Dear Nursing Home Administrator Letter: Revised SCREEN Form Implementation 09-08

November 12, 2009

DRS/DAL: # 09-08: Revised SCREEN Form Implementation

Dear Nursing Home Administrator:

The purpose of this letter is to inform you that amendments to Section 400.12 of Title 10 of the New York Compilation of Codes, Rules and Regulations (10 NYCRR) were adopted by the State Hospital Review and Planning Council on October 1, 2009. This regulatory action removed the SCREEN form from the regulation, providing the Department of Health (Department) with flexibility for making future revisions as necessary to the form.

Effective November 12, 2009, the revised SCREEN form, DOH-695 (2/2009), and the Instruction Manual for the form, will replace all pre-existing SCREEN forms and instructions. All SCREENS initiated on November 12, 2009 or later must be completed using SCREEN form DOH-695 (2/2009). Copies of the form and instructions are available in the Forms section on the Department's website, . The SCREEN form and instructions will also be available by faxing a request to the Department's Distribution Center at (518) 465-0432.

Section 400.11 of 10 NYCRR requires that each residential health care facility have trained and qualified SCREENERS on staff. Only SCREENERS who have completed a SCREEN training course for SCREEN form DOH-695 (2/2009) available since May 2009, and who have been assigned a ten-digit SCREENER identification number, may complete this SCREEN. The Department will continue to make SCREEN training available through Island Peer Review Organization (IPRO). Specific information regarding training and the schedule for training dates can be found at .

All SCREENERS are responsible for periodically checking the Department's website at and the Health Provider Network (HPN) for updates to the SCREEN form and instructions. Frequently Asked Questions regarding the SCREEN form and the PASRR process can also be found on the website and the HPN.

Any questions regarding the new SCREEN form or the PASRR process may be directed to Kathleen Minucci at (518) 408-1282.


Jacqueline Pappalardi
Director Division of Residential Services