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pdfFQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
FQ. FACILITY SCREENER QUESTIONNAIRE
(SCREENER ONLY)
RESPONDENT ROSTER
RR1-7
The Respondent Roster is a list (at the facility level) of all respondents (and potential respondents) identified in
the course of data collection.
RESPONDENT ROSTER
RR1
NAME
RR2
TITLE
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
RR2
Fill with entry in RR2.
Display the following list of codes in an F1 screen:
HEALTH CARE AND MEDICAL RECORDS STAFF TITLES
01
02
03
04
05
06
07
=
=
=
=
=
=
=
Director Of Nursing/VP Of Nursing
Assistant Director Of Nursing
Head Nurse/Nurse Supervisor/Charge Nurse
Nurse, Floor/Shift
Social Worker/Case Worker/Activities Coordinator Or Director
Medical Records Clerk/Supervisor/Director
Nurses Aide
MDS/QUALITY CONTROL TITLES
11
12
13
14
=
=
=
=
MDS Coordinator/Nurse
Case Mix Coordinator/Nurse
Care Plan Coordinator/Nurse
Quality Assurance Coordinator
ADMINISTRATIVE TITLES
21
22
23
24
25
26
27
28
=
=
=
=
=
=
=
=
Owner
Administrator/Executive Director
Assistant Administrator/Administrator In Training
Medical Director
Admissions Director/Coordinator
Human Resources Staff Member
VP For Operations
Administrative Assistant/Secretary/Receptionist
BUSINESS OR FINANCE TITLES
30
31
32
33
34
35
=
=
=
=
=
=
VP For Finance
Controller/Comptroller
Business Office Manager
Accounting Supervisor
Accounting/Billing Or Accounts Receivable Clerk/Bookkeeper
Electronic Data Processing Staff Member
91
=
OTHER (SPECIFY:
)
RR2
What is {RESPONDENT'S NAME}'s title or position?
SELECT ONE.
{TITLE CATEGORIES}
RR3-5 omitted.
2
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
SECTION FA. FACILITY DEFINITION
BOX FA1
If FA1-FA18 have already been completed, but ELIGIBILITY BLOCK (FA19-22) has
not been completed for all facility parts, and a respondent is selected who was
entered in FA18, go to FA17, p. 36.
Others, go to FAVERIF1.
FAVERIF1
IF SP IN AN ADULT/GROUP HOME OR SIMILAR RESIDENCE AT ANOTHER LOCATION, CODE "2" OR "3"
WITHOUT ASKING.
Before we begin, I need to verify that our information about you is correct.
Is {FACILITY} the exact name of this facility?
YES..............................................................................................
NO................................................................................................
1
0
IF ADULT/GROUP HOME
DISPLAYED GROUP HOME NAME IS CORRECT.....................
DISPLAYED GROUP HOME NAME IS NOT CORRECT ............
DK ................................................................................................
RF ................................................................................................
2
3
-8
-7
What is the exact name of this facility?
_____________________
FACILITY NAME
REASON FOR NAME UPDATE:
CORRECTING A TYPOGRAPHICAL ERROR ..........................1
CORRECTING SOME OTHER KIND OF ERROR.....................2
SPECIFYING MORE COMPLETE INFORMATION ...................3
FACILITY CHANGED ITS NAME
WHEN BOUGHT BY ANOTHER COMPANY..........................5
FACILITY CHANGED ITS NAME FOR SOME
OTHER REASON ...................................................................6
ADULT/GROUP HOME .............................................................9
OTHER (SPECIFY:_____________________) .......................91
FAVERIF2 moved.
FAVERIF3
{Is the address of the place where [SP NAME} lives.../Is {FACILITY}'s address...}
{ADDRESS1}
{CITY, STATE ZIP}?
YES..............................................................................................
NO................................................................................................
DK ................................................................................................
RF ................................................................................................
3
1
0
-8
-7
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
If 0 is entered in FAVERIF3, review address fields. If interviewer pressed enter on
each and all fields, go to FAVERIF4. Else, present ADDRESS UPDATE
SCREEN. Set a flag to indicate a change has been made. The ADDRESS
UPDATE screen collects the reason for change.
Else, continue.
BOX
FA1A
REASON FOR ADDRESS UPDATE: (
)
CORRECTING A TYPOGRAPHICAL ERROR ...........................
CORRECTING SOME OTHER KIND OF ERROR......................
SPECIFYING MORE COMPLETE INFORMATION ...................
FACILITY MOVED TO A DIFFERENT ADDRESS .....................
FACILITY CHANGED ITS ADDRESS FOR
SOME OTHER REASON .........................................................
ADULT/GROUP HOME...............................................................
OTHER (SPECIFY:_____________________) ..........................
1
2
3
7
8
9
91
FAVERIF4
{CODE "2" WITHOUT ASKING.}
{{Is ADMINISTRATOR'S NAME} {Are you/You are}} {still} the current administrator of {FACILITY}?
YES .............................................................................................
NO...............................................................................................
{RESPONDENT CONSIDERED ADMINISTRATOR...................
DK ..................................................................................................
RF .................................................................................................
1
0
2}
-8
-7
After the NAME has been entered and the TITLE confirmed, return to FAVERIF4 at the ADMINISTRATOR UPDATE
SCREEN. The UPDATE screen captures the reason for the change:
REASON FOR ADMINISTRATOR NAME UPDATE: (
)
CORRECTING A TYPOGRAPHICAL ERROR ..........................1
CORRECTING SOME OTHER KIND OF ERROR.....................2
SPECIFYING MORE COMPLETE INFORMATION ...................3
FACILITY CHANGED ADMINISTRATORS ..............................4
OTHER (SPECIFY:_____________________) .......................91
FAVERIF5
{VERIFY PHONE NUMBER IS FOR FQ RESPONDENT. DO NOT READ ALOUD.}
Is {FACILITY AREA CODE AND PHONE NUMBER} the correct phone number for {FACILITY}?
YES..............................................................................................
NO................................................................................................
DK ................................................................................................
RF ................................................................................................
What is the phone number?
(
)(
)-(
)
{Area code and state do not match. Verify and re-enter state and area code.}
4
1
0
-8
-7
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
The second UPDATE screen collects the reason for the change:
REASON FOR UPDATE: (
)
CORRECTING A TYPOGRAPHICAL ERROR ..........................1
CORRECTING SOME OTHER KIND OF ERROR.....................2
SPECIFYING MORE COMPLETE INFORMATION ...................3
FACILITY MOVED TO A DIFFERENT ADDRESS.....................7
ADULT/GROUP HOME .............................................................9
AREA CODE CHANGED .........................................................10
OTHER (SPECIFY:_____________________) .......................91
BOX
FA1B
If FAVERIF1=2 or 3, go to FAVERIF3A.
If baseline FQ, go to FAVERIF5A.
Else, go to BOX FA2.
FAVERIF3A
Is your office address...
{ADDRESS1}
{CITY, STATE ZIP}?
YES..............................................................................................
NO................................................................................................
RF ................................................................................................
BOX
FA1C
If 0 is entered in FAVERIF3A, review address fields:
If interviewer pressed enter on each and all fields, go to BOX FA2.
Else, present ADDRESS UPDATE SCREEN.
Else, go to BOX FA2.
5
1
0
-7
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
FAVERIF5A
When was {FACILITY} founded?
ENTER A 4-DIGIT YEAR.
MONTH (
) YEAR (
)
FAVERIF5B
Did it previously have a different name or address?
YES..............................................................................................
NO ...............................................................................................
1
0
(FAVERIF6)
FAVERIF5C
What was the previous name and address?
{FACILITY}
{ADDRESS)
(CITY, STATE, ZIP}
BOX
FA1D
Post name and address to the indicated variable names. Review fields:
If interviewer pressed enter on each field, go to FAVERIF6.
Else, continue.
FAVERIF5D
When did the name change occur?
ENTER A 4-DIGIT YEAR.
MONTH (
) YEAR (
)
FAVERIF6
Is {FACILITY} part of a chain--that is, a group of long-term care facilities operating under common management?
YES..............................................................................................
NO................................................................................................
PRESS F1 FOR EXPANDED DEFINITION.
BOX FA2
If Baseline FQ, go to FA1PRE.
If fall round, go to BOX FB1A.
If no FQ in or after most recent fall round, go to BOX FB1A.
Else, go to CLOSING 1.
6
1
0
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
FACILITY-LEVEL QUESTIONNAIRE
FA1PRE
Now I have a few questions about the structure of {FACILITY} and its certification and licensing to confirm that it
is eligible for this study.
PRESS ENTER TO CONTINUE.
BOX
FA1PRE
If FAVERIF6 = 1 (YES, FACILITY IS PART OF A CHAIN), go to FA1A.
Else, go to FA1.
FA1A
I understand that {FACILITY} is part of a chain -- that is, a group of long-term care facilities operating under
common management. Setting that aside, this next question is about the physical location of the home here.
PRESS ENTER TO CONTINUE.
FA1
Is {FACILITY} a free-standing nursing home?
PROBE: Free-standing nursing homes are not physically part of any other place or organization.
YES..............................................................................................
NO ...............................................................................................
1
0
(FAVERIF2)
(FAVERIF2)
IF VOLUNTEERED: {FACILITY} IS ...
CONTINUING CARE RETIREMENT COMMUNITY (CCRC) .....................
NURSING HOME/UNIT WITHIN A CCRC OR RETIREMENT CENTER.....
RETIREMENT COMMUNITY.......................................................................
