ZIP code of the alleged perpetrator.
Section 7 – Summary
When did you first learn of the incident? – Enter the date and time.
On what shift did the incident occur? – Mark the shift incident 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 client sustain injuries? – Check Yes or No. If yes, explain the injuries.
Did the client receive treatment at the CDTF or NTP? – Mark Yes or No. If yes, explain.
Was the client transferred to a hospital for treatment? – Mark Yes or No. If yes, provide details and outcomes of treatment and results of diagnostic tests.
Does the client have a history of elopements, suicidal ideations or attempts, self-harming behaviors or other? Mark Yes or No. If Yes, explain.
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 as a result of this incident – Check all boxes that apply.
Printed Name – Enter the printed name of the supervising authority.
Signature – Signature of the supervising authority.
Date – Enter the date of signature.
Email, fax or mail the completed incident form to the number or address above under Transmittal.