DAL 15-04: Revised Inspection Review Process

August 21, 2015

DAL 15-04

SUBJECT: Revised Inspection Review Process

Dear Administrator:

The purpose of this letter is to inform you of changes in the New York State Department of Health's (DOH) Inspection Review Process (IRP) for adult care facilities. This Dear Administrator Letter (DAL) supplements and clarifies DAL HCBC 06-13.

Please also be reminded that an Operator's request for an IRP proceeding does not negate the need for a POC/NOC to be submitted for all violations and findings within the required 30-day timeframe. In the event that corrective action requires more than 30 days, the facility must submit an acceptable Plan of Correction (POC) and timetable for correction. Regional office staff may require that corrective action be completed in fewer than 30 days, depending on the severity of the violation.

The changes summarized below are effective immediately.

  1. An Operator may request an IRP proceeding for violations classified as an endangerment as defined in 18 NYCRR 486.5(a)(4)(i-vi). When considering the request, please be advised that the condition that has been cited as an endangerment must no longer exist. This means that either the violation must have been corrected by the facility, or the circumstances must have otherwise changed such that residents are no longer endangered.

  2. Operators will be afforded one IRP opportunity. The IRP can be conducted by the appropriate DOH Regional Office or the Adult Care Facility/Assisted Living Surveillance Program's Central Office, whichever is the preference of the Operator.

  3. IRP proceedings can either be conducted through a face-to-face meeting or via a conference call, again, at the Operator's preference.

  4. Operators wishing to request an IRP must submit a written IRP Request Form (here and below) postmarked within ten (10) business days of the receipt of the Statement of Deficiencies (SOD). Requests will be accepted if submitted via fax. Oral requests will not be accepted. It is imperative that ACFs routinely access their Health Commerce System (HCS) accounts to ensure the timely (1) submission of an IRP request, (2) receipt of all DOH correspondence, including, but not limited to, Inspection Reports and (3) assignment of HCS roles.

  5. Operators will receive an acknowledgement letter within five (5) business days of the DOH's receipt of the Operator's written IRP Request Form. The IRP proceeding will occur within thirty (30) calendar days of receipt of the Operator's request and supporting documentation. In order to facilitate a productive meeting, the following written information must accompany the request for an IRP proceeding

    1. Whether the meeting is to be face-to-face or via conference call;
    2. A list of person(s) who will participate at the meeting or during the conference call;
    3. A list of the specific citations, by regulation and tag number, in dispute;
    4. Justification for modifying or deleting each finding and/or violation in dispute; and
    5. Copies of any supporting documentation. This includes documentation supporting any legal argument.

  6. The IRP proceeding will be limited to one hour. Only those items identified in the documentation that is included in the written IRP request will be discussed at the IRP. The Department's final decision will be based upon the information submitted and discussed during the IRP proceeding. The Department's IRP decision will be the final determination; a second IRP opportunity will not be available.

  7. The Department will notify Operators of the final decision in writing (IRP Determination Letter) within fifteen (15) business days after the proceeding. The IRP Determination Letter will be uploaded through the secure file transfer application on the Health Commerce System (HCS). Operators may request an explanation of the IRP determination within seven (7) calendar days from the date noted on the IRP Determination Letter. The request should be made by calling the office at which the IRP proceeding was conducted to schedule the discussion at a mutually agreeable date and time. This is not intended as an opportunity to provide additional information or dispute the IRP outcome, but rather to obtain feedback and education. Information will be provided via a teleconference, which will be limited to no more than twenty (20) minutes.

  8. If the IRP results in changes to the violation or finding identified during the survey, a new survey inspection report will be issued. Please be reminded that Operators are not required to post the Inspection Report within the facility until after the Operator has received the written notice of the Department's IRP determination. However, this does not negate the Department's obligation to provide copies of such reports to requestors pursuant to the Freedom of Information Law or when legal actions require such disclosure.

Operators wishing to avail themselves of a Regional Office IRP must submit written requests via postal service or fax to:

  • Western Regional Office, Adult Care Facility Program Manager, 335 E. Main Street, Rochester, NY 14604. Fax: (585) 423-8171
  • Central New York Regional Office, Adult Care Facility Program Manager, 217 South Salina Street, Syracuse, NY 13202. Fax: (315) 477-8583
  • Capital District Regional Office, Adult Care Facility Program Manager, 875 Central Avenue, Albany, NY 12206. Fax: (518) 408-5309
  • Metropolitan Area Regional Office, Adult Care Facility Program Manager, 90 Church Street, 15th floor, New York, NY 10007. Fax: (212) 417-2119

Operators wishing to avail themselves of a Central Office IRP must submit written requests via postal service or fax to:

  • Ms. Valerie A. Deetz, New York State Department of Health, Division of Adult Care Facilities and Assisted Living Surveillance, 875 Central Avenue, Albany, NY 12206. Fax: (518) 408-1249.

The Department will not consider inspection reports for which an IRP may be requested in making determinations regarding funding opportunities or placements on the Do Not Refer (DNR) list, while the process is pending. However, the Department may delay funding opportunities until after the process is completed.

The information presented above is intended to clarify the IRP and ensure a clear understanding of the process. If you have any questions or concerns regarding this correspondence, please contact Linda O'Connell, of my staff, at (518) 408-1133.


Valerie A. Deetz, Director
Division of ACF and Assisted Living Surveillance