Crosswalk

Revisions to CMS-3070I
INDIVIDUAL OBSERVATION WORKSHEET (CMS-3070I)
Page
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Section

1

Title

Action to be performed

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Change the title at top of
page 1 from

Changes to the Application

•

“Individual
Observation
Worksheet”

to

“ICF/IID Survey
Observation
Worksheet”

1st row

•

•

“ICF/IID Survey
Observation Worksheet”

•

•

Remove the word “Date” •
field in the 2nd data box
in the 1st row at the top
of the CMS-3070I form
Add the words “Type of
Survey” in the 2nd text
box in the 1st row

•

“Individual Observation
Worksheet”

to

1

Change the title at top of
page 1 from

Reasons for the Change

•

Remove the word “Date”
field in the 2nd data box in
the 1st row at the top of the
CMS-3070I form
Add the words “Type of
Survey” in the 2nd text box

The existing CMS-3070I form is titled “Individual
Observation Worksheet.” We believe that this title
can be confusing if used on the revised version of the
CMS-3070I form because it seems to indicate that
either this form is to be used to record one individual
observation or that this form is to be used to record
the observation of one particular individual.
Surveyors frequently perform multiple observations
during the survey of an ICF/IID facility.

These is no guidance or prohibitions that would
prevent surveyors from using the CMS-3070I form to
record multiple observations performed during one
survey.

Therefore, we have revised the CMS-3070I form to allow
surveyors to record all of their observations on one CMS3070I form.
•

•

We believe that the date field on the existing version of
the CMS-3070I form is intended to record the date that
the CMS-3070I form is completed. However, this
information is not important to CMS or the SA.
Important information to surveyors, the SA and CMS is
the type of survey performed. This is because there
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Revisions to CMS-3070I
INDIVIDUAL OBSERVATION WORKSHEET (CMS-3070I)
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Section

•

Action to be performed

Changes to the Application

located at the top of the
CMS-3070I form.

in the 1st row located at the
top of the CMS-3070I form.

Modify the title of the
existing 1st column from

•

“Time”

Modify the title of the
existing 1st column from

to

to

“Observations Date(s)”

Reasons for the Change

•

“Time”

“Observations Date(s)”
•

•

are different procedures and processes for each type
of survey.

For example, for an initial survey, the facility is new to
the AO and the surveyors, so they take time to become
familiar with the facilities medical record system, learn
how to access the records, become familiar with the
facilities policies and procedures and the facility itself.
This would mean that surveyors that are new to a
facility must review all documents, records extra
carefully so as not to miss anything.
Whereas, in renewal surveys, the surveyor may have
previously been involved in a survey at that facility
had gained familiarity with the facilities medical
record system, the layout of the facility, it’s policies &
procedures, and may be familiar with the staff. Such
familiarity makes the surveyors job a little easier if
they know how to access the facilities medical records
system, understand their policies & procedures, and
have reviewed them previously.
A complaint survey may be focused on only those
issues that are the subject of the complaint, and would
not be a full survey.

Therefore, we have removed the word “Date” in the 2nd
text box of row 1 and replaced it with the words “Type of
Survey” because this information is more important than

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Revisions to CMS-3070I
INDIVIDUAL OBSERVATION WORKSHEET (CMS-3070I)
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Section

Action to be performed

Changes to the Application

Reasons for the Change

the date the form was completed. Knowing the type of
survey performed can help guide the surveyors is how to
perform the survey.
We have also changed the title of the 1st column from
“Time” to “Observation Date”.
•

•

1

2nd row

•

•

Delete the 2nd row,
•
which collects
“Location/Start” in both
of the 2 data fields in this
row.
Add a new column #2
titled “Observation
Start & End Time(s)”

Delete the 2nd row, which
collects “Location/Start” in
both of the 2 data fields in
this row.

•

•

We did this because, during the course of a survey,
surveyor(s) or may do multiple observations with
several individuals at the facility (i.e. - patients,
patient’s family members, patient care staff, the facility
management personnel, etc.).

If the survey last for several days, the observations
may be performed on different days. Therefore, it is
important that the date of each observation be
recorded in the same area with the rest of the
observation information.

The 2nd row of the existing CMS-3070I form contains 2
separate text boxes, which both contain
“Location/Start”. It is unclear what information the
“Location/Start” data fields are intended to collect, or
why this same data field is listed twice.
We believe that the 2 “Location/Start” fields may be
intended to collect the location and start time for 2
surveyor observations. However, we believe that

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Revisions to CMS-3070I
INDIVIDUAL OBSERVATION WORKSHEET (CMS-3070I)
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Section

Action to be performed

•

Add a new column #4
titled “Observation
Location(s).”

Changes to the Application

•

Add a new column #2 titled
“Observation Start & End
Time(s)”

•

Add a new column #4 titled
“Observation Location(s).”

