|
DQA
|
F-00012
|
CBRF Completion Documents (PDF, 18 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00014
|
Ceiling Closure Inspection Checklist (PDF, 22 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00014
|
Ceiling Closure Inspection Checklist
|
Word
|
None
|
English
|
|
DQA
|
F-00015
|
Final Occupancy Inspection Checklist (PDF, 21 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00015
|
Final Occupancy Inspection Checklist
|
Word
|
None
|
English
|
|
DQA
|
F-00016
|
Wall Closure Inspection Checklist (PDF, 17 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00016
|
Wall Closure Inspection Checklist
|
Word
|
None
|
English
|
|
DQA
|
F-00027
|
CSAS Standards Recertification Application - DHS 75.03 (PDF, 58 KB)
|
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, 87 KB)
|
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, 9 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00140
|
Attestation and Acknowledgement for Provisional Approval as a Personal Care Agency (PDF, 9 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00157
|
Assisted Living Administrator Training Course - Trainer Approval Application (PDF, 60 KB)
|
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, 19 KB)
|
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, 68 KB)
|
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, 19 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00176
|
Project Proposal (PDF, 36 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00176
|
Project Proposal
|
Word
|
None
|
English
|
|
DQA
|
F-00191
|
Certified Outpatient Clinic Request for a Branch Office (PDF, 31 KB)
|
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, 10 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00261
|
Personal Care Agency Personnel Record Review
|
Word
|
None
|
English
|
|
DQA
|
F-00262
|
Personal Care Agency Application Materials Checklist (PDF, 18 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00262
|
Personal Care Agency Application Materials Checklist
|
Word
|
None
|
English
|
|
DQA
|
F-00263
|
Personal Care Agency Record Review (PDF, 18 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00263
|
Personal Care Agency Record Review
|
Word
|
None
|
English
|
|
DQA
|
F-00264
|
Personal Care Agency Surveyor Guide (PDF, 62 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00264
|
Personal Care Agency Surveyor Guide
|
Word
|
None
|
English
|
|
DQA
|
F-00273
|
Behavioral Health Services Initial Certification Application - DHS 94 (PDF, 123 KB)
|
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, 43 KB)
|
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, 51 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00302
|
CSAS Outpatient Clinic Services Application - DHS 75.13
|
Word
|
None
|
English
|
|
DQA
|
F-00309
|
Medicaid Provider Report (PDF, 65 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00309
|
Medicaid Provider Report
|
Word
|
None
|
English
|
|
DQA
|
F-00311
|
Nursing Home MDS 3.0 Section Q Referral (PDF, 66 KB)
|
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, 26 KB)
|
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, 29 KB)
|
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, 45 KB)
|
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, 20 KB)
|
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, 21 KB)
|
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, 52 KB)
|
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, 39 KB)
|
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, 39 KB)
|
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, 52 KB)
|
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, 56 KB)
|
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, 54 KB)
|
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, 59 KB)
|
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, 61 KB)
|
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, 62 KB)
|
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, 55 KB)
|
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, 60 KB)
|
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, 64 KB)
|
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, 63 KB)
|
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, 49 KB)
|
