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
W2

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

W3

5. County
6. City/County

W9 W10

A. Administrator .....................................................
B. Nurse.................................................................
C. Dietitian .............................................................
D. Pharmacist ........................................................
E. Records Administrator .......................................
F. Social Worker ....................................................
G. LSC Specialist ..................................................
H. Laboratorian ......................................................
I. Sanitarian ...........................................................
J. Therapist ............................................................
K. Physician ...........................................................
L. Psychologist ......................................................
M. Other (specify) ..................................................
W13.
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:

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)

W4

W5

Month / Day / Year

W6

14. If “Yes” to block 13, indicate either

W7

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.

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

Month / Day / Year

W1

(End)

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

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

B. Registered Nurse W24

(Begin)

A. Hospital Provider No. ........................

15. Survey Team Composition

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

11. Dates of
Survey

7. Other (specify)___________________________________

No

A. Direct Care Personnel W23

5. ZIP Code

8. Telephone No

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

Yes

4. State

.
.
.
.

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 .........................................................

W15

Total Number of Clients ......................................................
(including ICF/IID clients directly served)

W16

C. Total Number of ICF/IID Clients ..........................................
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

20. 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) Non-ambulatory

under 22(a)

Mobile

W29

22-45 (b)

Non-Mobile

W30

46-65 (c)

(2) Speech/Language Impairment

W32

Total

Hard of Hearing

Male

W52

Total

W35

Total

Impaired

W54

Blind

(1) Intellectual Disability

W38

Severe

W39

Profound

W40

Total
(2) Autism

W41

W42

(3) Cerebral Palsy

W43

(4) Epilepsy

W55

Total

W37

Moderate

D. MEDICAL CARE PLAN
E. DRUGS TO CONTROL BEHAVIOR
F. PHYSICAL RESTRAINTS
G. TIME-OUT ROOMS
H. APPLICATION OF PAINFUL OR NOXIOUS STIMULI
I. NUMBER ATTENDING OFF-CAMPUS DAY PROGRAMS
J. NUMBER OF COURT ORDERED ADMISSIONS

Controlled

W44

Uncontrolled
Total

W53

(4) Visual Impairment

W36

B. DISABILITIES

Mild

W50

W51

Deaf

W34

Female

W49

(3) Hearing Impairment

W33

(2) SEX

K. NUMBER OF CLIENTS OVER AGE 18 WITH A
LEGAL GUARDIAN ASSIGNED BY THE COURT

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

2

INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES

SURVEY REPORT

M. ALLEGATIONS OF ABUSE AND NEGLECT

no. of allegations of abuse investigated (a)
no. of allegations of neglect investigated (b)
Total

W68

W69

W70

N. NUMBER OF DEATHS

no. of deaths related to unusual incidents (a)
no. of deaths related to restraints (b)
no. of deaths for any reason (c)
Total

FORM CMS-3070G (03/13)

W71

W72

W73

W74

3

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.

(W73) Number of deaths for any reason.

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 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 QSOG_ICFIID@cms.hhs.gov.
FORM CMS-3070G (03/13)

4