Free Hospice Complaint-F-62287 - Wisconsin

DEPARTMENT OF HEALTH SERVICES
Division of Quality Assurance F-62287 (Rev. 07/08)

STATE OF WISCONSIN
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HOSPICE COMPLAINT
Completion of this form is voluntary. Personal information will be used to investigate the complaint, to communicate with the complainant, and will be used for no other purpose.

To assist in reviewing your concern, provide the following information.

1. HOSPICE
Name ­ Hospice Address City State Date Submitted Zip Code

2. COMPLAINANT
Name ­ Complainant Address Telephone Number City Relationship to the Patient State Zip Code

Do you wish to remain anonymous? 3. PATIENT
Name ­ Patient Address

Yes

No

Telephone Number City State Zip Code

4. DESCRIPTION OF CONCERN Describe the situation or incident, the names, dates, and what happened. Write clearly and be as specific as possible.

F-62287 (Rev. 07/08)

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HOSPICE PATIENT COMPLAINT RIGHTS AND PROCEDURES
Section 50.95 of the Wisconsin State Statutes authorizes the Department of Health Services to establish rules governing the operation of a hospice. Wisconsin Administrative Code HFS 131.21(4)(b) and (c), authorized by the above state statute, describes a hospice patient's right to file a complaint with the Department as follows: (b) (c) Express complaints to the Department, and to be given a statement provided by the Department setting forth the right to and procedure for filing verbal or written complaints with the Department; and Be advised of the availability of a toll-free hotline, including its telephone number, to receive complaints or questions about local hospices, and be advised of the availability of the long term care ombudsman to provide patient advocacy and other services under Chapter 16.009, Wis. Stats.

Wisconsin Administrative Code HFS 131.22(2)(b) and (c), authorized by the above state statute, describes a hospice family member's right to file a complaint with the Department as follows: (b) (c) Express complaints to the Department and be given a statement provided by the Department, setting forth the right to and procedure for filing verbal or written complaints with the Department; and Be advised of the availability of a toll-free hotline, including its telephone number, to receive complaints or questions about local hospices, and be advised of the availability of the long term care ombudsman to provide patient advocacy and other services under Chapter 16.009, Wis. Stats.

The above statute and rules mean: (1) (2) (3) You have a right to complain directly to the Department of Health Services; and You must be advised by the hospice serving you of this right and they must tell you how to go about filing a complaint. You must be advised of the right to receive patient advocacy services from the Board on Aging and Long Term Care (BALTC). Services from the BALTC include investigation of complaints, serving as a mediator to resolve problems or disputes relating to long-term care patients, and provision of information and counseling related to insurance policies available to supplement federal Medicare coverage. The BALTC may be contacted by calling its toll-free number at 1-800-815-0015. Copies of the complaint statement and complaint form will be provided to each hospice for distribution to each patient/family spokesperson prior to provision of any services and at the conclusion of the service agreement. If a patient or anyone representing the patient's interests has a concern with the patient's care and treatment or believes the patient's rights have been violated and the hospice has not resolved these concerns, a complaint may be filed by writing to Department of Health Services Division of Quality Assurance / Bureau of Health Services ATTN: Hospice Complaint Coordinator P.O. Box 2969 Madison, WI 53701-2969 or by calling the TOLL FREE Wisconsin Home Health / Hospice Hotline at 1-800-642-6552. The toll-free hotline operates a voice message system 24 hours a day. Calls received during the evening, on weekends, or holidays, are returned the next work day. The purpose of the hotline is to receive complaints regarding Wisconsin licensed and Medicare/Medicaid certified home health agencies and hospices and to provide information about Wisconsin home health agencies and hospices. Additional copies of the complaint form can be obtained by accessing the Department web site at

http://dhs.wisconsin.gov/forms/DQAnum.asp