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
|
|
DQA
|
F-00482
|
CCS Initial Certification Application - DHS 36, F-00482 (PDF, 164 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00482
|
CCS Initial Certification Application - DHS 36, F-00482
|
Word
|
None
|
English
|
|
DQA
|
F-00496
|
Plan Review Code Interpretation Request (PDF, 26 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00496
|
Plan Review Code Interpretation Request
|
Word
|
None
|
English
|
|
DQA
|
F-00512
|
Mental Health Day Treatment Program Initial Certification Application - DHS 61.75 (PDF, 46 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00512
|
Mental Health Day Treatment Program Initial Certification Application - DHS 61.75
|
Word
|
None
|
English
|
|
DQA
|
F-00513
|
CSAS Transitional Residential Treatment Service Initial Certification Application - DHS 75.14 (PDF, 35 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00513
|
CSAS Transitional Residential Treatment Service Initial Certification Application - DHS 75.14
|
Word
|
None
|
English
|
|
DQA
|
F-00514
|
CSAS Medically Monitored Treatment Service Initial Certification Application - DHS 75.11 (PDF, 35 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00514
|
CSAS Medically Monitored Treatment Service Initial Certification Application - DHS 75.11
|
Word
|
None
|
English
|
|
DQA
|
F-00515
|
CSAS Day Treatment Service Initial Certification Application - DHS 75.12 (PDF, 68 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00515
|
CSAS Day Treatment Service Initial Certification Application - DHS 75.12
|
Word
|
None
|
English
|
|
DQA
|
F-00516
|
CSAS Medically Managed Inpatient Treatment Service Initial Certification Application - DHS 75.10 (PDF, 37 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00516
|
CSAS Medically Managed Inpatient Treatment Service Initial Certification Application - DHS 75.10
|
Word
|
None
|
English
|
|
DQA
|
F-00517
|
CSAS Residential Intoxification Monitoring Service Initial Certification Application - DHS 75.09 (PDF, 31 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00517
|
CSAS Residential Intoxification Monitoring Service Initial Certification Application - DHS 75.09
|
Word
|
None
|
English
|
|
DQA
|
F-00518
|
CSAS Ambulatory Detoxification Service Initial Certification Application - DHS 75.08 (PDF, 518 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00518
|
CSAS Ambulatory Detoxification Service Initial Certification Application - DHS 75.08
|
Word
|
None
|
English
|
|
DQA
|
F-00519
|
CSAS Medically Managed Residential Detoxification Service Initial Certification Application - DHS 75.07 (PDF, 27 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00519
|
CSAS Medically Managed Residential Detoxification Service Initial Certification Application - DHS 75.07
|
Word
|
None
|
English
|
|
DQA
|
F-00520
|
CSAS Medically Managed Inpatient Detoxification Service Intitial Certification Application - DHS 75.06 (PDF, 25 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00520
|
CSAS Medically Managed Inpatient Detoxification Service Intitial Certification Application - DHS 75.06
|
Word
|
None
|
English
|
|
DQA
|
F-00521
|
CSAS Prevention Service Initial Certification Application - DHS 75.04 (PDF, 36 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00521
|
CSAS Prevention Service Initial Certification Application - DHS 75.04
|
Word
|
None
|
English
|
|
DQA
|
F-00523
|
Community Substance Abuse Service General Requirements Initial Certification Application - DHS 75.03 (PDF, 126 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00523
|
Community Substance Abuse Service General Requirements Initial Certification Application - DHS 75.03
|
Word
|
None
|
English
|
|
DQA
|
F-00537
|
CSAS Intervention Services Initial Certification Application - DHS 75.16 (PDF, 43 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00537
|
CSAS Intervention Services Initial Certification Application - DHS 75.16
|
Word
|
None
|
English
|
|
DQA
|
F-00538
|
CSAS Narcotic Treatment Service for Opiate Addiction Initial Certification Application - DHS 75.15 (PDF, 104 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00538
|
CSAS Narcotic Treatment Service for Opiate Addiction Initial Certification Application - DHS 75.15
