CMS-P-0015A Fac2019R85FQM

Variable Name

MR Screen Name

Question type

Question text/description

Code list

Routing

FACILITY QUESTIONNAIRE MISSING DATA SECTION SPECIFICATIONS
CRITERIA
SAMPLE TYPE= ALL and at least one key FQ variable is DK, RF, or NULL
SEASON=ALL
PLACEMENT
Administered in flexible order after FQ and RH sections are completed.

BOX FQMBEG

FQMISSNG

routing

FQMISS1

code one

BOX FQM1

routing

MSFNAME

FQM1A

Yes/No

ADDRNAME

FQM1B

text

BOX FQM2

routing

GO TO FQMISS1 - FQMISSNG.
THE FOLLOWING ITEMS ARE MISSING FROM FQ. CONFIRM THAT THE RESPONDENT CAN ANSWER AT
LEAST ONE QUESTION.
PRESS "1" TO CONTINUE.
(01) CONTINUE
IF (FQ1A - PLACNAME = DK OR RF) AND (FQM1A - MSFNAME = DK, EMPTY, OR NULL), GO TO FQM1A MSFNAME.
ELSE GO TO BOX FQM2.
(00) NO
I need to verify that our information about you is correct.
(01) YES
(-8) Don't Know
Is (FACILITY) the exact name of this (facility/home)?
(-9) Refused
What is the exact name of the place where (SP) was physically located on (REFERENCE DATE)?
IF (FQ2 - FADDROK = DK OR RF) AND (FQM2A - MSFADDR = DK, EMPTY, OR NULL), GO TO FQM2A MSFADDR.
ELSE GO TO BOX FQM2A1.

Is [READ ADDRESS LISTED BELOW] the correct address of the place where (SP) was physically located
on (REFERENCE DATE)?
What is the correct address of the place where (SP) was physically located on (REFERENCE
DATE)?

MSFADDR

FQM2A

Yes/No

ADDRESS
ADDRCITY
ADDRSTAT
ADDRZIP

FQM2B
FQM2B
FQM2B
FQM2B

Address
Address
Address
Address

ADDRESS
CITY
STATE
ZIP

BOX FQM2A1

routing

IF (FQ4 - MADDROK = RF) AND (FQM2C - MSMADDR = EMPTY, OR NULL), GO TO FQM2C - MSMADDR.
ELSE GO TO BOX FQM3.

MSMADDR

FQM2C

MAILADDR

FQM2D

Text

ADDRESS

MAILCITY

FQM2D

Text

CITY

MAILSTAT

MAILZIP

FQM2D

FQM2D

Is [READ ADDRESS LISTED BELOW] the correct address for your office?
What is the correct address for your office?

Text

Text

(01) BOX FQM1

(00) FQM1B - ADDRNAME
(01) BOX FQM2
(-8) BOX FQM2
(-9) BOX FQM2

(01) [Continuous answer]

(01) BOX FQM2

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) FQM2B - ADDRESS
(01) BOX FQM2A1
(-8) BOX FQM2A1
(-9) BOX FQM2A1

(01) [Continuous answer]
(01) [Continuous answer]
(01) [Continuous answer]
(01) [Continuous answer]

(01) FQM2B - ADDRCITY
(01) FQM2B - ADDRSTAT
(01) FQM2B - ADDRZIP
(01) BOX FQM2A1

(00) NO
(01) YES
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(00) FQM2D - MAILADDR
(01) BOX FQM3
(-9) BOX FQM3
(01) FQM2D - MAILCITY
(-8) FQM2D - MAILCITY
(-9) FQM2D - MAILCITY
(01) FQM2D - MAILSTAT
(-8) FQM2D - MAILSTAT
(-9) FQM2D - MAILSTAT

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) FQM2D - MAILSTAT
(-8) FQM2D - MAILSTAT
(-9) FQM2D - MAILSTAT

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(01) FQM2D - MAILZIP
(-8) FQM2D - MAILZIP
(-9) FQM2D - MAILZIP

STATE

ZIP

BOX FQM3

routing

MSFADMN

FQM3A

Yes/No

FACRNAMM

FQM3B

text

BOX FQM4

routing

IF (FQ3 - FADMNOK = DK OR RF) AND (FQM3A - MSFADMN = DK, EMPTY, OR NULL), GO TO FQM3A MSFADMN.
ELSE GO TO BOX FQM4.

