CMS-P-0015A MCBS Facility Round 46 Resident History

RH. RESIDENCE HISTORY

2006 Facility Interview
(Baseline and Core)

RH. RESIDENCE HISTORY
(BASELINE AND CORE)

BOX RHA

If SP is a live continuing facility resident still in the facility, go to RH2PRE.
If this is the first CAPI Residence History for this SP in this facility, go to RH1PRE.
If the SP is deceased at the end of previous round reference period, no Residence
History data is collected.

RH1PRE
Now, I would like to ask you about the places where {SP} stayed for one night or more between {January 1,
1997/January 1, {YEAR}/{her/his} admission to this facility} and today including staying in {other parts of
{FACILITY},} hospitals or other places. In answering these questions, it might be helpful for you to review records
that show discharges or transfers from {FACILITY/ELIGIBLE UNIT} to hospitals or other places.
PRESS ENTER TO CONTINUE. (BOX RH1)

RH2PRE
On my last visit {on {DATE OF PREVIOUS ROUND FACILITY INTERVIEW}}, {SP} was alive and a resident of
{UNIT WHERE SP WAS RESIDENT ON DATE OF PREVIOUS ROUND INTERVIEW/HOSPITAL NAME}. Now, I
would like to ask you about all the places {SP} has stayed since my last visit, including staying in {other parts of
{FACILITY},} hospitals or other places.
PRESS ENTER TO CONTINUE. (BOX RH1)

BOX RH1

If CFR
If Round=18, go to BOX RH1D.
Else, go to RH7.
If SSM1, go to RH2.
Otherwise, go to RH2A.

BOX RH1A - RH1 omitted.

1

RH. RESIDENCE HISTORY

2006 Facility Interview
(Baseline and Core)

RH2
On what date was {SP} most recently admitted to {FACILITY/ELIGIBLE UNIT}?
ADMIN
ORIGADMN

MONTH ( )

DAY ( )

YEAR ( )

RH2A
On what date do your records show {SP} was admitted to {FACILITY}?
IF SP NEVER ADMITTED, ENTER SHIFT/5 IN MONTH FIELD.
MONTH ( )
BOX RH2

DAY ( )

(RHENDB)

YEAR ( )

If facility has more than one unit go to RH2B, otherwise If SSM, go to BOX RH4. Else,
go to RH7.

2

RH. RESIDENCE HISTORY

2006 Facility Interview
(Baseline and Core)

RH2B
Where was {SP} a resident on {1/1/{YEAR}/FAD/RAD}?
IF A BED WAS HELD FOR SP, PROBE: Where was the bed that was held for SP on {FAD/RAD}?
{PLACE ROSTER VERSION 4}
USE ARROW KEYS. TO SELECT/DESELECT, PRESS ENTER. TO EXIT, PRESS ESC.

BOX RH3

Go to BOX RH4.

RH3
Please tell me the name and title of someone in {ELIGIBLE FACILITY} who could give me that information.
RECORD RESPONDENT INFORMATION ON PAPER FROG.
PRESS ENTER TO CONTINUE.

PROGRAMMER SPECS: Go to RHEND.

Box RH2 omitted.
RH4 omitted.
Box RH3 omitted.

BOX RH4

If SSM, ask RH6. Otherwise, go to RH7.

3

RH. RESIDENCE HISTORY

2006 Facility Interview
(Baseline and Core)

RH6
ASK IF NOT OBVIOUS.
Is {SP} male or female?
ROSTSEX

MALE ..........................................................................................
FEMALE......................................................................................

1
2

YES .............................................................................................
NO...............................................................................................
DK ...............................................................................................
RF ...............................................................................................

1
0
-8
-7

RH7
Is {SP} alive?

4

(BOX RH5)
(RH8)
(BOX RH5)
(BOX RH5)

RH. RESIDENCE HISTORY

2006 Facility Interview
(Baseline and Core)

RH8
On what date did {SP} die?
IF RESPONDENT ANSWERS "DK," PROBE: "Do you know what month {SP} died?"
MONTH ( )

BOX RH6

BOX RH5

DAY ( )

YEAR ( )

If month or year of death is DK or RF, go to RH3.
If day is DK or RF, set Date of Death to last day of month or today's date if month
of death = DOI month. Set flag to indicate current end of round reference
date was set to the end of the month and flag for retrieval. Go to BOX RH5.
Else, go to BOX RH5.

