COURT COUNTY .OF. . . . SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DEPARTMENT.OF.HEALTH AND HUMAN . . . . . . . ...... .. CENTERS FOR MEDICARE & MEDICAID SERVICES : Index No. FORM APPROVED OMB NO. 0938-0062 INTERMEDIATE CARE FACILITY FOR PERSONS WITH MENTAL RETARDATION : DEFICIENCIES REPORT Calendar No. Name of Facility DEFICIENCIES 1. DATA TAG NO. -against- : JUDICIAL SUBPOENA : Plaintiff(s) COMMENTS 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. Plaintiff(s) -against- : Index No. FORM APPROVED OMB NO. 0938-0062 COMMENTS Calendar No. JUDICIAL SUBPOENA : : : 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 : FORM APPROVED OMB NO. 0938-0062 Index No. 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 SIGNATURE TITLE DATE : : DATE Defendant(s) TITLE : ...................................................... DATE SIGNATURE SIGNATURE TITLE DATE PEOPLE OF THE STATE OF NEW YORK TITLE DATE SIGNATURETO TITLE DATE SIGNATURE TITLE DATE TITLE DATE SIGNATURETHE GREETINGS: SIGNATURE 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, SIGNATUREthe 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 day of DATE , one of the Justices of the , 20 SIGNATURE TITLE DATE SIGNATURE TITLE SIGNATURE TITLE SIGNATURE TITLE DATE SIGNATURE TITLE DATE SIGNATURE TITLE SIGNATURE TITLE DATE (Attorney must sign above and type name below) DATE Attorney(s) for Office and P.O. Address FORM CMS-3070H (11/00) DATE Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: DATE American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DEPARTMENT.OF.HEALTH AND HUMAN . . . . . . . ...... .. CENTERS FOR MEDICARE & MEDICAID SERVICES : Index No. FORM APPROVED OMB NO. 0938-0062 INTERMEDIATE CARE FACILITY FOR PERSONS WITH MENTAL RETARDATION : DEFICIENCIES REPORT-INSTRUCTIONS No. Calendar Plaintiff(s) : 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 signatures. 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.: 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 Facsimile No.: 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 E-Mail Address: 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, 7500 Security Boulevard, Baltimore, N2-14-26, Maryland 21244-1850. Mobile Tel. No.: FORM CMS-3070H (11/00) American LegalNet, Inc. www.USCourtForms.com