[Is (ADMINISTRATOR'S NAME)/Are you] (still) the current administrator of (FACILITY)?
What is the current administrator's name?
SELECT A RESPONSE BELOW OR ADD TO THE PERSON ROSTER.

FQM4A

Yes/No

(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

FQM4B

Numeric

AREA CODE

FQM4B

Numeric

(00) FQM3B - FACRNAMM
(01) BOX FQM4
(-8) BOX FQM4
(-9) BOX FQM4

(01) [Continuous answer]

(01) BOX FQM4

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

(00) FQM4B - ADDRAREA
(01) BOX FQM5
(-8) BOX FQM5
(-9) BOX FQM5
(01) FQM4B - ADDREXCH
(-8) FQM4B - ADDREXCH
(-9) FQM4B - ADDREXCH

IF (FQ5 - FPHONOK = DK OR RF) AND (FQM4A - MSFPHON = DK, EMPTY, OR NULL), GO TO FQM4A MSFPHON.
ELSE GO TO BOX FQM5.

MSFPHON

ADDREXCH

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

EXCHANGE
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

ADDRLOCL

FQM4B

Numeric

BOX FQM5

routing

LOCAL
IF (FA1 - PLACTYP1 = RF) AND (FQM5A - MSPLACTY = EMPTY OR NULL), GO TO FQM5A - MSPLACTY.
ELSE GO TO BOX FQM6.

(01) BOX FQM6
(04) BOX FQM6
(06) DO NOT DISPLAY.
(07) DO NOT DISPLAY.
(08) BOX FQM6
(09) BOX FQM6
(10) BOX FQM6
(11) BOX FQM6
(12) BOX FQM6
(13) DO NOT DISPLAY.
(15) BOX FQM6
(16) BOX FQM6
(17) BOX FQM6
(91) FQM5A - MSPLTPOS
(-9) BOX FQM6

(01) [Continuous answer]

(01) BOX FQM6

IF (FA12 - BEDSNUM = DK OR RF AND CCN='NOT FOUND', MISSING, DK, RF) AND (FQM6A - MSBEDSNU
= DK, EMPTY, OR NULL), GO TO FQM6A - MSBEDSNU.
ELSE GO TO BOX FQM7.
How many beds does (FACILITY) have?
PRESS F1 FOR EXPANDED DEFINITIONS OF "BEDS".
(01) [Continuous answer.]
(-8) Don't Know
NO. OF BEDS
(-9) Refused

(01) BOX FQM7
(-8) BOX FQM7
(-9) BOX FQM7

What type of place is (FACILITY)?
PRESS F1 FOR PLACE DEFINITIONS.

FQM5A

code one

MSPLTPOS

FQM5A

text

FQM6

MSBEDSNU

FQM6A

Numeric

(01) BOX FQM5
(-8) BOX FQM5
(-9) BOX FQM5

(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

SHOW CARD FA2

MSPLACTY

(01) FQM4B - ADDRLOCL
(-8) FQM4B - ADDRLOCL
(-9) FQM4B - ADDRLOCL

IF RESPONDENT REPORTS CCRC OR RETIREMENT COMMUNITY, PROBE FOR TYPE OF PLACE FOR UNIT
WHERE SP RESIDES. DO NOT ENTER "OTHER".
OTHER (SPECIFY)

BOX FQM7

routing

IF (FA13 - CAIDCRT1 = DK OR RF) AND (FQM7A - MSCAIDC1 = DK, EMPTY, OR NULL), GO TO FQM7A MSCAIDC1.
ELSE GO TO BOX FQM8.

Is (FACILITY) certified by [(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID] as a Nursing Facility (NF)?