|
Word
|
None
|
English
|
|
DQA
|
F-00544
|
CSAS Outpatient Treatment Service Initial Certification Application - DHS 75.13 (PDF, 30 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00544
|
CSAS Outpatient Treatment Service Initial Certification Application - DHS 75.13
|
Word
|
None
|
English
|
|
DQA
|
F-00545
|
Emergency Outpatient Service Initial Certification Application - DHS 75.05 (PDF, 37 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00545
|
Emergency Outpatient Service Initial Certification Application - DHS 75.05
|
Word
|
None
|
English
|
|
DQA
|
F-00546
|
CSP for Persons with Chronic Mental Illness Initial Certification Application - DHS 63 (PDF, 54 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00546
|
CSP for Persons with Chronic Mental Illness Initial Certification Application - DHS 63
|
Word
|
None
|
English
|
|
DQA
|
F-00547
|
Mental Health Inpatient Initial Certification Application - DHS 61.71 & 61.79 (PDF, 51 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00547
|
Mental Health Inpatient Initial Certification Application - DHS 61.71 & 61.79
|
Word
|
None
|
English
|
|
DQA
|
F-00548
|
Mental Health Day Treatment Services for Children Program Application - DHS 40 (PDF, 107 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00548
|
Mental Health Day Treatment Services for Children Program Application - DHS 40
|
Word
|
None
|
English
|
|
DQA
|
F-00551
|
Emergency Mental Health Service Program Initial Certification Application - DHS 34 (PDF, 144 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00551
|
Emergency Mental Health Service Program Initial Certification Application - DHS 34
|
Word
|
None
|
English
|
|
DQA
|
F-00571
|
Emergency Mental Health Service Program Recertification Application - DHS 34 (PDF, 51 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00571
|
Emergency Mental Health Service Program Recertification Application - DHS 34
|
Word
|
None
|
English
|
|
DQA
|
F-00657
|
Military Training Verification (PDF, 24 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-00657
|
Military Training Verification
|
Word
|
None
|
English
|
|
DQA
|
F-00728
|
Division of Quality Assurance Regulated Entity Automated Background Information Disclosure (BID) and Appendix
|
PDF
|
None
|
English
|
|
DQA
|
F-00728
|
Division of Quality Assurance Regulated Entity Automated Background Information Disclosure (BID) and Appendix
|
Word
|
None
|
English
|
|
DQA
|
F-00740
|
Quality Improvement Event Analysis Summary and Suggested Event Analysis Process
|
Restricted
|
None
|
English
|
|
DQA
|
F-00784
|
Personal Care Agency Client Rights
|
PDF
|
None
|
English
|
|
DQA
|
F-00784
|
Personal Care Agency Client Rights
|
Word
|
None
|
English
|
|
DQA
|
F-00785
|
Outpatient Mental Health Clinic Recertification Application
|
PDF
|
None
|
English
|
|
DQA
|
F-00785
|
Outpatient Mental Health Clinic Recertification Application
|
Word
|
None
|
English
|
|
OQA-0287
|
F-60287
|
Community Based Residential Facility (CBRF) Initial License Application (PDF, 90 KB)
|
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, 15 KB)
|
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, 31 KB)
|
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, 10 KB)
|
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, 24 KB)
|
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, 33 KB)
|
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, 77 KB)
|
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, 59 KB)
|
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, 25 KB)
|
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, 106 KB)
|
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, 62 KB)
|
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, 171 KB)
|
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, 20 KB)
|
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, 20 KB)
|
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, 20 KB)
|
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, 20 KB)
|
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, 20 KB)
|
PDF
|
None
|
English
|
|
OQA-2028
|
F-62028
|
Report of Hours Worked - Nurse Aide / Night
|
Word
|
None
|
English
|
|
OQA 2030
|
F-62030
|
Resident Census (PDF, 27 KB)
|
