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pdfVariable Name
MR Screen Name
Question type
Question text/description
Code list
Routing
(00) NO
(01) YES
(02) DISPLAYED GROUP HOME NAME IS CORRECT
(03) DISPLAYED GROUP HOME NAME IS NOT
CORRECT
(-8) Don't Know
(-9) Refused
(00) FQ1A - PLACNAME
(01) FQ2 - FADDROK
(02) FQ2 - FADDROK
(03) FQ1A - PLACNAME
(-8) FQCLOSE7 - NOTRESP
(-9) FQCLOSE7 - NOTRESP
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) FQ2 - FADDROK
(-8) FQ2 - FADDROK
(-9) FQ2 - FADDROK
FACILITY QUESTIONNAIRE SECTION SPECIFICATIONS
CRITERIA
SAMPLE TYPE=ALL
SEASON=ALL
PLACEMENT
Start of Facility Interview
BOX FQ1
FNAMEOK
PLACNAME
FQ1
FQ1A
routing
GO TO FQ1 - FNAMEOK.
code one
IF SP IS 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 is correct. Is (PRELOAD FACILITY) the exact name
of the place where (SP) (is/was) physically located [on or around (PREVIOUS INTERVIEW DATE)/on or
around (ADMISSION DATE REPORTED BY A PREVIOUS SOURCE)?
text
What is the exact name of the place where (SP) (is/was) physically located [on or around (PREVIOUS
INTERVIEW DATE)/on or around (ADMISSION DATE REPORTED BY A PREVIOUS SOURCE)]?
Next, I would like to verify the address of the place where (SP) (is/was) physically located [on or around
(PREVIOUS INTERVIEW DATE)/on or around (ADMISSION DATE REPORTED BY A PREVIOUS SOURCE)].
FADDROK
FQ2
yes/no
I have it listed as [READ ADDRESS BELOW]. Is this correct?
ADDRESS
ADDRCITY
ADDRSTAT
ADDRZIP
FQ2A
FQ2A
FQ2A
FQ2A
address
address
address
address
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
What is the correct address of the place where (SP) (is/was) physically located [on or around (PREVIOUS
INTERVIEW DATE)/on or around (ADMISSION DATE REPORTED BY A PREVIOUS SOURCE)]?
(01) [Continuous answer.]
PRESS F1 FOR STATE ABBREVIATIONS.
(-8) Don't Know
(-9) Refused
ADDRESS
(01) FQ2A - ADDRCITY
(-8) FQ2A - ADDRCITY
(-9) FQ2A - ADDRCITY
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) FQ2A - ADDRSTAT
(-8) FQ2A - ADDRSTAT
(-9) FQ2A - ADDRSTAT
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) FQ2A - ADDRZIP
(-8) FQ2A - ADDRZIP
(-9) FQ2A - ADDRZIP
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) FQ3 - FADMNOK
(-8) FQ3 - FADMNOK
(-9) FQ3 - FADMNOK
(00) FQ3A - FACRNAM1
(01) FQ4 - MADDROK
(02) FQ4 - MADDROK
(-8) FQ4 - MADDROK
(-9) FQ4 - MADDROK
(01) FQ4 - MADDROK
CITY
STATE
ZIP
FADMNOK
FQ3
code one
(CODE "2" WITHOUT ASKING.)
[Is (ADMINISTRATOR'S NAME)/Are you] (still) the current administrator of (FACILITY)?
(00) NO
(01) YES
(02) RESPONDENT CONSIDERED ADMINISTRATOR
(-8) Don't Know
(-9) Refused
FACRNAM1
FQ3A
roster
What is the current administrator's name?
SELECT A RESPONSE BELOW OR ADD TO THE PERSON ROSTER.
(01) [Continuous answer.]
MADDROK
FQ4
yes/no
(00) FQ2A - ADDRESS
(01) FQ3 - FADMNOK
(-8) FQ3 - FADMNOK
(-9) FQ3 - FADMNOK
(00) NO
Next, I would like to verify your office address. I have it listed as [READ ADDRESS LISTED BELOW]. Is this (01) YES
(-9) Refused
correct?
(00) FQ4A - MAILADD1
(01) FQ5 - FPHONOK
(-9) FQ5 - FPHONOK
What is the correct address for your office?
PRESS F1 FOR STATE ABBREVIATIONS.
FQ4A
FQ4A
text
ADDRESS
MAILCIT1
MAILSTA1
MAILZIP1
FPHONOK
MAILADD1
FQ4A
FQ4A
FQ5
text
text
text
yes/no
CITY
STATE
ZIP
(VERIFY PHONE NUMBER IS FOR FQ RESPONDENT. DO NOT READ ALOUD.)
Is (FACILITY AREA CODE AND PHONE NUMBER) the correct phone number for (FACILITY)?
What is the phone number?
ADDRAREA
FQ5A
Numeric
AREACODE
ADDREXCH
ADDRLOCL
FAINT1TC
FQ5A
FQ5A
Numeric
Numeric
BOX FQ7
routing
FAINTRO1
code one
BOX FA1
routing
EXCHANGE
LOCAL
IF BASELINE FQ, GO TO FAINTRO1 - FAINT1TC.
IF FALL ROUND OR ANNUAL FQ, GO TO FB0PRE - ANSWERFB.
ELSE GO TO CLOSING1 - RETURNAV.
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 "1" TO CONTINUE.
IF ADULT/GROUP HOME, GO TO FA5A - EFOWNDES.
ELSE GO TO FA1 - PLACTYP1.
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) FQ4A - MAILCIT1
(-8) FQ4A - MAILCIT1
(-9) FQ4A - MAILCIT1
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) FQ4A - MAILSTA1
(-8) FQ4A - MAILSTA1
(-9) FQ4A - MAILSTA1
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) FQ4A - MAILZIP1
(-8) FQ4A - MAILZIP1
(-9) FQ4A - MAILZIP1
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) FQ5 - FPHONOK
(-8) FQ5 - FPHONOK
(-9) FQ5 - FPHONOK
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FQ5A - ADDRAREA
(01) BOX FQ7
(-8) BOX FQ7
(-9) BOX FQ7
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) FQ5A - ADDREXCH
(-8) FQ5A - ADDREXCH
(-9) FQ5A - ADDREXCH
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) FQ5A - ADDRLOCL
(-8) FQ5A - ADDRLOCL
(-9) FQ5A - ADDRLOCL
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) BOX FQ7
(-8) BOX FQ7
(-9) BOX FQ7
(01) Continue
(01) BOX FA1
SHOW CARD FA2
What type of place is (FACILITY)?
PLACTYP1
FA1
code one
PRESS F1 FOR PLACE DEFINITIONS.
IF RESPONDENT REPORTS CCRC OR RETIREMENT COMMUNITY, PROBE FOR TYPE OF PLACE FOR UNIT
WHERE SP RESIDES. DO NOT ENTER "OTHER".
