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Nursing Compliance Forms Back to Course Index

 

GRIEVANCE, SUGGESTION, COMPLAINT FORM

 

  1. Please describe your grievance, complaint or suggestion.

 

 

  1. Describe what attempts you have made to resolve the grievance, complaint or suggestion.

 

 

  1. Describe how you would like to see this grievance, complaint or suggestion resolved:

 

 

Please complete this form and give it to your counselor or another staff member if you have a written grievance. Otherwise, please place this form in the Suggestion Box. The Palm Beach Institute considers client feedback very seriously, and will carefully review this form. As noted in the Client Grievance Procedure, a formal grievance process begins within 24 hours of your turning in this form.

 

_______________________________________________
Client Signature/Date

 

_______________________________________________  
Client Name (Please Print)

 

______________________________________________
Staff Signature/Date/Time

 

Response to Grievance:

_________________________________________________________________________________

 

Copy Given to Patient On Date: ___________________           By Staff Member: _______________________
                                                                                                                                     

 

 

CLIENT SATISFACTION SURVEY

 

Client(s) M.R. #:                                                       Date:

Staff on Duty:

Was staff involved in the incident?

Did staff witness incident:

Incident Type: (check one)

 

Abuse/Neglect/Exploitation

 

Automobile Accident

 

Sexual Battery

 

Use of Alcohol

 

Baker Act

 

Suicide Attempt

 

Aggressive/Abusive Behavior

 

Client Death

 

Theft

 

Use of Drugs

 

Elopement

 

Verbal threat of violence

 

Altercation

 

Law Violation

 

Other (explain on page 2)

 

 

Describe Incident In Detail on Page 2 of This Report:


Action Taken:  ___________________________________________________________

Supervisor Contacted:  ______________________         
Name of Supervisor:  _______________________
Called 911:  ___________                                                          
Follow up Necessary: _____________________________________________________________

 

Describe Incident:

 

Supervisory Intervention Strategy:

Describe Intervention:  _____________________________________________________________

Supervisor Signature: ___________________________   Date:______________________________

Printed Name:________________________________

Executive Director Comments: 
_______________________________________________________________________________________

_______________________________________________________________________________________ 

Executive / Clinical Director Signature: ________________________________________________________

Describe Incident:

_____________________________________________________________________________________

 

 

EMPLOYEE SATISFACTION SURVEY

 

Employee Name:_________________________                              Date Survey Completed: ____________________

 

This is a survey for the employees of the Palm Beach Institute. This survey is intended to give the management of PBI guidance as to improving the workplace environment. This survey can be answered anonymously, but we truly want to know how we’re doing, if something needs to be changed or if anyone has any concerns that need to be addressed. Please return completed surveys to the Quality Compliance Director before Friday, 5:00pm.


Please check one
: Administration _________ Clinical _________   Management ___________

Are you: Salaried _______ Hourly _______ Contract ________

 

I work: FT______    

               PT______

My shift is:

Day Shift ______     Evening Shift _____   Night Shift _____

How long have you worked here?

Less than 2 years ____             2-5 years ____             5-10 years ____             Over 10 years ____


Ratings:

Please give your assessment of the Palm Beach Institute on the following matters by circling one of the numbers from one to ten (one being terrible and ten being great):

 

(a) Compensation to employees                                 i            i   i               I     i         1 2 3 4 5 6 7 8 9 10

(b) Opportunity for advancement                                                                         1 2 3 4 5 6 7 8 9 10

(c) Benefits                                                                                                           1 2 3 4 5 6 7 8 9 10

(d) Friendly work environment                                                      i            iii           1 2 3 4 5 6 7 8 9 10

(e) Training                                                                              I                i         I     1 2 3 4 5 6 7 8 9 10

(f) Performance Evaluation                                                               i               i     1 2 3 4 5 6 7 8 9 10

(g) Supervision                                                                                                     1 2 3 4 5 6 7 8 9 10

(h) Culture                                                                                                            1 2 3 4 5 6 7 8 9 10

( I ) Job Security                                                                                                   1 2 3 4 5 6 7 8 9 10

( j ) Flexibility in performing job                                                     i                       1 2 3 4 5 6 7 8 9 10

(k) Overall satisfaction job                                                                     i                 1 2 3 4 5 6 7 8 9 10

 

Please give your assessment of the Palm Beach Institute on the following matters by circling one of the numbers from one to ten (one being poor and ten being excellent):

 

Employee Morale:    1 2 3 4 5 6 7 8 9 10

  1.  How would you describe general employee morale?
    _________________________________________________
  2. Do you have any specific recommendations to improve employee morale?
    _________________________________________________

 

Guidance:     1 2 3 4 5 6 7 8 9 10

  1.  Are you given enough guidance to perform your job?
    ________________________________________________
  2. Are you given enough feedback on your work?
    ________________________________________________

 

Training:     1 2 3 4 5 6 7 8 9 10

 

What additional training of employees, if any, do you believe would be beneficial?

