Date of Activity:
(Check One) Nursing Home
Residential Care Facility
IF YOU VISIT A MULTILEVEL FACILITY WITH A NURSING HOME, RESIDENTIAL CARE AND/OR ASSISTED LIVING, PLEASE COMPLETE A SEPARATE REPORT FOR EACH UNIT VISITED. IF REQUESTED TO VISIT A RESIDENT BY LTCOP STAFF, PLEASE COMPLETE A CASE INVESTIGATION REPORT.
PLEASE ASK IF THE FACILITY NEEDS ANY IN-SERVICE TRAINING.
Time of Day:
Time Spent in this unit: minutes
Travel Time (to and from): minutes
Time Spent on this report: minutes
(Check all that apply)
Routine visit to assigned facility
Quarterly monitoring visit
Participation in Survey
Family Council Meeting
Resident Council Meeting - (Please request an invitation to participate at least twice each year)
Observation Checklist and Action Taken
Homeward Bound (NF only) - information/brochure provided:(Enter the number of individuals in each category that received info/brochure)
DO NOT SHARE INFO WITH THE FACILITY WITHOUT THE RESIDENT'S PERMISSION.
Did you follow up on a previous concern? If so, what was the result? Please include the resident's name.
During this visit were any new problems addressed or identified? If so, what action did you take? (Please use this space if you need to clarify anything from the observation checklist.)
IF ANY CONCERNS, PLEASE CALL THE OFFICE AT 1(800)499-0229. THANK YOU.
"All long-term care consumers have the right to be treated with dignity and respect."
61 Winthrop St. l Augusta, Maine 04330
Voice/TTY: 1-800-499-0229 l Augusta Area: (207) 621-1079 l Fax: (207) 621-0509