PLACTPO1
FACHOME
FA1
FA1A
BOX FA1A
verbatim
OTHER (SPECIFY)
code one
IF ALREADY KNOWN, CODE WITHOUT ASKING:
Do you prefer that I call (FACILITY) a home or a facility?
routing
HOSPKIND
FA2
code one
You mentioned that (FACILITY) is a hospital. Please look at this card and tell me what kind of hospital it
is.
HOSPKIOS
FA2
verbatim
OTHER (SPECIFY)
yes/no
Does (FACILITY) have any beds that are either certified or licensed as a nursing facility or certified or
licensed as an ICF-MR (Intermediate Care Facility for the Mentally Retarded) ICF/IID (Intermediate Care
Facilities for Individuals with Intellectual Disabilities)?
routing
PRESS F1 FOR SUGGESTED PROBES.
IF FA2 - HOSPKIND = 1/AcuteCareHospital, GO TO FACLOSE2 - LEAVINEL.
ELSE GO TO FA3 - FACLPART.
FA2A
BOX FA2A
Is (FACILITY) part of a larger facility or campus?
FACLPART
FA3
(01) FA1A - FACHOME
(04) FA1A - FACHOME
(06) FA2 - HOSPKIND
(07) FA1A - FACHOME
(08) FA1A - FACHOME
(09) FA1A - FACHOME
(10) FA1A - FACHOME
(11) FA1A - FACHOME
(12) FA1A - FACHOME
(13) FACLOSE5 - LVNORES
(15) FA1A - FACHOME
(16) FA1A - FACHOME
(17) FA1A - FACHOME
(91) FA1 - PLACTPO1
(-9) FA1A - FACHOME
(01) [Continuous answer.]
(01) FA1A - FACHOME
(01) PREFERS HOME
(02) PREFERS FACILITY
(03) NO PREFERENECE
(01) BOX FA1A
(02) BOX FA1A
(03) BOX FA1A
(01) ACUTE CARE HOSPITAL
(02) PRIVATE PYSCHIATRIC HOSPITAL
(03) STATE OR COUNTY HOSPITAL FOR THE
MENTALLY ILL
(04) VA HOSPITAL, VA MEDICAL CENTER
(05) STATE HOSPITAL FOR THE MENTALLY
RETARDED INDIVIDUALS WITH INTELLECTUAL
DISABILITIES
(06) CHRONIC DISEASE, REHABILITATION,
GERIATRIC, OR OTHER LONG-TERM CARE
HOSPITAL
(91) OTHER
(01) FA2A - LCNDBEDS
(02) FA2A - LCNDBEDS
(03) FA2A - LCNDBEDS
(04) FA2A - LCNDBEDS
(05) FA2A - LCNDBEDS
(06) FA2A - LCNDBEDS
(91) FA2 - HOSPKIOS
(01) [Continuous answer.]
(01) FA2A - LCNDBEDS
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX FA2A
(01) FA3 - FACLPART
(-8) BOX FA2A
(-9) BOX FA2A
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FA5A - EFOWNDES
(01) FA4 - PLACTYP2
(-8) BOX FA6
(-9) BOX FA6
IF PLACTYP1 = 4/NursingHomeUnitCCRC or 7/HospitalBasedSNF, GO TO FA4 - PLACTYP2.
IF FA1-PLACTYP1 = 1/FreeStandingNursingHome, GO TO FA5A - EFOWNDES.
ELSE GO TO FA3 - FACLPART.
SHOW CARD FA3
LCNDBEDS
(01) FREE STANDING NURSING HOME
(04) NURSING HOME UNIT WITHIN A CCRC OR
RETIREMENT CENTER
(06) HOSPITAL
(07) HOSPITAL-BASED SNF UNIT
(08) ASSISTED LIVING FACILITY
(09) BOARD AND CARE HOME
(10) DOMICILIARY CARE HOME
(11) PERSONAL CARE HOME
(12) REST HOME/RETIREMENT HOME
(13) HOME OFFICE OR MANAGEMENT OFFICE FOR
A CHAIN OR GROUP OF OFF-SITE NURSING
FACILITIES
(15) MENTAL HEALTH CENTER/PSYCHIATRIC
SETTING
(16) INSTITUTION FOR THE MENTALLY RETARDED
INTELLECTUALLY DISABLED/DEVELOPMENTALLY
DISABLED
(17) REHABILITATION FACILITY
(91) OTHER
(-9) Refused
Yes/No
PRESS F1 FOR DEFINITION, EXAMPLES OF "LARGER" PLACES.
PLACTYP2
FA4
code one
SHOW CARD FA1
What type of place is (FACILITY) part of?
PRESS F1 FOR HOSPITAL DEFINITIONS.
PLACTPO2
FA4
verbatim
OTHER (SPECIFY)
LGPLCNAM
FA5
text
What is the name of the (CATEGORY SELECTED IN FA4 - PLACTYP2/place)?
SHOW CARD FA4
EFOWNDES
FA5A
code one
Which one of the categories on this card best describes the ownership of (FACILITY)?
EFOWNDOS
FA5A
verbatim
OTHER (SPECIFY)
BOX FA6
routing
BOX FA6A
routing
GO TO BOX FA6A.
IF FACILTIY IS ELIGIBLE, GO TO FA10 - ANSRELIG.
ELSE GO TO FACLOSE2 - LEAVINEL.
ANSRELIG
FA10
yes/no
FACRNAM2
FA11
roster
BOX FA7A
routing
CCNINTRO
FA11A
yes/no
(03) CONTINUING CARE RETIREMENT
COMMUNITY (CCRC)
(05) RETIREMENT COMMUNITY
(06) HOSPITAL
(08) ASSISTED LIVING FACILITY
(09) BOARD AND CARE HOME
(10) DOMICILIARY CARE HOME
(11) PERSONAL CARE HOME
(12) REST HOME/RETIREMENT HOME
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(01) [Continuous answer.]
(01) FOR PROFIT (INDIVIDUAL, PARTNERSHIP, OR
CORPORATION)
(02) PRIVATE NONPROFIT (RELIGIOUS GROUP,
NONPROFIT CORPORATION, ETC)
(03) CITY/COUNTY GOVERNMENT
(04) STATE GOVERNMENT
(05) VETERAN'S ADMINISTRATION
(06) OTHER FEDERAL AGENCY
(91) OTHER
(01) [Continuous answer.]
(03) FA5 - LGPLCNAM
(05) FA5 - LGPLCNAM
(06) FA5 - LGPLCNAM
(08) FA5 - LGPLCNAM
(09) FA5 - LGPLCNAM
(10) FA5 - LGPLCNAM
(11) FA5 - LGPLCNAM
(12) FA5 - LGPLCNAM
(91) FA4 - PLACTPO2
(-8) FA5 - LGPLCNAM
(-9) FA5 - LGPLCNAM
(01) FA5 - LGPLCNAM
(01) FA5A - EFOWNDES
(01) BOX FA6
(02) BOX FA6
(03) BOX FA6
(04) BOX FA6
(05) BOX FA6
(06) BOX FA6
(91) FA5A - EFOWNDOS
(01) BOX FA6
(00) NO
(01) YES
Would you be able to answer some questions about the certification status and, services offered at, and
(-8) Don't Know
number of beds for (FACILITY)?