HOSPITAL ...................................................................................................
HOSPITAL-BASED SNF UNIT ....................................................................
ASSISTED LIVING FACILITY......................................................................
BOARD AND CARE HOME .........................................................................
DOMICILIARY CARE HOME .......................................................................
PERSONAL CARE HOME...........................................................................
REST HOME/RETIREMENT HOME ...........................................................
MENTAL HEALTH CENTER/PSYCHIATRIC SETTING ..............................
INSTITUTION FOR THE MENTALLY
RETARDED/DEVELOPMENTALLY DISABLED.......................................
REHABILITATION FACILITY.......................................................................
ADULT/GROUP HOME ...............................................................................
HOME/MGMT. OFFICE FOR CHAIN/OFF-SITE NURSING FACILITIES....
OTHER (SPECIFY:_________)...................................................................
DK................................................................................................................
RF ................................................................................................................
PRESS F1 FOR DEFINITION OF FREE-STANDING AND HOSPITAL-BASED SNFS.
FAVERIF2
IF ALREADY KNOWN, CODE WITHOUT ASKING:
Do you prefer that I call {FACILITY} a home or a facility?
PREFERS HOME ........................................................................
PREFERS FACILITY ...................................................................
NO PREFERENCE ......................................................................
7
1
2
3
3
4
5
6
7
8
9
10
11
12
15
(BOX FA5)
(FA9)
(BOX FA5)
(BOX FA5)
(FA9)
(FAVERIF2)
(FAVERIF2)
(FAVERIF2)
(FAVERIF2)
(FAVERIF2)
(FAVERIF2)
16
17
18
13
91
-8
-7
(FAVERIF2)
(FAVERIF2)
(BOX FA5)
(FA5A)
(FAVERIF2)
(FAVERIF2)
(FAVERIF2)
FQ. FACILITY SCREENER QUESTIONNAIRE
BOX
FA2A
2006 Facility Interview
(Screener Only)
If FA1 = 1, go to FA19.
Else, continue.
FA2
Is {FACILITY} part of a larger {home/facility} or campus?
YES..............................................................................................
NO ...............................................................................................
DK................................................................................................
RF ................................................................................................
1
0
-8
-7
PRESS F1 FOR DEFINITION, EXAMPLES OF "LARGER" PLACES.
BOX FA3
If FA1 = 8, 9, 10, 11, 12, 15, 16, 17, or 91 and FA2 = 0, -8 or -7 go to BOX FA5.
If FA2 = 1, go to FA3.
Others, go to FA5.
FA3
IF ALREADY VOLUNTEERED, CODE WITHOUT ASKING:
What type of place is {FACILITY} part of?
SHOW
CARD
FA1
CONTINUING CARE RETIREMENT
COMMUNITY (CCRC) ........................................................
RETIREMENT COMMUNITY...............................................
HOSPITAL ...........................................................................
ASSISTED LIVING FACILITY..............................................
BOARD AND CARE HOME .................................................
DOMICILIARY CARE HOME ...............................................
PERSONAL CARE HOME...................................................
REST HOME........................................................................
OTHER (SPECIFY:___________________) .......................
PRESS F1 FOR HOSPITAL DEFINITIONS.
FA4
What is the name of the {CATEGORY SELECTED IN FA3/place}?
__________________________________________________
BOX FA4
Add to Place Roster, then
Go to BOX FA5.
8
3
5
6
8
9
10
11
12
91
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
FA5
What type of place is {FACILITY}?
SHOW
CARD
FA2
CONTINUING CARE RETIREMENT COMMUNITY (CCRC) .....................
NURSING HOME/UNIT WITHIN A CCRC OR RETIREMENT CENTER.....
RETIREMENT COMMUNITY.......................................................................
HOSPITAL ...................................................................................................
HOSPITAL-BASED SNF UNIT ....................................................................
ASSISTED LIVING FACILITY......................................................................
BOARD AND CARE HOME .........................................................................
DOMICILIARY CARE HOME .......................................................................
PERSONAL CARE HOME...........................................................................
REST HOME/RETIREMENT HOME ...........................................................
MENTAL HEALTH CENTER/PSYCHIATRIC SETTING ..............................
INSTITUTION FOR THE MENTALLY RETARDED/
DEVELOPMENTALLY DISABLED ...........................................................
REHABILITATION FACILITY.......................................................................
ADULT/GROUP HOME ...............................................................................
HOME OFFICE OR MANAGEMENT OFFICE FOR A CHAIN
OR GROUP OF OFF-SITE NURSING FACILITIES..................................
OTHER (SPECIFY:_________)...................................................................
RF ................................................................................................................
3
4
5
6
7
8
9
10
11
12
15
(BOX FA5)
(FA9)
(BOX FA5)
(BOX FA5)
(FA9)
(BOX FA5)
(BOX FA5)
(BOX FA5)
(BOX FA5)
(BOX FA5)
(BOX FA5)
16 (BOX FA5)
17 (BOX FA5)
18 (BOX FA5)
13 (FA 5A)
91 (BOX FA5)
-7 (BOX FA5)
PRESS F1 FOR HOSPITAL DEFINITIONS.
BOX FA4A omitted.
FA5A
COLLECT FACILITY CONTACT INFORMATION FOR FACILITY WHERE SP IS LOCATED (TARGET
FACILITY). THEN PRESS ENTER TO CONTINUE. (CLOSING 5)
9
FQ. FACILITY SCREENER QUESTIONNAIRE
BOX FA5
2006 Facility Interview
(Screener Only)
If FA1 or FA5 = 18, set LOCCODE = TARGET FACILITY and go to BOX FA11.
If FA3 = 6, set target facility LOCCODE = TARGET FACILITY, PART OF LARGER
FACILITY, set added place LOCCODE = LARGER FACILITY, and go to FA11.
If FA3 = 8-12, set added LOCCODE = PART OF LARGER FACILITY and set TARGET
LOCCODE = TARGET FACILITY, PART OF LARGER FACILITY and go to
FA11.
If FA1 or FA5 = 8-12, 15-17, 91 -8, or -7 and FA2 = 1, set target facility
LOCCODE = TARGET FACILITY, PART OF LARGER FACILITY, set added
place LOCCODE = LARGER FACILITY and go to FA11.
If FA1 or FA5 = 8-12, 15-17, 91, -8, or -7 and FA2 = 0, set LOCCODE = TARGET
FACILITY and go to BOX FA11.
If FA1 or FA5 = 3 or 5, set LOCCODE = TARGET FACILITY AND LARGER FACILITY
and go to FA11.
If FA1 or FA5 = 6, go to FA8.
Else, set LOCCODE = LARGER FACILITY and go to FA11.
FA7 omitted.
FA8
Does {LARGER FACILITY or any of its parts/FACILITY} have any beds that are certified or licensed as a
nursing {home/facility}?
Any beds certified or licensed as an ICF-MR (Intermediate Care Facility for the Mentally Retarded)?
YES TO EITHER..........................................................................
NO TO BOTH...............................................................................
DK................................................................................................
RF ................................................................................................
1
0
-8
-7
PRESS F1 FOR SUGGESTED PROBES
BOX FA7
If FA8 = 1 and no place has LOCCODE = LARGER FACILITY, set LOCCODE =
TARGET FACILITY AND LARGER FACILITY.
If FA8 = 1, set RHPLACTY = HOSPITAL and go to FA11.
If FA8 = 0 or -8, set RHPLACTY = HOSPITAL, set LOCCODE = TARGET FACILITY,
and go to FA16.
Else, go to BOX FA11.
FA9
What is the name of the {CATEGORY SELECTED IN FA1 OR FA5}?
__________________________________________________
10
FQ. FACILITY SCREENER QUESTIONNAIRE
BOX FA8
2006 Facility Interview
(Screener Only)
Add to Place Roster.
IF FA1 or FA5=7, add HOSPITAL NAME to database.
Set the locator code for the place added to Place Roster =LARGER FACILITY, and set
the locator code for the target facility = TARGET FACILITY, PART OF LARGER
FACILITY.
Then, if FA1 or FA5=7 (HOSPITAL-BASED SNF UNIT), go to FA16.
Others, go to FA11.
FA10 omitted.
11
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
FA11
Please tell me about all the parts or units of {LARGER FACILITY} where residents stay overnight.
{Please do not include acute care departments or units in this list.}
{PROBE: Any others?}
FA11
NAME
FA12
PLACE
TYPE
FA13
NUMBER
OF BEDS/
UNITS
FA14
ANOTHER
NAME?
(YES = 1, NO = 0)
FA15
ALSO KNOWN
AS...
PROBE: Any others?
FA12
When the cursor is in the PLACE TYPE column, in the question area above the matrix, replace question text for FA11,
"Please tell me about..." with FA12.
Display the following categories and codes across the bottom of the screen whenever the cursor is in the PLACE TYPE
column:
4
= NURSING HOME/UNIT
6
= HOSPITAL
8
= ASSISTED LIVING FACILITY
9
= BOARD AND CARE HOME
10 = DOMICILIARY CARE HOME
11 = PERSONAL CARE HOME
12 = REST HOME/RETIREMENT HOME
14 = INDEPENDENT LIVING UNITS
15 = MENTAL HEALTH CENTER/PSYCHIATRIC SETTING
16 = INSTITUTION FOR THE MENTALLY RETARDED/DEVELOPMENTALLY DISABLED
17 = REHABILITATION FACILITY
91 = OTHER (SPECIFY:_______________)
[NOTE: These categories can be mapped to the categories and subcategories in RH22. Absolute consistency with the
presentation in the residence history section is not desirable, however, because here we are asking specifically about a
place that we already know is part of a larger facility; in residence history, the questions are designed to categorize the place
where the SP resided, regardless of whether it was part of a larger place or not.]
