Official Federal Forms > Centers For Medicare And Medicaid Services
Intermediate Care Facility For Persons With Mental Retardation Deficiencies Report CMS-3070H - Official Federal Forms
| Intermediate Care Facility For Persons With Mental Retardation Deficiencies Report Form. This is a national form and can be used in Centers For Medicare And Medicaid Services . |
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COURT COUNTY .OF. . . . SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DEPARTMENT.OF.HEALTH AND HUMAN . . . . . . . ...... .. CENTERS FOR MEDICARE & MEDICAID SERVICES : INTERMEDIATE CARE FACILITY FOR PERSONS WITH MENTAL RETARDATION : DEFICIENCIES REPORT Calendar No. Name of Facility Index No. FORM APPROVED OMB NO. 0938-0062 Plaintiff(s) DEFICIENCIES 1. DATA TAG NO. : : : : JUDICIAL SUBPOENA COMMENTS -against- 2. COP/STND NO. Defendant(s) : ...................................................... THE PEOPLE OF THE STATE OF NEW YORK TO GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Witness, Honorable Court in County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: FORM CMS-3070H (11/00) American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DEPARTMENT.OF.HEALTH AND HUMAN . . . . . . . ...... .. CENTERS FOR MEDICARE & MEDICAID SERVICES : DEFICIENCIES 1. DATA TAG NO. 2. COP/STND NO. Index No. COMMENTS FORM APPROVED OMB NO. 0938-0062 : Plaintiff(s) : : : : Calendar No. JUDICIAL SUBPOENA -against- Defendant(s) : ...................................................... THE PEOPLE OF THE STATE OF NEW YORK TO GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Witness, Honorable Court in County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: FORM CMS-3070H (11/00) American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DEPARTMENT.OF.HEALTH AND HUMAN . . . . . . . ...... .. CENTERS FOR MEDICARE & MEDICAID SERVICES : INTERMEDIATE CARE FACILITY FOR PERSONS WITH MENTAL RETARDATION : DEFICIENCIES REPORT Calendar No. FOR INITIAL OR ANNUAL RECERTIFICATION SURVEY : I certify that I have reviewed the following requirements and condition for: (a) Full Survey ____, (b) Extended Survey ____, or JUDICIAL SUBPOENA Plaintiff(s) (c) Fundamental Survey ____, and unless indicated on this form, the facility was found to be in compliance with the Standard and the -against: Condition of Participation. SIGNATURE TITLE Index No. FORM APPROVED OMB NO. 0938-0062 : : DATE SIGNATURE TITLE DATE SIGNATURE Defendant(s) TITLE : ...................................................... TITLE DATE SIGNATURE SIGNATURETHE SIGNATURETO DATE PEOPLE OF THE STATE OF NEW YORK TITLE TITLE DATE DATE SIGNATURE TITLE DATE GREETINGS: SIGNATURE SIGNATUREthe TITLE DATE WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , Honorable Court TITLE at the DATE located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed FOR FOLLOW-UP SURVEY to testify and give evidence as a witness in this action on the part of the or adjourned date, 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 on _______________, and unless indicated on this form, the facility was found to be in compliance with the Standard and/or the Condition of Participation. SIGNATURE TITLE DATE Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a SIGNATUREresult of your failure to comply. TITLE DATE SIGNATURE Witness, Honorable Court in County, TITLE DATE , one of the Justices of the day of TITLE , 20 DATE SIGNATURE SIGNATURE TITLE DATE (Attorney must sign above and type name below) DATE SIGNATURE TITLE Attorney(s) for SIGNATURE TITLE DATE SIGNATURE TITLE DATE Office and P.O. Address SIGNATURE TITLE DATE SIGNATURE TITLE Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: DATE FORM CMS-3070H (11/00) American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DEPARTMENT.OF.HEALTH AND HUMAN . . . . . . . ...... .. CENTERS FOR MEDICARE & MEDICAID SERVICES : INTERMEDIATE CARE FACILITY FOR PERSONS WITH MENTAL RETARDATION : DEFICIENCIES REPORT-INSTRUCTIONS No. Calendar Plaintiff(s) : Index No. FORM APPROVED OMB NO. 0938-0062 JUDICIAL SUBPOENA Evaluate each of the requirements identified in the ICF/MR Interpretive Guidelines, -against: (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 deficientDefendant(s) and supporting findings. facility practice : ...................................................... 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 NEW YORK THE PEOPLE OF THE STATE OF the certifying statement on the last page. TO 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 signature
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