(-9) Refused
(00) FA11 - FACRNAM2
(01) FA12 - BEDSNUM BOX FA7A
(-8) FA11 - FACRNAM2
(-9) FA11 - FACRNAM2
What is the name of the most knowledgeable person to answer questions about (FACILITY)?
SELECT A RESPONSE BELOW OR ADD TO THE PERSON ROSTER.
IF PLACTYP1= 1/Free Standing Nursing Home, 4/NursingHomeUnitCCRC, 7/HospitalBasedSNF, or
17/Rehabilitation Facility, GO TO CCNINTRO.
ELSE GO TO FA12-BEDSNUM.
(01) CLOSING6 - FINOTRES
(01) [Continuous answer.]
Does [FACILITY) have a CMS Certification Number, also referred to as a Medicare/Medicaid Provider
(00) NO
Number, OSCAR Provider Number, or Medicare Identification Number? The CMS Certification Number is
(01) YES
a unique number assigned to any facility certified to participate in Medicare and/or Medicaid.
(-8) Don't Know
(-9) Refused
[IF NEEDED: The CMS Certification Number is not the same as the National Provider Identifier (NPI),
which is a unique 10-digit identification number issued to health care providers.]
Do you have a document that shows (FACILITY'S) CMS Certification Number?
CCNDOC
FA11B
yes/no
(00) NO
(01) YES
[IF NEEDED: The CMS Certification Number is also referred to as a Medicare/Medicaid Provider Number, (02) NO BUT FACILITY IS CERTIFIED BY MEDICARE
OSCAR Provider Number, or Medicare Identification Number.]
AND/OR MEDICAID
(-8) Don't Know
IF FACILITY RESPONDENT DOES NOT HAVE DOCUMENTATION, PROBE TO DETERMINE IF FACILITY IS
(-9) Refused
CERTIFIED BY MEDICARE AND/OR MEDICAID.
(00) FA12 - BEDSNUM
(01) CCNDOC
(-8) FA12 - BEDSNUM
(-9) FA12 - BEDSNUM
(00) FA12 - BEDSNUM
(01) CASPER_LU- CCN
(02) CASPER_LU- CCN
(-8) FA12 - BEDSNUM
(-9) FA12 - BEDSNUM
Please tell me the CMS Certification Number.
[If you don't know the CCN I can look up the number using your Facility name and address.]
START TYPING IN THE "CMS CERTIFICATION NUMBER" BOX TO LAUNCH THE LOOKUP.
CCN
CASPER_LU
lookup
(01) (value selected from lookup)
IF THE FACILITY RESPONDENT DOES NOT KNOW THE CMS CERTIFICATION NUMBER, PROBE TO CONFIRM
(-8) DON'T KNOW
THAT THE FACILITY IS CERTIFIED BY MEDICARE AND/OR MEDICAID. THEN, SELECT A DIFFERENT KEY TYPE
(-9) REFUSED
TO USE TO SEARCH THE LOOKUP, SUCH AS FACILITY NAME OR ADDRESS.
(01) BOX FA7B
(-8) BOX FA7C
(-9) BOX FA7C
IF YOU SELECTED THE WRONG FACILITY FROM THE LOOKUP, CLICK IN THE "CMS CERTIFICATION
NUMBER" BOX TO RELAUNCH THE LOOKUP AND SELECT THE CORRECT FACILITY.
IF YOU CANNOT FIND THE FACILITY'S CCN THEN SELECT "NOT FOUND" FROM THE LOOKUP TO PROCEED
WITH THE INTERVIEW.
BOX FA7B
routing
[CMS CERTIFICATION NUMBER]
IF CCN= 'NOT FOUND' THEN GO TO FA11D-NOTFOUND. ELSE, GO TO FA11C-LU_CONFIRM.
LU_CONFIRM
FA11C
yes/no
I'd like to verify the CMS Certification Number. I have selected (CCN). Is that correct?
NOTFOUND
FA11D
yes/no
BOX FA7C
routing
BEDSNUM
FA12
BOX FA8
Numeric
routing
(01) YES
(02) NO, GO BACK TO LOOKUP TO CHANGE
YOU SELECTED 'CCN NOT FOUND'. SELECT 01 TO CONTINUE WITHOUT A CCN. SELECT 02 TO RETURN TO (01) CONTINUE WITHOUT CCN
THE LOOKUP AND SELECT ANOTHER CCN.
(02) NO, GO BACK TO LOOKUP TO CHANGE
IF CCN IN ('NOT FOUND', MISSING, DK, RF), GO TO FA12-BEDSNUM.
ELSE GO TO BOX FA8.
(01) [Continuous answer.]
How many beds does (FACILITY) have?
(-8) Don't Know
PRESS F1 FOR EXPANDED DEFINITION OF "BEDS".
(-9) Refused
CARECRT1
CAIDICF
FA13
FA14
FA15
yes/no
yes/no
yes/no
(01) BOX FA8
(-8) BOX FA8
(-9) BOX FA8
IF FA12 - BEDSNUM < 3 AND FA12-BEDSNUM <> DK,RF, GO TO FACLOSE2 - LEAVINEL.
ELSE IF PLAC.PLACTYPE = 4/NursingHomeorNHUnit, 7/HospitalBasedSNF, OR 17/RehabilitationFacility,
GO TO FA13 - CAIDCRT1.
ELSE IF PLAC.PLACTYPE = 16/InstitutionForMentallyRetarded OR FA2 - HOSPKIND =
3/StateCountyHospitalForMentallyIll OR
5/StateHospitalForMentallyRetardedIndividualsWithIntellectualDisabilities OR
6/ChronicDiseaseLongTermHospital, GO TO FA15 - CAIDICF.
ELSE GO TO FA18 - HDEPTPCH.
Does (FACILITY) have any beds certified by [(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID] as Nursing
Facility (NF) beds?
[READ IF NECESSARY: We are concerned only with the place where (SP) is physically located.]
CAIDCRT1
(01) BOX FA7C
(02) CASPER_LU-CCN
IF R MENTIONS:
ICF-MR (INTERMEDIATE CARE FACILITY--MENTAL RETARDATION) ICF/IID (INTERMEDIATE CARE
FACILITIES FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES), SAY THAT YOU WILL ASK ABOUT THOSE
IN A MOMENT.
Does (FACILITY) have any beds certified by Medicare as SNF beds?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FA14 - CARECRT1
(01) FA14 - CARECRT1
(-8) FA14 - CARECRT1
(-9) FA14 - CARECRT1
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FA15 - CAIDICF
(01) FA15 - CAIDICF
(-8) FA15 - CAIDICF
(-9) FA15 - CAIDICF
(00) NO
Does (FACILITY) have any beds certified by [(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID] as ICF-MR (01) YES
(Intermediate Care Facility for the Mentally Retarded) ICF/IID (Intermediate Facilities For Individuals
(-8) Don't Know
With Intellectual Disabilities) beds?