____________________________________________________

 

Technology:     1 2 3 4 5 6 7 8 9 10

 

What additional technology do you believe would be beneficial for Palm Beach Institute?

____________________________________________________

  

Benefits:     1 2 3 4 5 6 7 8 9 10

  1.  What benefits do you find valuable that Palm Beach Institute offers?
    ________________________________________________
  2. What additional benefits would you like to see Palm Beach Institute offer?
    ________________________________________________
     

Flexibility:     1 2 3 4 5 6 7 8 9 10

  1.  Are you given enough flexibility to perform your job?
    ________________________________________________
  2. What additional flexibility do you think would be valuable to help you perform your job better?Are you given enough flexibility to perform your job?
    ________________________________________________

 

Supervisor:     1 2 3 4 5 6 7 8 9 10

  1.  Are you adequately supervised?
    ________________________________________________
  2. Is your supervisor fully aware of your concerns?
    ________________________________________________
  3. How would you improve any supervisory process:
    ________________________________________________

 

Hiring Process     1 2 3 4 5 6 7 8 9 10

  1.  How did you hear about Palm Beach Institute?
    _________________________________________________
  2. Were you responded to in a timely fashion?
    _________________________________________________
  3. Were you treated in a courteous manner?
    _________________________________________________
  4. Was the interview process comfortable and informative?
    _________________________________________________ 

 

Human Resources:     1 2 3 4 5 6 7 8 9 10

  1.  Was the initial orientation appropriate and informative?
    ________________________________________________
  2. Were the benefits, pay, and job expectations explained?
    ________________________________________________

 

Profitability:

Do you have suggestions to improve the profitability of Palm Beach Institute?

____________________________________________________

 

Miscellaneous:

Is there anything else that you believe needs change or improvement at Palm Beach Institute?
____________________________________________________

 

 

STAFF SURVEY ON PATIENT SAFETY

 

SD=strongly disagree             D=disagree                 N=neutral                     A=agree             SA=strongly agree                 

PERCEPTIONS OF PATIENT SAFETY:

SD

D

N

A

SA

Comments

Patient safety is a high priority

 

 

 

 

 

 

I am aware of the patient safety issues in my area

 

 

 

 

 

 

I am supported in attempts to provide safe care

 

 

 

 

 

 

Patients are provided with safe care in the facility

 

 

 

 

 

 

REPORTING OF ERRORS:

SD

D

N

A

SA

Comments

I understand when and how to report an error in care

 

 

 

 

 

 

Errors are used as an opportunity to improve care

 

 

 

 

 

 

There is a non-punitive approach to error reporting

 

 

 

 

 

 

I would feel comfortable in reporting an error in care

 

 

 

 

 

 

Thank you for your time & effort in completing this survey.

Your input is very important to us.

 

 

CLIENT SATISFACTION SURVEY

 

Today’s date:                                               

 

The following questionnaire will be used as a tool to evaluate the treatment you received at The Palm Beach Institute (PBI). PBI is committed to providing the highest quality treatment possible; for this reason, your feedback is very important, it will help us to improve our treatment program and PBI as a whole.

 

Please do not put your name on the questionnaire, be as direct as possible; all information that you share will remain completely confidential. When you complete the questionnaire, please return to the Alumni Coordinator or Case Manager.

During your stay, which programs did you utilize?

Detox________ Adolescent________ RTC/PHP________ Olive House________

Please rate each area on the table below:

 

Excellent

Good

Average

Poor

Not Apply

Please rate overall experience at PBI:

 

 

 

 

 

 

 

 

 

 

 

Intake Department (Prior to your admission):

Excellent

Good

Average

Poor

Not Apply

Who was your Intake Counselor:_____________________________

 

 

 

 

 

Promptness of return call

 

 

 

 

 

Availability

 

 

 

 

 

Helpfulness

 

 

 

 

 

Please rate overall intake experience:

 

 

 

 

 

Admission/Intake:

Excellent

Good

Average

Poor

Not Apply

Who was your Admission Counselor:_________________________

 

 

 

 

 

Prompt assistance upon arrival

 

 

 

 

 

Explained all documentation clearly & answered all questions

 

 

 

 

 

Please rate overall admission/business office experience:

 

