DAL 16-03: Revised Incident Report

January 26, 2016

DAL 16-03: Revised Incident Report

Dear Administrator:

The purpose of this letter is to inform Adult Care Facility operators that the Department of Health Adult Care Facility Incident Report, DSS-3123 has been revised. Modifications include reformatting, an added reference to The Justice Center for the Protection of People with Special Needs (Justice Center), the removal of reference to Quality of Care for the Mentally Disabled, action taken upon Quality Assurance review, and an addendum facilities are to utilize in the event of a resident death and/or attempted suicide. The form was updated with a Department of Health (DOH) form number.

As the form is referenced in the ACF regulations by their Department of Social Services (DSS) form number, the DSS number will remain along with the newly assigned DOH form number. The form number is DOH-5175 (DSS-3123).

Please note, this form and/or subsequent notifications identified on this form does not alleviate the facility from any reporting requirements to the Justice Center. Facilities are encouraged to visit the Justice Center's website for more information: http://www.justicecenter.ny.gov/home

If you have any questions regarding the revised form, please contact the Adult Care Facility Policy and Surveillance staff at (518) 408-1133 for further clarification.


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