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pdf2019 MCBS Facility Instrument
Variable Name
FQ-Facility Questionnaire
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
BOX FQ1
routing
PLACEMENT
Start of Facility Interview
GO TO FQ1 - FNAMEOK.
FNAMEOK
FQ1
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)?
PLACNAME
FQ1A
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)]?
yes/no
Next, I would like to verify the address of the place where (SP) (is/was) physically located [on or around (PREVIOUS (00) NO
(01) YES
INTERVIEW DATE)/on or around (ADMISSION DATE REPORTED BY A PREVIOUS SOURCE)].
(-8) Don't Know
(-9) Refused
I have it listed as [READ ADDRESS BELOW]. Is this correct?
FADDROK
ADDRESS
FQ2
FQ2A
address
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)]?
PRESS F1 FOR STATE ABBREVIATIONS.
ADDRESS
ADDRCITY
FQ2A
address
CITY
ADDRSTAT
FQ2A
address
STATE
ADDRZIP
FQ2A
address
ZIP
(00) FQ2A - ADDRESS
(01) FQ3 - FADMNOK
(-8) FQ3 - FADMNOK
(-9) FQ3 - FADMNOK
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) FQ2A - ADDRCITY
(-8) FQ2A - ADDRCITY
(-9) FQ2A - ADDRCITY
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) FQ2A - ADDRSTAT
(-8) FQ2A - ADDRSTAT
(-9) FQ2A - ADDRSTAT
(01) FQ2A - ADDRZIP
(-8) FQ2A - ADDRZIP
(-9) FQ2A - ADDRZIP
(01) FQ3 - FADMNOK
(-8) FQ3 - FADMNOK
(-9) FQ3 - FADMNOK
(00) FQ3A - FACRNAM1
(01) FQ4 - MADDROK
(02) FQ4 - MADDROK
(-8) FQ4 - MADDROK
(-9) FQ4 - MADDROK
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.]
(01) FQ4 - MADDROK
MADDROK
FQ4
yes/no
Next, I would like to verify your office address. I have it listed as [READ ADDRESS LISTED BELOW]. Is this
correct?
(00) NO
(01) YES
(-9) Refused
(00) FQ4A - MAILADD1
(01) FQ5 - FPHONOK
(-9) FQ5 - FPHONOK
(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) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(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
(01) FQ4A - MAILSTA1
(-8) FQ4A - MAILSTA1
(-9) FQ4A - MAILSTA1
(01) FQ4A - MAILZIP1
(-8) FQ4A - MAILZIP1
(-9) FQ4A - MAILZIP1
(01) FQ5 - FPHONOK
(-8) FQ5 - FPHONOK
(-9) FQ5 - FPHONOK
(00) FQ5A - ADDRAREA
(01) BOX FQ7
(-8) BOX FQ7
(-9) BOX FQ7
(01) FQ5A - ADDREXCH
(-8) FQ5A - ADDREXCH
(-9) FQ5A - ADDREXCH
(01) FQ5A - ADDRLOCL
(-8) FQ5A - ADDRLOCL
(-9) FQ5A - ADDRLOCL
FQ4A
FQ4A
text
What is the correct address for your office?
PRESS F1 FOR STATE ABBREVIATIONS.
ADDRESS
MAILCIT1
MAILADD1
text
CITY
MAILSTA1
FQ4A
text
STATE
MAILZIP1
FQ4A
text
ZIP
FPHONOK
FQ5
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)?
ADDRAREA
FQ5A
Numeric
ADDREXCH
FQ5A
Numeric
What is the phone number?
AREACODE
EXCHANGE
Page 1 of 9
2019 MCBS Facility Instrument
FQ-Facility Questionnaire
Variable Name
MR Screen Name Question Type
Question Text/Description
Code List
Routing
ADDRLOCL
FQ5A
Numeric
LOCAL
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) BOX FQ7
(-8) BOX FQ7
(-9) BOX FQ7
BOX FQ7
routing
FAINTRO1
code one
(01) Continue
(01) BOX FA1
FAINT1TC
BOX FA1
routing
PLACTYP1
FA1
code one
PLACTPO1
FA1
verbatim
FACHOME
FA1A
code one
BOX FA1A
routing
HOSPKIND
FA2
code one
HOSPKIOS
FA2
verbatim
LCNDBEDS
FA2A
yes/no
BOX FA2A
routing
FACLPART
FA3
Yes/No
PLACTYP2
FA4
code one
PLACTPO2
LGPLCNAM
FA4
FA5
verbatim
text
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) 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
SHOW CARD FA2
(09) BOARD AND CARE HOME
(10) DOMICILIARY CARE HOME
What type of place is (FACILITY)?
(11) PERSONAL CARE HOME
(12) REST HOME/RETIREMENT HOME
PRESS F1 FOR PLACE DEFINITIONS.
