| DQA
|
F-00012
|
CBRF Completion Documents
|
PDF
|
None
|
English
|
| DQA
|
F-00014
|
Ceiling Closure Inspection Checklist
|
PDF
|
None
|
English
|
| DQA
|
F-00014
|
Ceiling Closure Inspection Checklist
|
Word
|
None
|
English
|
| DQA
|
F-00015
|
Final Occupancy Inspection Checklist
|
PDF
|
None
|
English
|
| DQA
|
F-00015
|
Final Occupancy Inspection Checklist
|
Word
|
None
|
English
|
| DQA
|
F-00016
|
Wall Closure Inspection Checklist
|
PDF
|
None
|
English
|
| DQA
|
F-00016
|
Wall Closure Inspection Checklist
|
Word
|
None
|
English
|
| DQA
|
F-00027
|
CSAS Standards Recertification Application - DHS 75.03
|
PDF
|
None
|
English
|
| DQA
|
F-00027
|
CSAS Standards Recertification Application - DHS 75.03
|
Word
|
None
|
English
|
| DQA
|
F-00037D
|
DQA E-Mail Subscription Service Sign-Up
|
HTML
|
None
|
English
|
| DQA
|
F-00059
|
Outpatient Mental Health Clinic Application - DHS 35
|
PDF
|
None
|
English
|
| DQA
|
F-00059
|
Outpatient Mental Health Clinic Application - DHS 35
|
Word
|
None
|
English
|
| DQA
|
F-00119
|
Personal Care Agency Application for Approval
|
PDF
|
None
|
English
|
| DQA
|
F-00140
|
Attestation and Acknowledgement for Provisional Approval as a Personal Care Agency
|
PDF
|
None
|
English
|
| DQA
|
F-00157
|
Assisted Living Administrator Training Course - Trainer Approval Application
|
PDF
|
None
|
English
|
| DQA
|
F-00157
|
Assisted Living Administrator Training Course - Trainer Approval Application
|
Word
|
None
|
English
|
| DQA
|
F-00158
|
Assisted Living Administrator Training Course - Application for Training Curriculum
|
PDF
|
None
|
English
|
| DQA
|
F-00158
|
Assisted Living Administrator Training Course - Application for Training Curriculum
|
Word
|
None
|
English
|
| DQA
|
F-00161
|
Caregiver Misconduct Reporting Requirements Worksheet
|
PDF
|
None
|
English
|
| DQA
|
F-00161
|
Caregiver Misconduct Reporting Requirements Worksheet
|
Word
|
None
|
English
|
| DQA
|
F-00161A
|
Flowchart of Entity Investigation and Reporting Requirements for Caregiver Misconduct and Injuries
|
PDF
|
None
|
English
|
| DQA
|
F-00176
|
Project Proposal
|
PDF
|
None
|
English
|
| DQA
|
F-00176
|
Project Proposal
|
Word
|
None
|
English
|
| DQA
|
F-00191
|
Certified Outpatient Clinic Request for a Branch Office
|
PDF
|
None
|
English
|
| DQA
|
F-00191
|
Certified Outpatient Clinic Request for a Branch Office
|
Word
|
None
|
English
|
| DQA
|
F-00261
|
Personal Care Agency Personnel Record Review
|
PDF
|
None
|
English
|
| DQA
|
F-00262
|
Personal Care Agency Pre-Approval Desk Review Checklist
|
PDF
|
None
|
English
|
| DQA
|
F-00263
|
Personal Care Agency Record Review
|
PDF
|
None
|
English
|
| DQA
|
F-00264
|
Personal Care Agency Surveyor Guide
|
PDF
|
None
|
English
|
| DQA
|
F-00273
|
Behavioral Health Services Initial Certification Application - DHS 94
|
PDF
|
None
|
English
|
| DQA
|
F-00273
|
Behavioral Health Services Initial Certification Application - DHS 94
|
Word
|
None
|
English
|
| DQA
|
F-00276
|
Behavioral Health Services Renewal Certification Application - DHS 94 and 92
|
PDF
|
None
|
English
|
| DQA
|
F-00276
|
Behavioral Health Services Renewal Certification Application - DHS 94 and 92
|
Word
|
None
|
English
|
| DQA
|
F-00302
|
CSAS Outpatient Clinic Services Application - DHS 75.13
|
PDF
|
None
|
English
|
| DQA
|
F-00302
|
CSAS Outpatient Clinic Services Application - DHS 75.13
|
Word
|
None
|
English
|
| DQA
|
F-00309
|
Medicaid Provider Report
|
PDF
|
None
|
English
|
| DQA
|
F-00309
|
Medicaid Provider Report
|
Word
|
None
|
English
|
| DQA
|
F-00311
|
Nursing Home MDS 3.0 Section Q Referral
|
PDF
|
None
|
English
|
| DQA
|
F-00311
|
Nursing Home MDS 3.0 Section Q Referral
|
Word
|
None
|
English
|
| DQA
|
F-00338
|
Survey Guide - Hospice Direct Inpatient Unit Survey
|
PDF
|
None
|
English
|
| DQA
|
F-00338
|
Survey Guide - Hospice Direct Inpatient Unit Survey
|
Word
|
None
|
English
|
| DQA
|
F-00380
|
Outpatient Mental Health Clinic Certification Withdrawal
|
PDF
|
None
|
English
|
| DQA
|
F-00380
|
Outpatient Mental Health Clinic Certification Withdrawal
|
Word
|
None
|
English
|
| DQA
|
F-00381
|
Outpatient Mental Health Clinic Certification Withdrawal Checklist
|
PDF
|
None
|
English
|
| DQA
|
F-00381
|
Outpatient Mental Health Clinic Certification Withdrawal Checklist
|
Word
|
None
|
English
|
| DQA
|
F-00385
|
Nurse Aide Training - Student Waiver
|
PDF
|
None
|
English
|
| DQA
|
F-00385
|
Nurse Aide Training - Student Waiver
|
Word
|
None
|
English
|
| DQA
|
F-00386
|
Request for Americans with Disability Act (ADA) Accommodation
|
PDF
|
None
|
English
|
| DQA
|
F-00386
|
Request for Americans with Disability Act (ADA) Accommodation
|
Word
|
None
|
English
|
| DQA
|
F-00417
|
AODA Prevention Services Recertification Application - DHS 75.04
