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
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
10. State/County Code
11. Dates of Survey (mm/dd/yyyy)
Begin:
End:
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12. Type of Ownership or Control (enter number in box below)
1. Private (non-profit)
3. State
5. County
7. Other (specify):
2. Private (proprietary)
4. City/Town
6. City/County
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13. Is this ICF/IID a distinct part of a
14. If “Yes” to block 13, indicate either:
Hospital, SNF or NF? (check one)
A. Hospital Provider Number:
B. SNF Provider Number:
C. NF Provider Number:
Yes
No
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15. Survey Team Composition
16. Facility Data
Column 1: Indicate the number of disciplines
A. Is this ICF/IID a residential unit within a larger organization or agency in the State that
represented on the Survey team.
provides residential services to individuals with intellectual disabilities? (check one)
Column 2: Of the number in Column 1 represented on
Yes
No If “No”, proceed to item C.
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the Survey team, indicate the number who also qualify
as a QIDP. Indicate Name(s) and Title(s) on last page of
B. If “Yes,” indicate name and address of larger organization.
this form.
Name:
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A. Administrator
Address:
B. Nurse
City:
State:
Zip Code:
C. Dietitian
Name of CEO:
D. Pharmacist
Total Number of Beds:
Total Number of Clients:
E. Records Administrator
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(including ICF/IID clients directly served)
F. Social Worker
C. Total Number of ICF/IID Clients:
G. LSC Specialist
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H. Laboratorian
D. Is this ICF/IID community-based? (check one)
Yes
No
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I. Sanitarian
E. Total number of ICF/IID beds under this Provider No:
J. Therapist
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K. Physician
F. Total number of discrete living units under this Provider No:
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L. Psychologist
G. Age range of clients served:
from
to
M. Other (specify):
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N. Total number of Surveyors onsite
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H. Total number of off-campus day program sites used by ICF/IID clients:
O. Total number of QIDP Surveyors onsite
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17. Staffing: List the full time equivalents who function in this capacity:
18. Off-Campus Day Programs:
A. Direct Care Personnel
A. How many clients in the sample attend
.
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(483.430(d)(3))
off-campus day programs?
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B. Registered Nurse
B. In how many off-campus day program sites was
.
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(483.480(d)(3))
an observation done by the Surveyor?
C. Licensed Voc./Practical Nurse
.
(483.480(d)(2))
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D. Total Personnel (List the Full Time
.
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Equivalent for all employees)
FORM CMS-3070G (03/13)
1 4
1
2
3
4
Individual Service Plan (isp) For Individuals With Developmental Disabilities Living In The Community Template
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Form Ar1000rc5 - Arkansas Certificate For Individuals With Developmental Disabilities - 2014
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