Reasons for the Change

•

•

•

these data fields are not helpful, necessary, or
appropriate as located at top of the CMS-3070I form
for several reasons.

First, we believe that each of these data fields request
2 separate and very different pieces of information (i.e.
(1) location of observation and (2) start time of
observation. We believe, that this information should
be collected separately, in separate data fields, but in a
different location.

Second, we do not believe that there is adequate space
in each of the 2 data fields in the 3rd row of the existing
version of the CMS-3070I form in which to document
both the observation location and the observation
start time.

Third, since there are only 2 text boxes, which contain
the “Location/Start” data fields, the surveyor would
essentially be limited to documenting this information
for only 2 observations on each CMS-3070I form. Most
times during a survey, the surveyors will perform
more than 2 observations. Therefore, the current
versions of the CMS-3070I form would limit the
surveyor to documenting only 2 observations per
form.
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Section

Action to be performed

Changes to the Application

Reasons for the Change

•

•

Also, there is no way to tell what information in the
“Start/Location” fields at the top of the form
corresponds with the information in the columns
below. For example, if there are 5 observations
documented in the columns below, but only 2
“Start/Location” data fields completed, how are other
surveyors, the SA, or CMS to know which of the 5
Observation entries correspond with the 2
“Start/Location” entries above?
We believe that the start time and location for each
observation should definitely be recorded, but should
be recorded in the columns along with the rest of the
observation information.

Therefore, we have added a new 2nd column titled
“Observation Start & End Time(s)”

We have also added a new 4th column titled “Observation
Location(s)” to collect the location where the observation
took place.
•

We believe that relocating these data fields to the
columns will allows the surveyors to document
multiple observations performed for the same survey
on the same CMS-3070I form.

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Revisions to CMS-3070I
INDIVIDUAL OBSERVATION WORKSHEET (CMS-3070I)
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Section

1

2nd row
(new)

Action to be performed

•

•

Add a new 2nd row, with
2 text boxes

Add the following text to
each text box:

•

•

o Left box:
“Survey Start
Date”

3rd row

•

•

Delete the 3rd row,
which collects
“Time/Start” in the 1st
data fields, and
“Time/Finish” in the 2nd
data field.
Add a new column #2
titled “Observation
Dates, Start & End
Times”

Reasons for the Change

Add a new 2nd row, with 2
text boxes

We have deleted the existing 2nd row and added a new 2nd
row with 2 new text boxes which collect the following new
information:

Add the following text to
each text box:

o Left text box:
“Survey Start Date”

Left box text: “Survey Start Date”

•

o Right text box:
“Survey End Date”

o Right box:
“Survey End
Date”
1

Changes to the Application

•

•

Delete the 3rd row, which
collects “Time/Start” in the
1st data fields and
“Time/Finish” in the 2nd
data field.
Add a new column #2 titled
“Observation Dates, Start
& End Times”

•

Right Text Box: “Survey End Date”

We are adding these new data fields because we
believe that the survey start and end dates is
important information that helps identify which
survey a particular CMS-3070I form belongs. For
example, if the facility name placed on a CMS-3070I
form were incorrect or misspelled, the survey start
and end dates might help the surveyor, SA or CMS
identify the facility surveyed.

The 3rd row of the existing version of the CMS-3070I
form contains 2 data fields:
Left Side:

•

•

“Time/Start”

Right Side: “Time/Finish”

It is unclear whether the 2 data fields are intended to
collect the start and end times of the survey, or for an
individual observation.

If these data fields are intended to collect the start and
end time of an observation, the surveyor would be
limited to recording this information for only 1
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Section

Action to be performed

Changes to the Application

Reasons for the Change

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observation since the current version of the CMS3070I form contains only one set of these data fields.
Therefore, we do not think these data fields are
necessary or useful in their current form and location
at the top of the CMS-3070I form.
We believe that the start and end time for each
observation should be documented, but should be
documented in the same location with the other
observation information.

Therefore, we have added a new column #2 titled
“Observation Start & End Times.”
•

1

4th row

•

•

Delete the 4th row of the
existing CMS-3070I
form.

Create a new 3rd column
titled “Name of
Surveyor Conducting
Observation.”

•

Delete the 4th row of the
existing CMC-3070I form.

•

Create a new 3rd column
titled “Name of Surveyor
Conducting Observation.”

•

•

We believe that adding a column with this data
field will allow the surveyors to document multiple
observations performed during the same survey on
the same CMS-3070I form.

We believe that the “Surveyor” data field is intended
to document the name of a surveyor that collects the
Observation information that is documented on the
CMS-3070I form.

We further believe that the “Client Codes” data field is
intended to allow the surveyor conducting the
Observation to document the code name used for the
person observed, as their actual names should not be
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Revisions to CMS-3070I
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Section

Action to be performed

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Create a new 5th column
titled “Client Codes.”