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, 24 KB)
|
PDF
|
None
|
English
|
|
OQA-2069
|
F-62069
|
Home Health Agency Complaint Report
|
Word
|
None
|
English
|
|
DQA
|
F-62069A
|
Personal Care Agency Complaint Report (PDF, 25 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-62069A
|
Personal Care Agency Complaint Report
|
Word
|
None
|
English
|
|
DQA
|
F-62069S
|
Informe de Queja de Agencia de Cuidado de Salud en el Hogar (Home Health Agency Complaint Report - Spanish) (PDF, 29 KB)
|
PDF
|
None
|
Spanish
|
|
DQA
|
F-62069S
|
Informe de Queja de Agencia de Cuidado de Salud en el Hogar (Home Health Agency Complaint Report - Spanish)
|
Word
|
None
|
Spanish
|
|
OQA-2092
|
F-62092
|
Hospital Certificate of Approval Application (PDF, 82 KB)
|
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, 32 KB)
|
PDF
|
None
|
English
|
|
OQA-2151
|
F-62151
|
Nursing Home Residents' Rights Complaint Report
|
Word
|
None
|
English
|
|
DQA
|
F-62155
|
Living Unit Census Report (PDF, 19 KB)
|
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, 51 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-62156
|
Living Unit Direct Care Staffing Report - Day Shift (PDF, 14 KB)
|
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, 13 KB)
|
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, 13 KB)
|
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, 21 KB)
|
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, 22 KB)
|
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, 22 KB)
|
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, 55 KB)
|
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, 22 KB)
|
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, 10 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-62231
|
Home Health Agency Personnel Record Review
|
Word
|
None
|
English
|
|
DQA
|
F-62232
|
Hospice Contracts and Agreements Review (PDF, 21 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-62232
|
Hospice Contracts and Agreements Review
|
Word
|
None
|
English
|
|
DQA
|
F-62233
|
Hospice Personnel Record Review (PDF, 14 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-62233
|
Hospice Personnel Record Review
|
Word
|
None
|
English
|
|
DQA
|
F-62236
|
Hospice Clinical Record Review (PDF, 27 KB)
|
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, 28 KB)
|
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, 35 KB)
|
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, 17 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-62274A
|
Personal Care Agency Consent for Home Visit
|
Word
|
None
|
English
|
|
DQA
|
F-62274AH
|
Personal Care Agency Consent for Home Visit - Hmong
|
PDF
|
None
|
Hmong
|
|
DQA
|
F-62274AH
|
Personal Care Agency Consent for Home Visit - Hmong
|
Word
|
None
|
Hmong
|
|
DQA
|
F-62274S
|
Personal Care Agency Consent for Home Visit - Spanish (PDF, 17 KB)
|
PDF
|
None
|
Spanish
|
|
DQA
|
F-62274S
|
Personal Care Agency Consent for Home Visit - Spanish
|
Word
|
None
|
Spanish
|
|
OQA-2281
|
F-62281
|
Care Level Change Notice (PDF, 56 KB)
|
PDF
|
None
|
English
|
|
OQA-2281
|
F-62281
|
Care Level Change Notice
|
Word
|
None
|
English
|
|
OQA-2287
|
F-62287
|
Hospice Patient Complaint (PDF, 30 KB)
|
PDF
|
None
|
English
|
|
OQA-2287
|
F-62287
|
Hospice Patient Complaint
|
Word
|
None
|
English
|
|
DQA
|
F-62287S
|
Informe de Queja de Hospicio (PDF, 33 KB)
|
PDF
|
None
|
Spanish
|
|
DQA
|
F-62287S
|
Informe de Queja de Hospicio
|
Word
|
None
|
Spanish
|
|
OQA-2288
|
F-62288
|
Care Level Determination Worksheet (PDF, 36 KB)
|
PDF
|
None
|
English
|
|
OQA-2308
|
F-62308
|
Authorization to Accept Personal Service and Receive Registered and Certified Mail (PDF, 54 KB)
|
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, 15 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-62316
|
Hospice Patient Rights
|
Word
|
None
|
English
|
|
DQA
|
F-62318
|
Hospice Quality Assessment and Performance Improvement Reivew (PDF, 14 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-62318
|
Hospice Quality Assessment and Performance Improvement Reivew
|
Word
|
None
|
English
|
|
DQA
|
F-62319
|
Hospice Volunteer Program Review (PDF, 14 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-62319
|
Hospice Volunteer Program Review
|
Word