FA12
What type of (place/unit) is that?
SHOW
CARD
RH2
PROBE WITH CATEGORIES BELOW MATRIX.
PRESS F1 FOR DEFINITION OF ASSISTED LIVING FACILITY, BOARD AND CARE HOME,
DOMICILIARY CARE HOME, PERSONAL CARE HOME, AND REST HOME.
FA13
How many beds {or individual units} are in {PLACE/UNIT}?
12
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
FA14
Is {PLACE/UNIT} also known by some other name?
YES..............................................................................................
NO ...............................................................................................
13
1
0
(BOX FA10)
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
FA15
What name is that?
ALSO KNOWN AS . . .
BOX FA9 omitted.
BOX FA10
1. Post each Part/Unit to Place Roster.
2. If target facility's locator code = TARGET FACILITY, PART OF LARGER FACILITY,
code all other parts/units listed in FA11-15 as PART OF LARGER FACILITY.
Else, code all parts/units as PART OF TARGET FACILITY.
3. For each Place:
If FA3, FA5, or FA12 = DK or RF, set a flag for data retrieval of PLACTYPE.
Else, continue.
4. If HOSPITAL created at FA11-15 (PLCREATE = 32), go to FA16
Else, go to BOX FA11.
FA16
You mentioned that {NAME IN FA11} is a hospital. Please look at this card and tell me what kind of hospital it
is.
SHOW
CARD
FA3
A.
B.
C.
D.
E.
F.
ACUTE CARE HOSPITAL........................................................
PRIVATE PSYCHIATRIC HOSPITAL ......................................
STATE OR COUNTY HOSPITAL FOR THE MENTALLY ILL ..
VA HOSPITAL, VA MEDICAL CENTER...................................
STATE HOSPITAL FOR THE MENTALLY RETARDED ..........
CHRONIC DISEASE, REHABILITATION, GERIATRIC, OR
OTHER LONG-TERM CARE HOSPITAL.............................
OTHER (SPECIFY:______________________) .....................
14
1
2
3
4
5
6
91
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
Review Status Code and Place Type for each Place. If missing for a Place, assign a value to the
missing item(s) based on the following table:
IF
THEN ASSIGN:
MCBS STATUS CODE
FOR TARGET
FACILITIES
FA1, FA3 or FA5 =
3 (CCRC)
MCBS PLACE TYPE
ELIGIBLE
ELIGIBLE LTC
ELIGIBLE
ELIGIBLE LTC
18 ADULT/GROUP HOME
ELIGIBLE
ELIGIBLE LTC
13 (HOME OFFICE)
INELIGIBLE
COMMUNITY
8 (ASSISTED LIVING FACILITY)
ELIGIBLE
ELIGIBLE LTC
9 (BOARD AND CARE HOME)
ELIGIBLE
ELIGIBLE LTC
10 (DOMICILIARY CARE HOME)
ELIGIBLE
ELIGIBLE LTC
14 (INDEPENDENT LIVING UNITS)
INELIGIBLE
COMMUNITY
5 (RETIREMENT COMMUNITY)
FA1 or FA5 =
FA1, FA5, or FA12 =
BOX
FA11
15 (MENTAL HEALTH/ PSYCHIATRIC ELIGIBLE
ELIGIBLE LTC
4 (NURSING HOME/ UNIT)
ELIGIBLE
ELIGIBLE LTC
11 PERSONAL CARE HOME)
ELIGIBLE
ELIGIBLE LTC
12 (REST HOME)
ELIGIBLE
ELIGIBLE LTC
16 (MR/DD)
ELIGIBLE
ELIGIBLE LTC
17 (REHABILITATION FACILITY)
ELIGIBLE
ELIGIBLE LTC
91 (OTHER)
ELIGIBLE
ELIGIBLE LTC
ELIGIBLE
ELIGIBLE LTC
ELIGIBLE
ELIGIBLE LTC
FA1, FA3, FA5, or FA12 = DK or RF
IF FA1, FA5, or FA12=6 AND
FA16 not=1 or –1
(ANY OTHER KIND OF HOSPITAL)
Leave blank all others with missing MCBS Status or Place Type.
No further action is required in the Facility-level Questionnaire for all Places with MCBS
Status=INELIGIBLE.
Then go to FA16a (PLACROST).
FA16a (PLACROST)
HERE IS THE CURRENT PLACE ROSTER FOR YOUR REVIEW:
{PLACE ROSTER VERSION 1}
USE ARROW KEYS. TO EXIT, PRESS ESC.
15
FQ. FACILITY SCREENER QUESTIONNAIRE
BOX
FA12
2006 Facility Interview
(Screener Only)
1.
If the Target Facility's locator code = TARGET FACILITY AND LARGER
FACILITY, set MCBS status=ELIGIBLE. (Eligibility will be determined for its parts
in the steps below.) Go to next place. If no remaining places, go to Item 5 below.
2.
If
Place hasflag
locator
code=PART
OF TARGET
set TENTATIVE
ADDITION
= YES
for this Place
and go to FACILITY,
the next Place
or Item 5 below.
3.
If
Place hasflag
locator
code=PART
OF LARGER
set TENTATIVE
ADDITION
= YES
for this Place
and go to FACILITY,
the next Place
or Item 5 below.
4.
Unless
thego
Place
is the
Target
Facility,
Place and
to next
Place
or Item
5. set MCBS status=INELIGIBLE for this
5.
If the target facility's
MCBS
and no Place is flagged
TENTATIVE
ADDITION,
gostatus=INELIGIBLE,
to CLOSING 2.
Else, loop through FA17 and FA18 for each TENTATIVE ADDITION.
Else, if no TENTATIVE ADDITIONs, go to FA19 for MCBS FACILITY.
FA17
Would you be able to answer some questions about the certification status and bed size for {TENTATIVE
ADDITION}?
YES..............................................................................................
NO................................................................................................
DK ................................................................................................
RF ................................................................................................
BOX
FA13
1
0
-8
-7
If 1 is entered in FA17: Repeat FA17 for all TENTATIVE ADDITIONS identified; if no
remaining TENTATIVE ADDITIONS, go to BOX FA14.
If 0, -7, or -8 is entered in FA17, go to RR1, using question text from FA18 for the
NAME CELL.
FA18
Who would be the most knowledgeable person to answer questions about {TENTATIVE ADDITION}?
NAME
BOX
FA14
TITLE
Repeat FA17 and FA18 for each TENTATIVE ADDITION identified for this respondent.
When FA17 and FA18 have been asked for all TENTATIVE ADDITIONS for this
respondent, set a counter for each TENTATIVE ADDITION FOR WHICH FA17=1
(YES).
If TARGET FACILITY is eligible, go to FA19 for target facility.
If target facility is ineligible, and FA17=1 (YES) for Tentative Additions for this
respondent, go to FA19 for first such tentative addition.
Else, go to CLOSING 6.
16
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
FA19
{{Let's turn first to {FACILITY}/{Now let's turn to {FACILITY}.}}
{How many beds does {FACILITY} have?/According to the information I obtained earlier, {FACILITY} has [READ
NUMBER BELOW] beds.}
{
}
NO. OF BEDS
{PRESS ENTER TO CONTINUE/DK = -8, RF = -7.}
PRESS F1 FOR EXPANDED DEFINITION OF "BEDS".
BOX
FA14A
If PLACTYPE=4, 7, or 17, go to FA20.
If FA1, FA5, or FA12=16 (MR/DD), go to FA21B.
If FA16=3, 5, or 6, go to FA21B.
Else, go to FA22B.
17
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
FA20
Does {FACILITY} have any beds certified by {"PREFERRED" NAME FOR MEDICAID} {(or {"ALLOWED FOR"
NAME(S) FOR MEDICAID})} as a Nursing Facility (NF) beds?
IF R MENTIONS:
ICF-MR (INTERMEDIATE CARE FACILITY--MENTAL RETARDATION), SAY THAT YOU WILL ASK
ABOUT THOSE IN A MOMENT.
YES..............................................................................................
NO................................................................................................
DK ................................................................................................
RF ................................................................................................
18
1
0
-8
-7
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
FA21
Does {FACILITY} have any beds certified by Medicare as SNF beds?
YES .............................................................................................
NO...............................................................................................
DK ...............................................................................................
RF ...............................................................................................
1
0
-8
-7
FA21A moved to FA85.
FA21B
Does {FACILITY} have any beds certified by {"PREFERRED" NAME FOR MEDICAID} {(or {"ALLOWED
FOR" NAME(S) FOR MEDICAID})} as ICF-MR (Intermediate Care Facility for the Mentally Retarded) beds?
YES .............................................................................................
NO...............................................................................................
DK ...............................................................................................
RF ...............................................................................................
1
0
-8
-7
FA22
Does {FACILITY} have any beds that are {not certified by {Medicaid or Medicare} but are} licensed as
nursing {home/facility} beds by the {STATE} State Health Department or by some other State or Federal
agency?
YES, LICENSED BY STATE HEALTH DEPARTMENT ..............
YES, LICENSED BY SOME OTHER AGENCY
(SPECIFY:______________________)..................................
NO, NOT LICENSED ..................................................................
DK ...............................................................................................
