DAL 17-04: Revised Inspection Review Process

January 26, 2017

DAL 17-04: Revised Inspection Review Process

Dear Administrator:

The purpose of this letter is to inform you of modifications made to the current adult care facility Inspection Review Process (IRP) as outlined in Dear Administrator Letter (DAL) 15-04.

Please be aware 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.

Revisions to DAL 15-04 are summarized below and are effective immediately. All other information contained in DAL 15-04 will remain applicable.

  1. All IRPs will now be conducted in the New York State Department of Health's Central Office via an in-person meeting or conference call.
  2. Operators wishing to request an IRP must submit a written IRP Request Form (attached) postmarked within ten (10) business days of the receipt of the Statement of Deficiencies (SOD) and should include all supporting documentation.
  3. Requests will be acknowledged and a meeting will be scheduled within five (5) business days of the DOH's receipt of the Operator's written IRP Request Form.
  4. Within 5 business days of receiving the acknowledgement and notification of the scheduled IRP date, additional supporting information may be submitted and must include:
    • The original IRP Request Form;
    • Date of submission of additional supporting information; and
    • Description of the supporting documentation.
  5. The IRP proceeding will be limited to one hour. Only those items received within the above identified time frames will be discussed at the IRP.
  6. 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 New York State Department of Health's Central Office 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.

Operators wishing to avail themselves of an 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 reflects modifications made to DAL 15-04 and posted to the Health Commerce System on August 24, 2015 If you have any questions or concerns regarding this correspondence, please contact Patricia Vickery, of my staff, at (518) 408-1133.


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