|
None
|
English
|
|
DQA
|
F-62320
|
Hospice Survey Information (PDF, 15 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-62320
|
Hospice Survey Information
|
Word
|
None
|
English
|
|
DQA
|
F-62321
|
Hospice Program Review (PDF, 13 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-62321
|
Hospice Program Review
|
Word
|
None
|
English
|
|
DQA
|
F-62322
|
Hospice Inpatient Clinical Record Review (PDF, 23 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-62322
|
Hospice Inpatient Clinical Record Review
|
Word
|
None
|
English
|
|
OQA-2333
|
F-62333
|
Plan Approval Application and Instructions (PDF, 81 KB)
|
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, 12 KB)
|
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
|
|
DQA
|
F-62369S
|
Renuncia a Los Servicios de Hospicio o Cuidado de Salud en el Hogar de un Residente Con Enfermedad Terminal (PDF, 13 KB)
|
PDF
|
None
|
Spanish
|
|
DQA
|
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, 55 KB)
|
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, 35 KB)
|
PDF
|
None
|
English
|
|
OQA-2372
|
F-62372
|
Community Based Residential Facility (CBRF) Resident Satisfaction Evaluation
|
Word
|
None
|
English
|
|
DQA
|
F-62372S
|
Facilidad Residencial Basada en la Comunidad (CBRF) Evaluacion de Satisfacction al Cliente (PDF, 23 KB)
|
PDF
|
None
|
Spanish
|
|
DQA
|
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, 38 KB)
|
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, 33 KB)
|
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, 54 KB)
|
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, 24 KB)
|
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, 58 KB)
|
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, 59 KB)
|
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, 20 KB)
|
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, 20 KB)
|
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, 20 KB)
|
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, 102 KB)
|
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, 34 KB)
|
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/Resident Death Determination (PDF, 76 KB)
|
PDF
|
None
|
English
|
|
OQA-2470
|
F-62470
|
Client/Patient/Resident Death Determination
|
Word
|
None
|
English
|
|
OQA-2494
|
F-62494
|
Health Care Facility Construction Documentation Checklist (PDF, 28 KB)
|
PDF
|
None
|
English
|
|
OQA-2494
|
F-62494
|
Health Care Facility Construction Documentation Checklist
|
Word
|
None
|
English
|
|
OQA-2495
|
F-62495
|
Compliance Statement (PDF, 30 KB)
|
PDF
|
None
|
English
|
|
OQA-2495
|
F-62495
|
Compliance Statement
|
Word
|
None
|
English
|
|
OQA-2496
|
F-62496
|
Free-Standing CBRF Plan Approval Application (PDF, 52 KB)
|
PDF
|
None
|
English
|
|
OQA-2496
|
F-62496
|
Free-Standing CBRF Plan Approval Application
|
Word
|
None
|
English
|
|
OQA-2500
|
F-62500
|
Fire Report (PDF, 34 KB)
|
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, 62 KB)
|
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, 57 KB)
|
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, 66 KB)
|
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, 177 KB)
|
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, 38 KB)
|
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, 16 KB)
|
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, 28 KB)
|
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, 44 KB)
|
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, 22 KB)
|
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, 57 KB)
|
PDF
|
None
|
English
|
|
OQA-2548
|
F-62548
|
Assisted Living Facility Request for Waiver, Approval, Variance, Exception
|
Word
|
None
|
English
|
|
OQA-2569
|
F-62569
|
Individual Provider Status Approval Application (PDF, 38 KB)
|
PDF
|
None
|
English
|
|
OQA-2569
|
F-62569
|
Individual Provider Status Approval Application
|
Word
|
None
|
English
|
|
OQA-2579
|
F-62579
|
Post Survey Questionnaire (PDF, 33 KB)
|
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, 56 KB)
|
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, 76 KB)
|
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, 33 KB)
|
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, 20 KB)
|
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, 24 KB)