If current round is 26, and:
person entered facility before Round 22, or;
person entered facility at or after Round 22
and did not get BQ, continue.
Else, go to BOX RH7.

BQ10A.
{Is/Was} {SP} of Hispanic or Latino origin?
HISPORG
D_ETHNIC

YES..............................................................................................
NO................................................................................................

5

1
0

RH. RESIDENCE HISTORY

2006 Facility Interview
(Baseline and Core)

BQ11A.
Please look at this card and tell me what {is/was} {SP}’s race. SELECT ALL THAT APPLY.

SHOW
CARD
RH1

BOX RH7

RACEAI
RACEAS
RACEAA
RACENH
RACEWH
RACEOTH
D_RACE
D_RACE2

AMERICAN INDIAN OR ALASKAN NATIVE
ASIAN
BLACK OR AFRICAN AMERICAN
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
WHITE
ANOTHER RACE (SPECIFY)

If SP is deceased:
- Set the current end of round reference period to the date of death from RH8.
- If day was DK or RF in RH8, set the date of death from BOX RH6.
Otherwise set the end of the current round end of reference period to the current
DOI (display "today").
If SSM1 or SSM2, go to RH9.
Others go to BOX RH9A.

6

RH. RESIDENCE HISTORY

2006 Facility Interview
(Baseline and Core)

RH9
What {is/was} {SP's} date of birth? ENTER A 4-DIGIT YEAR.
D_DOB

BOX RH9

MONTH ( ) DAY ( )

YEAR (

)

If year of birth is DK or RF, go to RH10. Otherwise, go to BOX RH9A.

RH10
Approximately how old {is/was} {SP}?
APPROXIMATE AGE IN YEARS (

BOX
RH9A

)

If SSM1, CFC, FFC, or FCF, go to RH11B.
If SSM2 go to RH43PRE.
If the SP was a live CFR, go to RH11A.

RH11PRE omitted.

7

RH. RESIDENCE HISTORY

2006 Facility Interview
(Baseline and Core)

RH11A
{Between {DATE OF PREVIOUS ROUND FACILITY INTERVIEW}, (the date of my last visit) and {CURRENT
ROUND END OF REFERENCE PERIOD} has {SP} been in {UNIT WHERE SP WAS A RESIDENT ON DATE OF
PREVIOUS ROUND INTERVIEW} the whole time or has {she/he} spent one or more nights {in [READ UNITS
BELOW],} in a hospital, or in some other place?
YES, WHOLE TIME ....................................................................
NO, OTHER PLACE ...................................................................
DK ................................................................................................
RF ................................................................................................

1
0
-8
-7

(BOX RH10)
(RH13)
(BOX RH10)
(BOX RH10)

{PLACE ROSTER VERSION 3}

RH11B
Between {REF DATE} and today has {SP} been in {FACILITY/ELIGIBLE UNIT} the whole time or has {she/he} spent one
or more nights {in [READ UNITS BELOW],} in a hospital, or in some other place?
YES, WHOLE TIME ....................................................................
NO, OTHER PLACE ...................................................................
DK................................................................................................
RF ................................................................................................

1
0
-8
-7

(BOX RH10)
(RH13)
(BOX RH10)
(BOX RH10)

1
0
-8
-7

(BOX RH10)
(RH13)
(BOX RH10)
(BOX RH10)

{PLACE ROSTER VERSION 3}

RH12
Between {RH13 DATE} and today was {SP} in {CURRENT PLACE} the whole time?
YES, WHOLE TIME ....................................................................
NO, LEFT ....................................................................................
DK................................................................................................
RF ................................................................................................

8

RH. RESIDENCE HISTORY

BOX
RH10

2006 Facility Interview
(Baseline and Core)

If coming from RH11A and RH11A is YES, or
coming from RH11B and RH11B is YES, or
coming from RH12 and RH12 is YES:
If SP is alive or vital status is not known, go to BOX RH27.
Else, go to RH12A.
Else, if coming from RH11A and RH11A is -8 (DK) or -7 (RF), or
coming from RH11B and RH11B is -8 (DK) or -7 (RF), or
coming from RH12 and RH12 is -8 (DK) or -7 (RF):
If the SP is alive or vital status is not known, go to RH12B.
Else, go to RH12A.

