Supporting Statement – Part A
ICF/IID Survey Report Form (CMS-3070G-I) and Supporting Regulations
Background
This is a request for an extension of the currently approved Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) survey report forms (Forms 3070G-I.
In the Medicaid program, the Centers for Medicare & Medicaid Services (CMS) has the responsibility and authority to establish survey and certification policy on which provider compliance with the regulations is based. The information collection requirements contained in these regulations are used to determine ICFIID compliance with the CoPs.
The information collected with forms 3070G-I is used to determine the level of compliance with ICF/IID CoPs necessary to participate in the Medicare/Medicaid program. A certification statement is provided at the end of the form to certify that each ICF/IID CoP and related requirements have been reviewed by the survey team and unless indicated on the survey report form, the facility was found to be in compliance with the requirement. Information needed to monitor the State’s performance as well as the ICF/IID program in general, is available to CMS only through the use of information abstracted from the survey report form. The form varies in length depending upon the number of deficiencies recorded.
The survey report form is the instrument used by the State survey agency to record data collected during surveys in order to determine compliance with discreet requirements and to report to the Federal government. The form summarizes data relative to survey team characteristics, facility characteristics, client population and the special needs of clients. The form serves as a coding worksheet designed to facilitate data entry and retrieval into the Automated Survey Processing Environment Suite (ASPEN) in the State and at the CMS regional offices.
Finally, the form serves as an aid to help the surveyor structure and record key observation data for subsequent reference and retrieval. The form is used in conjunction with the regulation text and additional surveyor aids called interpretive guidelines and probes.
The effective implementation date of the ICF/IID regulation was October 3, 1988. State surveyors began surveying for compliance with the regulation as of that date. The forms for which renewal is requested are compatible with the regulation and consist of three parts:
3070G This is the cover sheet for the ICF/IID survey report form, which summarizes data relative to facility characteristics including a description of the client population served, special needs of that population and essential characteristics of the survey conducted. This part provides comprehensive descriptive information about the facility, the clients served and the survey team. The information collected also enables CMS to compare specific characteristics about the ICF/IID and their clients with other Medicare and Medicaid providers. Physical restraint data is currently being captured on this form under individual characteristics, as are breakouts on abuse and neglect and deaths.
3070H This part of the form is used in conjunction with the regulation text and interpretive guidelines and includes basic information on non-compliance. Surveyors record all deficiencies found during a survey and affix their signatures certifying their review of all regulatory requirements.
3070I This form is used to record and structure surveyors’ observations of service delivery in the facility so that salient data relative to compliance with the statutory active treatment requirements are available for analysis and retrieval. This is an optional form which structures more consistent and reliable enforcement of the active treatment requirement.
A. Justification
1 . Need and Legal Basis
This activity is authorized by Title XIX of the Social Security Act, Section 1905(d). This section recognizes ICF/IID as Medicaid providers and allows the Secretary to establish standards and to use State resources under contract in determining compliance with these standards. These standards are found in 42 CFR 431.52, 431.151, 435.1009, 440.150, 440.220, 442.1, 442.10-442.16, 442 .30, 442.40, 442.42, 442.100-442.119, 483.400-483.480, 488.332, 488.400, and 498.3-498.5.
To determine compliance with the requirements, section 1902(a)(33)(B) of the Social Security Act requires the State to utilize the same agency used by the Secretary under Section 1864 of the Act to determine whether institutions meet the requirements for participating in the program. For Medicaid purposes, certification is based on the State survey agency’s recording of a provider’s compliance or non-compliance with the health and safety requirements published in the regulations.
In order for the State survey agency to report to CMS its generic findings on provider compliance or non-compliance with the individual requirements, the agency completes the 3070H. Each condition or requirement found out of compliance is identified in the space provided with appropriate explanatory statements regarding negative findings.
Demographic data from 3070G enables CMS to analyze trends in characteristics that are essential for future planning. The information is also used in comparing survey performance to client characteristics.
Data obtained from the 3070I (the observation worksheet) provides structure to obtain more consistent and reliable enforcement of the active treatment requirements.