|
PDF
|
None
|
English
|
| DQA
|
F-00417
|
AODA Prevention Services Recertification Application - DHS 75.04
|
Word
|
None
|
English
|
| DQA
|
F-00438
|
Community Substance Abuse Services (CSAS) Verification of Criteria - DHS 75.02 (11)
|
PDF
|
None
|
English
|
| DQA
|
F-00438
|
Community Substance Abuse Services (CSAS) Verification of Criteria - DHS 75.02 (11)
|
Word
|
None
|
English
|
| OQA
|
F-00439
|
Community Substance Abuse Services (CSAS) Emergency Outpatient Service Recertification Application - DHS 75.05
|
PDF
|
None
|
English
|
| OQA
|
F-00439
|
Community Substance Abuse Services (CSAS) Emergency Outpatient Service Recertification Application - DHS 75.05
|
Word
|
None
|
English
|
| DQA
|
F-00464
|
CSAS Medically Managed Inpatient Detoxification Service Recertification Application - DHS 75.06
|
PDF
|
None
|
English
|
| DQA
|
F-00464
|
CSAS Medically Managed Inpatient Detoxification Service Recertification Application - DHS 75.06
|
Word
|
None
|
English
|
| DQA
|
F-00465
|
CSAS Medically Managed Residential Detoxification Service Recertification Application - DHS 75.07
|
PDF
|
None
|
English
|
| DQA
|
F-00465
|
CSAS Medically Managed Residential Detoxification Service Recertification Application - DHS 75.07
|
Word
|
None
|
English
|
| DQA
|
F-00466
|
CSAS Ambulatory Detoxification Service Recertification Application - DHS 75.08
|
PDF
|
None
|
English
|
| DQA
|
F-00466
|
CSAS Ambulatory Detoxification Service Recertification Application - DHS 75.08
|
Word
|
None
|
English
|
| DQA
|
F-00467
|
CSAS Residential Intoxification Monitoring Service Recertification Application - DHS 75.09
|
PDF
|
None
|
English
|
| DQA
|
F-00467
|
CSAS Residential Intoxification Monitoring Service Recertification Application - DHS 75.09
|
Word
|
None
|
English
|
| DQA
|
F-00468
|
CSAS Medically Managed Inpatient Treatment Service Recertification Application - DHS 75.10
|
PDF
|
None
|
English
|
| DQA
|
F-00468
|
CSAS Medically Managed Inpatient Treatment Service Recertification Application - DHS 75.10
|
Word
|
None
|
English
|
| DQA
|
F-00469
|
CSAS Medically Monitored Treatment Service Recertification Application - DHS 75.11
|
PDF
|
None
|
English
|
| DQA
|
F-00469
|
CSAS Medically Monitored Treatment Service Recertification Application - DHS 75.11
|
Word
|
None
|
English
|
| DQA
|
F-00470
|
CSAS Day Treatment Service Recertification Application - DHS 75.12
|
PDF
|
None
|
English
|
| DQA
|
F-00470
|
CSAS Day Treatment Service Recertification Application - DHS 75.12
|
Word
|
None
|
English
|
| DQA
|
F-00471
|
CSAS Transitional Residential Treatment Service Recertification Application - DHS 75.14
|
PDF
|
None
|
English
|
| DQA
|
F-00471
|
CSAS Transitional Residential Treatment Service Recertification Application - DHS 75.14
|
Word
|
None
|
English
|
| DQA
|
F-00472
|
CSAS Narcotic Treatment Service for Opiate Addiction Recertification Application - DHS 75.15
|
PDF
|
None
|
English
|
| DQA
|
F-00472
|
CSAS Narcotic Treatment Service for Opiate Addiction Recertification Application - DHS 75.15
|
Word
|
None
|
English
|
| DQA
|
F-00473
|
CSAS Intervention Service Recertification Application - DHS 75.16
|
PDF
|
None
|
English
|
| DQA
|
F-00473
|
CSAS Intervention Service Recertification Application - DHS 75.16
|
Word
|
None
|
English
|
| DQA
|
F-00475
|
Comprehensive Community Services for Persons with Mental Disorders and Substance-Use Disorders Recertification Application Chapter DHS 36
|
PDF
|
None
|
English
|
| DQA
|
F-00475
|
Comprehensive Community Services for Persons with Mental Disorders and Substance-Use Disorders Recertification Application Chapter DHS 36
|
Word
|
None
|
English
|
|
|
F-00496
|
Plan Review Code Interpretation Request
|
PDF
|
None
|
English
|
|
|
F-00496
|
Plan Review Code Interpretation Request
|
Word
|
None
|
English
|
|
|
F-00512
|
Mental Health Day Treatment Program Initial Certification Application - DHS 61.75
|
PDF
|
None
|
English
|
|
|
F-00512
|
Mental Health Day Treatment Program Initial Certification Application - DHS 61.75
|
Word
|
None
|
English
|
|
|
F-00513
|
CSAS Transitional Residential Treatment Service Initial Certification Application - DHS 75.14
|
PDF
|
None
|
English
|
|
|
F-00513
|
CSAS Transitional Residential Treatment Service Initial Certification Application - DHS 75.14
|
Word
|
None
|
English
|
|
|
F-00514
|
CSAS Medically Monitored Treatment Service Initial Certification Application - DHS 75.11
|
PDF
|
None
|
English
|
|
|
F-00514
|
CSAS Medically Monitored Treatment Service Initial Certification Application - DHS 75.11
|
Word
|
None
|
English
|
|
|
F-00515
|
CSAS Day Treatment Service Initial Certification Application - DHS 75.12
|
PDF
|
None
|
English
|
|
|
F-00515
|
