Free Community Based Residential Facility (CBRF) Residents' Rights Complaint Report-F-62430 - Wisconsin


File Size: 59.3 kB
Pages: 2
File Format: PDF
State: Wisconsin
Category: Health Care
Author: Division of Quality Assurance
Word Count: 430 Words, 2,847 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dhs.wisconsin.gov/forms1/F6/F62430.pdf

Download Community Based Residential Facility (CBRF) Residents' Rights Complaint Report-F-62430 ( 59.3 kB)


Preview Community Based Residential Facility (CBRF) Residents' Rights Complaint Report-F-62430
DEPARTMENT OF HEALTH SERVICES
Division of Quality Assurance F-62430 (Rev. 04/09)

STATE OF WISCONSIN
Page 1 of 2

COMMUNITY BASED RESIDENTIAL FACILITY (CBRF) RESIDENTS' RIGHTS COMPLAINT REPORT






Chapter 50.09 of the Wisconsin State Statutes establishes the rights of residents in community-based residential facilities and requires all facilities to establish a system of reviewing complaints and allegations of violations of residents' rights under Section 50.09(6), Wis. Stats. The Statute requires the facility to summarize complaints or allegations of violations of residents' rights and to report this information to the Department of Health Services per Section 50.03(4)(c), Wis. Stats. Failure to provide residents' rights information may result in revocation of your license under Section 50.03(4)(c)1., Wis. Stats. Personal information reported to the Department is collected to comply with Section 50.09(6)(d), Wis. Stats., and will be used for no other purpose.

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This report must be submitted with the biennial report for a continuing facility. A sample report is attached. If you have any questions about completing this requirement, please contact your Division of Quality Assurance Assisted Living Regional Director. Contact information is available at http://dhs.wisconsin.gov/rl_dsl/Contacts/ALSreglmap.htm Return ONE COPY of this form and all attachments to your Division of Quality Assurance REGIONAL OFFICE. KEEP A COPY OF THIS FORM AND A COPY OF ALL STATEMENTS ON FILE AT YOUR FACILITY.
License Number

Name - Facility Address City Zip Code

Telephone Number

FAX Number

Section 50.09(6)(d), Wis. Stats., requires submission of a statement that includes a description of the complaint or violation of rights and contains the following: 1. 2. 3. 4. 5. 6. 7. Original date of the report; Date or approximate date of the incident; Date or estimated date of disposition; Full name of person or persons initiating the complaint or allegation of violation; Full names of residents involved; Full names of witnesses and informants; and Disposition of the matter.

F-62430 (Rev. 04/09)

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SAMPLE RESIDENTS' RIGHTS COMPLAINT REPORT
A Report on the Rights of Residents per Chapter 50.09(6)(d), Wis. Stats.
Name - Facility Address City Telephone Number Zip Code

Full Names of Persons Initiating the Complaint and Relationship to Resident

Full Names of Residents Involved in Incident

Full Names of Informants or Witnesses Other than Those Listed Above

Give a brief description of the incident (include date and time of day). Describe the disposition of the matter and the date of disposition.

SIGNATURE - Individual Completing This Form

Date Signed

Name ­ Individual Completing This Form (Print or type.)

Title