Form CMS-3070G 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

SURVEY REPORT

1. Name of Facility

2. Street Address

3. City and/or County

6. Medicaid Provider No.

7. Name of CEO

9. State/Region code

10. State/County code

5. ZIP Code

8. Telephone No

W2

12. Type of Ownership or Control (enter number in box below
1. Private (non-profit)
3. State
2. Private (proprietary)
4. City/Town

13. Is this ICF/IID a distinct part of a Hospital, SNF or NF?
Yes

4. State

W3

5. County
6. City/County

11. Dates of
Survey

(Begin)
Month / Day / Year

W1

(End)
W4

W5

Month / Day / Year

7. Other (specify)___________________________________
W6

14. If “Yes” to block 13, indicate either
A. Hospital Provider No. ........................

No

B. SNF Provider No. ..............................
W7

15. Survey Team Composition

Column 1: Indicate the number of disciplines represented on the
Survey team.

Column 2: Of the number in column 1 represented on the Survey
team, indicate the number who also qualify as a QIDP.
Indicate Name(s) and Title(s) on last page of this form.
W9 W10

A. Administrator .....................................................
B. Nurse.................................................................
C. Dietitian .............................................................
D. Pharmacist ........................................................
E. Records Administrator .......................................
F. Social Worker ....................................................

C. NF Provider No. ................................

W8

16. Facility Data
A. Is this ICF/IID a residential unit within a larger organization or agency in the State
that provides residential services to individuals with intellectual disabilities?
(check one)
Yes
No
If “No”, proceed to item C.
W13
B. If “Yes,” indicate name and address of larger organization.

Name
Address
City

State

ZIP Code

Name of CEO

W14

Total Number of Beds .........................................................

G. LSC Specialist ..................................................

W15

H. Medical Laboratory Technologist..................................................
.... Total Number of Clients ......................................................
I. Public Health Specialist .......................................................
....

(including ICF/IID clients directly served)

W16

C. Total Number of ICF/IID Clients ..........................................
J. Physical Therapist ........................................................
....
K. Physician ...........................................................
L. Psychologist ......................................................
M. Other (specify) ..................................................
W11
N. Total number of Surveyors onsite ...................
W1
.2
O. Total number of QIDP Surveyors onsite .........

17. Staffing: List the full time equivalents who function in this capacity:

A. Direct Care Personnel W23

(483.430(d)(3)) ..........................

B. Registered Nurse W24

(483.480(d)(3)) ..........................

C. Licensed Voc./Practical Nurse W25
(483.480(d)(2)) ..........................

D. Total Personnel W26 ....................
(List the Full Time Equivalent for all employees)

FORM CMS-3070G (03/13)

.
.
.
.

W17

D. Is this ICF/IID community-based? (check
one) ....................

Yes

No
W18

E. Total number of ICF/IID beds under this Provider No .........
W19

F. Total number of discrete living units under this Provider No..
W21

W20

G. Age range of clients served..............................from

to

H. Total number of off-campus day program
sites used by ICF/IID clients .....................................................

W22

18. Off-Campus Day Programs:

A. How many clients in the sample attend
off-campus day programs? ............................................
B. In how many off-campus day program sites
was an observation done by the Surveyor?...................

W27

W28

19. Individual Characteristics (Note: The total number in Items B-L (Col.(a)) may exceed the facility’s population
because some clients have multiple disabilities)
A.

C. OTHER DISABILITIES
(1) Age

(1) Ambulatory Status

under 22(a)

Ambulatory

W29

22-45 (b)

Non-Ambulatory

W30

46-65 (c)

(2) Speech/Language Impairment

W32

Total

Partial Hearing Loss

Male

W52

Total

W35

Total

Visually Impaired

W54

Blind

(1) Intellectual Disability

W38

Severe

W39

Profound

W40

Total
(2) Autism Spectrum Disorder

W41

W42

(3) Cerebral Palsy

W43

W55

Total

W37

Moderate

D. Medical care plan
E. Use of drugs to control behavior
F. Use of physical restraints
G. Use of time-out rooms
H. Application of painful or noxious stimuli
I. Number attending off-campus day programs
J. Number of Court Ordered admissions

(4) Seizure Disorder
Controlled
Uncontrolled
Total

W53

(4) Visual Impairment

W36

B. DISABILITIES

Mild

W50

W51

Deaf

W34

Female

W49

(3) Hearing Impairment

W33

(2) SEX

W44

K. Number of clients over 18 with a Court ordered
Legal Guardian

W45

L. OTHER (specify)

W46

(1)
(2)
(3)

FORM CMS-3070G (03/13)

W48

Total

W31

66+ (d)

W47

W56

W57

W58

W59

W60

W61

W62

W63

W64

W65

W66

W67

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INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES

SURVEY REPORT

M. ALLEGATIONS OF ABUSE AND NEGLECT

a. Number of allegations of abuse investigated
b. Number of allegations of neglect investigated

Total

W68

W69

W70

N. NUMBER OF DEATHS

a. Number of deaths related to unusual incident
b. Number of deaths related to restraints
c. Number of deaths for any reason

Total

FORM CMS-3070G (03/13)

W71

W72

W73

W74

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ALLEGATIONS OF ABUSE AND NEGLECT AND NUMBER OF DEATHS

DATA ENTRY INSTRUCTIONS

M. Allegation of abuse and neglect
(W68) Number of allegations of abuse investigated.
(W69) Number of allegation of neglect investigated.

According to 42CFR §488.301:
Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting
physical harm, pain or mental anguish.
Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental
illness.
Consistent with the referenced definitions, enter the number of allegations of abuse and or neglect investigated,
including investigations resulting from complaints, follow ups, initials or recertifications. If there is no information
to report, leave the field blank.
(W70) Total
This field represents a combined total of W68 (allegations of abuse investigated) and W69 (allegations of neglect

investigated). The total for this field is program generated therefore,
no data input is necessary.
N. Number of Deaths

(W71) Number of deaths related to unusual incidents.

Insert the number of deaths that occurred as a result of unusual incidents.

This includes all unexpected or unanticipated
deaths not included in W72 or W73.
(W72) Number of death related to restraints.

Insert the number of deaths that occurred as a result of the use of restraints.

of deaths for any reason.
(W73) Number

Insert the number of deaths occurring for any reason.

Do not include information contained is W71 and W72 above.
(W74) Total
This field represents a combined total of W71 (number of deaths related to unusual incidents), W72
(number of deaths related to restraints), and W73 (number of deaths for any reason).
The total for this field is program generated; therefore, no data input is necessary.
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 XX/XX/202X). This is a mandatory
information collection. The time required to complete this information collection is estimated to average 72 hours per response, which
includes completion of the survey and the CMS-3007G, CMS-3070H & CMS-3070I forms, and which also includes the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have
comments, regarding 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 Disclosure****
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 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 Donald Howard at [email protected].
FORM CMS-3070G (03/13)

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