CSAS Day Treatment Service Initial Certification Application - DHS 75.12
|
Word
|
None
|
English
|
|
|
F-00516
|
CSAS Medically Managed Inpatient Treatment Service Initial Certification Application - DHS 75.10
|
PDF
|
None
|
English
|
|
|
F-00516
|
CSAS Medically Managed Inpatient Treatment Service Initial Certification Application - DHS 75.10
|
Word
|
None
|
English
|
|
|
F-00517
|
CSAS Residential Intoxification Monitoring Service Initial Certification Application - DHS 75.09
|
PDF
|
None
|
English
|
|
|
F-00517
|
CSAS Residential Intoxification Monitoring Service Initial Certification Application - DHS 75.09
|
Word
|
None
|
English
|
|
|
F-00518
|
CSAS Ambulatory Detoxification Service Initial Certification Application - DHS 75.08
|
PDF
|
None
|
English
|
|
|
F-00518
|
CSAS Ambulatory Detoxification Service Initial Certification Application - DHS 75.08
|
Word
|
None
|
English
|
|
|
F-00519
|
CSAS Medically Managed Residential Detoxification Service Initial Certification Application - DHS 75.07
|
PDF
|
None
|
English
|
|
|
F-00519
|
CSAS Medically Managed Residential Detoxification Service Initial Certification Application - DHS 75.07
|
Word
|
None
|
English
|
|
|
F-00520
|
CSAS Medically Managed Inpatient Detoxification Service Intitial Certification Application - DHS 75.06
|
PDF
|
None
|
English
|
|
|
F-00520
|
CSAS Medically Managed Inpatient Detoxification Service Intitial Certification Application - DHS 75.06
|
Word
|
None
|
English
|
|
|
F-00521
|
CSAS Prevention Service Initial Certification Application - DHS 75.04
|
PDF
|
None
|
English
|
|
|
F-00521
|
CSAS Prevention Service Initial Certification Application - DHS 75.04
|
Word
|
None
|
English
|
|
|
F-00523
|
Community Substance Abuse Service General Requirements Initial Certification Application - DHS 75.03
|
PDF
|
None
|
English
|
|
|
F-00523
|
Community Substance Abuse Service General Requirements Initial Certification Application - DHS 75.03
|
Word
|
None
|
English
|
|
|
F-00537
|
CSAS Intervention Services Initial Certification Application - DHS 75.16
|
PDF
|
None
|
English
|
|
|
F-00537
|
CSAS Intervention Services Initial Certification Application - DHS 75.16
|
Word
|
None
|
English
|
|
|
F-00538
|
CSAS Narcotic Treatment Service for Opiate Addiction Initial Certification Application - DHS 75.15
|
PDF
|
None
|
English
|
|
|
F-00538
|
CSAS Narcotic Treatment Service for Opiate Addiction Initial Certification Application - DHS 75.15
|
Word
|
None
|
English
|
|
|
F-00544
|
CSAS Outpatient Treatment Service Initial Certification Application - DHS 75.13
|
PDF
|
None
|
English
|
|
|
F-00544
|
CSAS Outpatient Treatment Service Initial Certification Application - DHS 75.13
|
Word
|
None
|
English
|
|
|
F-00545
|
Emergency Outpatient Service Initial Certification Application - DHS 75.05
|
PDF
|
None
|
English
|
|
|
F-00545
|
Emergency Outpatient Service Initial Certification Application - DHS 75.05
|
Word
|
None
|
English
|
|
|
F-00546
|
CSP for Persons with Chronic Mental Illness Initial Certification Application - DHS 63
|
PDF
|
None
|
English
|
|
|
F-00546
|
CSP for Persons with Chronic Mental Illness Initial Certification Application - DHS 63
|
Word
|
None
|
English
|
|
|
F-00547
|
Mental Health Inpatient Initial Certification Application - DHS 61.71 & 61.79
|
PDF
|
None
|
English
|
|
|
F-00547
|
Mental Health Inpatient Initial Certification Application - DHS 61.71 & 61.79
|
Word
|
None
|
English
|
|
|
F-00548
|
Mental Health Day Treatment Services for Children Program Application - DHS 40
|
PDF
|
None
|
English
|
|
|
F-00548
|
Mental Health Day Treatment Services for Children Program Application - DHS 40
|
Word
|
None
|
English
|
| OQA-0287
|
F-60287
|
Community Based Residential Facility (CBRF) Initial License Application
|
PDF
|
None
|
English
|
| OQA-0287
|
F-60287
|
Community Based Residential Facility (CBRF) Initial License Application
|
Word
|
None
|
English
|
| OQA-0290
|
F-60290
|
CBRF Identification of Hazards Request
|
PDF
|
None
|
English
|
| OQA-0290
|
F-60290
|
CBRF Identification of Hazards Request
|
Word
|
None
|
English
|
| OQA-0309
|
F-60309
|
Self Supervision Evaluation and Waiver Request*
|
PDF
|
None
|
English
|
| OQA-0309
|
F-60309
|
Self Supervision Evaluation and Waiver Request*
|
Word
|
None
|
English
|
| OQA-0367
|
F-60367
|
Community Advisory Committee Documentation
|
PDF
|
None
|
English
|
| OQA-0367
|
F-60367
|
Community Advisory Committee Documentation
|
Word
|
None
|
English
|
| OQA-0795
|
F-60795
|
Community Based Residential Facility (CBRF) Fire Inspection
|
PDF
|
None
|
English
|
| OQA-0795
|
F-60795
|
Community Based Residential Facility (CBRF) Fire Inspection
|
Word
|
None
|
English
|
| OQA-0820
|
F-60820
|
Corporate Guardianship Program Status Application
|
PDF
|
None
|
English
