REVIEW INFORMATION DIVISION OF QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT PROVIDER LEGAL NAME BUREAU OF STANDARDS COMPLIANCE Regulatory Compliance Site Review Instrument Chemical Dependence Outpatient Programs SERVICE SITE ADDRESS QA-3CD CITY, TOWN, VILLAGE ZIP DATE(S) OF REVIEW (Applicable to Outpatient Programs and Outpatient Rehabilitation Programs) Part I REVIEW NUMBER OPERATING CERTIFICATE NUMBER Patient Case Records Part II Service Management PROVIDER NUMBER PRU NUMBER Note: Pursuant to Mental Hygiene Law and the Office of Alcoholism and Substance Abuse Services’ (OASAS) Regulations, this Site Review Instrument is designed for the express purpose of conducting OASAS regulatory compliance reviews of its certified providers. Use of this Site Review Instrument as a self-assessment tool may be a helpful indicator of LEAD REGULATORY COMPLIANCE INSPECTOR a provider’s regulatory compliance. However, please note that the Site Review Instrument: (1) is not the sole basis for determining compliance with OASAS’ requirements; (2) does not supersede OASAS’ official Regulations, and should not be relied upon as a regulatory reference in lieu of the Regulations; and (3) is subject to periodic revision without notice. ADDITIONAL REGULATORY COMPLIANCE INSPECTOR(S) (if applicable)
DIVISION OF QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT BUREAU OF STANDARDS COMPLIANCE Regulatory Compliance Site Review Instrument Chemical Dependence Outpatient Programs QA-3CD (Applicable to Outpatient Programs and Outpatient Rehabilitation Programs) Part I Patient Case Records Part II Service Management Note: Pursuant to Mental Hygiene Law and the Office of Alcoholism and Substance Abuse Services’ (OASAS) Regulations, this Site Review Instrument is designed for the express purpose of conducting OASAS regulatory compliance reviews of its certified providers. Use of this Site Review Instrument as a self-assessment tool may be a helpful indicator of a provider’s regulatory compliance. However, please note that the Site Review Instrument: (1) is not the sole basis for determining compliance with OASAS’ requirements; (2) does not supersede OASAS’ official Regulations, and should not be relied upon as a regulatory reference in lieu of the Regulations; and (3) is subject to periodic revision without notice. REVIEW INFORMATION PROVIDER LEGAL NAME SERVICE SITE ADDRESS CITY, TOWN, VILLAGE ZIP DATE(S) OF REVIEW REVIEW NUMBER OPERATING CERTIFICATE NUMBER PROVIDER NUMBER PRU NUMBER LEAD REGULATORY COMPLIANCE INSPECTOR ADDITIONAL REGULATORY COMPLIANCE INSPECTOR(S) (if applicable)
DRAFT-Part-822-Outpatient-SRI-6-2-16.docx