Vitalis Compliant Form
Date of Report
-
Month
-
Day
Year
Date
Name of Client
First Name
Last Name
Name of Vitalis Staff Involved (if applicable)
First Name
Last Name
Date of Occurence of Incident
-
Month
-
Day
Year
Date
Location of Incident
Home
Community
Agency Office
Other
Nature of complaint (select all that apply)
No call / no show
Failure to follow standard precautions (hand hygiene, transfer procedures, etc)
Failure to provide care according to approved plan of care
Inappropriate use of phone at work place
Acceptance of gifts from client
Tardiness
Use of client's food
Pilfering
Use of unacceptable language
Unconducive Work Environment
Unprofessional / aggressive behavior (argumentative, rude, impolite)
Hazardous situation in client home
Work requested outside of approved plan of care / task checklist
Other
Detailed description of complaints or allegations
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Name of Person Completing this form
First Name
Last Name
Email of person completing this form
example@example.com
Phone Number of person completing this form
Please enter a valid phone number.
The person making this complaint is:
Client
Client's representative
Vitalis Caregiver
Vitalis Admin Staff
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Name of Vitalis Admin Staff Working On Complaint
First Name
Last Name
Actions Taken To Investigate
Supportive Documentation (select all that apply)
Home Visit Made
Patient Charts Review
Conference call with client and family
Employee file reviewed
Written response to complainant
Report made to Department of Health
Other
Resolution / Response / Intervention
Response to Complainant:
Verbal
Written (attach copy)
Other
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Additional Action Taken
Signature
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Thanks for completing this form. Once you submit it, a Vitalis Admin staff will be in touch.
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