DAL 15-15: Revised ACF DSS Forms: 2900 and 3026

November 3, 2015

DAL 15-15: Revised ACF DSS Forms: 2900 and 3026

Dear Administrator:

The purpose of this letter is to inform you that the Adult Care Facility Daily Resident Census Report (DSS 2900) and the Chronological Admission and Discharge Register (DSS 3026) were revised to eliminate content that is no longer applicable, to standardize information contained in the forms and to improve their overall appearance. As the forms are referenced in the ACF regulations by their DSS form numbers, the DSS numbers will remain along with the newly assigned DOH form numbers. The following revised forms are attached and highlights of the revisions are described below.

  • DOH-5176 (DSS 2900): Daily Resident Census Report. Changed orientation of document from portrait to landscape, included facility operating certificate number, ACF capacity, month and year, page number, resident's room number, level of care and absent from facility codes. Eliminated documentation of certified beds as this information is available elsewhere.
  • DOH-5177 (DSS 3026): Chronological Admission and Discharge Register. Included facility operating certificate number, level of care codes and added a level of care column to the table. In addition, included under Admission/Discharge Codes a code for "Another Adult Home/Enriched Housing Program." Eliminated Health Related Facility (HRF) from the Admission/Discharge Codes as this level of care is no longer applicable.

The Division of ACF/Assisted Living Surveillance will continue to review and update existing forms and notify you of changes. If you have questions regarding the revised forms, please contact the Division of ACF/Assisted Living Surveillance at (518) 408-1133 for further clarification.


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