Who at LTCOP asked you to visit this resident?:
Date of Case Investigation:
Residential Care Facility
Time of Day:
Time Spent on Case Inv: minutes
Travel Time (to and from): minutes
Time Spent on this report: minutes
This report should include only time spent on case investigation. If you also made a routine visit or a quarterly visit on the same date, please complete a separate visit report form for each type of visit. Do not include the time spent on case investigation in your visit report time and do not duplicate travel time on each report, only include on one report for that date.
Please remember to report all relevant information after each contact. This form must be submitted to the office within 24 hours of your contact.
DO NOT SHARE INFO WITH THE FACILITY WITHOUT THE RESIDENT'S PERMISSION.
Case Investigation Notes (what is the resident's complaint? Did they give you permission to follow up with the facility? Who did you speak with? What was their response? Does the resident feel the issue is resolved? Will you provide any further follow up?)
"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