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 (CMS-3070H)
Name of Facility:

Deficiencies

1. Data Tag Number 2. CoP/Standard Number

CMS-3070H / OMB Approval Expires XX/XX/202X

Comments

Page | 1

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 (CMS-3070H)
Name of Facility:

Deficiencies

1. Data Tag Number 2. CoP/Standard Number

CMS-3070H / OMB Approval Expires XX/XX/202X

(Continued)

Comments

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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 (CMS-3070H)
(Continued)

Name of Facility:

FOR INITIAL OR ANNUAL RECERTIFICATION SURVEY
I certify that I have reviewed the following requirements and conditions for (CHECK ONE): (a) Full Survey_________,
(b) Extended Survey ________, or (c) Focused Fundamental Survey _________, and unless indicated on this form, the
facility was found to be in compliance with the Standards and the Conditions of Participation.

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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, which was performed on _________________, and unless
indicated on this form, the facility was found to be in compliance with the Standards and/or the Conditions of
Participation.

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CMS-3070H / OMB Approval Expires XX/XX/202X

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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 (CMS-3070H)
(Continued)

INSTRUCTION FOR COMPLETION THE CMS-3070H FORM
Evaluate each of the requirements identified in the ICF/IID Interpretive Guidelines, (Appendix “J” of
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 the second page and add the correct page number for each
additional page added.
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 page 3, 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 XX/XX/202X). This is a mandatory to retain or obtain a benefit
information collection. The time required to complete this information collection is estimated to average 72
hours per response, which includes the time required to perform the survey and complete the CMS-3070G,
CMS-3070H & CMS-3070I forms. The time required to complete this information collection 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 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 Donald Howard at QSOG_ICFIID@cms.hhs.gov.

CMS-3070H / OMB Approval Expires XX/XX/202X

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