2. Information Users
CMS uses the information collected to monitor State conformance with Federal certification policy. The survey results are analyzed by the CMS regional offices and the Centers for Clinical Standards and Quality within CMS’s central office. Information about facility and client characteristics and compliance with requirements from this form is coded into the ASPEN Suite and serves as the data base for provider compliance histories, trends in utilization and present and future survey and certification policy nationally. Additionally, since ASPEN serves as the only national data base containing characteristics of the services provided by all the ICF/IID, the data collected from this form enables CMS to analyze characteristics of the clients served by the program in relation to deficiencies and client needs. This information is also available to the public upon request.
3. Use of Information Technology
The survey forms (3070G and H) serve primarily as a coding worksheet for inputting data relative to the facilities, clients and compliance/non-compliance into the ASPEN Suite. The standardized format provides for consistent reporting by State survey agencies. As a result of redesigning the survey form, data can be keyed on-site into lap-top computers used by State surveyors. Because the form can be duplicated by the computer, there are decreased costs for storage of the forms and surveyors have direct access to a sufficient supply of the forms as well as to information regarding previous compliance histories of the facilities being surveyed.
4. Duplication of Efforts
These forms do not duplicate any other information collection system. The form addresses specific requirements for participation in the ICF/IID program. State survey agencies conduct the required surveys with Federal funds under contract with CMS. This form is a basic deliverable under these contracts and is CMS’ only source of survey data for ICF/IID.
5. Small Businesses
These information collection requirements do not have a significant effect on small business. This regulation applies to all sizes of ICF/IID (e.g. 4 or more beds). Every effort was made to reduce this burden in the initial and continued development of the regulations.
6. Less Frequent Collection
State submission of the survey report form depends upon the frequency of provider surveys as required by regulation and also upon the availability of survey funds. Currently, each facility is required to be surveyed on at least an annual basis. Additional follow-up or monitoring by surveyors may be necessary for a facility which is not in compliance with Federal requirements. It is a basic contract requirement that State surveyors transmit their compliance findings for each survey they conduct.
If this information is collected less frequently, CMS would not be in compliance with the law.
7. Special Circumstances
There are no special circumstances associated with this collection.
8. Federal Register/Outside Consultation
CMS published a Federal Register notice with a 60-day comment period on November 4, 2016 (81 FR 76945). There were no comments received.
CMS has worked closely with a wide spectrum of public and private organizations in the development of this form. The forms were modified when pertinent comments were received.
9. Payments/Gifts to Respondents
There are no payments or gifts associated with this collection.
10. Confidentiality
We do not pledge confidentiality.
11. Sensitive Questions
There are no questions of a sensitive nature associated with this form.
12. Burden Estimates (Hours & Wages)
Form 3070G-I
There are 6,310 ICF/IID nationally, which are surveyed annually by the State survey agency.
The survey report form is completed by the State surveyor based on the results of their investigation of provider compliance with each Condition of Participation and associated requirements. The surveyor indicates on the form only those requirements which are found deficient and provides statements to support each finding of non-compliance. Since the form is completed by indicating those requirements which are found to be non-compliant and recording explanatory statements about the evidence, we estimate that experienced State agency surveyors can complete the entire form in approximately 3 hours.
(Annual Burden Hour Calculation as follows: 6,310 facilities x 3hrs = 18,930 hours).
13. Capital Costs
There are no capital costs associated with this information collection.
14. Cost to Federal Government
Total Federal Cost $ 605,760
Number of Providers 6310
Number of providers surveyed annually 6310
Contracting costs per hour for surveyors $ 32.00
Time required to complete forms 3 hours
Total costs to complete forms $ 605,760
15. Changes to Burden
There are no program changes. Burden change is due to the following:
The response time of three hours remains unchanged from the previous submission
3 years ago. There are 6,310 (as of September 2016) facilities surveyed annually X 3 hours to complete the forms, totaling 18,930 burden hours. The burden changed due to a decrease in facilities when individuals were moved from larger institutions to smaller community settings.
16. Publication/Tabulation Dates
There are no publication and tabulation dates associated with this collection.
17. Expiration Date
CMS will display the expiration date.
18. Certification Statement
There are no exceptions to the certification statement.
| File Type | application/msword |
| File Modified | 2017-01-27 |
| File Created | 2016-10-28 |