|
| OQA-0820
|
F-60820
|
Corporate Guardianship Program Status Application
|
Word
|
None
|
English
|
| OQA-0945
|
F-60945
|
Adult Family Home Initial License Application
|
PDF
|
None
|
English
|
| OQA-0945
|
F-60945
|
Adult Family Home Initial License Application
|
Word
|
None
|
English
|
| OQA-0947
|
F-60947
|
Adult Day Care Certification Standards Checklist
|
PDF
|
None
|
English
|
| OQA-0947
|
F-60947
|
Adult Day Care Certification Standards Checklist
|
Word
|
None
|
English
|
| OQA-0953
|
F-60953
|
Adult Family Home Fire Safety Guide
|
PDF
|
None
|
English
|
| OQA-0953
|
F-60953
|
Adult Family Home Fire Safety Guide
|
Word
|
None
|
English
|
| OQA-2019
|
F-62019
|
License Application - Nursing Home, Facility for the Developmentally Disabled or Institute for Mental Disease
|
PDF
|
None
|
English
|
| OQA-2019
|
F-62019
|
License Application - Nursing Home, Facility for the Developmentally Disabled or Institute for Mental Disease
|
Word
|
None
|
English
|
| OQA 2022A
|
F-62022A
|
Instructions for Report of Hours Worked and Resident Census Forms
|
PDF
|
None
|
English
|
| OQA-2022A
|
F-62022A
|
Instructions for Report of Hours Worked and Resident Census Forms
|
Word
|
None
|
English
|
| OQA 2023
|
F-62023
|
Report of Hours Worked - Registered Nurse / Day
|
PDF
|
None
|
English
|
| OQA-2023
|
F-62023
|
Report of Hours Worked - Registered Nurse / Day
|
Word
|
None
|
English
|
| OQA 2024
|
F-62024
|
Report of Hours Worked - Nurse Aide / Day
|
PDF
|
None
|
English
|
| OQA-2024
|
F-62024
|
Report of Hours Worked - Nurse Aide / Day
|
Word
|
None
|
English
|
| OQA 2025
|
F-62025
|
Report of Hours Worked - Registered Nurse / Evening
|
PDF
|
None
|
English
|
| OQA-2025
|
F-62025
|
Report of Hours Worked - Registered Nurse / Evening
|
Word
|
None
|
English
|
| OQA 2026
|
F-62026
|
Report of Hours Worked - Nurse Aide / Evening
|
PDF
|
None
|
English
|
| OQA-2026
|
F-62026
|
Report of Hours Worked - Nurse Aide / Evening
|
Word
|
None
|
English
|
| OQA 2027
|
F-62027
|
Report of Hours Worked - Registered Nurse / Night
|
PDF
|
None
|
English
|
| OQA-2027
|
F-62027
|
Report of Hours Worked - Registered Nurse / Night
|
Word
|
None
|
English
|
| OQA 2028
|
F-62028
|
Report of Hours Worked - Nurse Aide / Night
|
PDF
|
None
|
English
|
| OQA-2028
|
F-62028
|
Report of Hours Worked - Nurse Aide / Night
|
Word
|
None
|
English
|
| OQA 2030
|
F-62030
|
Resident Census
|
PDF
|
None
|
English
|
| OQA-2030
|
F-62030
|
Resident Census
|
Word
|
None
|
English
|
| OQA-2062
|
F-62062
|
Hospice License Application
|
Restricted
|
None
|
English
|
| OQA-2069
|
F-62069
|
Home Health Agency Complaint Report*
|
PDF
|
None
|
English
|
| OQA-2069
|
F-62069
|
Home Health Agency Complaint Report*
|
Word
|
None
|
English
|
| DQA
|
F-62069A
|
Personal Care Agency Complaint Report
|
PDF
|
None
|
English
|
|
|
F-62069S
|
Informe de Queja de Agencia de Cuidado de Salud en el Hogar
|
PDF
|
None
|
Spanish
|
|
|
F-62069S
|
Informe de Queja de Agencia de Cuidado de Salud en el Hogar
|
Word
|
None
|
Spanish
|
| OQA-2092
|
F-62092
|
Hospital Certificate of Approval Application*
|
PDF
|
None
|
English
|
| OQA-2092
|
F-62092
|
Hospital Certificate of Approval Application
|
Word
|
None
|
English
|
| OQA-2151
|
F-62151
|
Nursing Home Residents' Rights Complaint Report*
|
PDF
|
None
|
English
|
| OQA-2151
|
F-62151
|
Nursing Home Residents' Rights Complaint Report*
|
Word
|
None
|
English
|
| DQA
|
F-62155
|
Living Unit Census Report
|
PDF
|
None
|
English
|
| OQA-2155
|
F-62155
|
Living Unit Census Report
|
Word
|
None
|
English
|
| OQA-2155A
|
F-62155I
|
Living Unit Census and Direct Care Staff Reports Instructions
|
PDF
|
None
|
English
|
| DQA
|
F-62156
|
Living Unit Direct Care Staffing Report - Day Shift
|
PDF
|
None
|
English
|
| OQA-2156
|
F-62156
|
Living Unit Direct Care Staff Report - Day Shift
|
Word
|
None
|
English
|
| DQA
|
F-62157
|
Living Unit Direct Care Staffing Report - Evening Shift
|
PDF
|
None
|
English
|
| OQA-2157
|
F-62157
|
Living Unit Direct Care Staff Report - Evening Shift
|
Word
|
None
|
English
|
| DQA
|
F-62158
|
Living Unit Direct Care Staffing Report - Night Shift
|
PDF
|
None
|
English
|
| OQA-2158
|
F-62158
|
Living Unit Direct Care Staff Report - Night Shift
|
Word
|
None
|
English
|
| OQA 2164
|
F-62164
|
Report of Hours Worked - Licensed Practical Nurse / Day
|
PDF
|
None
|
English
|
| OQA-2164
|
F-62164
|
Report of Hours Worked - Licensed Practical Nurse / Day
|
Word
|
None
|
English
|
| OQA 2165
|
F-62165
|
Report of Hours Worked - Licensed Practical Nurse / Evening
|
PDF
|
None
|
English
|
| OQA-2165
|
F-62165
|
Report of Hours Worked - Licensed Practical Nurse / Evening
|
Word
|
None
|
English
|
| OQA 2166
|
F-62166
|
Report of Hours Worked - Licensed Practical Nurse / Night
