Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)

Medicare Current Beneficiary Survey (MCBS)

Attachment 4 Questionnaire Comprehensive Format Section by Section HHS_04.01.0000

Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)

OMB: 0938-0568

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BOX HHS1

BOX HHS1

Page Order # :

10

BOX INSTRUCTIONS
( HHS1010 )	

IF SP RECEIVED CARE FROM AT LEAST ONE HOME HEALTH
PROFESSIONAL DURING THE PREVIOUS ROUND, GO TO BOX HHS1A (HHS1015 ).
ELSE GO TO BOX HHS2 - (HHS1030 ).

ASSIGNMENTS

TECHNICAL NOTES
173

HHProfPrevRnd

SP received care from Home Health professional during
previous round =
There is an EVNT where EVNT.EVNTTYPE='HP' &
HERO where (HERO.HEROEVNT=EVNTNUM &
HERORND=previous round & HERO.HERODFLG
^=1/Yes & (HERO.OTHMEALS^= empty or
HERO.HELPUNIT^=empty)).

DESIGN NOTES
Begin Loop 1: Collect current round Home health information regarding
each Home Health professional visit from previous round.

1:19:42 PM Monday, November 03, 2008	

Page 1 of 15

BOX HHS1A

BOX HHS1A

Page Order # :

15

BOX INSTRUCTIONS
( HHS1015 )	

CREATE CURRENT ROUND HERO RECORD FOR HH PROVIDER BEING
ASKED ABOUT .
GO TO HHS1 - PROFPROB ( HHS1020 ).

ASSIGNMENTS
Home Health events are stored on EVNT and HERO.

EVNT Key = EVNT.EVNTBASE + EVNT.EVNTNUM

EVNT.EVNTNUM = number of Home Health Event.

EVNT.EVNTPROV = number of Home Health Provider associated with event.

Round specific Home Health event details are stored on HERO. Each Home Health event

from the previous round will automatically have a current round HERO generated:

HERO key = HERO.HEROBASE + HERO.HEROEVNT + HERO.HERORND

HERO.HEROEVNT = EVNT.EVNTNUM for Home Health Event.

HERO.HERORND = current round.

Set HERO variables as instructed below.

HEROEVNT

HERO.HEROEVNT = EVNT.EVNTNUM.

HERORND

HERO.HERORND=current round.

TECHNICAL NOTES

DESIGN NOTES

1:19:42 PM Monday, November 03, 2008	

Page 2 of 15

HHS1

HHS1

Page Order # :

Design Screen Type:	

Yes/No

Fields:	

Field 1:

PROFPROB

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

20

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:	

If someone works for this Provider, display "someone from" and
"anyone from".
Else do not display.
Display "at home" in Bold in the second sentence.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:	

Display Provider and Subprovider Names for the first/next Home
Health provider currently being asked about.
Column 1, header = DO NOT DISPLAY A HEADER

Column 1, display =

If someone works for this provider, display Provider Name, 

PROV.PROVNAME, followed by Subprovider Name,

PROV.SUBPROV, in parenthesis.

Ex: PROVIDER NAME (SUBPROVIDER NAME).

Else display Provider Name, PROV.PROVNAME.


TEXT:
Context Header:

1:19:43 PM Monday, November 03, 2008	

Page 3 of 15

HHS1
Int. Instr I:
We recorded that [you/(SP)] had been helped at home by (someone
from) [READ PROVIDER BELOW] between (SUMMARY
REFERENCE DATE) and (REFERENCE DATE). Has (anyone from)
[READ PROVIDER BELOW] helped [you/(SP)] at home (since
REFERENCE DATE/between REFERENCE DATE and DATE OF
DEATH/ INSTITUTIONALIZATION)?

Question Text:

Int. Instr II:

INPUT FIELDS / ROUTING

PROFPROB

Field1:

( HHS1020 )

HERO.PROFPROB

Cheshire Name:
Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TProfprob
1
No
No

Number Label
1 Yes

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX HHS3 - (HHS1050 )

2

English text: YES
No

BOX HHS5 - (HHS1090 )

3

English text: NO
HomeHealthEnteredInError

BOX HHS5 - (HHS1090 )

English text: HOME HEALTH ENTERED IN ERROR IN PREVIOUS ROUND
Attribute
Don't know

Route
BOX HHS5 - (HHS1090 )

Refusal

BOX HHS5 - (HHS1090 )

BACKGROUND VARIABLE ASSIGNMENTS
SETTING DELETE FLAGS:

If HHS1 - PROFPROB=3/HomeHealthEnteredInError, then set the following flags:

1) Set HERO.HERODFLG=1/Yes on previous round HERO.