RF ...............................................................................................
BOX
FA15_1
1
2
0
-8
-7
If FA20, FA21, or FA21B = 1, go to FA22B.
Else, continue.
FA22A
Does {FACILITY} provide 24-hour a day, on-site supervision by an RN or LPN 7 days a week?
FHLPNURS
YES..............................................................................................
NO................................................................................................
DK ................................................................................................
RF ................................................................................................
1
0
-8
-7
FA22B
Does {FACILITY} have any beds licensed as personal care, board and care, assisted living, or domiciliary care
beds by the {STATE} State Health Department or by some other state or local government agency?
YES, LICENSED BY STATE HEALTH DEPARTMENT ...............
YES, LICENSED BY SOME OTHER AGENCY
(SPECIFY:___________________________________).............
NO, NOT LICENSED ...................................................................
DK ................................................................................................
RF ................................................................................................
19
1
2
0
-8
-7
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
FA22C
In addition to room and board, does {FACILITY/ELIGIBLE UNIT} routinely provide...
ROOMCARE
SUPRVMED
FHLPBATH
FHLPDRESS
FHLPSHOP
FHLPWALK
FHLPEAT
FHLPCOMM
YES=1, NO=0, DK=-8, RF=-7
( )
( )
( )
( )
( )
( )
( )
( )
Nursing or medical care?
Supervision over medications?
Help with bathing?
Help with dressing?
Help with correspondence/shopping?
Help with walking?
Help with eating?
Help with communications?
BOX
FA15A1
If FA22A asked for this PLACE, go to BOX FA15A.
Else, continue.
FA23
Does {FACILITY} provide 24-hour a day, on-site supervision by a caregiver 7 days a week?
YES .............................................................................................
NO...............................................................................................
DK ...............................................................................................
RF ...............................................................................................
BOX
FA15A
1
0
-8
-7
Return to FA19 for next PLACE that has FA17 = 1 (YES) for this respondent.
If no remaining place, go to BOX FA16.
BOX FA16
To be deemed eligible, a place must (1) have three or more beds, and (2) be certified by Medicaid or Medicare or be
licensed as a nursing home or other long-term care facility, or provide at least one personal care service, or provide 24
hour, 7 day a week supervision by a caretaker.
Subject each place looped through FA19-23 with this respondent to the steps in BOX FA16, one place at a time.
20
FQ. FACILITY SCREENER QUESTIONNAIRE
BOX
FA16
2006 Facility Interview
(Screener Only)
1.
If FA19 is less than 3, flag FACILITY/TENTATIVE ADDITION as INELIGIBLE, set
Place Type = INELIGIBLE LTC, decrement counter, and go to next Place or Item
6 below.
Others, go to Item 2 below. [NOTE: This means DK and REF are assumed equal
to 3 or more.]
2.
If FA20 or FA21 = 1 (YES, CERTIFIED BY MEDICAID OR MEDICARE) or if
FA22 = 1 or 2 (LICENSED BY STATE HEALTH DEPT. OR SOME OTHER
AGENCY), or FA22A=1 (PROVIDES AROUND THE CLOCK NURSING
SUPERVISION AS NH) or FA22B = 1 or 2 (LICENSED BY STATE HEALTH
DEPARTMENT OR OTHER AGENCY AS OTHER LONG-TERM CARE
FACILITY) or FA22C = at least one "YES" response or FA23 = 1 (PROVIDES
AROUND-THE-CLOCK SUPERVISION), set MCBS STATUS = ELIGIBLE and go
to next Place or Item 6 below.
3.
If eligibility block (FA20-23) is indeterminate, decrement counter, set a flag for
retrieval, ask FA18 and go to next Place or Item 5.
Others go to Item 4.
4.
Set MCBS STATUS = INELIGIBLE, set Place Type = COMMUNITY, decrement
counter, and go to next Place or Item 6.
5.
If no remaining places for this respondent, but there are other pending tentative
additions, go to CLOSING 6.
Else,
6.
If Group Home (FA1 or FA5=18) go to FA31.
If counter > 1, go to FA24PRE.
If counter = 1, go to BOX FA16A.
If counter = 0, go to CLOSING 2.
Else, go to FA31PRE.
FA24PRE
All of the remaining questions will refer to {FACILITY and} {[READ FAC/UNITS LISTED BELOW]} combined.
{PLACE ROSTER VERSION 5}
PRESS ENTER TO CONTINUE.
BOX FA17 omitted.
FA24a
The questions are about the number of nursing beds and residents by payor type, special care units, and
staffing. Can you answer these questions about {all/both} of these places?
YES..............................................................................................
NO................................................................................................
DK ................................................................................................
RF ................................................................................................
1
0
-8
-7
(FA25)
(RR1)
(FA25)
(RR1)
FA24b
Who would be the best person to answer questions about [READ FACILITIES/UNITS LISTED ABOVE]?
NAME
TITLE
21
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
PROGRAMMER SPECS:
After the name and title have been posted to the Respondent Roster, go to CLOSING 6.
BOX
FA16A
If FA19 (NUMBER OF BEDS) never equals DK or RF and the SUM OF FA19 can be
calculated, go to FA25PRE.
Else, go to FA25.
FA25PRE
{From information I collected earlier, I understand that {FACILITY/[READ FAC/UNITS LISTED ABOVE]} has
{SUM OF FA19, NUMBER OF BEDS IN FACILITY} nursing or long-term care beds.}
FA25
Does {FACILITY/[READ FAC/UNITS LISTED ABOVE]} have any beds that are not licensed or certified or
otherwise identified as nursing or other long-term care beds?
YES .............................................................................................
NO...............................................................................................
DK ...............................................................................................
RF ...............................................................................................
1
0
-8
-7
(FA26)
(BOX FA18)
(BOX FA18)
(BOX FA18)
PRESS F1 FOR DEFINITION OF "OTHERWISE IDENTIFIED".
FA26
Display the following codes for TYPE across bottom of screen:
6
14
91
=
=
=
HOSPITAL
INDEPENDENT LIVING
OTHER (SPECIFY:
)
FA26
Please look at this card and tell me how you would describe the beds or units that are not certified or licensed or
otherwise identified as nursing or other long-term care beds.
PROBE: What kind of place is it?
SHOW
CARD
FA5
PRESS F1 FOR MORE ON NON-LTC BEDS.
FA27
What is the name of the place or unit?
IF SAME AS TYPE, ENTER SHIFT/5. FOR ANY OTHER NAME, ENTER TEXT.
22
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
PROGRAMMER SPECS:
If FA27=SHIFT/5 (SAME AS TYPE), display "The {TYPE CATEGORY} unit" in NAME field. Truncate names as
follows:
6
14
91
=
=
=
HOSPITAL
INDEP LIVING
FIRST 12 CHARACTERS OF SPECIFIED TEXT
FA28
How many beds or individual units are dedicated to {UNIT NAME}?
_____________
NUMBER
(
)
BEDS = 1
INDIVIDUAL UNITS = 2
OTHER (SPECIFY:_________) = 91
FA29
When did the (place/unit) begin operation?
YEAR (
)
PROBE: Any other non-long-term care beds or units?
FA30
So, that is a total of {NUMBER OF BEDS AND UNITS/AN UNKNOWN TOTAL OF} {beds/units/OTHER}
that are not licensed or certified or otherwise identified as nursing or other long-term care beds (or units). Is
that correct?
YES..............................................................................................
NO................................................................................................
1
0
BOX17B omitted.
FA30a (PLACROST)
HERE IS THE CURRENT PLACE ROSTER FOR YOUR REVIEW:
{PLACE ROSTER VERSION 1}
USE ARROW KEYS. TO EXIT, PRESS ESC.
FA31PRE
Now we are going to ask only about the parts of {FACILITY} that have beds designated as nursing or other longterm care beds.
PRESS ENTER TO CONTINUE.
BOX
FA18
If FACILITY is a LARGER FACILITY or is part of a LARGER FACILITY go to BOX
FA19.
Others, go to FA31.
23
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
FA31
Which one of the categories on this card best describes the ownership of {FACILITY}?
FACOWNED
SHOW
CARD
FA6
FOR PROFIT (INDIVIDUAL, PARTNERSHIP, OR
CORPORATION) ......................................................... 1
PRIVATE NONPROFIT (RELIGIOUS GROUP,
NONPROFIT CORP., ETC.) ........................................ 2
CITY/COUNTY GOVERNMENT ..................................... 3
STATE GOVERNMENT .................................................. 4
VETERAN'S ADMINISTRATION..................................... 5
OTHER FEDERAL AGENCY .......................................... 6
OTHER (SPECIFY:______________________) ............ 91
FA32 - FA42 omitted.
BOX
FA19
If FA20 and FA21 both = 1, go to FA43.
Others, go to BOX FA20.
FA43
I have recorded that {FACILITY} contains beds that are certified by {"PREFERRED" NAME FOR MEDICAID}
{(or {"ALLOWED FOR" NAME(S) FOR MEDICAID})} as Nursing Facility beds and by Medicare as Skilled
Nursing Facility beds. How many beds are dually certified (that is, certified by both)?
MANDMBED
BOX
FA20
_____________
NO. OF BEDS
If FA20 = 1, go to FA44.
Others, go to BOX FA21.
24
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
FA44
{I have recorded that {FACILITY} contains beds that are certified by {"PREFERRED" NAME {FOR MEDICAID}
{(or {"ALLOWED FOR" NAME(S) FOR MEDICAID})} as Nursing Facility beds.} How many beds are certified
under {"PREFERRED" NAME FOR MEDICAID} {or {ALLOWED FOR NAME(S) FOR MEDICAID}} {only}?
