DAL: DRS-NH 10-09 - Program Survey Report Questionnaire

August 17, 2010

Dear Nursing Home Administrator:

The purpose of this letter is to distribute the Program Survey Report (PSR) questionnaire for the Adult Day Health Care Program.

The attached PSR questionnaire must be completed for each Adult Day Health Care Program (ADHCP) that your facility operates. The questionnaire is based on New York State Title 10 NYCRR Part 425 and is used by the Department of Health as a resource document to determine regulatory compliance for your Adult Day Health Care Program.

The PSR is to be completed by the Adult Day Health Care Program for the period July 1, 2009 through June 30, 2010. The completed PSR questionnaire must be mailed to the NYSDOH Regional Office where the program is located by September 20, 2010.

Nursing home administrators are required to certify the accuracy of the report. Thereafter, at the time of an onsite visit, the program will be given an opportunity to update the questionnaire. If you have any questions, please contact the appropriate Regional Office Program Director.

Thank you for your cooperation in submitting the completed PSR questionnaire on time, and your continued efforts to provide quality care and services to ADHCP registrants.


Jacqueline Pappalardi, Director
Division of Residential Services