Intermediate Care Facilities For Individuals With Intellectual Disabilities Deficiencies Report {CMS-3070H}

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB NO. 0938-0062 Name of Facility INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES DEFICIENCIES REPORT DEFICIENCIES 1. DATA TAG NO. 2. CoP/STND NO. COMMENTS FORM CMS-3070H (03/13) American LegalNet, Inc. www.FormsWorkFlow.com DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB NO. 0938-0062 DEFICIENCIES 1. DATA TAG NO. 2. CoP/STND NO. COMMENTS FORM CMS-3070H (03/13) American LegalNet, Inc. www.FormsWorkFlow.com 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 SIGNATURE SIGNATURE SIGNATURE SIGNATURE SIGNATURE SIGNATURE SIGNATURE SIGNATURE TITLE TITLE TITLE TITLE TITLE TITLE TITLE TITLE TITLE DATE DATE DATE DATE DATE DATE DATE DATE 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 SIGNATURE SIGNATURE SIGNATURE SIGNATURE SIGNATURE SIGNATURE SIGNATURE SIGNATURE TITLE TITLE TITLE TITLE TITLE TITLE TITLE TITLE TITLE DATE DATE DATE DATE DATE DATE DATE DATE DATE FORM CMS-3070H (03/13) American LegalNet, Inc. www.FormsWorkFlow.com 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. 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 3 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 any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. FORM CMS-3070H (03/13) American LegalNet, Inc. www.FormsWorkFlow.com 4