MCAIDBED
MCDSNFN
BOX
FA21
_____________
NO. OF BEDS
If FA21 = 1, go to FA45.
Others, go to BOX FA22.
FA45
{I have recorded that {FACILITY} contains beds that are certified by Medicare as Skilled Nursing Facility beds.}
How many beds are certified under Medicare {only}?
MCAREBED
BOX
FA22
_____________
NO. OF BEDS
If FA22 = 1 or 2, go to FA45A.
Others, go to BOX FA22A.
FA45A
I have recorded that {FACILITY} contains beds that are licensed as nursing facility beds but not certified by
{"PREFERRED NAME" FOR MEDICAID} {(or "ALLOWED NAME(S) FOR MEDICAID)} or Medicare. How many
beds are licensed but not certified as nursing home beds {only}?
MNORMBED
BOX
FA22A
_____________
NO. OF BEDS
If FA21B=1, go FA45B
Else, go to BOX FA22B.
FA45B
I have recorded that {FACILITY} contains beds that are certified by {"PREFERRED" NAME {FOR MEDICAID}}
{(or "ALLOWED NAME(S) FOR MEDICAID)} as ICF-MR (Intermediate Care Facility for the Mentally Retarded)
beds. How many beds are certified as ICF-MR beds {only}?
ICFMRBED
MCDICFMR
_____________
NO. OF BEDS
25
FQ. FACILITY SCREENER QUESTIONNAIRE
BOX
FA22B
2006 Facility Interview
(Screener Only)
If FA22B=1 or 2, go to FA45C
Else, go to BOX FA22D.
FA45C
I recorded earlier that {FACILITY} contains beds that are licensed as a personal care, board and care,
assisted living, domiciliary care, or other type of long-term care beds. How many beds are licensed as
one of these types of long-term care {only}?
OTLTCBED
BOX
FA22D
_____________
NO. OF BEDS
If cannot calculate number of remaining beds, go to BOX FA22E.
Others, go to FA46.
26
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
FA46
So, there are a total of { } LTC beds in the facility:
{{ } are dually certified nursing beds,}
{{ } are certified by {"PREFERRED" ........MEDICAID"} as nursing beds {only}},
{{ } are certified as nursing beds by Medicare {only},}
{{ } are not certified by Medicare or {"PREFERRED" ........MEDICAID"} but are licensed as nursing beds,}
{{ } are certified by {"PREFERRED" ........MEDICAID"} as ICF-MR beds,}
{{ } are licensed as personal care, assisted living, or other type of long-term care beds,}
{{ } are other long-term care beds which are neither certified or licensed}.
Is that correct?
NLTCBEDS
BOX
FA22E
YES..............................................................................................
NO ...............................................................................................
1
0
IF FA20=1 or FA21=1, or FA21B=1, go to FA47 PRE; else
go to FA49.
FA47PRE
Next, I'm going to ask about the number of current residents having {"PREFERRED" NAME FOR MEDICAID}
{(or {"ALLOWED FOR" NAME(S) FOR MEDICAID)}, Medicare, and private pay/{"PREFERRED" NAME
FOR MEDICAID} {(or {"ALLOWED FOR" NAME(S) FOR MEDICAID)} and private pay/Medicare and
private pay/private pay} as their source of payment.
If you need to go get the relevant records, I can pause for a moment.
ALLOW RESPONDENT TIME TO GATHER RECORDS, IF NECESSARY.
PRESS ENTER TO CONTINUE.
BOX
FA22F
If FA20 = 1, or FA21B=1, go to FA47.
Else, if FA21 = 1, go to FA48.
Else, go to FA49.
FA47
Based on your most recent daily census, how many current residents have {"PREFERRED" NAME FOR
MEDICAID} {(or {"ALLOWED FOR" NAME(S) FOR MEDICAID)} as a source of payment?
______________________
NUMBER OF RESIDENTS
BOX
FA22G
If FA21 = 1, go to FA48.
Else, go to FA49.
FA48
Based on your most recent daily census, how many current residents have Medicare as their primary source of
payment?
______________________
NUMBER OF RESIDENTS
27
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
FA49
Based on your most recent daily census, how many of the current residents in {FACILITY} have private pay as their
only source of payment for basic care?
______________________
NUMBER OF RESIDENTS
FA52
How many residents were in {FACILITY} altogether at midnight last night?
______________________
NUMBER OF RESIDENTS
FA53 moved to SAQ.
BOX
FA22H
If FA1 or FA5 = 18, go to FR7PRE.
Else, continue.
FA54
Next, we're interested in learning about any special care units within {FACILITY} -- units with a specified number
of beds identified and dedicated for residents with specific needs or diagnoses. Does {FACILITY} have any
special care units, such as those listed on this card?
SHOW
CARD
FA7
AT LEAST ONE SPECIAL CARE UNIT MENTIONED ....................... 1
NO SPECIAL CARE UNITS................................................................ 0
DK....................................................................................................... -8
RF....................................................................................................... -7
FA55
Display the following codes for TYPE across bottom of screen:
1
2
3
4
5
6
7
8
9
91
=
=
=
=
=
=
=
=
=
=
ALZHEIMER'S AND RELATED DEMENTIAS
AIDS/HIV
DIALYSIS
CHILDREN WITH DISABILITIES
BRAIN INJURY (TRAUMATIC OR ACQUIRED)
HOSPICE
HUNTINGTON'S DISEASE
REHABILITATION
VENTILATOR/PULMONARY
OTHER (SPECIFY:______________________)
FA55
What kind of special care unit(s) does {FACILITY} have?
SHOW
CARD
FA7
PRESS F1 FOR DIALYSIS DEFINITION.
FA56
PROBE: Any others?
What is the name of the unit?
IF SAME AS TYPE, ENTER SHIFT/5. FOR ANY OTHER NAME, ENTER TEXT.
28
(BOX FA27)
(BOX FA27)
(BOX FA27)
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
FA57
How many beds are dedicated to {UNIT NAME}?
_____________
NO. OF BEDS
FA59
Does {UNIT NAME} have direct care patient staff dedicated to it?
YES..............................................................................................
NO................................................................................................
1
0
FA60
In what year did the unit begin operation?
YEAR (
)
FA61
Is any resident's care in the unit paid for by {"PREFERRED" NAME FOR MEDICAID} {(or {"ALLOWED FOR"
NAME(S) FOR MEDICAID})}?
YES..............................................................................................
NO ...............................................................................................
DK................................................................................................
RF ................................................................................................
1
0
8
-7
FA62 omitted.
FA63
Is any resident's care in the unit paid for by Medicare?
YES.............................................................................................. 1
NO ............................................................................................... 0
DK................................................................................................... -8
RF ................................................................................................... -7
FA64 omitted.
BOX
FA23
If sum of FA19 minus SUM OF BEDS OR UNITS IN FA28 minus SUM OF BEDS in
FA57 > 0, go to FA65.
If sum of FA19 minus SUM OF BEDS OR UNITS IN FA28 minus the SUM OF BEDS in
FA57 < 0, present the following message: THE NUMBER OF BEDS IN SPECIAL
CARE UNITS (SUM OF FA57) CANNOT BE GREATER THAN THE TOTAL
NUMBER OF BEDS IN THE FACILITY (SUM OF FA19). BACK UP, REVIEW
ENTRIES IN FA57, FA19, AND FA13 CORRECT IF NECESSARY.
If sum of FA19 minus SUM OF BEDS OR UNITS IN FA28 minus SUM OF BEDS in
FA57 = 0, go to Box FA23a.
Others, if FA65 and FA66 have not been asked, go to FA65.
Else, go to BOX FA23a.
29
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
FA65
{So that makes a total of {SUM OF BEDS IN FA57} special care unit beds in {FACILITY}. You told me earlier that
there are {SUM OF NUMBER OF BEDS IN FA43, FA44, FA45, FA45A} certified or licensed nursing {home/facility}
beds in {FACILITY} altogether.
So that leaves {DIFFERENCE/some number of} beds that are not part of a special care unit.
Is that correct?
YES..............................................................................................
NO ...............................................................................................
DK................................................................................................
RF ................................................................................................
1
0
-8
-7
FA66
What can I call that part of {FACILITY} -- the general population unit, or do you have another name for these
beds?
IF GENERAL POPULATION UNIT, ENTER SHIFT/5. FOR ANY OTHER NAME, ENTER TEXT.
BOX
FA23a
Post all Places added in FA55-66 to the Place Roster. Set MCBS STATUS =
ELIGIBLE;
If {FACILITY} fill in FA25 is filled with PLACE NAME from Place Roster (this means
there is only one eligible place), set locator code = PART OF TARGET
FACILITY; else if {FACILITY} fill in FA25 is filled with "[READ FACILITIES/UNITS
IN HEADER ABOVE.]", set locator code = PART OF LARGER FACILITY.
set Place Type = ELIGIBLE LONG-TERM CARE.
FA66a (PLACROST)
HERE IS THE CURRENT PLACE ROSTER FOR YOUR REVIEW:
{PLACE ROSTER VERSION 1}
USE ARROW KEYS. TO EXIT, PRESS ESC.
FA67PRE through FA76 omitted.
BOX
FA27
If {FACILITY} locator code = PART OF LARGER FACILITY or PART OF TARGET
FACILITY, or TARGET FACILITY, PART OF LARGER FACILITY, or TARGET
FACILITY AND LARGER FACILITY go to FA77PRE.