(-9) Refused
(00) FA16 - HDEPTLIC
(01) FA16 - HDEPTLIC
(-8) FA16 - HDEPTLIC
(-9) FA16 - HDEPTLIC
HDEPTLIC
FA16
code one
Does (FACILITY) have any beds that are [not certified by (Medicaid and Medicare/Medicare/Medicaid)
but are] licensed as nursing home beds by the (STATE) State Health Department or by some other State
or Federal Agency?
HDEPTLOS
FA16
verbatim
OTHER AGENCY (SPECIFY)
HDEPTPCH
FA18
code one
HDEPTPOS
FA18
verbatim
BOX FA9
routing
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?
OTHER AGENCY (SPECIFY)
IF CCN IN ('NOT FOUND', MISSING, DK, RF), GO TO FA19 - NORMCARE.
ELSE GO TO BOX FA13.
In addition to room and board, does (FACILITY) routinely provide…
NORMCARE
FA19
list
nursing or medical care?
SUPRMEDI
FA19
list
supervision over medications?
HELPBATH
FA19
list
help with bathing?
HELPDRES
FA19
list
help with dressing?
HELPSHOP
FA19
list
help with correspondence or shopping?
HELPWALK
FA19
list
help with walking?
HELPEAT
FA19
list
help with eating?
HELPCOMM
FA19
list
help with communications?
BOX FA13
routing
IF FA13 - CAIDCRT1, FA14 - CARECRT1, OR FA15 - CAIDICF = 1/Yes, GO TO FA20 - CARESUP.
ELSE GO TO FA19A - RNLPNSUP.
RNLPNSUP
FA19A
yes/no
Does (FACILITY) provide 24-hour a day, on-site supervision by an RN or LPN 7 days a week?
CARESUP
FA20
yes/no
Does (FACILITY) provide 24-hour a day, on-site supervision by a caregiver 7 days a week
BOX FA16A
routing
GO TO BOX FA16.
(00) NO, NOT LICENSED
(01) YES, LICENSED BY STATE HEALTH
DEPARTMENT
(02) YES, LICENSED BY SOME OTHER AGENCY
(-8) Don't Know
(-9) Refused
(00) FA18 - HDEPTPCH
(01) FA18 - HDEPTPCH
(02) FA16 - HDEPTLOS
(-8) FA18 - HDEPTPCH
(-9) FA18 - HDEPTPCH
(01) [Continuous answer.]
(01) FA18 - HDEPTPCH
(00) NO, NOT LICENSED
(01) YES, LICENSED BY STATE HEALTH
DEPARTMENT
(02) YES, LICENSED BY SOME OTHER AGENCY
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(00) FA19 - NORMCARE BOX FA9
(01) FA19 - NORMCARE BOX FA9
(02) FA18 - HDEPTPOS
(-8) FA19 - NORMCARE BOX FA9
(-9) FA19 - NORMCARE BOX FA9
(01) FA19 - NORMCARE BOX FA9
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FA19 - SUPRMEDI
(01) FA19 - SUPRMEDI
(-8) FA19 - SUPRMEDI
(-9) FA19 - SUPRMEDI
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FA19 - HELPBATH
(01) FA19 - HELPBATH
(-8) FA19 - HELPBATH
(-9) FA19 - HELPBATH
(00) FA19 - HELPDRES
(01) FA19 - HELPDRES
(-8) FA19 - HELPDRES
(-9) FA19 - HELPDRES
(00) FA19 - HELPSHOP FA19 - HELPEAT
(01) FA19 - HELPSHOP FA19 - HELPEAT
(-8) FA19 - HELPSHOP FA19 - HELPEAT
(-9) FA19 - HELPSHOP FA19 - HELPEAT
(00) FA19 - HELPWALK
(01) FA19 - HELPWALK
(-8) FA19 - HELPWALK
(-9) FA19 - HELPWALK
(00) FA19 - HELPEAT
(01) FA19 - HELPEAT
(-8) FA19 - HELPEAT
(-9) FA19 - HELPEAT
(00) FA19 - HELPCOMM BOX FA13
(01) FA19 - HELPCOMM BOX FA13
(-8) FA19 - HELPCOMM BOX FA13
(-9) FA19 - HELPCOMM BOX FA13
(00) BOX FA13
(01) BOX FA13
(-8) BOX FA13
(-9) BOX FA13
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX FA16A
(01) BOX FA16A
(-8) BOX FA16A
(-9) BOX FA16A
(00) BOX FA16A
(01) BOX FA16A
(-8) BOX FA16A
(-9) BOX FA16A
BOX FA16
routing
ANSRFACQ
FA22
yes/no
FACRNAM3
FA23
roster
FA24PRCT
ANYBEDUL
BOX FA17
routing
FA24PRE
code one
FA24
yes/no
IF FQ.ELIGSTAT = 1/FacilityEligible and CCN IN ('NOT FOUND', MISSING, DK, OR RF), GO TO FA22 ANSRFACQ.
IF FQ.ELIGSTAT = 1/FacilityEligible and (CCN=NON-MISSING AND CCN NOT EQUAL TO 'NOT FOUND'), GO
TO FA35 - MIDNTRES.
ELSE IF FQ.ELIGSTAT = 2/FacilityIneligible, GO TO FACLOSE2 - LEAVINEL.
ELSE GO TO FA11 - FACRNAM2.
(00) NO
The next questions are about the number of nursing beds and residents by payer type and staffing. Can (01) YES
(-8) Don't Know
you answer these questions about (FACILITY)?
(-9) Refused
Who would be the best person to answer questions about (FACILITY)?
(01) [Continuous answer.]
FA25
Numeric
BOX FA18
routing
MANDMBED
FA26
Numeric
MCAIDBED
FA27
Numeric
BOX FA20
routing
MCAREBED
MNORMBED
ICFMRBED
OTLTCBED
FA28
Numeric
BOX FA21
routing
FA29
Numeric
BOX FA22
routing
FA30
Numeric
BOX FA23
routing
FA31
Numeric
BOX FA24
routing
(01) CLOSING6 - FINOTRES
SELECT A RESPONSE BELOW OR ADD TO THE PERSON ROSTER.
IF FA12 - BEDSNUM <> DK OR RF, GO TO FA24PRE - FA24PRCT.
ELSE GO TO FA24 - ANYBEDUL.
From information I collected earlier, I understand that (FACILITY) has a total of (NUMBER OF BEDS IN
FACILITY) beds.
[IF NECESSARY: We are concerned only with the place where (SP) is physically located.]
PRESS "1" TO CONTINUE.
Does (FACILITY) have any beds that are not licensed or certified or otherwise identified as nursing or
other long-term care beds?
PRESS F1 FOR DEFINITION OF "OTHERWISE IDENTIFIED".
ULBEDS
(00) FA23 - FACRNAM3
(01) BOX FA17
(-8) BOX FA17
(-9) FA23 - FACRNAM3
How many beds are not licensed or certified or otherwise identified as nursing or other long-term care
beds?
