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CMS3070G Intermediate Care Facilities for Individuals with Intellectual Disabilities

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FORM CMS-3070G (03/13) 1 4
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 4. State 5. ZIP Code
6. Medicaid Provider Number 7. Name of CEO 8. Telephone No.
9. State/Region Code
W2
10. State/County Code
W3
11. Dates of Survey (mm/dd/yyyy)
Begin: W4 End: W5
12. Type of Ownership or Control (enter number in box below)
1. Private (non-profit)
2. Private (proprietary)
3. State
4. City/Town
5. County
6. City/County
7. Other (specify):
W6
13. Is this ICF/IID a distinct part of a
Hospital, SNF or NF? (check one)
Yes No
W7
15. Survey Team Composition
Column 1: Indicate the number of disciplines
represented on the Survey team.
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.
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):
N. Total number of Surveyors onsite W11
O. Total number of QIDP Surveyors onsite W12
14. If “Yes” to block 13, indicate either:
A. Hospital Provider Number: B. SNF Provider Number: C. NF Provider Number:
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:
Total Number of Beds:
W14 Total Number of Clients: W15
(including ICF/IID clients directly served)
C. Total Number of ICF/IID Clients:
W16
D. Is this ICF/IID community-based? (check one) Yes No
W17
E. Total number of ICF/IID beds under this Provider No:
W18
F.
Total number of discrete living units under this Provider No
:
W19
G. Age range of clients served: W20 W21 from to
H. Total number of off-campus day program sites used by ICF/IID clients:
W22
17. Staffing: List the full time equivalents who function in this capacity:
A. Direct Care Personnel
. W23
(483.430(d)(3))
B. Registered Nurse
W24
(483.480(d)(3))
.
C. Licensed Voc./Practical Nurse
W25
(483.480(d)(2))
.
D. Total Personnel (List the Full Time
. W26
Equivalent for all employees)
18. Off-Campus Day Programs:
A. How many clients in the sample attend
off-campus day programs?
W27
B. In how many off-campus day program sites was
an observation done by the Surveyor?
W28
FORM CMS-3070G (03/13) 1 4
19. 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. AGE AND SEX
(1) Age
under 22(a)
W29
22-45 (b)
W30
46-65 (c)
W31
66+ (d)
W32
Total:
W33
(2) Sex
Male
W34
Female
W35
Total:
W36
B. DISABILITIES
(1) Intellectual Disability
Mild
W37
Moderate
W38
Severe
W39
Profound
W40
Total:
W41
(2) Autism
W42
(3) Cerebral Palsy
W43
(4) Epilepsy
Controlled
W44
Uncontrolled
W45
Total:
W46
C. OTHER DISABILITIES
(1) Non-ambulatory
Mobile
W47
Non-Mobile
W48
Total:
W49
(2) Speech/Language
Impairment W50
(3) Hearing Impairment
Hard of Hearing
W51
Deaf
W52
Total:
W53
(4) Visual Impairment
Impaired
W54
Blind
W55
Total:
W56
D. MEDICAL CARE PLAN
W57
E. DRUGS TO CONTROL
BEHAVIOR W58
F. PHYSICAL RESTRAINTS
W59
G. TIME-OUT ROOMS
W60
H. APPLICATION OF PAINFUL
OR NOXIOUS STIMULI W61
I. NUMBER ATTENDING OFF-
CAMPUS DAY PROGRAMS W62
J. NUMBER OF COURT
ORDERED ADMISSIONS W63
K. NUMBER OF CLIENTS
OVER AGE 18 WITH A LEGAL
GUARDIAN ASSIGNED BY
THE COURT W64
L. OTHER (specify)
(1)
W65
(2)
W66
(3)
W67
INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES
SURVEY REPORT
FORM CMS-3070G (03/13) 1 4
M. ALLEGATIONS OF ABUSE AND NEGLECT
No. of allegations of
abuse investigated (a)
W68
No. of allegations of
neglect investigated (b) W69
Total:
W70
N. NUMBER OF DEATHS
No. of deaths related to
unusual incidents (a)
W71
No. of deaths related to
restraints (b) W72
No. of deaths for any
reason (c) W73
Total:
W74
FORM CMS-3070G (03/13) 1 4
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 DEA THS
(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.
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.
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CMS3070G Intermediate Care Facilities for Individuals with Intellectual Disabilities

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Completed 18 September 2019

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