Others, go to FR7PRE.
FA77PRE
The next question is about {LARGER FACILITY} as a whole.
PRESS THE F2 KEY TO REVIEW PLACE ROSTER.
PRESS ENTER TO CONTINUE.
30
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
FA77
Which one of the categories on this card best describes the ownership of {LARGER FACILITY}?
FOR PROFIT (INDIVIDUAL, PARTNERSHIP,
OR CORPORATION) ..................................................................... 1
PRIVATE NONPROFIT
(RELIGIOUS GROUP, NONPROFIT CORP., ETC.)........................... 2
SHOW
CARD
FA6
CITY/COUNTY GOVERNMENT .............................................................
STATE GOVERNMENT ..........................................................................
VETERAN'S ADMINISTRATION ............................................................
OTHER FEDERAL AGENCY ..................................................................
OTHER (SPECIFY:______________________) ....................................
BOX
FA24
Go to FR7PRE.
FA78 through FA84A omitted.
31
3
4
5
6
91
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
SECTION FB
LTC ELIGIBILITY BLOCK
BOX
FB1A
IF THIS FACILITY WAS DETERMINED TO BE COMPLEX AT BASELINE
(FACL.COMPLEXF = 1), GO TO FB0PRE;
ELSE, GO TO FB1PRE.
FBOPRE
HERE IS THE CURRENT PLACE ROSTER FOR YOUR REVIEW:
{PLACE ROSTER VERSION 1}
USE ARROW KEYS. TO EXIT, PRESS ESC.
FB0A
Would you be able to answer some questions about the certification status, services offered, and the number
of beds for [READ PLACES LISTED BELOW]?
{ELIGIBLE PARTS OF FACILITY}
YES..............................................................................................
NO ...............................................................................................
DK................................................................................................
RF ................................................................................................
1
0
-8
-7
(FB1PRE)
(FB5O)
(FB5O)
(FB5O)
BOX FB1B omitted.
FB1PRE
I would like to review with you some information that I collected about {FACILITY/[READ FAC/UNITS LISTED
ABOVE]} the last time I was here.
PRESS ENTER TO CONTINUE.
BOX
FB2
If all PLAC.CAIDCRT1 = -1 and PLACTYPE ^ = 17, go to BOX FB4.
If FACL.MCAIDCRT = 1, go to FB1.
Else, go to FB2.
FB1
Is {FACILITY/[READ FAC/UNITS LISTED ABOVE]} still certified by Medicaid as a Nursing Facility (NF)?
YES..............................................................................................
NO ...............................................................................................
1
0
(BOX FB3)
(BOX FB3)
FB2
Is {FACILITY/[READ FAC/UNITS LISTED ABOVE]} certified by Medicaid as a Nursing Facility (NF)?
YES..............................................................................................
NO ...............................................................................................
32
1
0
(BOX FB3)
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
FB4
Based on your most recent daily census, how many current residents have {"PREFERRED" NAME FOR
MEDICAID} {(or {"ALLOWED FOR" NAME(S) FOR MEDICAID})} as a source of payment?
____________________________
# OF MEDICAID RESIDENTS
BOX FB3
If FACL.MCARECRT = 1, go to FB5;
Else, go to FB6.
FB5
Is {FACILITY/[READ FAC/UNITS LISTED ABOVE]} still certified by Medicare as a Skilled Nursing Facility (SNF)?
YES..............................................................................................
NO................................................................................................
1
0
(FB10)
(FB10)
FB6
Is {FACILITY/[READ FAC/UNITS LISTED ABOVE]} certified by Medicare as a Skilled Nursing Facility (SNF)?
YES..............................................................................................
NO................................................................................................
1
0
(FB10)
FB8
Based on your most recent daily census, how many current residents have Medicare as their primary source of
payment?
__________________________
# OF MEDICARE RESIDENTS
FB10
Based on your most recent daily census, how many of the current residents in {FACILITY/[READ FAC/UNITS
LISTED ABOVE]} have private pay as their only source of payment for basic care?
_____________________________
# OF PRIVATE PAY RESIDENTS
BOX FB4
If FACL.ICFMRCRT = 1, go to FB11.
If any PLAC.CAIDICF ^ = -1 or PLACTYPE = 17, go to FB12.
Else, go to BOX FB4A.
FB11
Is {FACILITY/[READ FAC/UNITS LISTED ABOVE]} still certified by Medicaid as an Intermediate Care Facility
for the Mentally Retarded (ICF/MR)?
YES..............................................................................................
NO................................................................................................
33
1
0
(BOX FB4A)
(BOX FB4A)
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
FB12
Is {FACILITY/[READ FAC/UNITS LISTED ABOVE]} certified by Medicaid as an Intermediate Care Facility for
the Mentally Retarded (ICF/MR)?
YES..............................................................................................
NO................................................................................................
BOX
FB4A
1
0
If any FACL.HDLICCRT = 1 or 2, continue.
If any PLACTYPE = 4 or 7 or 17 and is not a special care unit, go to FB22.
Else, go to BOX FB4C.
FB14
Does {FACILITY} still have beds that are {not certified by {Medicaid or Medicare} but are} licensed as nursing
home beds by {the {STATE} State Health Department or by some other State or Federal agency}?
YES..............................................................................................
NO................................................................................................
1
0
(BOX FB4C)
(BOX FB4C)
FB22
Does {FACILITY} have any beds that are {not certified by {Medicaid or Medicare} but are} licensed as nursing
{home/facility} beds by the {STATE} State Health Department or by some other State or Federal agency?
YES, LICENSED BY STATE HEALTH DEPARTMENT ...............
YES, LICENSED BY SOME OTHER AGENCY
(SPECIFY:______________________) ..................................
NO, NOT LICENSED ...................................................................
BOX
FB4B
1
2
0
If facility is now Medicaid or Medicare certified, go to BOX FB4C.
Else, continue.
FB16
Does {FACILITY} provide 24-hours a day, on-site supervision by an RN or LPN 7 days a week?
YES..............................................................................................
NO ...............................................................................................
BOX
FB4C
1
0
If facility licensed as a personal care home, board and care home, assisted living
facility, domiciliary care home or rest home by the {STATE} State Health
Department or by some other state agency (FA22B=1 or 2), go to FB48.
Else, go to FB47.
FB48
Is {FACILITY/[READ FAC/UNITS LISTED ABOVE]} still licensed as a personal care home, board and care
home, assisted living facility, domiciliary care home or rest home by the {STATE} State Health Department or by
some other state or local government agency?
YES..............................................................................................
NO................................................................................................
34
1
0
(FB22C)
(FB22C)
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
FB47
Is {FACILITY/[READ FAC/UNITS LISTED ABOVE]} licensed as a personal care home, board and care home,
assisted living facility, domiciliary care home or rest home by the {STATE} State Health Department or by some
other state or local government agency?
YES, LICENSED BY STATE HEALTH DEPARTMENT ...............
YES, LICENSED BY SOME OTHER AGENCY
(SPECIFY): __________________) ......................................
NO, NOT LICENSED ...................................................................
FB22C
In addition to room and board, does {FACILITY/ELIGIBLE UNIT} routinely provide...
YES=1, NO=0
( )
( )
( )
( )
( )
( )
( )
( )
Nursing or medical care?
Supervision over medications?
Help with bathing?
Help with dressing?
Help with correspondence/shopping?
Help with walking?
Help with eating?
Help with communications?
BOX FB6
If FB16 asked, go to BOX FB7.
Else, continue.
35
1
2
0
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
FB23
Does {FACILITY} provide 24-hour a day, on-site supervision by a caregiver 7 days a week?
YES..............................................................................................
NO................................................................................................
DK ................................................................................................
RF ................................................................................................
BOX FB7
BOX
FB7A
1
0
-8
-7
(BOX FB7A)
(BOX FB7)
(FB50)
(FB50)
If now certified by Medicaid or Medicare or licensed as a nursing home and having 24hour nursing supervision or licensed or personal care, board and care, assisted
living, domicilary care, or rest, continue.
Else, set MCBS STATUS = INELIGIBLE and go to CLOSING2.
If number of beds missing from baseline or previous fall round FQ, go to FB19A.
Else, continue.
36
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
ELIGIBLE-BEDS COUNT BLOCK
FB19
I have recorded that {FACILITY} has [READ NUMBER BELOW] beds that provide long-term care. Is this still
the number of beds providing long-term care in {FACILITY} {and [READ FAC/UNITS LISTED BELOW]}?
___{________}___
NO. OF BEDS
{ELIGIBLE PARTS OF FACILITY}
YES..............................................................................................
NO................................................................................................
1
0
(BOX FB8)
FB19A
How many beds that provide long-term care does {FACILITY} have?
PROBE: {Only count the beds in {FACILITY} and [READ FAC/UNITS LISTED BELOW].} Do not count
"independent living" beds or those that don't provide 24-hour-a-day assistance or supervision with daily living
activities.
______________
NO. OF BEDS
{ELIGIBLE PARTS OF FACILITY}
(BOX FB8)
FB50
Who would be the best person to answer these questions about [READ FACILITIES/UNITS LISTED ABOVE]?
NAME
TITLE
PROGRAMMER SPECS:
After the name and title have been posted to the Respondent Roster,
If coming from FB23 or before, keep responses through FAVERIF6 and go to CLOSING 6.
Else, keep responses through FB23 and go to CLOSING 6.