IF FACILITY CERTIFIED BY BOTH MEDICAID AND MEDICARE, GO TO FA26 - MANDMBED.
ELSE IF FACILITY IS CERTIFIED BY MEDICAID, GO TO FA27 - MCAIDBED.
ELSE GO TO BOX FA20.
I have recorded that (FACILITY) contains beds that are certified by [(PREFERRED NAME(S) FOR
MEDICAID)/MEDICAID] as Nursing Facility beds and by Medicare as Skilled Nursing Facility beds. How
many beds are dually certified (that is, certified by both)?
I have recorded that (FACILITY) contains beds that are certified by [(PREFERRED NAME(S) FOR
MEDICAID)/MEDICAID] as Nursing Facility beds. How many beds are certified under [(PREFERRED
NAME(S) FOR MEDICAID)/MEDICAID] (only)?
IF FA14 - CARECRT1 = 1/Yes, GO TO FA28 - MCAREBED.
ELSE GO TO BOX FA21.
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)?
IF FA16 - HDEPTLIC = 1/YesStateHealthDept OR 2/YesOtherAgency, GO TO FA29 - MNORMBED.
ELSE GO TO BOX FA22.
I have recorded that (FACILITY) contains beds that are licensed as nursing facility beds but not certified
by [(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID] or Medicare. How many beds are licensed but not
certified as nursing home beds (only)?
IF FA15 - CAIDICF = 1/Yes, GO TO FA30 - ICFMRBED.
ELSE GO TO BOX FA23.
I have recorded that (FACILITY) contains beds that are certified by [(PREFERRED NAME(S) FOR
MEDICAID)/MEDICAID] as ICF-MR (Intermediate Care Facility for the Mentally Retarded) ICF/IID
(Intermediate Care Facilities for Individuals with Intellectual Disabilities) beds. How many beds are
certified as ICF-MR ICF/IID beds (only)?
IF FA18 - HDEPTPCH = 1/YesStateHealthDept OR 2/YesOtherAgency, GO TO FA31 - OTLTCBED.
ELSE GO TO BOX FA24.
I recorded earlier that (FACILITY) contains beds that are licensed as 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)?
IF CANNOT CALCULATE NUMBER OF REMAINING BEDS, GO TO FA35 - MIDNTRES.
ELSE, GO TO FA32 - NHBEDCOR.
(01) Continue
(01) FA24 - ANYBEDUL
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(00) BOX FA18
(01) FA25 - ULBEDS
(-8) BOX FA18
(-9) BOX FA18
(01) BOX FA18
(-8) BOX FA18
(-9) BOX FA18
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) FA27 - MCAIDBED
(-8) FA27 - MCAIDBED
(-9) FA27 - MCAIDBED
(01) BOX FA20
(-8) BOX FA20
(-9) BOX FA20
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) BOX FA21
(-8) BOX FA21
(-9) BOX FA21
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) BOX FA22
(-8) BOX FA22
(-9) BOX FA22
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) BOX FA23
(-8) BOX FA23
(-9) BOX FA23
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) BOX FA24
(-8) BOX FA24
(-9) BOX FA24
So, there are a total of (TOTAL # LTC BEDS) LTC beds in the (facility/home).
[REVIEW NUMBER OF BEDS BY TYPE.]
NHBEDCOR
FA32
yes/no
NHBEDEX
FA32VB
verbatim
MIDNTRES
FA35
Numeric
ANSWERFB
FB0PRE
yes/no
FB1PRECT
FB1PRE
code one
(00) No
That leaves (NUMBER OF BEDS LEFT) long-term care beds that are neither certified or licensed as nursing (01) Yes
home or other long-term care beds.
Is that correct?
PLEASE ENTER A BRIEF EXPLANATION:
(01) [Continuous answer.]
(01) [Continuous answer.]
How many residents were in (FACILITY) altogether at midnight last night?
(-8) Don't Know
(-9) Refused
(00) NO
Would you be able to answer some questions about the certification status and, services offered at, and (01) YES
number of beds for (FACILITY)?
(-8) Don't Know
(-9) Refused
I would like to review with you some information that I collected about (FACILITY) the last time I was
here.
(01) Continue
(00) FA32VB - NHBEDEX
(01) FA35 - MIDNTRES
(01) FA35 - MIDNTRES
(01) FR1PRE - FR1PRECT
(-8) FR1PRE - FR1PRECT
(-9) FR1PRE - FR1PRECT
(00) FB19 - FACRNAM4
(01) FB1PRE - FB1PRECT
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4
(01) BOX FB1 BOX FA36
PRESS "1" TO CONTINUE.
IF BPRELOADPLAC.PLACTYP1= 1/Free Standing Nursing Home, 4/NursingHomeUnitCCRC,
7/HospitalBasedSNF, or 17/Rehabilitation Facility AND PRELOADED CMS CERTIFICATION NUMBER
(BPRELOADFQ.CCN) IS NON-MISSING GO TO FB11A - CCNCNFRM.
BOX FA36
CCNCNFRM
CCNINTRO
FB11A
FB11B
routing
yes/no
yes/no
IF BPRELOADPLAC.PLACTYP1= 1/Free Standing Nursing Home, 4/NursingHomeUnitCCRC,
7/HospitalBasedSNF, or 17/Rehabilitation Facility AND PRELOADED CMS CERTIFICATION NUMBER
(BPRELOADFQ.CCN) IN ('NOT FOUND', MISSING, DK, RF), GO TO FB11B - CCNINTRO.
ELSE GO TO BOX FB1.
You previously told me that (FACILITY)'s CMS Certification Number is [(BPRELOADFQ.CCN]. Is that still
your CCN?
(00) NO
(01) YES
[IF NEEDED: The CMS Certification Number is also referred to as a Medicare/Medicaid Provider Number, (-8) Don't Know
OSCAR Provider Number, Medicare Identification Number, or Provider Number. The CMS Certification
(-9) Refused
Number is not the same as the National Provider Identifier (NPI), which is a unique 10-digit identification
number issued to health care providers.]
Does [FACILITY) have a CMS Certification Number, also referred to as a Medicare/Medicaid Provider
(00) NO
Number, OSCAR Provider Number, or Medicare Identification Number? The CMS Certification Number is
(01) YES
a unique number assigned to any facility certified to participate in Medicare and/or Medicaid.
(-8) Don't Know
(-9) Refused
[IF NEEDED: The CMS Certification Number is not the same as the National Provider Identifier (NPI),
which is a unique 10-digit identification number issued to health care providers.]
(00) BOX FB1
(01) FB11C - CCNDOC
(-8) BOX FB1
(-9) BOX FB1
Do you have a document that shows (FACILITY'S) CMS Certification Number?
CCNDOC
FB11C
yes/no
(00) NO
(01) YES
[IF NEEDED: The CMS Certification Number is also referred to as a Medicare/Medicaid Provider Number, (02) NO BUT FACILITY IS CERTIFIED BY MEDICARE
OSCAR Provider Number, or Medicare Identification Number.]