 

 

 

 

Medical/Psychiatric:

Excellent

Good

Average

Poor

Not Apply

Please rate Physician and/or Physician’s Assistant

 

 

 

 

 

Please rate Nursing Staff

 

 

 

 

 

Personal Caring

 

 

 

 

 

Availability

 

 

 

 

 

Assistance in understanding treatment process

 

 

 

 

 

Explanation of test & test results

 

 

 

 

 

Care of physical problems

 

 

 

 

 

Care of psychiatric problems

 

 

 

 

 

Professionalism in medical care

 

 

 

 

 

Assistance in understanding medications

 

 

 

 

 

Please rate overall Medical/Psychiatric experience:

 

 

 

 

 

Counseling:

Excellent

Good

Average

Poor

Not Apply

Who is/was your Primary Therapist:__________________________

 

 

 

 

 

Rapport with therapist

 

 

 

 

 

Caring & helpfulness of counselors

 

 

 

 

 

Helpful interaction with therapist

 

 

 

 

 

Well run therapeutic sessions

 

 

 

 

 

Family involvement

 

 

 

 

 

Scheduling/keeping appointments

 

 

 

 

 

Guidance in looking at self

 

 

 

 

 

Assistance in treatment planning

 

 

 

 

 

Assistance in explaining recovery principles

 

 

 

 

 

Assistance in applying recovery steps

 

 

 

 

 

Felt validated and listened to by therapist

 

 

 

 

 

Treated with respect and dignity by therapist

 

 

 

 

 

Freedom to express my frustrations with therapist

 

 

 

 

 

Able to express my individuality

 

 

 

 

 

Please rate your overall experience in counseling:

 

 

 

 

 

Program Components:

Excellent

Good

Average

Poor

Not Apply

Consistent, fair program rules

 

 

 

 

 

12 Step Programming

 

 

 

 

 

Group counseling

 

 

 

 

 

Individual counseling

 

 

 

 

 

Books, Literature, Handouts

 

 

 

 

 

Written assignments

 

 

 

 

 

Fitness

 

 

 

 

 

Enjoyable recreation activities

 

 

 

 

 

Aftercare planning

 

 

 

 

 

AA/NA Meetings

 

 

 

 

 

Information on spirituality

 

 

 

 

 

Art Therapy

 

 

 

 

 

Family Workshop

 

 

 

 

 

School time

 

 

 

 

 

Please rate overall Program Components:

 

 

 

 

 

Non-medical staff (BHTs)

Excellent

Good

Average

Poor

Not Apply

Competent

 

 

 

 

 

Caring

 

 

 

 

 

Freedom to express my frustrations with techs

 

 

 

 

 

Felt validated and listened to by the techs

 

 

 

 

 

Treated with respect and dignity by techs

 

 

 

 

 

Knowledge of programs and recovery steps

 

 

 

 

 

Please rate your overall experience with BHT’s(Techs):

 

 

 

 

 

 

 

 

 

 

 

Facility Accommodations:

Excellent

Good

Average

Poor

Not Apply

Quietness

 

 

 

 

 

Safe, Confidential Environment

 

 

 

 

 

Cleanliness

 

 

 

 

 

Lighting

 

 

 

 

 

Maintenance of Facility & Equipment

 

 

 

 

 

Maintenance of grounds

 

 

 

 

 

Comfort

 

 

 

 

 

Please rate overall living accommodations:

 

 

 

 

 

Dining:

Excellent

Good

Average

Poor

Not Apply

Quality of food

 

 

 

 

 

Quantity of food

 

 

 

 

 

Balanced meals

 

 

 

 

 

Variety

 

 

 

 

 

Cleanliness of dinnerware/utensils

 

 

 

 

 

Cleanliness of dining area

 

 

 

 

 

Special diet/nutritional needs met

 

 

 

 

 

Patient Safety:

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

I was informed of the purpose and nature of tests, treatment, procedures and medications.

 

 

 

 

 

I was given the opportunity to ask questions or seek further information if I was unsure of anything pertaining to my care.

 

 

 

 

 

Staff confirmed my identity prior to performing tasks or procedures, or giving me medications.

 

 

 

 

 

Staff appeared to take the proper time and safety precautions while caring for me.

 

 

 

 

 

I perceive that I was provided with safe and competent care.