BOX FB8
If FB19A < 3, set MCBS STATUS=INELIGIBLE and go to CLOSING2.
If now certified by both Medicaid and Medicare, go to FB43.
Else, go to BOX FB9.
FB43
I have recorded that {FACILITY} contains beds that are certified by {"PREFERRED" NAME FOR MEDICAID}
{(or {"ALLOWED FOR" NAME(S) FOR MEDICAID})} as Nursing Facility beds and by Medicare as Skilled
Nursing Facility beds. How many beds are dually certified (that is, certified by both)?
_____________
NO. OF BEDS
37
FQ. FACILITY SCREENER QUESTIONNAIRE
BOX FB9
2006 Facility Interview
(Screener Only)
If now Medicaid certified, go to FB44.
Others, go to BOX FB10.
FB44
{I have recorded that {FACILITY} contains beds that are certified by {"PREFERRED" NAME {FOR MEDICAID} {(or
{"ALLOWED FOR" NAME(S) FOR MEDICAID})} as Nursing Facility beds.} How many beds are certified under
{"PREFERRED" NAME FOR MEDICAID} {or {ALLOWED FOR NAME(S) FOR MEDICAID}} {only}?
_____________
NO. OF BEDS
BOX
FB10
If now Medicare certified, go to FB45.
Others, go to BOX FB11.
FB45
{I have recorded that {FACILITY} contains beds that are certified by Medicare as Skilled Nursing Facility beds.}
How many beds are certified under Medicare {only}?
_____________
NO. OF BEDS
BOX
FB11
If now licensed for NH beds but not certified, go to FB45A.
Others, go to BOX FB12.
FB45A
I have recorded that {FACILITY} contains beds that are licensed as nursing facility beds but not certified by
{"PREFERRED NAME" FOR MEDICAID} {(or "ALLOWED NAME(S) FOR MEDICAID)} or Medicare. How many
beds are licensed but not certified as nursing home beds {only}?
_____________
NO. OF BEDS
BOX FB12
If now ICF-MR Medicaid certified, go FB45B
Else, go to BOX FB13.
FB45B
I have recorded that {FACILITY} contains beds that are certified by {"PREFERRED" NAME {FOR MEDICAID}} {(or
"ALLOWED NAME(S) FOR MEDICAID)} as ICF-MR (Intermediate Care Facility for the Mentally Retarded) beds.
How many beds are certified as ICF-MR beds {only}?
_____________
NO. OF BEDS
BOX
FB13
If FA22B=1 or 2, go to FB45C
Else, go to BOX FB14.
38
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
FB45C
I recorded earlier that {FACILITY} contains beds that are licensed as a personal care, board and care, assisted
living, domiciliary care, or other type of long-term care beds. How many beds are licensed as one of these types of
long-term care {only}?
_____________
NO. OF BEDS
BOX
FB14
If cannot calculate number of remaining beds, go to FR7PRE.
Others, go to FB46.
FB46
So, there are a total of { } LTC beds in the facility:
{{ } are dually certified nursing beds,}
{{ } are certified by {"PREFERRED" ........MEDICAID"} as nursing beds {only}},
{{ } are certified as nursing beds by Medicare {only},}
{{ } are not certified by Medicare or {"PREFERRED" ........MEDICAID"} but are licensed as nursing beds,}
{{ } are certified by {"PREFERRED" ........MEDICAID"} as ICF-MR beds,}
{{ } are licensed as personal care, assisted living, or other type of long-term care beds,}
{{ } are other long-term care beds which are neither certified or licensed}.
Is that correct?
YES..............................................................................................
NO ...............................................................................................
39
1
0
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
SECTION FR. FACILITY RATE SCHEDULE
FR7PRE
Next, I'd like to get some information on the basic rates residents in [READ FACILITY/UNITS ABOVE] are charged.
(Most {facilities/homes} have one or more set rates they charge their residents for room and board and basic
services. Usually this rate includes basic nursing services and sometimes it includes medical services as well. I'm
interested in the basic rates charged by {FACILITY} for {{"PREFERRED" NAME FOR MEDICAID} {(or {"ALLOWED
FOR" NAME(S) FOR MEDICAID}),} private pay, {and Medicare} residents.
PRESS F2 TO REVIEW THE PLACE ROSTER.
PRESS ENTER TO CONTINUE.
FR7
Do you have more than one basic rate?
YES .............................................................................................
NO .............................................................................................
DK .............................................................................................
Else, do not display
FR8
What is the {highest} rate you bill for residents' basic care?
$
.
DK (FR9)
RF (BOX FR4)
PER
BOX FR1
1. DAY
2. WEEK
3. MONTH
91. OTHER
IfFR7 = 1, go to FR9.
Else go to BOX FR4.
FR9
What is the lowest rate you bill for residents' basic care?
$
.
DK (BOX FR4)
RF (BOX FR4)
PER
1. DAY
2. WEEK
3. MONTH
91. OTHER
40
1
0
-8
FQ. FACILITY SCREENER QUESTIONNAIRE
BOX FR4
2006 Facility Interview
(Screener Only)
If coming from FB section, go to CLOSING1.
Else, continue.
41
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
SECTION FG: FACILITY RECORDS ORGANIZATION GRID
FG1PRE
Next, I need some information about the organization of {FACILITY}'s records and staff responsibilities.
PRESS F2 TO REVIEW PLACE ROSTER.
PRESS ENTER TO CONTINUE.
FG1 omitted.
FG1A omitted.
FG2 moved into FG4.
FG2a and FG2b omitted.
FG3
RESIDENCE HISTORY RECORDS: I may need information about where [READ SP NAME(S) FROM CASE
INFORMATION SHEET] lived prior to entering {FACILITY}, and if (he/she/they) (has/have) left, where (he/she/they)
went. What is the name and title of the staff member who would be the best source for this information?
RECORD NAME AND TITLE ON PAPER FROG.
PRESS ENTER TO CONTINUE.
FG4
HEALTH STATUS RECORDS: I will also need some information about [SP(s)] health status at the time of
admission to {FACILITY} and about the MDS forms. What are the names and titles of the staff members who would
be the best source for this information?
RECORD NAME AND TITLE ON PAPER FROG.
IF LOCATED OUTSIDE FACILITY, PROBE FOR ADDRESS.
PRESCRIPTION MEDICINE RECORDS: I will also be collecting information about the use of prescribed
medicines. Who would be the best source for this information? (What is (his/her) title?)
RECORD NAME AND TITLE ON PAPER FROG.
PRESS ENTER TO CONTINUE.
FG4A
HEALTH CARE SERVICES: I will also need information about the health care services [SP(S)] may have received
this year - services outside this {facili} as well as care from any physicians, therapists, or other providers who saw
residents here. What staff member would be the best source for this information? Could you tell me (his/her) title?
RECORD NAME AND TITLE ON PAPER FROG.
PRESS ENTER TO CONTINUE.
42
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
FG5
BACKGROUND RECORDS: I will also be collecting some background information such as the resident's age,
education, and other demographic characteristics. What is the name and title of the person who would be the best
source for this information?
RECORD NAME AND TITLE ON PAPER FROG.
HEALTH INSURANCE RECORDS: I will also be collecting information on sources of health insurance coverage for
residents. What is the name and title of the staff member who would be the best source for this information?
RECORD NAME AND TITLE ON PAPER FROG.
PRESS ENTER TO CONTINUE.
FG5A
EXPENDITURE RECORDS: I'll also need to talk to someone about billing and payments received for services
provided.
What is the name and title of the person I should talk to about this kind of information?
RECORD NAME AND TITLE ON PAPER FROG.
PRESS ENTER TO CONTINUE.
FG6-11 omitted.
BOXES FG1 and FG2 omitted.
BOX FA29 omitted.
CLOSING 1
Thank you.
THE FACILITY-LEVEL QUESTIONS FOR THIS CASE ARE COMPLETE FOR THIS ROUND.
PRESS ENTER TO RETURN TO FACILITY NAVIGATION SCREEN.
CLOSING 2
Thank you. Those are all the questions I have for you at the moment. We will want to interview (SP NAME(S)) in
the near future.
PRESS ENTER TO RETURN TO FACILITY NAVIGATION SCREEN.
CALL HOME SUMMARY REPORT omitted.
CLOSING 3 omitted.
CLOSING 4 omitted.
CLOSING 5
Thank you. Those are all the questions I have for you at the moment for this {FACILITY}. Someone from my office
may call you to verify some of the data I have collected. We appreciate your help on this important study.
PRESS ENTER TO RETURN TO FACILITY NAVIGATION SCREEN.
43
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
CLOSING 6
Thank you. Those are all the questions I have for you at the moment. Right now, I need to make arrangements to
speak to {NAMED RESPONDENT}.
PRESS ENTER TO RETURN TO FACILITY NAVIGATION SCREEN.
CLOSING 7 omitted.
44
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
SECTION MD: FACILITY MISSING DATA
RETRIEVE FACILITY LEVEL MISSING DATA
FQ_MISS1
THE FOLLOWING ITEMS ARE MISSING FROM FQ.
CONFIRM THAT RESPONDENT CAN ANSWER AT LEAST ONE QUESTION.
