DAL: DRS-NH 13-08 - Program Survey Report Questionnaire
November 25, 2013
DAL: DAL NH 13-08 - Program Survey Report Questionnaire
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 between October 1, 2012 and September 30, 2013. The completed PSR questionnaire must be mailed to the NYSDOH Regional Office in which the program is located by December 13, 2013.
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.
Jacqueline Pappalardi, Director
Division of Nursing Homes and ICF/IID Surveillance
DAL: DAL NH 13-08
- Program Survey Report Questionnaire (PDF, 26KB)