|
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, 11 KB)
|
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, 26 KB)
|
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, 21 KB)
|
PDF
|
None
|
Spanish
|
|
OQA-2603
|
F-62603
|
Adult Day Care and Family Adult Day Care Background Character Verification (PDF, 61 KB)
|
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, 29 KB)
|
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, 27 KB)
|
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, 25 KB)
|
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, 51 KB)
|
PDF
|
None
|
English
|
|
OQA-2611
|
F-62611
|
Family Adult Day Care Certification Standards Checklist
|
Word
|
None
|
English
|
|
OQA-2617
|
F-62617
|
Alleged Nursing Home Resident Mistreatment, Neglect and Abuse Report
|
System
|
None
|
English
|
|
DQA
|
F-62641
|
Hospice Inpatient Symptom Management and Respite Contract or Agreement Review (PDF, 16 KB)
|
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, 62 KB)
|
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, 61 KB)
|
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, 58 KB)
|
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, 23 KB)
|
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, 12 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-62648A
|
Personal Care Agency Sample Selection
|
Word
|
None
|
English
|
|
DQA
|
F-62651
|
Home Health Agency Calendar Worksheet - Prescribed Visits (PDF, 12 KB)
|
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, 13 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-62651A
|
Personal Care Agency Calendar Worksheet - Prescribed Visists
|
Word
|
None
|
English
|
|
DQA
|
F-62652
|
Home Health Agency Licensure Survey Home Visit Guide (PDF, 20 KB)
|
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, 24 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-62652A
|
Personal Care Agency Home Visit Guide
|
Word
|
None
|
English
|
|
DQA
|
F-62653
|
Home Health Agency Licensure Survey Entrance Conference Guide (PDF, 14 KB)
|
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, 14 KB)
|
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, 12 KB)
|
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, 13 KB)
|
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, 16 KB)
|
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, 29 KB)
|
PDF
|
None
|
English
|
|
OQA-2674A
|
F-62674A
|
Model Balance Sheet
|
Word
|
None
|
English
|
|
DQA
|
F-62680
|
Home Health Agency Clinical Record Review (PDF, 22 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-62680
|
Home Health Agency Clinical Record Review
|
Word
|
None
|
English
|
|
DQA
|
F-62687
|
Nurse Aide Training Program Trainer Application (PDF, 25 KB)
|
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, 25 KB)
|
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, 28 KB)
|
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, 20 KB)
|
PDF
|
None
|
English
|
|
DQA
|
F-62696
|
Student Nurse/Graduate Nurse Verification
|
Word
|
None
|
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-9261
|
F-69261
|
Extended / Partial Extended Survey Worksheet
|
Paper
|
Form Center
|
English
|
|
OQA-9265
|
F-69265
|
Medication Pass Worksheet CMS-677
|
Paper
|
Form Center
|
English
|
|
OQA-9305
|
F-69305
|
Roster / Sample Matrix
|
Paper
|
Form Center
|
English
|
|
OQA-9306
|
F-69306
|
General Observations of The Facility CMS-803
|
Paper
|
Form Center
|
English
|
|
OQA-9307
|
F-69307
|
Kitchen / Food Service Observation HCFA-804
|
Paper
|
Form Center
|
English
|
|
OQA-9308
|
F-69308
|
Resident Review Worksheet HCFA-805
|
Paper
|
Form Center
|
English
|
|
OQA-9309
|
F-69309
|
Quality of Life Assessment - Resident Interview
|
Paper
|
Form Center
|
English
|
|
OQA-9310
|
F-69310
|
Quality of Life Assessment - Group Interview
|
Paper
|
Form Center
|
English
|
|
OQA-9311
|
F-69311
|
Quality of Life Assessment - Family Interview
|
Paper
|
Form Center
|
English
|
|
OQA-9312
|
F-69312
|
Surveyor Notes Worksheet CMS-807
|
Paper
|
Form Center
|
English
|
|
HFS-0069
|
F-82069
|
Background Info Disclosure Appendix
|
PDF
|
None
|
English
|
|
HFS-0069
|
F-82069
|
Background Info Disclosure Appendix
|
Word
|
None
|
English
|
