DAL: NH 17-08 Adult Day Health Care Program Survey Report Letter and Questionnaire

November 29, 2017

Dear Nursing Home 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 Title 10 NYCRR Part 425 and is used by the Department of Health as a resource document to determine regulatory compliance for your Adult Day Health Care Program.

The PSR is to be completed by the Adult Day Health Care Program for the period from October 1, 2016 through September 30, 2017. The completed PSR questionnaire must be mailed to the NYSDOH Regional Office in which the program is located by December 31, 2017.

Nursing home administrators are required to certify the accuracy of the report. Thereafter, at the time of an onsite visit, the program will be given an opportunity 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.


Shelly Glock, Director
Director of Nursing Homes and ICF/IID Surveillance Center for Health Care Quality and Surveillance