Form Cms-3070h - Icf/iid Deficiencies Report Page 4

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Form Approved

CENTERS FOR MEDICARE & MEDICAID SERVICES

OMB NO. 0938-0062

INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES

DEFICIENCIES REPORT

Evaluate each of the requirements identified in the ICF/IID Interpretive Guidelines,

(Appendix “J” to 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 FIRST page (front and back).

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 the last page, and add the additional signatures.

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.

FORM CMS-3070H (03/13)