1:19:47 PM Monday, November 03, 2008

Page 4 of 15

HHS1
2) (If there is no other Home Health visit linked to this event) and EVNT.PREVHERO ^=
1/Yes, set EVNT.EVNTDFLG=1/Yes on this EVNT:
DETERMINE WHETHER OR NOT ANOTHER HH VISIT IS LINKED TO THIS EVENT:
If there is a HERO where (HERO.HEROEVNT=this EVNT.EVNTNUM and
HERO.HERORND ^= previous round & HERO.HERODFLG ^= 1/Yes and
(HERO.OTHMEALS ^= empty or HERO.HELPUNIT ^= empty)), then there is a Home
Health visit linked to this event.
HERODFLG	

If HHS1 ­
PROFPROB=3/HomeHealthEnteredInError, set
HERO.HERODFLG=1/Yes on HERO where
HERO.HERORND=previous round.

EVNTDFLG	

If HHS1 - PROFPROB=3/HomeHealthEnteredInError
and there is no other Home Health visit linked to this
event and EVNT.PREVHERO ^= 1/Yes, set
EVNT.EVNTDFLG=1/Yes.

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
166

SomeoneWorksForProv	 If someone works for this Provider =
PROV.SUBPROV ^= empty.

DESIGN NOTES

1:19:47 PM Monday, November 03, 2008	

Page 5 of 15

BOX HHS2

BOX HHS2

Page Order # :

30

BOX INSTRUCTIONS
( HHS1030 )	

IF SP RECEIVED HOME HEALTH CARE FROM AT LEAST ONE FRIEND OR
RELATIVE DURING THE PREVIOUS ROUND, GO TO BOX HHS2A ­
(HHS1035 ).
ELSE GO TO BOX HHS6 - (HHS1095 ).

ASSIGNMENTS

TECHNICAL NOTES
174

HHFriendPrevRnd

SP received Home Health care from friend/relative during
previous round =
There is an EVNT where EVNT.EVNTTYPE='HF' &
HERO where (HERO.HEROEVNT=EVNTNUM &
HERORND=previous round & HERO.HERODFLG
^=1/Yes & (HERO.OTHMEALS^= empty or
HERO.HELPUNIT^=empty)).

DESIGN NOTES
Begin Loop 2: Collect current round Home health information regarding
each Home Health friend/relative visit from previous round.

1:19:47 PM Monday, November 03, 2008	

Page 6 of 15

BOX HHS2A

BOX HHS2A

Page Order # :

35

BOX INSTRUCTIONS
( HHS1035 )	

CREATE CURRENT ROUND HERO RECORD FOR HH PROVIDER BEING
ASKED ABOUT .
GO TO HHS2 - FRNDPROB ( HHS1040 ).

ASSIGNMENTS
Home Health events are stored on EVNT and HERO.

EVNT Key = EVNT.EVNTBASE + EVNT.EVNTNUM

EVNT.EVNTNUM = number of Home Health Event.

EVNT.EVNTPROV = number of Home Health Provider associated with event.

Round specific Home Health event details are stored on HERO. Each Home Health event

from the previous round will automatically have a current round HERO generated:

HERO key = HERO.HEROBASE + HERO.HEROEVNT + HERO.HERORND

HERO.HEROEVNT = EVNT.EVNTNUM for Home Health Event.

HERO.HERORND = current round.

Set HERO variables as instructed below.

HEROEVNT

HERO.HEROEVNT = EVNT.EVNTNUM.

HERORND

HERO.HERORND=current round.