AND/OR MEDICAID
(-8) Don't Know
IF FACILITY RESPONDENT DOES NOT HAVE DOCUMENTATION, PROBE TO DETERMINE IF FACILITY IS
(-9) Refused
CERTIFIED BY MEDICARE AND/OR MEDICAID.
(00) FB11B - CCNINTRO
(01) BOX FB1
(-8) FB11B - CCNINTRO
(-9) FB11B - CCNINTRO
(00) BOX FB1
(01) CASPER_LU - CCN
(02) CASPER_LU - CCN
(-8) BOX FB1
(-9) BOX FB1
Please tell me the CMS Certification Number.
[If you don't know the CCN I can look up the number using your Facility name and address.]
START TYPING IN THE "CMS CERTIFICATION NUMBER" BOX TO LAUNCH THE LOOKUP.
CCN
CASPER_LU
lookup
(01) (value selected from lookup)
IF THE FACILITY RESPONDENT DOES NOT KNOW THE CMS CERTIFICATION NUMBER, PROBE TO CONFIRM
(-8) DON'T KNOW
THAT THE FACILITY IS CERTIFIED BY MEDICARE AND/OR MEDICAID. THEN, SELECT A DIFFERENT KEY TYPE
(-9) REFUSED
TO USE TO SEARCH THE LOOKUP, SUCH AS FACILITY NAME OR ADDRESS.
(01) BOX FA37
(-8) BOX FA38
(-9) BOX FA38
IF YOU SELECTED THE WRONG FACILITY FROM THE LOOKUP, CLICK IN THE "CMS CERTIFICATION
NUMBER" BOX TO RELAUNCH THE LOOKUP AND SELECT THE CORRECT FACILITY.
IF YOU CANNOT FIND THE FACILITY'S CCN THEN SELECT "NOT FOUND" FROM THE LOOKUP TO PROCEED
WITH THE INTERVIEW.
BOX FA37
routing
[CMS CERTIFICATION NUMBER]
IF CCN= 'NOT FOUND' THEN GO TO FB11E-NOTFOUND. ELSE, GO TO FB11D-LU_CONFIRM.
LU_CONFIRM
FB11D
yes/no
I'd like to verify the CMS Certification Number I have selected. I have selected (CCN). Is that correct?
NOTFOUND
FB11E
yes/no
BOX FA38
routing
BOX FB1
routing
CAIDCERT
FB2
yes/no
CARECERT
FB5
yes/no
BOX FB3
routing
FMRCERT
FB9
yes/no
BOX FB4
routing
HDLICEN
FB11
code one
HDLICOS
FB11
verbatim
PCHLICEN
FB14
code one
PCHLICOS
FB14
verbatim
BOX FB4A
routing
(01) YES
(02) NO, GO BACK TO LOOKUP TO CHANGE
YOU SELECTED 'CCN NOT FOUND'. SELECT 01 TO CONTINUE WITHOUT A CCN. SELECT 02 TO RETURN TO (01) CONTINUE WITHOUT CCN
THE LOOKUP AND SELECT ANOTHER CCN.
(02) NO, GO BACK TO LOOKUP TO CHANGE
IF CCN IN ('NOT FOUND', MISSING, DK, RF), GO TO FA12-BEDSNUM.
ELSE GO TO BOX FA8.
IF PreloadFQ.CAIDCERT = EMTPY, GO TO BOX FB3.
ELSE GO TO FB2 - CAIDCERT.
(00) NO
(01) YES
Is (FACILITY) (still) certified by Medicaid as a Nursing Facility (NF)?
(-8) Don't Know
(-9) Refused
(00) NO
(01) YES
Is (FACILITY) (still) certified by Medicare as a Skilled Nursing Facility (SNF)?
(-8) Don't Know
(-9) Refused
IF PreloadFQ.FMRCERT <> EMPTY, GO TO FB9 - FMRCERT.
ELSE GO TO BOX FB4.
(00) NO
Is (FACILITY) (still) certified by Medicaid as an Intermediate Care Facility for the Mentally Retarded (ICF- (01) YES
MR) Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID)?
(-8) Don't Know
(-9) Refused
IF PreloadFQ.HDLICEN <> EMPTY, GO TO FB11 - HDLICEN.
ELSE GO TO FB14 - PCHLICEN.
(00) NO, NOT LICENSED
(01) YES, LICENSED BY STATE HEALTH
Does (FACILITY) (still have/have any) beds that are [not certified by (Medicaid and
DEPARTMENT
Medicare/Medicare/Medicaid) but are] licensed as nursing (facility/home) beds by the (STATE) State
(02) YES, LICENSED BY SOME OTHER AGENCY
Health Department or by some other State or Federal agency?
(-8) Don't Know
(-9) Refused
OTHER AGENCY (SPECIFY)
(01) [Continuous answer.]
(00) NO, NOT LICENSED
(01) YES, LICENSED BY STATE HEALTH
Is (FACILITY) (still) licensed as a personal care home, board and care home, assisted living facility,
DEPARTMENT
domiciliary care home or rest home by the (STATE) State Health Department or by some other state or
(02) YES, LICENSED BY SOME OTHER AGENCY
local government agency?
(-8) Don't Know
(-9) Refused
OTHER AGENCY (SPECIFY)
(01) [Continuous answer.]
IF CCN= MISSING, DK, RF, GO TO FB15 - NURSCARE
ELSE GO TO BOX FB5.
(01) BOX FA38
(02) CASPER_LU-CCN
(01) BOX FA38
(02) CASPER_LU-CCN
(00) FB5 - CARECERT
(01) FB5 - CARECERT
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4
(00) BOX FB3
(01) BOX FB3
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4
(00) BOX FB4
(01) BOX FB4
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4
(00) FB14 - PCHLICEN
(01) FB14 - PCHLICEN
(02) FB11 - HDLICOS
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4
(01) FB14 - PCHLICEN
(00) FB15 - NURSCARE BOX FB4A
(01) FB15 - NURSCARE BOX FB4A
(02) FB14 - PCHLICOS
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4
(01) FB15 - NURSCARE BOX FB4A
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FB15 - MEDISUPR
(01) FB15 - MEDISUPR
(-8) FB15 - MEDISUPR
(-9) FB15 - MEDISUPR
supervision over medications?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FB15 - BATHHELP
(01) FB15 - BATHHELP
(-8) FB15 - BATHHELP
(-9) FB15 - BATHHELP
help with bathing?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FB15 - DRESHELP
(01) FB15 - DRESHELP
(-8) FB15 - DRESHELP
(-9) FB15 - DRESHELP
help with dressing?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FB15 - SHOPHELP FB15 - EATHELP
(01) FB15 - SHOPHELP FB15 - EATHELP
(-8) FB15 - SHOPHELP FB15 - EATHELP
(-9) FB15 - SHOPHELP FB15 - EATHELP
help with correspondence or shopping?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FB15 - WALKHELP
(01) FB15 - WALKHELP
(-8) FB15 - WALKHELP
(-9) FB15 - WALKHELP
help with walking?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FB15 - EATHELP
(01) FB15 - EATHELP
(-8) FB15 - EATHELP
(-9) FB15 - EATHELP
help with eating?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FB15 - COMMHELP BOX FB5AA
(01) FB15 - COMMHELP BOX FB5AA
(-8) FB15 - COMMHELP BOX FB5AA
(-9) FB15 - COMMHELP BOX FB5AA
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX FB5AA
(01) BOX FB5AA
(-8) BOX FB5AA
(-9) BOX FB5AA
Does (FACILITY) provide 24-hour a day, on-site supervision by an RN or LPN 7 days a week?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX FB8
(01) BOX FB8
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4
yes/no
Does (FACILITY) provide 24-hour a day, on-site supervision by a caregiver 7 days a week?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX FB8
(01) BOX FB8
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4
routing
IF FB2-CAIDCERT = 1/Yes OR FB5-CARECERT = 1/Yes OR FB9-FMRCERT = 1/Yes OR FB11-HDLICEN =
1/YesStateHealthAgency OR 2/YesOtherAgency OR FB14-PCHLICEN = 1/YesStateHealthAgency OR
2/YesOtherAgency OR FQ.PROVHELP = 1/Indicated OR FB15A-NURSSUP = 1/Yes OR FB16-CGIVSUP =
1/Yes OR CCN= NON-MISSING, GO TO BOX FB9.