RH12A
Was {she/he} in {CURRENT PLACE} when {she/he} died on {DATE OF DEATH} or somewhere else?
IN {CURRENT PLACE} ...............................................................
SOMEWHERE ELSE .................................................................
DK ...............................................................................................
RF ..............................................................................................

1
0
-8
-7

(BOX RH27)
(RH13)
(BOX RH27)
(BOX RH27)

1
0
-8
-7

(BOX RH27)
(RH13)
(BOX RH27)
(BOX RH27)

RH12B
Is {she/he} still at {CURRENT PLACE}?
YES ............................................................................................
NO ..............................................................................................
DK ...............................................................................................
RF ..............................................................................................

9

RH. RESIDENCE HISTORY

2006 Facility Interview
(Baseline and Core)

RH13
DATE

START DATE: {START DATE}

When did {SP} leave {CURRENT PLACE}?
MONTH (

BOX
RH11

) DAY (

) YEAR (

)

If RH13 date is missing or partially missing, go to RH14.
Else go to RH21.

RH14
About how many nights did {she/he} spend there?
# OF NIGHTS (

RH15-20 omitted.

BOX RH12 omitted.

10

) (RH21)

RH. RESIDENCE HISTORY

2006 Facility Interview
(Baseline and Core)

TIMELINE MATRIX/FORM
PLACE ROSTER

RH21
{Where did {she/he} go on {RH13 DATE}/Where is {she/he}living now/
Where was {she/he} staying when {she/he} died on {DATE OF DEATH}/What was the name of that place?}?
{PLACE ROSTER VERSION 2}
USE ARROW KEYS. ENTER=SELECT/DESELECT. CTRL/A=ADD. CTRL/D=DELETE. ESC=EXIT.
DISCHTO
DISCHTOS
FACDISC
FACDIOS

BOX
RH13

If place added, go to RH22.
Otherwise, (place selected):
If coming from pre-stay, go to RH44A.
If not coming from RH12A or RH12B and place selected is a target facility unit, go
to BOX RH24.
If place selected is a hospital, go to BOX RH15A.
Otherwise, go to BOX RH18.

RH21A omitted.
BOX RH14 omitted.

11

RH. RESIDENCE HISTORY

2006 Facility Interview
(Baseline and Core)

RH22
Please look at this card and tell me what kind of place {NAME FROM RH21} is.

SHOW
CARD
RH1

OTHER NURSING HOME/REHAB CENTER......................... 1
PERSONAL CARE HOME/RESIDENTIAL CARE FACILITY . 2
CCRC/RETIREMENT HOME/CENTER ................................. 3
HOSPITAL.............................................................................. 4
PRIVATE HOME OR APARTMENT....................................... 5
OTHER LTC FACILITY .......................................................... 7
ADMFROS OTHER (SPECIFY: _____________________)..................... 91

PRESS F1 FOR DEFINITIONS.

RH22A-RH22G omitted.

Set place type to answer coded in RH22.

BOX
RH15

If coming from pre-stay and RH22 = 1, go to RH27.
Else, if RH22 = 1, 2, or 7 (PLACKIND = 1, 2, or 7), Classify as eligible LTC stay, set
flag to search NHPI if not previously searched, and go to BOX RH24.
Else if RH22 = 3 (PLACKIND = 3), go to BOX RH18.
Else if RH22 = 4 (PLACKIND = 4), classify as hospital stay and go to BOX RH15A.
Otherwise (RH22 = 5 or 91 (PLACKIND = 5 or 91), classify as community stay and go
to RH30.

12

RH. RESIDENCE HISTORY

2006 Facility Interview
(Baseline and Core)

HOSPITAL QUESTIONS

RH23 omitted.

BOX
RH15A

If hospital not previously searched call LOOKUP module with: place: hospital name
from RH21 directory: AHA
If LOOK-UP module returned "Not found, interviewer added name and address", or
"Not found, interviewer unable to add name and address", or "Found, hospital
does not have a SNF wing", classify as hospital stay:
If coming from RH12A or RH12B, go to BOX RH31.
Else, go to BOX RH24.
Else, LOOK-UP module returned, "Found, hospital does have a SNF wing", go to
RH25.

RH24 and BOX RH16 omitted.

RH25
Was {SP} staying in a SNF wing or SNF unit of {HOSPITAL NAME FROM RH21}?
YES..............................................................................................
NO................................................................................................
DK ................................................................................................
RF ................................................................................................