{FAVERIF1
{FAVERIF3
{FAVERIF4
{FAVERIF5
{FA_PLACE
{FA19
{FA20
{FA21
{FA21B
{FA22
{FA22B
{FA85
{FR1PRE
IS SF'S NAME CORRECT?}
IS SF'S ADDRESS CORRECT?}
IS SF'S ADMINISTRATOR CORRECT?}
IS SF'S PHONE NUMBER CORRECT?}
TYPE FOR {PLACE NAME}?}
NUMBER OF BEDS IN{FACILITY/TENTATIVE ADDITION}?}
MEDICAID CERTIFICATION FOR {FACILITY/TENTATIVE ADDITION}?}
MEDICARE CERTIFICATION FOR {FACILITY/TENTATIVE ADDITION}?}
MEDICAID-ICF/MR CERTIFICATION FOR {FACILITY/TENTATIVE ADDITION}?}
STATE DEPARTMENT LICENSING FOR{FACILITY/TENTATIVE ADDITION}?}
NON-NURSING LICENSING FOR {FACILITY/TENTATIVE ADDITION}?}
SAQ MISSING FOR{FACILITY/ELIGIBLE UNIT}}
RATE SCHEDULE MISSING FOR {FACILITY/ELIGIBLE UNIT}}
PRESS ENTER TO CONTINUE.
FAVERIF1
I need to verify that I'm in the right place and that our information about you is correct.
Is {FACILITY} the exact name of this {home/facility}?
YES..............................................................................................
NO ...............................................................................................
DK................................................................................................
RF ................................................................................................
1
0
-8
-7
What is the exact name of this facility?
________________________________________
FACILITY NAME
Set a flag to indicate a change has been made. Use the updated FACILITY name for FACILITY. Fill in all
questions that follow. The second UPDATE screen captures the reason for change:
REASON FOR NAME UPDATE:
CORRECTING A TYPOGRAPHICAL ERROR ............................ 1
CORRECTING SOME OTHER KIND OF ERROR ...................... 2
SPECIFYING MORE COMPLETE INFORMATION..................... 3
FACILITY CHANGED ITS NAME
WHEN BOUGHT BY ANOTHER COMPANY .............................. 5
FACILITY CHANGED ITS NAME FOR SOME
OTHER REASON ..................................................................... 6
OTHER (SPECIFY:_____________________) ........................... 91
45
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
FAVERIF3
{Is the address of the place where [SP NAME} lives.../Is {FACILITY}'s address...}
{ADDRESS1}
{CITY, STATE ZIP}?
YES..............................................................................................
NO ...............................................................................................
DK................................................................................................
RF ................................................................................................
1
0
-8
-7
REASON FOR ADDRESS UPDATE:
CORRECTING A TYPOGRAPHICAL ERROR ............................ 1
CORRECTING SOME OTHER KIND OF ERROR ...................... 2
SPECIFYING MORE COMPLETE INFORMATION..................... 3
FACILITY MOVED TO A DIFFERENT ADDRESS ...................... 7
FACILITY CHANGED ITS ADDRESS FOR
SOME OTHER REASON.......................................................... 8
OTHER (SPECIFY:_____________________) ........................... 91
BOX
FA1A
If 0 is entered in FAVERIF3, review address fields. If interviewer pressed enter on
each and all fields, go to FAVERIF4. Else, present ADDRESS UPDATE
SCREEN. Set a flag to indicate a change has been made. The ADDRESS
UPDATE screen collects the reason for change.
Else, continue.
46
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
FAVERIF4
{CODE "2" WITHOUT ASKING.}
{{Is ADMINISTRATOR'S NAME} {Are you/You are}} {still} the current administrator of {FACILITY}?
YES.............................................................................................. 1
NO ............................................................................................... 0
{RESPONDENT CONSIDERED ADMINISTRATOR........................ 2}
DK................................................................................................... -8
RF .................................................................................................. -7
What is the current administrator's name?
After the NAME has been entered and the TITLE confirmed, return to FAVERIF4 at the ADMINISTRATOR UPDATE
SCREEN. The UPDATE screen captures the reason for the change:
REASON FOR ADMINISTRATOR NAME UPDATE: (
)
CORRECTING A TYPOGRAPHICAL ERROR ..........................1
CORRECTING SOME OTHER KIND OF ERROR ....................2
SPECIFYING MORE COMPLETE INFORMATION...................3
FACILITY CHANGED ADMINISTRATORS ..............................4
OTHER (SPECIFY:_____________________) .......................91
FAVERIF5
{VERIFY PHONE NUMBER IS FOR FQ RESPONDENT. DO NOT READ ALOUD.}
Is {FACILITY AREA CODE AND PHONE NUMBER} the correct phone number for {FACILITY}?
YES..............................................................................................
NO ...............................................................................................
DK................................................................................................
RF ................................................................................................
What is the phone number?
(
)(
)-(
)
{Area code and state do not match. Verify and re-enter state and area code.}
The second UPDATE screen collects the reason for the change:
REASON FOR UPDATE: (
)
CORRECTING A TYPOGRAPHICAL ERROR ..........................1
CORRECTING SOME OTHER KIND OF ERROR ....................2
SPECIFYING MORE COMPLETE INFORMATION...................3
FACILITY MOVED TO A DIFFERENT ADDRESS ....................7
ADULT/GROUP HOME .............................................................9
AREA CODE CHANGED .........................................................10
OTHER (SPECIFY:_____________________) .......................91
47
1
0
-8
-7
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
FA_PLACE
What type of place is {FACILITY/PLACE/UNIT}?
SHOW
CARD
RH2
NURSING HOME/UNIT ............... 4
HOSPITAL .................................... 6
ASSISTED LIVING FACILITY ...... 8
BOARD AND CARE HOME ......... 9
DOMICILIARY CARE HOME ....... 10
PERSONAL CARE HOME ........... 11
REST HOME/RETIREMENT
HOME .......................................... 12
INDEPENDENT LIVING UNITS ... 14
MENTAL HEALTH CENTER/
PSYCHIATRIC SETTING ............ 15
INSTITUTION FOR THE
MENTALLY RETARDED/
DEVELOPMENTALLY
DISABLED ................................... 16
REHABILITATION FACILITY ....... 17
OTHER (SPECIFY:_________) ... 91
REFUSED .................................... -7
PRESS F1 FOR DEFINITIONS OF ASSISTED LIVING FACILITY, BOARD AND CARE HOME, DOMICILIARY
CARE HOME, PERSONAL CARE HOME, AND REST HOME.
FA19
{Now let's turn to {FACILITY}.}
{How many beds does {FACILITY} have?/According to the information I obtained earlier, {FACILITY} has [READ
NUMBER BELOW] beds.}
{
}
NO. OF BEDS
{PRESS ENTER TO CONTINUE/DK=-8, RF=-7.}
PRESS F1 FOR EXPANDED DEFINITION OF "BEDS".
FA20
Is {FACILITY} certified by {"PREFERRED" NAME FOR MEDICAID} {(or {"ALLOWED FOR" NAME(S) FOR
MEDICAID})} as a Nursing Facility (NF)?
IF R MENTIONS:
-ICF (INTERMEDIATE CARE FACILITY), NOTE IN COMMENTS AND ENTER 1.
-ICF-MR (INTERMEDIATE CARE FACILITY-MENTAL RETARDATION), NOTE IN COMMENTS AND ENTER
0.
YES..............................................................................................
NO ...............................................................................................
DK................................................................................................
RF ................................................................................................
1
0
-8
-7
FA21
Is {FACILITY} certified by Medicare as a SNF?
YES..............................................................................................
NO................................................................................................
DK ................................................................................................
RF ................................................................................................
48
1
0
-8
-7
FQ. FACILITY SCREENER QUESTIONNAIRE
2006 Facility Interview
(Screener Only)
FA21B
Does {FACILITY} have any beds certified by {"PREFERRED" NAME FOR MEDICAID} {(or {"ALLOWED FOR"
NAME(S) FOR MEDICAID})} as ICF-MR (Intermediate Care Facility for the Mentally Retarded) beds?
YES..............................................................................................
NO................................................................................................
DK ................................................................................................
RF ................................................................................................
1
0
-8
-7
FA22
Is {FACILITY} licensed as a nursing {home/facility} by the {STATE} State Health Department or by some other
agency?
YES, LICENSED BY STATE HEALTH DEPARTMENT ...............
YES, LICENSED BY SOME OTHER AGENCY
)...................................................
(SPECIFY:
NO, NOT LICENSED ...................................................................
DK ................................................................................................
RF ................................................................................................
1
2
0
-8
-7
FA22B
Does {FACILITY} have any beds licensed as personal care, board and care, assisted living, or domiciliary care
beds by the {STATE} State Health Department or by some other state agency?
YES, LICENSED BY STATE HEALTH DEPARTMENT ...............
YES, LICENSED BY SOME OTHER AGENCY
(SPECIFY:___________________________________).............
NO, NOT LICENSED ...................................................................
DK................................................................................................
RF ................................................................................................
1
2
0
-8
-7
FA23 omitted.
FA31 omitted.
FA77 omitted.
BOX
FACOMP
If there is no facility missing data, that is, there are no items listed on FQ_MISS1, and
FA85=2 or 4, and FR1PRE=1 or 0, go to FAEND; else go to MD Management
screen (FQ_MISS).
FAEND
YOU HAVE COMPLETED DATA COLLECTION FOR FACILITY LEVEL MISSING DATA.
PRESS ENTER TO RETURN TO FACILITY NAVIGATION SCREEN.
49
| File Type | application/pdf |
| File Title | Microsoft Word - F_Facility Questionnaire_FQ.doc |
| Author | mf46 |
| File Modified | 2006-10-25 |
| File Created | 2006-10-25 |