CMS-3070H Intermediate Care Facilities for Individuals with Intell

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB NO. 0938-0062

INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES
DEFICIENCIES REPORT

Name of Facility

DEFICIENCIES
1. DATA TAG NO.

FORM CMS-3070H (03/13)

2. CoP/STND NO.

COMMENTS

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

DEFICIENCIES
1. DATA TAG NO.

FORM CMS-3070H (03/13)

2. CoP/STND NO.

Form Approved
OMB NO. 0938-0062

COMMENTS

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB NO. 0938-0062

INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES
DEFICIENCIES REPORT
FOR INITIAL OR ANNUAL RECERTIFICATION SURVEY
I certify that I have reviewed the following requirements and conditions for: (a) Full Survey _____, (b) Extended Survey _____,
or (c) Fundamental Survey _______, and unless indicated on this form, the facility was found to be in compliance with the
Standards and the Conditions of Participation.
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FOR FOLLOW-UP SURVEY
For the purpose of this onsite visit, I certify that I have reviewed each Condition of Participation and related Standard(s) found
not to be in compliance during the survey on ______________, and unless indicated on this form, the facility was found to be
in compliance with the Standards and/or the Conditions of Participation.
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FORM CMS-3070H (03/13)

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB NO. 0938-0062

INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES
DEFICIENCIES REPORT
Evaluate each of the requirements identified in the ICF/IID Interpretive Guidelines,
(Appendix “J” to the SOM). For each identified deficiency:
A. In the first column, identify the data tag number.
B. In the second column, write the regulatory citation. If it is a Condition of
Participation, enter “CoP” below the regulatory citation.
C. In column three, describe deficient facility practice and supporting findings.
D. Draw horizontal lines to separate identified tag numbers.
E. If more space is needed, photocopy FIRST page (front and back).
F. Each surveyor must sign the certifying statement on the last page.
G. If there are more surveyors to sign the last page, than are lines available on
which to sign, photocopy the last page, and add the additional signatures.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0938-0062. The time required to complete this information collection is estimated to average three hours per response, including the time
to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland
21244-1850. *****CMS Disclaimer*****Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports
Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will
not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact the ICF/IID mailbox at [email protected].
Expiration 02/28/2021
FORM CMS-3070H (03/13)

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