Supporting Statement A for CMS-3070G-I. 10.25.21

Supporting Statement A

ICF/IID Survey Report Forms (CMS-3070G-I)

1. Background

This is a request for a revision of the OMB approval of the three-part Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) survey report forms (consisting of forms CMS-3070G, CMS-3070-H and CMS-3070I). These forms are approved under OMB control number 0938-0062.

The information collected with forms 3070G, CMS-3070H and CMS-3070I is used by the surveyors from the State Survey Agencies (SAs) to determine the level of compliance with the ICF/IID Conditions of Participation (CoPs) necessary to participate in the Medicare/Medicaid program and to report any non-compliance with the ICF/IID CoPs to the Federal government. These forms summarize the survey team characteristics, facility characteristics, client population, and the special needs of clients. These forms are used in conjunction with the CMS regulation text and additional surveyor aids such as the CMS interpretive guidelines and probes. The CMS-3070G-I forms serves as coding worksheets, designed to facilitate data entry and retrieval into the Automated Survey Processing Environment Suite (ASPEN) in the State and at the CMS regional offices.

The 3070G form is titled “Intermediate Care Facilities For Individuals With Intellectual Disabilities Survey Report.” The CMS-3070G form serves as the “cover sheet” for the ICF/IID survey report form set, and summarizes facility characteristics. On this form, surveyors record information about the ICF/IID such as its demographic information. Demographic data from 3070G enables CMS to analyze trends in characteristics that are essential for future planning.

The CMS-3070G form also collects information about the type of ownership of the facility, and facility data including, but not limited to, the number of beds, number of clients, age range of clients served, types of disabilities of the client population, types and number of staffing, and whether day programs are offered. Physical restraint data and information about abuse, neglect and deaths is also collected.

The information collected on the CMS-3070G form is used in comparing survey performance to client characteristics. This information enables CMS to compare specific characteristics about the ICF/IID and their clients with other Medicare and Medicaid providers.

The CMS-3070H form is titled “Intermediate Care Facilities For Individuals With Intellectual Disabilities Deficiencies Report.” This form is used by SA surveyors to document information about deficiencies and non-compliance found during the survey of an ICF/IID.

Each CMS condition or requirement found to be out of compliance is identified in the space provided. An explanatory statement about each negative findings is also provided. Each completed CMS-3070H form varies in length depending upon the number of deficiencies recorded.

An attestation statement is provided at the end of the CMS-3070H form, which is to be signed by each member of the survey team. This attestation statement certifies that each surveyor has reviewed each ICF/IID CoP and related requirements and unless indicated on the CMS- 3070H survey report form, the facility is found to comply with these requirements. CMS relies on the information contained on the CMS-3070H form to monitor the State’s performance as well as that of each ICF/IID program.

The CMS-3070I form is titled “Individual Observation Worksheet.” This is an optional form, which structures more consistent and reliable enforcement of the active treatment requirements.

The CMS-3070I form records the surveyor’s observations of service delivery within the facility so that data regarding compliance with the statutory active treatment requirements are available for analysis and retrieval. This form is used by the surveyors to document their observations of the clients and staff within the ICF/IID as well as active treatment provided through both inpatient and day programs. The observations range from how clients and staff work on ADLs, as well as other targeted treatment plan interventions and goals. The observations are a catalyst that will potentially lead to the surveyors need to conduct interviews and perform record review to support their observation findings.

2. Justification

1. Need and Legal Basis

The information collection requirements to determine ICF/IID compliance with the CoPs is authorized by Title XIX, §1905(d) of the Social Security Act (“the Act”). This statute recognizes ICF/IID facilities as Medicaid providers and allows the Secretary to establish standards and to use State resources under contract in determining compliance with those standards.

To determine compliance with the requirements, §1902(a)(33)(B) of the Act requires the State to utilize the same agency used by the Secretary under §1864 of the Act to determine whether institutions meet the requirements for participating in the program. For Medicaid purposes, certification is based on the SA’s recording of a provider’s compliance or non- compliance with the health and safety requirements published in the regulations.

In the Medicaid program, the Centers for Medicare & Medicaid Services (CMS) has the responsibility and authority to establish regulations and survey and certification policy upon which provider compliance is based. The implementation date of the CMS ICF/IID regulations was October 3, 1988. SA surveyors began surveying for ICF/IID compliance with the CMS regulations as of that date.

2. Information Users

CMS uses the information collected to monitor State conformance with Federal certification policy. The CMS location offices and the Centers analyze the survey results for Clinical Standards and Quality within CMS’s Baltimore location office. Information about facility and client characteristics and compliance with requirements from this form is coded into the ASPEN Suite and serves as the database for provider compliance histories, trends in utilization, present and future survey, and certification policy nationally. Additionally, since ASPEN serves as the only national database containing characteristics of the services provided by all the ICF/IID, the data collected from this form enables CMS to analyze characteristics of the clients served by the program in relation to deficiencies and client needs. This information is also available to the public upon request.