Changes to the Application

•

Create a new 5th column
titled “Client Codes.”

Reasons for the Change

•

•

•

used. Such code names might be “Patient A”, “Patient
B”, “Patient C”, etc., or “RN1”, “RN2”, “RN3”, etc.
Having these data fields located at the top of the CMS3070I form limits the amount of information that can
be documented in them because they are a limited size
and allow only one line of these. Therefore, these data
fields are not conducive to documenting the names of
multiple surveyors who, might conduct Observations
during the survey. Also, this might limit the CMS3070I form to use for documenting the survey
information for Observations performed by only one
surveyor. If several surveyors perform Observations
during the same survey, they would each have to fill
out separate CMS-3070I forms. The new “Name of
Surveyor Conducting Observation” column will allow
several surveyors to document complete information
about multiple Observations on the same CMS-3070I
form.

Also, if information about multiple surveys is
documented in the columns below, it would be difficult
for CMS or the State Survey Agency to determine
which of this survey information these data fields
apply to.

Finally, we believe that the name of the surveyor and
client codes should be recorded, but should be
recorded in the same area where the rest of the

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INDIVIDUAL OBSERVATION WORKSHEET (CMS-3070I)
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2

2

Section

Action to be performed

Changes to the Application

Reasons for the Change

Top
margin
of page
2form

Add the standard header to
the top margin of page 2.

Add the standard header to the
top margin of page 2.

•

Top of
page 2

Add the name of the form to
the top of page 2

We have added the following
form name to the top of page 2:

•

“ICF/IID SURVEY
OBSERVATIONS WORKSHEET –
CMS-3070I (continued)”

Observation information is documented. Therefore, we
have added a new 3rd column titled “Name of
Surveyor Conducting Observation” which will collect
the name of the surveyor that conducts each
Observation. We have also created a new 5th column
titled “Client Codes” which will collect this
information for each Observation conducted.
On page 2 of the current version of the CMS-3070I
form, there is no header. Such a header is usually
included on all pages of CMS forms.

Therefore, we have added this header the page 2 of the
revised version of the CMS-3070I form.

•

There is no form title on page 2 of the existing version
of the CMS-3070I form.
We believe that it is necessary for every CMS form to
have the form title and page number on each page of
the form. We say this because if a multiple page form
were to become separated, the pages could easily be
identified and put back together in the proper order.

Therefore, we have added the form title at the top of the
revised CMS-3070I form.

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Revisions to CMS-3070I
INDIVIDUAL OBSERVATION WORKSHEET (CMS-3070I)
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Section

Action to be performed

Changes to the Application

2

Top of
page 2

Add a new row, at top of
page 2, under the form
name, to add the following 3
new data fields:

Add a new row, at top of page 2,
under the form name, to add
the following 3 new data fields:

•

Middle: Survey Start Date

•

Left side: Facility Name

Middle: Survey Start Date

Right side: Survey End Date

Left side: Facility Name

Reasons for the Change

Right side: Survey End Date

There is no title or data fields that collect identifying
information, such as the name of the facility being
surveyed or survey dates on the 2nd page of the
existing version of the CMS-3070I form.

We believe that this is a problem because if the pages
of several completed CMS-3070I forms were to
become mixed up, there would be no way for the SA or
CMS to identify which 2nd pages belong to which 1st
pages of the CMS-3070I forms.

We have corrected this oversight be adding a new row at
the top of the 2nd page with 3 data fields to collect the
following information:
Left side: Facility Name
Middle: Survey Start Date
Right side: Survey End Date

•

2

Bottom
of page

•

Remove the PRA
Disclosure Statement
from page 2.

•

Remove the PRA Disclosure
Statement from page 2.

•

We believe that adding this row with these data fields
will make the 2nd page of the CMS-3070I form more
identifiable and therefore more secure.
On the existing version of the CMS-3070I page, the
PRA disclosure statement is located on the bottom of
the 2nd page. This PRA disclosure statement is
problematic for the following reasons:
o It is outdated and therefore not accurate;

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Section

Action to be performed

Changes to the Application

Reasons for the Change

o It is squished at the end of the data columns at
the end of page 2, and
o PRA disclosure statement text is in a very tiny
font and difficult to read.

New
page
#3

Top of
page

•
•

Add a new 3rd page.

Add updated PRA
Disclosure Statement
language in 12-point
font on the new 3rd page.

•
•

Add a new 3rd page.

Add updated PRA
Disclosure Statement
language in 12-point font on
the new 3rd page.

•

•

o The PRA disclosure statement takes up valuable
space at the bottom of page 2 upon which
Observation information can be documented.

To remedy the situations stated above, we have
deleted the inaccurate and difficult to read PRA
disclosure language from the bottom of page 2.

We have added a new 3rd page and added updated and
accurate PRA disclosure language on this page. This
PRA disclosure statement is in 12-point font that is
clearly visible and easy to read.

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