Qcc 100 form 2025

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The document is a reporting form (QCC-100) for the Commission on Quality of Care, requiring programs operated or certified by OMH or OPWDD to report deaths of service recipients within three working days. It includes detailed instructions for completing the form, necessary recipient information, and guidelines for submitting the report. The form captures data on the deceased's health status, circumstances of death, and any relevant medical history.

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Click ‘Get Form’ to open the QCC 100 form in the editor.
Begin with Section 1, where you will input the Reporting Agency/Facility/Program Data. Fill in the name of your agency, address, and contact details for the Executive Director and the person preparing the report.
Move to Section 2 for Recipient Information. Enter the recipient's name, date of birth, age, gender, and physical attributes like weight and height. Specify their service relationship to your agency at the time of death.
In Section 3, document Death Data including date and time of death, place pronounced dead, cause of death, and any autopsy details if applicable.
Finally, complete Section 4 with a Narrative Summary detailing the recipient’s health status and circumstances surrounding their death. Be thorough in your descriptions as this section is crucial.

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