Dear Nursing Home Administrator Letter: Program Survey Report Questionnaire

August 4, 2009

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 1 of the previous year to June 30 of the present year. The completed PSR questionnaire must be mailed to the NYSDOH Regional Office where the program is located by September 07, 2009.

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.

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.


Jacqueline Pappalardi, Director
Division of Residential Services

cc: Mark Kissinger
     Valerie Deetz