|
PDF
|
None
|
English
|
| OQA-2166
|
F-62166
|
Report of Hours Worked - Licensed Practical Nurse / Night
|
Word
|
None
|
English
|
| OQA-2194
|
F-62194
|
Title XIX Recipient Termination Notice*
|
PDF
|
None
|
English
|
| OQA-2194
|
F-62194
|
Title XIX Recipient Termination Notice*
|
Word
|
None
|
English
|
| OQA-2224
|
F-62224
|
Notice of Substantial Change Nurse Aide Training Program
|
PDF
|
None
|
English
|
| OQA-2224
|
F-62224
|
Notice of Substantial Change Nurse Aide Training Program
|
Word
|
None
|
English
|
| DQA
|
F-62231
|
Home Health Agency Personnel Record Review
|
PDF
|
None
|
English
|
| DQA
|
F-62231
|
Home Health Agency Personnel Record Review
|
Word
|
None
|
English
|
| DQA
|
F-62232
|
Hospice Contracts and Agreements Review
|
PDF
|
None
|
English
|
| DQA
|
F-62232
|
Hospice Contracts and Agreements Review
|
Word
|
None
|
English
|
| DQA
|
F-62233
|
Hospice Personnel Record Review
|
PDF
|
None
|
English
|
| DQA
|
F-62233
|
Hospice Personnel Record Review
|
Word
|
None
|
English
|
| DQA
|
F-62236
|
Hospice Clinical Record Review
|
PDF
|
None
|
English
|
| DQA
|
F-62236
|
Hospice Clinical Record Review
|
Word
|
None
|
English
|
| OQA-2256
|
F-62256
|
Request for Title XIX Care Level Determination*
|
PDF
|
None
|
English
|
| OQA-2256
|
F-62256
|
Request for Title XIX Care Level Determination
|
Word
|
None
|
English
|
| OQA-2256A
|
F-62256A
|
Request for Title XIX Care Level Determination Addendum for Developmentally Disabled Client / Residents*
|
PDF
|
None
|
English
|
| OQA-2256A
|
F-62256A
|
Request for Title XIX Care Level Determination Addendum for Developmentally Disabled Client / Residents*
|
Word
|
None
|
English
|
| DQA
|
F-62274A
|
Personal Care Agency Consent for Home Visit
|
PDF
|
None
|
English
|
|
|
F-62274S
|
Consentimiento Para Visita a Domicilio de Cliente de una Agencia de Cuidado Personal
|
PDF
|
None
|
Spanish
|
|
|
F-62274S
|
Consentimiento Para Visita a Domicilio de Cliente de una Agencia de Cuidado Personal
|
Word
|
None
|
Spanish
|
| OQA-2281
|
F-62281
|
Care Level Change Notice
|
PDF
|
None
|
English
|
| OQA-2281
|
F-62281
|
Care Level Change Notice
|
Word
|
None
|
English
|
| OQA-2287
|
F-62287
|
Hospice Patient Complaint*
|
PDF
|
None
|
English
|
| OQA-2287
|
F-62287
|
Hospice Patient Complaint*
|
Word
|
None
|
English
|
|
|
F-62287S
|
Informe de Queja de Hospicio
|
PDF
|
None
|
Spanish
|
|
|
F-62287S
|
Informe de Queja de Hospicio
|
Word
|
None
|
Spanish
|
| OQA-2288
|
F-62288
|
Care Level Determination Worksheet
|
PDF
|
None
|
English
|
| OQA-2308
|
F-62308
|
Authorization to Accept Personal Service and Receive Registered and Certified Mail*
|
PDF
|
None
|
English
|
| OQA-2308
|
F-62308
|
Authorization to Accept Personal Service and Receive Registered and Certified Mail*
|
Word
|
None
|
English
|
| DQA
|
F-62316
|
Hospice Patient Rights
|
PDF
|
None
|
English
|
| DQA
|
F-62316
|
Hospice Patient Rights
|
Word
|
None
|
English
|
| DQA
|
F-62318
|
Hospice Quality Assessment and Performance Improvement Reivew
|
PDF
|
None
|
English
|
| DQA
|
F-62318
|
Hospice Quality Assessment and Performance Improvement Reivew
|
Word
|
None
|
English
|
| DQA
|
F-62319
|
Hospice Volunteer Program Review
|
PDF
|
None
|
English
|
| DQA
|
F-62319
|
Hospice Volunteer Program Review
|
Word
|
None
|
English
|
| DQA
|
F-62320
|
Hospice Survey Information
|
PDF
|
None
|
English
|
| DQA
|
F-62320
|
Hospice Survey Information
|
Word
|
None
|
English
|
| DQA
|
F-62321
|
Hospice Program Review
|
PDF
|
None
|
English
|
| DQA
|
F-62321
|
Hospice Program Review
|
Word
|
None
|
English
|
| DQA
|
F-62322
|
Hospice Inpatient Clinical Record Review
|
PDF
|
None
|
English
|
| DQA
|
F-62322
|
Hospice Inpatient Clinical Record Review
|
Word
|
None
|
English
|
| OQA-2333
|
F-62333
|
Plan Approval Application and Instructions*
|
PDF
|
None
|
English
|
| OQA-2333
|
F-62333
|
Plan Approval Application and Instructions
|
Word
|
None
|
English
|
| OQA-2369
|
F-62369
|
Waiver of Hospice or Home Health Services by a Terminally Ill Resident of a Community Based Residential Facility (CBRF)
|
PDF
|
None
|
English
|
| OQA-2369
|
F-62369
|
Waiver of Hospice or Home Health Services by a Terminally Ill Resident of a Community Based Residential Facility (CBRF)
|
Word
|
None
|
English
|
|
|
F-62369S
|
Renuncia a Los Servicios de Hospicio o Cuidado de Salud en el Hogar de un Residente Con Enfermedad Terminal
|
PDF
|
None
|
Spanish
|
|
|
F-62369S
|
Renuncia a Los Servicios de Hospicio o Cuidado de Salud en el Hogar de un Residente Con Enfermedad Terminal
|
Word
|
None
|
Spanish
|
| OQA-2370
|
F-62370
|
Significant Change in Health Screening Instrument Model Form
|
PDF
|
None
|
English
|
| OQA-2370
|
F-62370
|
Significant Change in Health Screening Instrument Model Form
