"Personal Care Homes Complaint Reporting Form" - Saskatchewan, Canada

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PERSONAL CARE HOMES
COMPLAINT REPORTING FORM
As the licensing and monitoring body for Personal Care Homes (PCHs) in Saskatchewan,
the PCH Program of Saskatchewan Health takes your complaint seriously and will
investigate. From time to time the investigation may take several months depending on
the complexity of the complaint.
Typically the complaint investigation process is as follows:
• the complainant completes this form providing as much detail as possible, and
submits the form to the PCH Program,
• a PCH Consultant will review all of the information and conduct an investigation.
Contact with other parties may be necessary.
• if the complaint is founded, the PCH Consultant will work with the PCH Licensee
to gain compliance with the PCHs legislation.
• the complainant will be notified upon conclusion of the investigation.
_______________________________________________________________________
Please complete the following:
Name of Personal Care Home Operator:_____________________________________
Address of PCH: ________________________________________________________
Name of Resident: _______________________________________________________
Name of Complainant: ___________________________________________________
Address of Complainant:__________________________________________________
Phone # of Complainant (Bus.): ________________ (Res.):______________________
Relationship to Resident: _________________________________________________
Use the space below to identify your concerns paying particular attention to details such
as individuals involved, date, time, witnesses to the incident and issue(s) (food,
environment, care, resident rights and privileges/conflict of interest, etc.). Please use the
reverse page if you need more space.
If you have any questions or require assistance to complete this form, please contact the
Personal Care Homes Program at (306) 787-1715.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
PERSONAL CARE HOMES
COMPLAINT REPORTING FORM
As the licensing and monitoring body for Personal Care Homes (PCHs) in Saskatchewan,
the PCH Program of Saskatchewan Health takes your complaint seriously and will
investigate. From time to time the investigation may take several months depending on
the complexity of the complaint.
Typically the complaint investigation process is as follows:
• the complainant completes this form providing as much detail as possible, and
submits the form to the PCH Program,
• a PCH Consultant will review all of the information and conduct an investigation.
Contact with other parties may be necessary.
• if the complaint is founded, the PCH Consultant will work with the PCH Licensee
to gain compliance with the PCHs legislation.
• the complainant will be notified upon conclusion of the investigation.
_______________________________________________________________________
Please complete the following:
Name of Personal Care Home Operator:_____________________________________
Address of PCH: ________________________________________________________
Name of Resident: _______________________________________________________
Name of Complainant: ___________________________________________________
Address of Complainant:__________________________________________________
Phone # of Complainant (Bus.): ________________ (Res.):______________________
Relationship to Resident: _________________________________________________
Use the space below to identify your concerns paying particular attention to details such
as individuals involved, date, time, witnesses to the incident and issue(s) (food,
environment, care, resident rights and privileges/conflict of interest, etc.). Please use the
reverse page if you need more space.
If you have any questions or require assistance to complete this form, please contact the
Personal Care Homes Program at (306) 787-1715.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
What is your expectation from the investigation of this complaint?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Licensed personal care home operators are required to provide safe and adequate care to the
residents in their home. The information you have provided will assist Saskatchewan Health
officials in determining if the Licensee is providing safe and adequate care to their residents.
While most complaint investigations are used to educate Licensees and staff to ensure they
understand the requirements of the legislation, some investigations result in appropriate action
being taken against a personal care licence, i.e., amendment, suspension or cancellation of the
licence. Please be advised that every effort is being taken to keep your name confidential (if this
is your preference), however, during the course of the investigation, your identity may be
assumed by or disclosed to the Licensee or their legal counsel in the interest of administrative
fairness. By completing and signing this form, you are consenting to the release of your name
and the details of your concerns to the Licensee or their legal counsel during the course of the
investigation or follow-up enforcement, or any legal proceedings.
___________________________________
_____________________
Signature of Complainant
Date:
Return to:
Attention: Personal Care Homes Consultant (Complaints)
Personal Care Homes Program
Community Care Branch
Ministry of Health
Main Floor - T. C. Douglas Bldg
3475 Albert Street
Regina, SK S4S 6X6
Fax: (306) 787-7095
Web Link:
http://www.saskatchewan.ca/residents/health/accessing-health-care-
services/care-at-home-and-outside-the-hospital/personal-care-homes#report-a-problem-
with-a-personal-care-home
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