In the realm of health services within Wisconsin, ensuring the rights and welfare of residents in community-based residential facilities (CBRFs) is of paramount importance. Under the stipulations of Chapter 50.09 of the Wisconsin State Statutes, CBRFs are mandated to have a formal process in place for the review and management of complaints and allegations concerning the violation of resident's rights. Integral to this process is the F-62430 form, a critical document designed to summarize and report these complaints and allegations of resident rights violations to the Department of Health Services, as required under Section 50.03(4)(c), Wis. Stats. The form not only serves as a conduit for reporting but is also a legal requirement that, if not complied with, could result in significant consequences, including the revocation of the facility's license. The F-62430 form is a comprehensive tool that requires detailed information regarding the original date of the report, dates or approximate dates of the incident and its disposition, names of individuals initiating the complaint, involved residents, witnesses, and the final resolution of the matter. This ensures a systemic approach to addressing and rectifying complaints, further underscoring the state's commitment to protecting the rights and dignity of individuals residing in CBRFs.
| Question | Answer |
|---|---|
| Form Name | Form 62430 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | F62430 wisconsin cbrf resident rights form |
DEPARTMENT OF HEALTH SERVICES |
STATE OF WISCONSIN |
Division of Quality Assurance |
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
●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.
_________________________________________________________________________________________________
●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.
Name - Facility
License Number
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.Original date of the report;
2.Date or approximate date of the incident;
3.Date or estimated date of disposition;
4.Full name of person or persons initiating the complaint or allegation of violation;
5.Full names of residents involved;
6.Full names of witnesses and informants; and
7.Disposition of the matter.
Page 2 of 2 |
SAMPLE RESIDENTS' RIGHTS COMPLAINT REPORT
A Report on the Rights of Residents per Chapter 50.09(6)(d), Wis. Stats.
Name - Facility
Address
Telephone Number
City |
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