Intermediate Care Facilities For Individuals With Intellectual Disabilities Survey Report {CMS-3070G}

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 6. Medicaid Provider Number 9. State/Region Code W2 3. City and/or County 7. Name of CEO 10. State/County Code W3 4. State 8. Telephone No. 5. ZIP Code 11. Dates of Survey (mm/dd/yyyy) Begin: 7. Other (specify): W6 W4 End: W5 12. Type of Ownership or Control (enter number in box below) 1. Private (non-profit) 3. State 2. Private (proprietary) 4. City/Town 13. Is this ICF/IID a distinct part of a Hospital, SNF or NF? (check one) Yes No W7 5. County 6. City/County 14. If "Yes" to block 13, indicate either: A. Hospital Provider Number: B. SNF Provider Number: C. NF Provider Number: W8 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 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: Name of CEO: Total Number of Beds: W14 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 O. Total number of QIDP Surveyors onsite W11 W12 State: Zip Code: Total Number of Clients: (including ICF/IID clients directly served) W15 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: from W20 to W21 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 (483.430(d)(3)) B. Registered Nurse (483.480(d)(3)) C. Licensed Voc./Practical Nurse (483.480(d)(2)) D. Total Personnel (List the Full Time Equivalent for all employees) FORM CMS-3070G (03/13) 18. Off-Campus Day Programs: W23 . . . . A. How many clients in the sample attend off-campus day programs? B. In how many off-campus day program sites was an observation done by the Surveyor? W27 W28 W24 W25 W26 1 4 American LegalNet, Inc. www.FormsWorkFlow.com 19. Individual Characteristics (NOTE: The total number in Items B­L (Col.(a)) may exceed the facility's population because some clients have multiple disabilities) A. AGE AND SEX (1) Age under 22(a) 22-45 (b) 46-65 (c) 66+ (d) Total: (2) Sex Male Female Total: B. DISABILITIES (1) Intellectual Disability Mild Moderate Severe Profound Total: (2) Autism (3) Cerebral Palsy (4) Epilepsy Controlled Uncontrolled Total: W44 W37 W34 W29 C. OTHER DISABILITIES (1) Non-ambulatory Mobile Non-Mobile Total: (2) Speech/Language Impairment (3) Hearing Impairment Hard of Hearing Deaf Total: (4) Visual Impairment Impaired Blind Total: D. MEDICAL CARE PLAN E. DRUGS TO CONTROL BEHAVIOR F. PHYSICAL RESTRAINTS G. TIME-OUT ROOMS H. APPLICATION OF PAINFUL OR NOXIOUS STIMULI I. NUMBER ATTENDING OFF CAMPUS DAY PROGRAMS J. NUMBER OF COURT ORDERED ADMISSIONS K. NUMBER OF CLIENTS OVER AGE 18 WITH A LEGAL GUARDIAN ASSIGNED BY THE COURT L. OTHER (specify) (1) (2) (3) W65 W54 W51 W47 W30 W48 W31 W49 W32 W50 W33 W52 W35 W53 W36 W55 W56 W38 W57 W39 W58 W40 W59 W41 W60 W42 W61 W43 W62 W63 W45 W64 W46 W66 W67 FORM CMS-3070G (03/13) American LegalNet, Inc. www.FormsWorkFlow.com 1 4 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES SURVEY REPORT M. ALLEGATIONS OF ABUSE AND NEGLECT No. of allegations of abuse investigated (a) No. of allegations of neglect investigated (b) Total: N. NUMBER OF DEATHS No. of deaths related to unusual incidents (a) No. of deaths related to restraints (b) No. of deaths for any reason (c) Total: W71 W68 W69 W70 W72 W73 W74 FORM CMS-3070G (03/13) American LegalNet, Inc. www.FormsWorkFlow.com 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 DEATHS (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 collecti