ELSE GO TO FBCLOSE2 - LEVINEL2.
routing
IF PreloadFQ.TOTELBED = DK, RF AND CCN in ('NOT FOUND', MISSING, DK, RF), GO TO FB18 - TOTELBED.
ELSE IF CCN IN ('NOT FOUND', MISSING, DK, RF), GO TO FB17 - SAMEBEDS.
ELSE GO TO FB27-MIDNTCNT.
In addition to room and board, does (FACILITY) routinely provide…
NURSCARE
FB15
List
nursing or medical care?
MEDISUPR
BATHHELP
DRESHELP
SHOPHELP
WALKHELP
EATHELP
COMMHELP
NURSSUP
CGIVSUP
FB15
FB15
FB15
FB15
FB15
FB15
List
List
List
List
List
List
FB15
List
help with communications?
BOX FB5AA
routing
IF ANY ITEM IN FB15 = DK OR RF, GO TO FB19 - FACRNAM4.
ELSE GO TO BOX FB5.
BOX FB5
routing
IF FB2-CAIDCERT = 1/Yes OR FB5-CARECERT = 1/Yes OR FB9-FMRCERT = 1/Yes, GO TO FB16 - CGIVSUP.
ELSE GO TO FB15A - NURSSUP.
FB15A
FB16
BOX FB8
BOX FB9
yes/no
SAMEBEDS
FB17
Yes/No
I have recorded that (FACILITY) has [PREVIOUS TOTAL # LTC BEDS] beds that provide long-term care. Is
this still the number of beds providing long-term care in (FACILITY)?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
How many beds does (FACILITY) have that provide long-term care?
TOTELBED
FB18
Numeric
FACRNAM4
FB19
Roster
BOX FB11
routing
CANDCBED
CAIDBEDS
CAREBEDS
HDLICBED
FB20
Numeric
BOX FB12
routing
FB21
Numeric
BOX FB13
routing
FB22
Numeric
BOX FB14
routing
(01) [Continuous answer.]
(-8) Don't Know
[PROBE: Do not count "independent living" beds or those that don't provide 24-hour a day assistance or
(-9) Refused
supervision with daily living activities.]
Who would be the best person to answer these questions about (FACILITY)?
(01) [Continuous answer.]
SELECT A RESPONSE BELOW OR ADD TO THE PERSON ROSTER.
IF FQ.ELIGSTAT = 2/FacilityIneligible, GO TO FBCLOSE2 - LEVINEL2.
ELSE IF FB2-CAIDCERT = 1/Yes AND FB5-CARECERT = 1/Yes, GO TO FB20 - CANDCBED.
ELSE GO TO BOX FB12.
I have recorded that (FACILITY) contains beds that are certified by [(PREFERRED NAME(S) FOR
(01) [Continuous answer.]
MEDICAID)/MEDICAID] as Nursing Facility beds and by Medicare as Skilled Nursing Facility beds. How
(-8) Don't Know
many beds are dually certified (that is, certified by both)?
(-9) Refused
IF FB2-CAIDCERT = 1/Yes, GO TO FB21 - CAIDBEDS.
ELSE GO TO BOX FB13.
[I have recorded that (FACILITY) contains beds that are certified by [(PREFERRED NAME(S) FOR
(01) [Continuous answer.]
(-8) Don't Know
MEDICAID)/MEDICAID] as Nursing Facility beds.] How many beds are certified under [(PREFERRED
(-9) Refused
NAME(S) FOR MEDICAID)/MEDICAID] (only)?
IF FB5-CARECERT = 1/Yes, GO TO FB22 - CAREBEDS.
ELSE, GO TO BOX FB14.
(01) [Continuous answer.]
[I have recorded that (FACILITY) contains beds that are certified by Medicare as Skilled Nursing Facility
(-8) Don't Know
beds.] How many beds are certified under Medicare (only)?
(-9) Refused
IF FB11-HDLICEN = 1/YesStateHealthAgency or 2/YesOtherAgency, GO TO FB23 - HDLICBED.
ELSE GO TO BOX FB15.
I have recorded that (FACILITY) contains beds that are licensed as nursing facility beds but not certified (01) [Continuous answer.]
by [(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID] or Medicare. How many beds are licensed but not (-8) Don't Know
(-9) Refused
certified as nursing home beds (only)?
IF FB9-FMRCERT = 1/Yes, GO TO FB24 - FMRBEDS.
ELSE GO TO BOX FB16.
I have recorded that (FACILITY) contains beds that are certified by [(PREFERRED NAME(S) FOR
(01) [Continuous answer.]
MEDICAID)/MEDICAID] as ICF-MR (Intermediate Care Facility for the Mentally Retarded) ICF/IID
(-8) Don't Know
(Intermediate Care Facilities for Individuals with Intellectual Disabilities) beds. How many beds are
(-9) Refused
certified as ICF-MR ICF/IID beds (only)?
IF FB14-PCLICEN = 1/YesStatHealthDept OR 2/YesOtherAgency, GO TO FB25 - PCHBED.
ELSE GO TO BOX FB17.
I recorded earlier that (FACILITY) contains beds that are licensed as personal care, board and care,
(01) [Continuous answer.]
assisted living, domiciliary care, or other type of long-term care beds. How many beds are licensed as
(-8) Don't Know
one of these types of long-term care (only)?
(-9) Refused
IF CANNOT CALCULATE NUMBER OF REMAINING BEDS, GO TO FB27 - MIDNTCNT.
ELSE GO TO FB26 - FBBEDCOR.
So, there are a total of (TOTAL # LTC BEDS) LTC beds in the (facility/home).