TECHNICAL NOTES

DESIGN NOTES

1:19:47 PM Monday, November 03, 2008	

Page 7 of 15

HHS2

HHS2

Page Order # :

Design Screen Type:	

Yes/No

Fields:	

Field 1:

FRNDPROB

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

40

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:	

If someone works for this Provider, display "someone from" and
"anyone from".
Else do not display.
Display "at home" in Bold in the second sentence.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:	

Display Provider and Subprovider Names for the first/next Home
Health provider currently being asked about.
Column 1, header = DO NOT DISPLAY A HEADER

Column 1, display =

If someone works for this provider, display Provider Name, 

PROV.PROVNAME, followed by Subprovider Name,

PROV.SUBPROV, in parenthesis.

Ex: PROVIDER NAME (SUBPROVIDER NAME).

Else display Provider Name, PROV.PROVNAME.


TEXT:
Context Header:

1:19:49 PM Monday, November 03, 2008	

Page 8 of 15

HHS2
Int. Instr I:
We recorded that [you/(SP)] had received personal care or help with
daily needs at home from (someone from) [READ PROVIDER
BELOW] between (SUMMARY REFERENCE DATE) and
(REFERENCE DATE). [Have you/Has (SP)] received personal care
or help with daily needs at home from (anyone from) [READ
PROVIDER BELOW] (since REFERENCE DATE/between
REFERENCE DATE and DATE OF DEATH/
INSTITUTIONALIZATION)?

Question Text:

Int. Instr II:

INPUT FIELDS / ROUTING

FRNDPROB

Field1:

( HHS1040 )

HERO.FRNDPROB

Cheshire Name:
Item Text display:
Item Text:
Label:

Label Position:

Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TProfprob
1
No
No

Number Label
1 Yes
2
3

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX HHS3 - (HHS1050 )

English text: YES
No

BOX HHS5 - (HHS1090 )

English text: NO
HomeHealthEnteredInError
BOX HHS5 - (HHS1090 )
English text: HOME HEALTH ENTERED IN ERROR IN PREVIOUS ROUND

Attribute
Don't know

Route
BOX HHS5 - (HHS1090 )

Refusal

BOX HHS5 - (HHS1090 )

BACKGROUND VARIABLE ASSIGNMENTS
SETTING DELETE FLAGS:

If HHS2 - FRNDPROB=3/HomeHealthEnteredInError, then set the following flags:

1:19:52 PM Monday, November 03, 2008

Page 9 of 15

HHS2
1) Set HERO.HERODFLG=1/Yes on previous round HERO.

2) (If there is no other Home Health visit linked to this event) and EVNT.PREVHERO ^= 

1/Yes, set EVNT.EVNTDFLG=1/Yes on this EVNT:

DETERMINE WHETHER OR NOT ANOTHER HH VISIT IS LINKED TO THIS EVENT:

If there is a HERO where (HERO.HEROEVNT=this EVNT.EVNTNUM and

HERO.HERORND ^= previous round & HERO.HERODFLG ^= 1/Yes and

(HERO.OTHMEALS ^= empty or HERO.HELPUNIT ^= empty)), then there is a Home

Health visit linked to this event.

HERODFLG	

If HHS2 ­
FRNDPROB=3/HomeHealthEnteredInError, set
HERO.HERODFLG=1/Yes on HERO where
HERO.HERORND=previous round.

EVNTDFLG	

If HHS2 - FRNDPROB=3/HomeHealthEnteredInError
and there is no other Home Health visit linked to this
event and EVNT.PREVHERO ^= 1/Yes, set
EVNT.EVNTDFLG=1/Yes.

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES
166

SomeoneWorksForProv	 If someone works for this Provider =
PROV.SUBPROV ^= empty.

DESIGN NOTES

1:19:52 PM Monday, November 03, 2008	

Page 10 of 15

BOX HHS3

BOX HHS3

Page Order # :

50

BOX INSTRUCTIONS
( HHS1050 )

IF TYPE OF HOME HEALTH PROVIDER ORGANIZATION IS A MEAL
PROGRAM, GO TO HHS3 - OTHMEALS ( HHS1070 ).
ELSE GO TO BOX HH1BB - (HHQ1102 ).

ASSIGNMENTS

TECHNICAL NOTES
175

ProviderMealProgram

Type of Home Health Provider Organization is a Meal
Program =
PROV.HHPLACE=2/MealProgram.

DESIGN NOTES
If Provider is not a meal program, BOX HHS3 is routed directly to BOX
HH1BB in the HH section to collect current round Home Health event
details.