|
Word
|
None
|
English
|
| OQA-2372
|
F-62372
|
Community Based Residential Facility (CBRF) Resident Satisfaction Evaluation
|
PDF
|
None
|
English
|
| OQA-2372
|
F-62372
|
Community Based Residential Facility (CBRF) Resident Satisfaction Evaluation
|
Word
|
None
|
English
|
|
|
F-62372S
|
Facilidad Residencial Basada en la Comunidad (CBRF) Evaluacion de Satisfacction al Cliente
|
PDF
|
None
|
Spanish
|
|
|
F-62372S
|
Facilidad Residencial Basada en la Comunidad (CBRF) Evaluacion de Satisfacction al Cliente
|
Word
|
None
|
Spanish
|
| OQA-2373
|
F-62373
|
Resident Evacuation Assessment
|
PDF
|
None
|
English
|
| OQA-2373
|
F-62373
|
Resident Evacuation Assessment
|
Word
|
None
|
English
|
| OQA-2380
|
F-62380
|
Residential Care Apartment Complex (RCAC) Initial Certification or Registration Application
|
PDF
|
None
|
English
|
| OQA-2380
|
F-62380
|
Residential Care Apartment Complex (RCAC) Initial Certification or Registration Application
|
Word
|
None
|
English
|
| OQA-2381
|
F-62381
|
Residential Care Apartment Complex Regulations Compliance Statement
|
PDF
|
None
|
English
|
| OQA-2381
|
F-62381
|
Residential Care Apartment Complex Regulations Compliance Statement
|
Word
|
None
|
English
|
| OQA-2416
|
F-62416
|
Community Based Residential Facility (CBRF) Initial Licensure Checklist
|
PDF
|
None
|
English
|
| OQA-2416
|
F-62416
|
Community Based Residential Facility (CBRF) Initial Licensure Checklist
|
Word
|
None
|
English
|
| OQA-2418
|
F-62418
|
Adult Day Care Initial Certification Application
|
PDF
|
None
|
English
|
| OQA-2418
|
F-62418
|
Adult Day Care Initial Certification Application
|
Word
|
None
|
English
|
| OQA-2430
|
F-62430
|
Community Based Residential Facility Residents' Rights Complaint Report*
|
PDF
|
None
|
English
|
| OQA-2430
|
F-62430
|
Community Based Residential Facility Residents' Rights Complaint Report*
|
Word
|
None
|
English
|
| DQA
|
F-62440
|
Report of Hours Worked - Other Direct Care Nurse Aide / Day
|
PDF
|
None
|
English
|
| OQA-62440
|
F-62440
|
Report of Hours Worked - Other Direct Care Nurse Aide / Day
|
Word
|
None
|
English
|
| DQA
|
F-62441
|
Report of Hours Worked - Other Direct Care Nurse Aide / Evening
|
PDF
|
None
|
English
|
| OQA-62441
|
F-62441
|
Report of Hours Worked - Other Direct Care Nurse Aide / Evening
|
Word
|
None
|
English
|
| DQA
|
F-62442
|
Report of Hours Worked - Other Direct Care Nurse Aide / Night
|
PDF
|
None
|
English
|
| OQA-62442
|
F-62442
|
Report of Hours Worked - Other Direct Care Nurse Aide / Night
|
Word
|
None
|
English
|
| OQA-2447
|
F-62447
|
Incident Report of Caregiver Misconduct and Injuries of Unknown Source*
|
PDF
|
None
|
English
|
| OQA-2447
|
F-62447
|
Incident Report of Caregiver Misconduct and Injuries of Unknown Source*
|
Word
|
None
|
English
|
| OQA-2457
|
F-62457
|
Request for Permission to Start Footings, Foundation and/or Demolition
|
PDF
|
None
|
English
|
| OQA-2457
|
F-62457
|
Request for Permission to Start Footings, Foundation and/or Demolition
|
Word
|
None
|
English
|
| OQA-2461
|
F-62461
|
Application For Critical Access Hospital Certification Of Approval
|
Paper
|
Program
|
English
|
| OQA-2461I
|
F-62461I
|
Instructions - Application For Critical Access Hospital Certification Of Approval
|
Paper
|
Program
|
English
|
| OQA-2470
|
F-62470
|
Client / Patient Death Determination
|
PDF
|
None
|
English
|
| OQA-2470
|
F-62470
|
Client / Patient Death Determination
|
Word
|
None
|
English
|
| OQA-2494
|
F-62494
|
Health Care Facility Construction Documentation Checklist*
|
PDF
|
None
|
English
|
| OQA-2494
|
F-62494
|
Health Care Facility Construction Documentation Checklist*
|
Word
|
None
|
English
|
| OQA-2495
|
F-62495
|
Compliance Statement*
|
PDF
|
None
|
English
|
| OQA-2495
|
F-62495
|
Compliance Statement*
|
Word
|
None
|
English
|
| OQA-2496
|
F-62496
|
Free-Standing CBRF Plan Approval Application*
|
PDF
|
None
|
English
|
| OQA-2496
|
F-62496
|
Free-Standing CBRF Plan Approval Application
|
Word
|
None
|
English
|
| OQA-2500
|
F-62500
|
Fire Report
|
PDF
|
None
|
English
|
| OQA-2500
|
F-62500
|
Fire Report
|
Word
|
None
|
English
|
| OQA-2501
|
F-62501
|
Laboratory Application for Approval to Perform Alcohol Tests*
|
PDF
|
None
|
English
|
| OQA-2501
|
F-62501
|
Laboratory Application for Approval to Perform Alcohol Tests*
|
Word
|
None
|
English
|
| OQA-2502
|
F-62502
|
Analyst Application to Perform Alcohol Tests*
|
PDF
|
None
|
English
|
| OQA-2502
|
F-62502
|
Analyst Application to Perform Alcohol Tests*
|
Word
|
None
|
English
|
| OQA-2503
|
F-62503
|
Application for Blood / Urine Alcohol Analysis Procedure Approval*
|
PDF
|
None
|
English
|
| OQA-2503
|
F-62503
|
Application for Blood / Urine Alcohol Analysis Procedure Approval*
|