3. Use of Information Technology

The survey forms (CMS-3070G and CMS-3070H) serve primarily as a coding worksheet for inputting data relative to the facilities, clients, and compliance/non-compliance into the ASPEN Suite. The standardized format provides for consistent reporting by State survey agencies. Data can be keyed on-site into laptop computers used by State surveyors. Because the form can be duplicated by the computer, there are decreased costs for storage of the forms and surveyors have direct access to a sufficient supply of the forms as well as to information regarding previous compliance histories of the facilities being surveyed.

4. Duplication of Efforts

These forms do not duplicate any other information collection system. The form addresses specific requirements for participation in the ICF/IID program. SAs conduct the required surveys with Federal funds under contract with CMS. This form is a basic deliverable under these contracts and is CMS’ only source of survey data for ICF/IID.

5. Small Businesses

These information collection requirements do not have a significant effect on small business. This regulation applies to all sizes of ICF/IID (e.g. 4 or more beds). Every effort was made to reduce this burden in the initial and continued development of the regulations.

6. Less Frequent Collection

State submission of the survey report form depends upon the frequency of provider surveys as required by regulation and upon the availability of survey funds. Currently, each ICF/IID is required to be surveyed on an annual basis. If this information were collected less frequently, CMS would not comply with the law.

Additional follow-up or monitoring by surveyors may be necessary for a facility, which does not comply with Federal requirements. It is a basic contract requirement that State surveyors transmit their compliance findings for each survey they conduct.

7. Special Circumstances

There are no special circumstances associated with this collection.

8. Federal Register/Outside Consultation

The 60-day Federal Register notice was published on August 20, 2021 (86 FR 46854). No public comments were received.

The 30-day Federal Register notice was published on November 1, 2021 (86 FR 60244).

9. Payments/Gifts to Respondents

There are no payments or gifts associated with this collection.

10. Confidentiality

We do not pledge confidentiality.

11. Sensitive Questions

There are no questions of a sensitive nature associated with this form.

12. Burden Estimates (Hours & Wages)

There are 5,758 ICFs/IID nationally. These ICF/IID are surveyed on an annual basis by the SAs.

We estimate that it would take 3 hours to complete the CMS-3070G-I forms. We further estimate that the total time burden across all 5,758 ICF/IDDs for completion of the CMS-3070G-I forms would be 17,274 hours.

• 3 hours x 5,758 ICF/IIDs = 17,274 hours

We believe that the person that would complete the CMS-3070G-I forms would be a surveyor. We believe that this surveyor would be a clinician such as a Registered Nurse (R.N.).

According to the U.S. Bureau of Labor Statistics, the mean hourly wage for a Registered Nurse (RN) is $38.47¹. This wage, adjusted for the employers overhead and fringe benefits, would be $76.94.

We estimate that the cost burden for the time spent by the RN surveyor to complete each CMS-3070G-I form would be $230.82

• 3 hours x $76.94 = $230.82

We further estimate that the total cost burden across all ICF/IDDs for the completion of all CMS-3070G-I forms annually would be $1,329,062.

• 5,758 x $230.82 = $1,329,062

13. Capital Costs

No capital costs associated with this information collection.

14. Cost to Federal Government

There are no costs to the Federal Government associated with this information collection.

15. Changes to Burden

The table below shows the change to the burden from the last PRA package.

Tasks	Total Requested	Difference Due to Adjustment in OPDIV Office Estimate	Currently Approved
Annual Responses for the CMS- 3070G-I	5,758 responses	-342 responses	6,100 responses
b. Hours to complete each form CMS-3070G-I	3 hours	0 hours	3 hours
c. Annual burden hours across all CMS-3070G-I forms	17,274 hours	- 1,026 hours	18,300 hours
d. Annual cost burden per each CMC-3070G-I form	$230.82	+$23.76	$207.06
e. Annual Cost Burden Across All CMS-3070G-I forms	$1,329,062	+$65,996	$1,263,066

As the above table shows, the total annual cost burden has increased by $23.76 per each ICF/IDD and $65,996 across all ICF/IDDs annually. This cost increase has occurred because in the current PRA package, we have used an adjusted hourly wage rate for an RN surveyor of $76.94. In the previous PRA package, a lower wage rate of $69.02 was used. Use of the higher wage rate in this PRA package is directly attributable to the increased cost burden.

16. Publication/Tabulation Dates

There are no publication and tabulation dates associated with this collection.

17. Expiration Date

CMS will display the expiration date on the data collection instruments.

18. Certification Statement

There are no exceptions to the certification statement.

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