FB23
Numeric
BOX FB15
routing
FB24
Numeric
BOX FB16
routing
FB25
Numeric
BOX FB17
routing
FBBEDCOR
FB26
yes/no
[REVIEW NUMBER OF BEDS BY TYPE.]
FBBEDEX
FB26VB
verbatim
Is that correct?
PLEASE ENTER A BRIEF EXPLANATION:
MIDNTCNT
FB27
Numeric
FMRBEDS
PCHBED
How many residents were in (FACILITY) altogether at midnight last
night?
(00) FB18 - TOTELBED
(01) BOX FB11
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4
(01) BOX FB11
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4
(01) CLOSING6B - FINOTRSB
(01) BOX FB12
(-8) BOX FB12
(-9) BOX FB12
(01) BOX FB13
(-8) BOX FB13
(-9) BOX FB13
(01) BOX FB14
(-8) BOX FB14
(-9) BOX FB14
(01) BOX FB15
(-8) BOX FB15
(-9) BOX FB15
(01) BOX FB16
(-8) BOX FB16
(-9) BOX FB16
(01) BOX FB17
(-8) BOX FB17
(-9) BOX FB17
(00) NO
(01) YES
(00) FB26VB - FBBEDEX
(01) FB27 - MIDNTCNT
(01) [Continuous answer.]
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) FB27 - MIDNTCNT
(01) FR1PRE - FR1PRECT
(-8) FR1PRE - FR1PRECT
(-9) FR1PRE - FR1PRECT
FR1PRECT
FR1PRE
No Entry
Next, I'd like to get some information on the basic rates residents in (FACILITY) are charged. Most
facilities 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(S) FOR
MEDICAID)/MEDICAID], Medicare, and private pay/[(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID]
and private pay/Medicare and private pay/private pay) residents.
(01) Continue
(01) FR2 - RATEPRB
(00) FR5 - SINGRATE
(01) FR3-HIGHRATE
(-8) FR5 - SINGRATE
[IF NECESSARY: We are concerned only with the place where (SP) is physically located.]
PRESS "1" TO CONTINUE.
RATEPRB
FR2
yes/no
Do you have more than one basic rate?
(00) NO
(01) YES
(-8) Don't Know
HIGHRATE
FR3
Quantity Unit
What is the highest rate you bill for residents' basic care?
ENTER A WHOLE DOLLAR AMOUNT FOLLOWED BY A DECIMAL AND CENTS ".00" TO ".99".
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) FR3 - HIGHPER
(-8) FR4-LOWRATE
(-9) BOX FR2
(01) FR4 - LOWRATE
(02) FR4 - LOWRATE
(03) FR4 - LOWRATE
(91) FR3 - HIGHPROS
HIGHPER
FR3
code one
HIGH RATE UNIT
(01) DAY
(02) WEEK
(03) MONTH
(91) OTHER
HIGHPROS
FR3
verbatim
OTHER (SPECIFY)
(01) [Continuous answer.]
(01) FR4 - LOWRATE
Quantity Unit
What is the lowest rate you bill for residents' basic care?
ENTER A WHOLE DOLLAR AMOUNT FOLLOWED BY A DECIMAL AND CENTS ".00" TO ".99".
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) FR4 - LOWPER
(-8) BOX FR2
(-9) BOX FR2
(01) BOX FR2
(02) BOX FR2
(03) BOX FR2
(91) FR4 - LOWPEROS
LOWRATE
FR4
LOWPER
FR4
code one
LOW RATE UNIT
(01) DAY
(02) WEEK
(03) MONTH
(91) OTHER
LOPEROS
FR4
verbatim
OTHER (SPECIFY)
(01) [Continuous answer.]
(01) BOX FR2
Quantity Unit
What is the rate you bill for residents' basic care?
ENTER A WHOLE DOLLAR AMOUNT FOLLOWED BY A DECIMAL AND CENTS ".00" TO ".99".
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) FR5 - SINGPER
(-8) BOX FR2
(-9) BOX FR2
(01) DAY
(02) WEEK
(03) MONTH
(91) OTHER
(01) BOX FR2
(02) BOX FR2
(03) BOX FR2
(91) FR5 - SINGPEROS
(01) [Continuous answer.]
(01) BOX FR2
SINGRATE
FR5
SINGPER
FR5
code one
SINGLE RATE UNIT
SINGPEROS
FR5
BOX FR2
verbatim
routing
OTHER (SPECIFY)
GO TO CLOSING1 - RETURNAV.
code one
Thank you. Those are all the questions I have for you at the moment. Someone from my office may call
you to verify some of the data I have collected. We appreciate your help on this important study.
(01) Continue
THE FACILITY-LEVEL QUESTIONS FOR THIS CASE ARE COMPLETE FOR THIS ROUND.
RETURNAV
CLOSING1
(01) BOX FACEND
PRESS "1" TO RETURN TO FACILITY NAVIGATION SCREEN.
YOU ARE ABOUT TO LEAVE FQ BECAUSE THE FACILITY IS INELIGIBLE.
LEAVINEL
FACLOSE2
code one
LEVINEL2
FBCLOSE2
code one
LVNORES
FACLOSE5
code one
FINOTRES
CLOSING6
code one
IF THIS IS NOT RIGHT, BACK UP TO MAKE APPROPRIATE CORRECTIONS. OTHERWISE, ENTER 1.
YOU ARE ABOUT TO LEAVE FQ BECAUSE THE FACILITY IS INELIGIBLE.
YOU ARE ABOUT TO LEAVE FQ BECAUSE THIS IS A "HOME OFFICE" WITH NO RESIDENTS.
IF THIS IS NOT RIGHT, BACK UP TO MAKE APPROPRIATE CORRECTIONS. OTHERWISE, COLLECT FACILITY
CONTACT INFORMATION FOR FACILITY WHERE SP IS LOCATED.
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 "1" TO RETURN TO FACILITY NAVIGATION SCREEN.
(01) Continue
(01) BOX FACEND
(01) Continue
(01) BOX FACEND
(01) Continue
(01) BOX FACEND
(01) Continue
(01) BOX FACEND
FINOTRSB
CLOSING6B
code one
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).
(01) Continue
(01) BOX FACEND
(01) Continue
(01) BOX FACEND
PRESS "1" TO RETURN TO FACILITY NAVIGATION SCREEN.
YOU ARE ABOUT TO LEAVE FQ BECAUSE THE RESPONDENT IS NOT ABLE TO VERIFY INFORMATION
ABOUT THE FACILITY.
NOTRESP
FQCLOSE7
BOX FACEND
code one
routing
IF THIS IS NOT RIGHT, BACK UP TO MAKE APPROPRIATE CORRECTIONS. OTHERWISE, PRESS "1" TO
RETURN TO FACILITY NAVIGATION SCREEN.
GO TO NAVIGATOR
| File Type | application/pdf |
| Author | Andrea Mayfield |
| File Modified | 2018-05-04 |
| File Created | 2018-05-04 |