 

 

 

 

 

 1.  Prior to your admission is this program, what were your expectations of The Palm Beach Institute?

_______________________________________________________________________________________

_______________________________________________________________________________________ 

2.  How have your expectations changed?

_______________________________________________________________________________________

_______________________________________________________________________________________ 

3.     What do you consider to be the main strengths of the program?

_______________________________________________________________________________________

_______________________________________________________________________________________ 

4.  Where did you hear about our program?  

____  Therapist   ____12 Step   ___ Friend   ___Psychiatrist   ___Media   ___Conference   ___Alumni   ___Internet   ___Other

5.  Did you consider any other treatment programs before choosing PBI:  if yes, what program/s? _____________________________

6.     What were the major reasons you chose PBI for treatment?

___  Programming   ___Cost   ___Number of Patients  ___Cost  ___Not our choice  ____ Other

7.     How did you pay for your treatment?  ____  Insurance   ___Cash   ___Combination of both

8.  How old are you?  ___13-17   ___18-29   ___30-39   ___40-49   ___50-59   ____60-Over

9.  What city, state, and/or country do you reside:  _____________________________________________

10.  Would you choose PBI again?  ___Yes  ___No

Why or why not?  ___________________________________________________________________

11.  Is there a staff person that you would like to recognize that gave you exceptional care while in treatment at PBI?

_______________________________________________________________________________

12.  If you rated anything below an Average/Normal on the above survey, please explain what you would like to see improved:

_______________________________________________________________________________

Please share any additional comments or suggestions you may have to improve our care:

_______________________________________________________________________________________

_______________________________________________________________________________________ 

_______________________________________________________________________________________

_______________________________________________________________________________________ 

 

GRIEVANCE, SUGGESTION, COMPLAINT FORM

Please describe your grievance, complaint or suggestion.

 

 

Describe what attempts you have made to resolve the grievance, complaint or suggestion.

 

 

Describe how you would like to see this grievance, complaint or suggestion resolved:

 

 

Please complete this form and give it to your counselor or another staff member if you have a written grievance. Otherwise, please place this form in the Suggestion Box. The Palm Beach Institute considers client feedback very seriously, and will carefully review this form. As noted in the Client Grievance Procedure, a formal grievance process begins within 24 hours of your turning in this form.

 

__________________________________             
Client Signature/Date

 

__________________________________
Client Name (Please Print)

 

__________________________________            
Staff Signature/Date/Time

 

Response to Grievance:

_______________________________________________________________________________________

_______________________________________________________________________________________ 

Copy Given to Patient On Date: ___________________           By Staff Member: _________________________________
                                                                 

 

 

CLIENT SATISFACTION SURVEY

Client(s) M.R. #:                                                       Date:

Staff on Duty:

Was staff involved in the incident?

Did staff witness incident:

Incident Type: (check one)

 

Abuse/Neglect/Exploitation

 

Automobile Accident

 

Sexual Battery

 

Use of Alcohol

 

Baker Act

 

Suicide Attempt

 

Aggressive/Abusive Behavior

 

Client Death

 

Theft

 

Use of Drugs

 

Elopement

 

Verbal threat of violence

 

Altercation

 

Law Violation

 

Other (explain on page 2)

 

Describe Incident In Detail on Page 2 of This Report:

Action Taken:

Supervisor Contacted:   _______________________            Name of Supervisor:  ___________________

Called 911:  ________________          Follow up Necessary:  ____________________________________

Describe Incident:
______________________________________________

Supervisory Intervention Strategy:  
______________________________________________

Describe Intervention: 
___________________________________________________

Supervisor Signature: ___________________________  Date:__________________________________

Printed Name:________________________________

Executive Director Comments:
_______________________________________________________________________________________

_______________________________________________________________________________________ 

Comments: ____________________________________________________________________________

_______________________________________________________________________________________

Executive / Clinical Director Signature: ________________________________________________________

 

Describe Incident:
____________________________________________________________________________

 

STAFF SURVEY ON PATIENT SAFETY

 

SD=strongly disagree             D=disagree                 N=neutral                     A=agree             SA=strongly agree                 

PERCEPTIONS OF PATIENT SAFETY:

SD

D

N

A

SA

Comments

Patient safety is a high priority

 

 

 

 

 

 

I am aware of the patient safety issues in my area

 

 

 

 

 

 

I am supported in attempts to provide safe care

 

 

 

 

 

 

Patients are provided with safe care in the facility

 

 

 

 

 

 

REPORTING OF ERRORS:

SD

D

N

A

SA

Comments

I understand when and how to report an error in care

 

 

 

 

 

 

Errors are used as an opportunity to improve care

 

 

 

 

 

 

There is a non-punitive approach to error reporting

 

 

 

 

 

 

I would feel comfortable in reporting an error in care

 

 

 

 

 

 

Thank you for your time & effort in completing this survey.

Your input is very important to us.