MSCAIDC1

FQM7A

Yes/No

BOX FQM8

routing

IF R MENTIONS:
-ICF (INTERMEDIATE CARE FACILITY), NOTE IN COMMENTS AND ENTER 1.
-ICF/MR (INTERMEDIATE CARE FACILITY- MENTAL RETARDATION) ICF/IID (INTERMEDIATE CARE
FACILITIES FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES), NOTE IN COMMENTS AND ENTER 0.
IF (FA14 - CARECRT1 = DK OR RF) AND (FQM8A - MSCAREC1 = DK, EMPTY, OR NULL), GO TO FQM8A MSCAREC1.
ELSE GO TO BOX FQM9.

Yes/No
MSCAREC1

FQM8A

BOX FQM9

routing

Yes/No
MSCAIDIC

FQM9A

BOX FQM10

MSHDEPTL
MSHDPLOS

Is (FACILITY) certified by Medicare as a SNF?
IF (FA15 - CAIDICF = DK OR RF) AND (FQM9A - MSCAIDIC = DK, EMPTY, OR NULL), GO TO FQM9A MSCAIDIC.
ELSE GO TO BOX FQM10.
Does (FACILITY) have any beds certified by [(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID] as ICFMR (Intermediate Care Facility for the Mentally Retarded) ICF/IID (Intermediate Care Facilities for
Individuals with Intellectual Disabilities) beds?
IF (FA16 - HDEPTLIC = DK OR RF) AND (FQM10A - MSHDEPTL = DK, EMPTY, OR NULL) AND (FA13 CAIDCRT1, FA14 - CARECRT1, FA15 - CAIDICF, FQM7A - MSCAIDC1, FQM8A - MSCAREC1 AND FQM9A MSCAIDIC <> 1/Yes) GO TO FQM10A - MSHDEPTL.
ELSE GO TO BOX FQM11.

(00) BOX FQM8
(01) BOX FQM8
(-8) BOX FQM8
(-9) BOX FQM8

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) BOX FQM9
(01) BOX FQM9
(-8) BOX FQM9
(-9) BOX FQM9

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) BOX FQM10
(01) BOX FQM10
(-8) BOX FQM10
(-9) BOX FQM10

(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) BOX FQM11
(01) BOX FQM11
(02) FQM10A - MSHDPLOS
(-8) BOX FQM11
(-9) BOX FQM11
(01) BOX FQM11

(00) BOX FQMCOMP
(01) BOX FQMCOMP
(02) FQM11A - MSHDPPOS
(-8) BOX FQMCOMP
(-9) BOX FQMCOMP

routing

FQM10A
FQM10A

code one
text

BOX FQM11

routing

Is (FACILITY) licensed as a nursing (facility/home) by the (STATE) State Health Department or by some
other agency?
OTHER AGENCY (SPECIFY)
IF (FA18 - HDEPTPCH = DK OR RF) AND (FQM11A - MSHDEPTP = DK, EMPTY, OR NULL), GO TO FQM11A MSHDEPTP.
ELSE GO TO BOX FQMCOMP.

code one

(00) NO, NOT LICENSED
(01) YES, LICENSED BY STATE HEALTH
DEPARTMENT
(02) YES, LICENSED BY SOME OTHER AGENCY
Does (FACILITY) have any beds licensed as personal care, board and care, assisted living, or domiciliary (-8) Don't Know
care beds by the (STATE) State Health Department or by some other state agency?
(-9) Refused

MSHDEPTP

FQM11A

MSHDPPOS

FQM11A
BOX FQMCOMP

routing

GO TO FQMEND - FQMSEND.
YOU HAVE REACHED THE END OF THE SECTION FOR FACILITY LEVEL MISSING DATA.

FQMEND
BOX FQMEND

code one
routing

PRESS "1" TO RETURN TO FACILITY NAVIGATION SCREEN.
GO TO NAVIGATOR

FQMSEND

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

OTHER AGENCY (SPECIFY)

(01) [Continuous answer]

(01) BOX FQM11

(01) CONTINUE

(01) BOX FQMEND