Dear Long Term Care Facility Administrator: Program Survey Report Questionnaire

Date August 1, 2008
DAL DRS 08-07
Subject Program Survey Report Questionnaire

Dear Long Term Care Facility 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 that your facility operates. The questionnaire is based on New York State regulations in 10 NYCRR Part 425 and is used by the Department of Health as a source document to determine the Adult Day Health Care Programs' compliance with those requirements.

The PSR is to be completed by the Adult Day Health Care Program for the period from July 1st of the previous year to June 30th of the present year. The completed PSR questionnaire must be mailed to the NYSDOH Regional Office where the program is located by September 4, 2008.

You are also required to certify the accuracy of the report. At the time of any onsite visit, you will be given an opportunity by the surveyor to update the questionnaire. If you have any questions, please contact the appropriate Regional Office Program Director.

The Department also plans to collect additional information on service utilization and acuity levels of Adult Day Health Care program residents. Information regarding this data collection will be posted to the HPN within the next several weeks.

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.


Valerie A. Deetz, Deputy Director
Division of Residential Services