Word
|
None
|
English
|
| OQA-2504
|
F-62504
|
Community Based Substance Abuse Services Or Mental Health Clinic Certification Application
|
Restricted
|
None
|
English
|
| OQA-2519
|
F-62519
|
Hospice Comparisons of State (DHS 131) and Federal Conditions of Participation
|
PDF
|
None
|
English
|
| OQA-2519
|
F-62519
|
Hospice Comparisons of State (DHS 131) and Federal Conditions of Participation
|
Word
|
None
|
English
|
| DQA
|
F-62520
|
Caregiver Program Complaince Check
|
PDF
|
None
|
English
|
| OQA-2520
|
F-62520
|
Caregiver Program Compliance Check
|
Word
|
None
|
English
|
| OQA-2528
|
F-62528
|
Residential Care Apartment Complex Initial Certification of Registration Checklist
|
PDF
|
None
|
English
|
| OQA-2528
|
F-62528
|
Residential Care Apartment Complex Initial Certification of Registration Checklist
|
Word
|
None
|
English
|
| DQA
|
F-62536
|
Home Health Agency Prelicensure Desk Review Checklist
|
PDF
|
None
|
English
|
| DQA
|
F-62536
|
Home Health Agency Prelicensure Desk Review Checklist
|
Word
|
None
|
English
|
| OQA-2537
|
F-62537
|
Petition for Building Code Variance
|
PDF
|
None
|
English
|
| OQA-2537
|
F-62537
|
Petition for Building Code Variance
|
Word
|
None
|
English
|
| OQA-2546
|
F-62546
|
Corporate Guardianship Program Annual Report
|
PDF
|
None
|
English
|
| OQA-2546
|
F-62546
|
Corporate Guardianship Program Annual Report
|
Word
|
None
|
English
|
| OQA-2548
|
F-62548
|
Assisted Living Facility Request for Waiver, Approval, Variance, Exception*
|
PDF
|
None
|
English
|
| OQA-2548
|
F-62548
|
Assisted Living Facility Request for Waiver, Approval, Variance, Exception*
|
Word
|
None
|
English
|
| OQA-2569
|
F-62569
|
Application for Individual Provider Status Approval*
|
PDF
|
None
|
English
|
| OQA-2569
|
F-62569
|
Application for Individual Provider Status Approval*
|
Word
|
None
|
English
|
| OQA-2570
|
F-62570
|
Supervisor Affidavit*
|
PDF
|
None
|
English
|
| OQA-2570
|
F-62570
|
Supervisor Affidavit*
|
Word
|
None
|
English
|
| OQA-2579
|
F-62579
|
Post Survey Questionnaire*
|
PDF
|
None
|
English
|
| OQA-2579
|
F-62579
|
Post Survey Questionnaire*
|
Word
|
None
|
English
|
| OQA-2586
|
F-62586
|
Challenge Exam Applicant Nurse Aide / Medication Aide*
|
PDF
|
None
|
English
|
| OQA-2586
|
F-62586
|
Challenge Exam Applicant Nurse Aide / Medication Aide*
|
Word
|
None
|
English
|
| OQA-2588
|
F-62588
|
Feeding Assistant Training Program Application
|
PDF
|
None
|
English
|
| OQA-2588
|
F-62588
|
Feeding Assistant Training Program Application
|
Word
|
None
|
English
|
| OQA-2589
|
F-62589
|
Request for Approval to use Telehealth
|
PDF
|
None
|
English
|
| OQA-2589
|
F-62589
|
Request for Approval to use Telehealth
|
Word
|
None
|
English
|
| OQA-2590
|
F-62590
|
Post On-Site Review Questionnaire Nurse Aide Training Programs
|
PDF
|
None
|
English
|
| OQA-2590
|
F-62590
|
Post On-Site Review Questionnaire Nurse Aide Training Programs
|
Word
|
None
|
English
|
| DQA
|
F-62594
|
Notice of Substantial Change Feeding Assistant TrainingProgram
|
PDF
|
None
|
English
|
| DQA
|
F-62594
|
Notice of Substantial Change Feeding Assistant Training Program
|
Word
|
None
|
English
|
| DQA
|
F-62595
|
Long Term Care Facility Feeding Assistant Roster
|
PDF
|
None
|
English
|
| DQA
|
F-62595
|
Long Term Care Facility Feeding Assistant Roster
|
Word
|
None
|
English
|
| OQA-2601
|
F-62601
|
Rights of Home Health Agency Patients
|
PDF
|
None
|
English
|
| DQA
|
F-62601
|
Rights of Home Health Agency Patients
|
Word
|
None
|
English
|
| OQA-2601S
|
F-62601S
|
Rights of Home Health Agency Patients - Spanish
|
PDF
|
None
|
Spanish
|
| OQA-2603
|
F-62603
|
Adult Day Care and Family Adult Day Care Background Character Verification
|
PDF
|
None
|
English
|
| OQA-2603
|
F-62603
|
Adult Day Care and Family Adult Day Care Background Character Verification
|
Word
|
None
|
English
|
| OQA-2607
|
F-62607
|
Request for Use of Restraints, Isolation, or Protective Equipment as Part of a Behavior Support Plan
|
PDF
|
None
|
English
|
| OQA-2607
|
F-62607
|
Request for Use of Restraints, Isolation, or Protective Equipment as Part of a Behavior Support Plan
|
Word
|
None
|
English
|
| OQA-2608
|
F-62608
|
Request for Use of Medical Restraints
|
PDF
|
None
|
English
|
| OQA-2608
|
F-62608
|
Request for Use of Medical Restraints
|
Word
|
None
|
English
|
| OQA-2610
|
F-62610
|
Nurse Aide Training Program Primary Instructor Application
|
PDF
|
None
|
English
|
| OQA-2610
|
F-62610
|
Nurse Aide Training Program Primary Instructor Application
|
Word
|
None
|
English
|
| OQA-2611
|
F-62611
|
Family Adult Day Care Certification Standards Checklist
|
PDF
|
None
|
English
|
| OQA-2611
|
F-62611
|
Family Adult Day Care Certification Standards Checklist
|
Word
|
None
|