BOX
RH17

1
0
-8
-7

If RH25 = "1," classify as eligible LTC stay. Otherwise, classify as hospital stay.
If coming from RH12A or RH12B, go to BOX RH31.
Else, go to BOX RH24.

RH25A omitted.

BOX RH17A and RH25B omitted.

13

RH. RESIDENCE HISTORY

2006 Facility Interview
(Baseline and Core)

OTHER PLACE QUESTIONS
RH25A omitted.
RH26 omitted.

BOX
RH18

If PLACKIND = 1, 2, or 7, classify as eligible LTC stay:
If coming from RH12A or RH12B, search on NHPI if not previously searched
and go to BOX RH31.
Else, set flag to search on NHPI if not previously searched, and go to BOX
RH24.
If PLACKIND = 5 or 91, classify as community stay and go to RH30.
Else, if PLACKIND = 3, go to RH27.

RH27
Was {she/he} staying in a nursing wing, nursing unit, assisted living unit, or personal care unit of {PLACE NAME
FROM RH21}?
YES..............................................................................................
NO................................................................................................
DK ................................................................................................
RF ................................................................................................

BOX
RH19

1
0
-8
-7

If RH27 = 1, classify as eligible LTC stay:
If coming from RH12A or RH12B, search on NHPI if not previously searched
and go to BOX RH31.
Else, set flag to search on NHPI if not previously searched, and go to BOX
RH24.
Otherwise, go to RH29.

RH28 omitted.
RH29
Was {she/he} staying in a private home or apartment at {PLACE NAME FROM RH21}?
YES .............................................................................................
NO...............................................................................................
DK ...............................................................................................
RF ...............................................................................................

BOX
RH21

If RH29 =1, classify as community stay and go to RH30.
Else, classify as eligible LTC stay:
If coming from RH12A or RH12B, go to BOX RH31.
Else, go to BOX RH24.

14

1
0
-8
-7

RH. RESIDENCE HISTORY

2006 Facility Interview
(Baseline and Core)

RH30
Who {lives/lived} with {her/him} there?
SELECT ALL THAT APPLY.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
91.
92.
93.

ALONE
SPOUSE
DAUGHTER
SON
MOTHER
FATHER
SISTER
BROTHER
DAUGHTER-IN-LAW
SON-IN-LAW
GRANDDAUGHTER
GRANDSON
NIECE
NEPHEW
FRIEND
NURSE/AIDE
BOARDER
GUARDIAN
OTHER FEMALE RELATIVE, SPECIFY
OTHER MALE RELATIVE, SPECIFY
OTHER NONRELATIVE, SPECIFY

LIVWRELA

{How many {PLURAL FORM OF RELATIONSHIP CODE} {live/lived} there? (

)}

RH31
When there, {does/did} {SP} receive help with home health services from someone who {is/was} paid?
YES..............................................................................................
NO ...............................................................................................
DK................................................................................................
RF ................................................................................................
PRESS F1 FOR DEFINITION OF PAID HOME HEALTH SERVICES.

RH32 - RH34, BOX RH22 - BOX RH23 omitted.

BOX
RH24

If coming from pre-stay, go to RH44A.
If coming from RH12A or RH12B, go to BOX RH31.
Else, go to RH12.

RH35 omitted.
RH36 moved to after BOX RH31.
RH37-38 omitted.
BOX RH25, RH26 omitted.
RH39 - RH42 omitted.

15

1
0
-8
-7

RH. RESIDENCE HISTORY

2006 Facility Interview
(Baseline and Core)

PRE-STAY ITEMS

BOX
RH26A

If current stay includes 1/1/{CURRENT YEAR} or is Shift/5, go to RH11B.
If first time here, go to RH43PRE.
Otherwise, go to RH44.

RH43PRE
Now, I would like to ask you about the places where {SP} stayed before {she/he} came to {FACILITY} on {FAD}
including staying in a hospital.
PRESS ENTER TO CONTINUE.

(RH44)

RH44
Do you know where {SP} stayed immediately before {she/he} came to {FACILITY/FAD UNIT/PLACE FROM RH21}
on {FAD/DATE FROM RH44A}?
YES..............................................................................................
NO................................................................................................

1
0

(RH21)
(RH45)

RH44A
When did {she/he} start staying at {PLACE NAME FROM RH21}?
PROBE FOR YEAR.
IF R NEVER WILL KNOW YEAR, ENTER SHIFT/5 IN MONTH.
MONTH (

BOX
RH26B

) DAY (

) YEAR (

)

(BOX RH26B)

If date in RH44A is on or before 1/1/{YEAR}, go to RH11B.
Else, go to BOX RH26A.

