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

2

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.
SIGNATURE

TITLE

DATE

SIGNATURE

TITLE

DATE

SIGNATURE

TITLE

DATE

SIGNATURE

TITLE

DATE

SIGNATURE

TITLE

DATE

SIGNATURE

TITLE

DATE

SIGNATURE

TITLE

DATE

SIGNATURE

TITLE

DATE

SIGNATURE

TITLE

DATE

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.
SIGNATURE

TITLE

DATE

SIGNATURE

TITLE

DATE

SIGNATURE

TITLE

DATE

SIGNATURE

TITLE

DATE

SIGNATURE

TITLE

DATE

SIGNATURE

TITLE

DATE

SIGNATURE

TITLE

DATE

SIGNATURE

TITLE

DATE

SIGNATURE

TITLE

DATE

FORM CMS-3070H (03/13)

3

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.

PRA Disclosure Statement: 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 (Expires 2/28/2021). This information collection is mandatory for states to complete as authorized by
Title XIX of the Social Security Act, Section 1905(d). 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. The information collection
records data relative to facility characteristics, including a description of the client population served and essential characteristics of the survey conducted in order to determine
compliance with discreet requirements and to report to the Federal government. Under the Privacy Act of 1974, any personally identifying information obtained will be kept private to the
extent of the law. 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, and 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].
FORM CMS-3070H (03/13)

4