English
|
| DQA
|
F-62641
|
Hospice Inpatient Symptom Management and Respite Contract or Agreement Review
|
PDF
|
None
|
English
|
| DQA
|
F-62641
|
Hospice Inpatient Symptom Management and Respite Contract or Agreement Review
|
Word
|
None
|
English
|
| OQA-2643
|
F-62643
|
Drug Repository Program Notice of Participation or Withdrawal
|
PDF
|
None
|
English
|
| OQA-2643
|
F-62643
|
Drug Repository Program Notice of Participation or Withdrawal
|
Word
|
None
|
English
|
| OQA-2644
|
F-62644
|
Drug Repository Program Donation, Transfer, and Destruction Record
|
PDF
|
None
|
English
|
| OQA-2644
|
F-62644
|
Drug Repository Program Donation, Transfer, and Destruction Record
|
Word
|
None
|
English
|
| OQA-2645
|
F-62645
|
Drug Repository Program Recipient Record
|
PDF
|
None
|
English
|
| OQA-2645
|
F-62645
|
Drug Repository Program Recipient Record
|
Word
|
None
|
English
|
| DQA
|
F-62646
|
Home Health Agency (HHA) Patient Rights Statement Review
|
PDF
|
None
|
English
|
| DQA
|
F-62646
|
Home Health Agency (HHA) Patient Rights Statement Review
|
Word
|
None
|
English
|
| DQA
|
F-62648A
|
Personal Care Agency Sample Selection
|
PDF
|
None
|
English
|
| DQA
|
F-62651
|
Home Health Agency Calendar Worksheet - Prescribed Visits
|
PDF
|
None
|
English
|
| DQA
|
F-62651
|
Home Health Agency Calendar Worksheet - Prescribed Visits
|
Word
|
None
|
English
|
| DQA
|
F-62651A
|
Personal Care Agency Calendar Worksheet - Prescribed Visits
|
PDF
|
None
|
English
|
| DQA
|
F-62652
|
Home Health Agency Licensure Survey Home Visit Guide
|
PDF
|
None
|
English
|
| DQA
|
F-62652
|
Home Health Agency Licensure Survey Home Visit Guide
|
Word
|
None
|
English
|
| DQA
|
F-62652A
|
Personal Care Agency Home Visit Guide
|
PDF
|
None
|
English
|
| DQA
|
F-62653
|
Home Health Agency Licensure Survey Entrance Conference Guide
|
PDF
|
None
|
English
|
| DQA
|
F-62653
|
Home Health Agency Licensure Survey Entrance Conference Guide
|
Word
|
None
|
English
|
| DQA
|
F-62654
|
Home Health Agency Licensure Survey Exit Conference Guide
|
PDF
|
None
|
English
|
| DQA
|
F-62654
|
Home Health Agency Licensure Survey Exit Conference Guide
|
Word
|
None
|
English
|
| DQA
|
F-62657
|
Home Health Agency Contract Review Worksheet
|
PDF
|
None
|
English
|
| DQA
|
F-62657
|
Home Health Agency Contract Review Worksheet
|
Word
|
None
|
English
|
| DQA
|
F-62658
|
Home Health Agency Program Evaluation Review Worksheet DHS 133.07(3)
|
PDF
|
None
|
English
|
| DQA
|
F-62658
|
Home Health Agency Program Evaluation Review Worksheet DHS 133.07(3)
|
Word
|
None
|
English
|
| OQA-2671
|
F-62671
|
Adult Family Home Initial Licensure Checklist
|
PDF
|
None
|
English
|
| OQA-2671
|
F-62671
|
Adult Family Home Initial Licensure Checklist
|
Word
|
None
|
English
|
| OQA-2674
|
F-62674
|
Home Health Agency License Application
|
Restricted
|
None
|
English
|
| OQA-2674A
|
F-62674A
|
Model Balance Sheet
|
PDF
|
None
|
English
|
| OQA-2674A
|
F-62674A
|
Model Balance Sheet
|
Word
|
None
|
English
|
| DQA
|
F-62680
|
Home Health Agency Clinical Record Review
|
PDF
|
None
|
English
|
| DQA
|
F-62680
|
Home Health Agency Clinical Record Review
|
Word
|
None
|
English
|
| DQA
|
F-62683
|
Home Health Agency Annual Fee Calculation
|
PDF
|
None
|
English
|
| OQA-2683
|
F-62683
|
Home Health Agency Annual Fee Calculation
|
Word
|
None
|
English
|
| DQA
|
F-62687
|
Nurse Aide Training Program Trainer Application
|
PDF
|
None
|
English
|
| DQA
|
F-62687
|
Nurse Aide Training Program Trainer Application
|
Word
|
None
|
English
|
| DQA
|
F-62688
|
Feeding Assistant Training Program Trainer Application
|
PDF
|
None
|
English
|
| DQA
|
F-62688
|
Feeding Assistant Training Program Trainer Application
|
Word
|
None
|
English
|
| DQA
|
F-62692
|
Feeding Assistant Training Program Primary Instructor Application
|
PDF
|
None
|
English
|
| DQA
|
F-62692
|
Feeding Assistant Training Program Primary Instructor Application
|
Word
|
None
|
English
|
| DQA
|
F-62696
|
Student Nurse/Graduate Nurse Verification
|
PDF
|
None
|
English
|
| DQA
|
F-62696
|
Student Nurse/Graduate Nurse Verification
|
Word
|
None
|
English
|
| OQA-9251
|
F-69251
|
Hospice Request For Certification In The Medicare Program
|
Paper
|
Form Center
|
English
|
| OQA-9259
|
F-69259
|
Long Term Care Facility Application For Medicare and Medicaid Cms671
|
Paper
|
Form Center
|
English
|
| OQA-9260
|
F-69260
|
Resident Census and Conditions of Residents CMS-672
|
Paper
|
Form Center
|
English
|
| OQA-9305A
|
F-69305A
|
Provider Instructions For HCFA-802
|
Paper
|
Form Center
|
English
|
| HFS-0069
|
F-82069
|
Background Info Disclosure Appendix
|
PDF
|
None
|
English
|
| HFS-0069A
|
F-82069A
|
Background Information Disclosure Appendix and Instructions
|
PDF
|
None
|
English
|