RH45
Please tell me the name and title of someone in {FACILITY} who could give me that information.
RECORD RESPONDENT INFORMATION ON PAPER FROG.
PRESS ENTER TO CONTINUE.

(RH11B)

RH46, RH47 omitted.

16

RH. RESIDENCE HISTORY

2006 Facility Interview
(Baseline and Core)

NHPI LOOKUP

BOX
RH27

If there are no places to search on the NHPI, go to BOX RH31 (tracing contact).
Otherwise, go to LOOKPRE.

LOOKPRE
Now I need to look up the {NUMBER/the} {place/places} you told me about.
PRESS ENTER TO CONTINUE.

BOX
RH28

BOX
RH29

Call LOOKUP module with:
place:
next place flagged to search NHPI
directory: NHPI

Go to BOX RH27.

BOX RH29A omitted.

17

RH. RESIDENCE HISTORY

2006 Facility Interview
(Baseline and Core)

TRACING CONTACT

BOX
RH31

If SP is alive and not a resident of an eligible or ineligible LTC unit of facility, go to
RH36.
Otherwise, go to RH49A.

RH36
Earlier you told me {SP} had been discharged to {DISCHARGE PLACE}.
Was {SP} formally discharged from {FACILITY/UNIT} for the stay at {LAST PLACE NAME FROM RH21} that began
on {LAST DATE FROM RH13}?
YES .............................................................................................
NO ...............................................................................................
DK ...............................................................................................
RF ...............................................................................................

1
0
-8
-7

PRESS F1 FOR DEFINITION OF FORMAL DISCHARGE
RH48
Please tell me the name, address, and telephone number of someone we could contact to keep track of {SP} at
{DISCHARGE PLACE}.
CONTACT NAME
STREET ADDRESS
CITY, STATE, ZIP CODE
(AREA CODE) TELEPHONE NUMBER
PROGRAMMER SPEC: If DK or RF entered in contact name field go to RH49A, otherwise go to RH49.

18

RH. RESIDENCE HISTORY

2006 Facility Interview
(Baseline and Core)

RH49
What is the relationship of {CONTACT NAME FROM RH48} to {SP}?
SELECT ONE.
1. SP
2. SPOUSE
3. DAUGHTER
4. SON
5. MOTHER
6. FATHER
7. SISTER
8. BROTHER
9. DAUGHTER-IN-LAW
10. SON-IN-LAW
11. GRANDDAUGHTER
12. GRANDSON
13. NIECE
14. NEPHEW
15. FRIEND/NEIGHBOR
16. NURSE/NURSE'S AIDE
17. BOARDER
18. GUARDIAN
91. OTHER FEMALE RELATIVE, SPECIFY
92. OTHER MALE RELATIVE, SPECIFY
93. OTHER NONRELATIVE, SPECIFY
-8. DK
-7. RF

19

RH. RESIDENCE HISTORY

2006 Facility Interview
(Baseline and Core)

BOX RH32, RH33 omitted.
RH49A
WAS “CONSENT” REQUIRED AND OBTAINED FOR THIS SP?
YES.........................................................
NO ..........................................................

1
2

(RH50)

PRESS F1 FOR A DEFINITION OF “CONSENT”.

RH49B
WAS THE “CONSENT” WRITTEN OR VERBAL (BY TELEPHONE)?
WRITTEN ...............................................
VERBAL..................................................

1
2

ALL .........................................................
MAJORITY..............................................
HALF.......................................................
SOME .....................................................
NONE .....................................................

1
2
3
4
5

RH50
DID YOU ABSTRACT?

(RHEND)

RH51
WHY DID YOU ABSTRACT?
NO KNOWLEDGEABLE RESPONDENT AVAILABLE ................ 1
NO TIME/STAFF BURDEN TOO GREAT ................................... 2
REFUSAL--UNWILLING TO COOPERATE................................. 3
OTHER (SPECIFY:_____________________) .......................... 91

RHEND
YOU HAVE COMPLETED Residence History FOR THIS SP. THANK RESPONDENT AND PRESS ENTER TO
RETURN TO THE NAVIGATION SCREEN.

20

RH. RESIDENCE HISTORY

2006 Facility Interview
(Baseline and Core)

21