1:19:52 PM Monday, November 03, 2008

Page 11 of 15

HHS3

HHS3

Page Order # :

Design Screen Type:	

Yes/No

Fields:	

Field 1:

OTHMEALS

Enable Functions:	

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:	

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:	

Add Line
Delete Line

No
No

70

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:	

Display name of first/next home health provider currently being
asked about, PROV.PROVNAME.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:

Int. Instr I:

Question Text:

Since (REFERENCE DATE), has (PROVIDER NAME) provided any

services to [you/(SP)] other than delivering meals?

Int. Instr II:
INPUT FIELDS / ROUTING

1:19:54 PM Monday, November 03, 2008	

Page 12 of 15

HHS3
OTHMEALS

Field1:
Cheshire Name:

( HHS1070 )

HERO.OTHMEALS

Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TYesNoDKRF
1
No
No

Number Label
1 Yes
2

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX HH1BB - (HHQ1102 )

English text: YES
No

BOX HHS5 - (HHS1090 )

English text: NO
Attribute
Don't know

Route
BOX HHS5 - (HHS1090 )

Refusal

BOX HHS5 - (HHS1090 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES
If the Home Health Provider Organization provided any other services other

than meals, HHS3 is routed directly to BOX HH1BB in the HH section to

collect current round Home Health event details.


1:19:56 PM Monday, November 03, 2008

Page 13 of 15

BOX HHS5

BOX HHS5

Page Order # :

90

BOX INSTRUCTIONS
( HHS1090 )	

IF ASKING ABOUT HOME HEALTH PROFESSIONALS FROM THE
PREVIOUS ROUND, THEN .
IF SP RECEIVED CARE FROM ANOTHER HOME HEALTH
PROFESSIONAL DURING THE PREVIOUS ROUND, GO TO BOX HHS1A (HHS1015 ).
ELSE GO TO BOX HHS2 - (HHS1030 ).
ELSE IF ASKING ABOUT HOME HEALTH CARE FROM A FRIEND OR
RELATIVE FROM THE PREVIOUS ROUND, THEN .
IF SP RECEIVED HOME HEALTH CARE FROM ANOTHER FRIEND OR
RELATIVE DURING THE PREVIOUS ROUND, GO TO BOX HHS2A ­
(HHS1035 ).
ELSE GO TO BOX HHS6 - (HHS1095 ).
ELSE GO TO BOX HHS6 - (HHS1095 ).

ASSIGNMENTS

TECHNICAL NOTES
173

HHProfPrevRnd

SP received care from Home Health professional during
previous round =
There is an EVNT where EVNT.EVNTTYPE='HP' &
HERO where (HERO.HEROEVNT=EVNTNUM &
HERORND=previous round & HERO.HERODFLG
^=1/Yes & (HERO.OTHMEALS^= empty or
HERO.HELPUNIT^=empty)).

174

HHFriendPrevRnd

SP received Home Health care from friend/relative during
previous round =
There is an EVNT where EVNT.EVNTTYPE='HF' &
HERO where (HERO.HEROEVNT=EVNTNUM &
HERORND=previous round & HERO.HERODFLG
^=1/Yes & (HERO.OTHMEALS^= empty or
HERO.HELPUNIT^=empty)).

DESIGN NOTES
BOX HHS5 serves as an End Loop Box for Loop 1 and Loop 2.
If asking about Home Health professionals from BOX HHS1, BOX HHS5
will route back to BOX HHS1A for the next Home Health professional from
the previous round. Otherwise BOX HHS5 will route to BOX HHS2 to
check for previous round Home Health Friends/Relatives.
Else if asking about Home Health Friends/Relatives from BOX HHS2,
BOX HHS5 will route back to BOX HHS2A for the next Home Health
friend/relative. Otherwise BOX HHS5 will route to BOX HHS6 to complete
HHS section.

1:19:56 PM Monday, November 03, 2008	

Page 14 of 15

BOX HHS6

BOX HHS6

Page Order # :

100

BOX INSTRUCTIONS
( HHS1095 )

GO TO NEXT SECTION .

ASSIGNMENTS

TECHNICAL NOTES

DESIGN NOTES

1:19:56 PM Monday, November 03, 2008

Page 15 of 15


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