(13) HOME OFFICE OR MANAGEMENT OFFICE FOR A
CHAIN OR GROUP OF OFF-SITE NURSING
IF RESPONDENT REPORTS CCRC OR RETIREMENT COMMUNITY, PROBE FOR TYPE OF PLACE FOR UNIT FACILITIES
WHERE SP RESIDES. DO NOT ENTER "OTHER".
(15) MENTAL HEALTH CENTER/PSYCHIATRIC
SETTING
(16) INSTITUTION FOR THE INTELLECTUALLY
DISABLED/DEVELOPMENTALLY DISABLED
(17) REHABILITATION FACILITY
(91) OTHER
(-9) Refused
OTHER (SPECIFY)
(01) [Continuous answer.]
(01) PREFERS HOME
IF ALREADY KNOWN, CODE WITHOUT ASKING:
(02) PREFERS FACILITY
Do you prefer that I call (FACILITY) a home or a facility?
(03) NO PREFERENECE
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.
(01) ACUTE CARE HOSPITAL
(02) PRIVATE PYSCHIATRIC HOSPITAL
(03) STATE OR COUNTY HOSPITAL FOR THE
MENTALLY ILL
SHOW CARD FA3
(04) VA HOSPITAL, VA MEDICAL CENTER
(05) STATE HOSPITAL FOR INDIVIDUALS WITH
You mentioned that (FACILITY) is a hospital. Please look at this card and tell me what kind of hospital it is.
INTELLECTUAL DISABILITIES
(06) CHRONIC DISEASE, REHABILITATION,
GERIATRIC, OR OTHER LONG-TERM CARE
HOSPITAL
(91) OTHER
OTHER (SPECIFY)
(01) [Continuous answer.]
Does (FACILITY) have any beds that are either certified or licensed as a nursing facility or certified or licensed as an (00) NO
ICF/IID (Intermediate Care Facilities for Individuals with Intellectual Disabilities)?
(01) YES
(-8) Don't Know
PRESS F1 FOR SUGGESTED PROBES.
(-9) Refused
IF FA2 - HOSPKIND = 1/AcuteCareHospital, GO TO FACLOSE2 - LEAVINEL.
ELSE GO TO FA3 - FACLPART.
(00) NO
Is (FACILITY) part of a larger facility or campus?
(01) YES
(-8) Don't Know
PRESS F1 FOR DEFINITION, EXAMPLES OF "LARGER" PLACES.
(-9) Refused
(03) CONTINUING CARE RETIREMENT COMMUNITY
(CCRC)
(05) RETIREMENT COMMUNITY
(06) HOSPITAL
SHOW CARD FA1
(08) ASSISTED LIVING FACILITY
What type of place is (FACILITY) part of?
(09) BOARD AND CARE HOME
(10) DOMICILIARY CARE HOME
PRESS F1 FOR HOSPITAL DEFINITIONS.
(11) PERSONAL CARE HOME
(12) REST HOME/RETIREMENT HOME
(91) OTHER
(-8) Don't Know
(-9) Refused
OTHER (SPECIFY)
(01) [Continuous answer.]
What is the name of the (CATEGORY SELECTED IN FA4 - PLACTYP2/place)?
(01) [Continuous answer.]
(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) FA1A - FACHOME
(01) BOX FA1A
(02) BOX FA1A
(03) BOX FA1A
(01) FA2A - LCNDBEDS
(02) FA2A - LCNDBEDS
(03) FA2A - LCNDBEDS
(04) FA2A - LCNDBEDS
(05) FA2A - LCNDBEDS
(06) FA2A - LCNDBEDS
(91) FA2 - HOSPKIOS
(01) FA2A - LCNDBEDS
(00) BOX FA2A
(01) FA3 - FACLPART
(-8) BOX FA2A
(-9) BOX FA2A
(00) FA5A - EFOWNDES
(01) FA4 - PLACTYP2
(-8) BOX FA6
(-9) BOX FA6
(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
Page 2 of 9
2019 MCBS Facility Instrument
Variable Name
FQ-Facility Questionnaire
MR Screen Name Question Type
EFOWNDES
FA5A
code one
EFOWNDOS
FA5A
BOX FA6
verbatim
routing
BOX FA6A
routing
Question Text/Description
SHOW CARD FA4
Which one of the categories on this card best describes the ownership of (FACILITY)?
OTHER (SPECIFY)
GO TO BOX FA6A.
IF FACILTIY IS ELIGIBLE, GO TO FA10 - ANSRELIG.
ELSE GO TO FACLOSE2 - LEAVINEL.
ANSRELIG
FA10
yes/no
Would you be able to answer some questions about the certification status and services offered at (FACILITY)?
FACRNAM2
FA11
roster
What is the name of the most knowledgeable person to answer questions about (FACILITY)?
SELECT A RESPONSE BELOW OR ADD TO THE PERSON ROSTER.
BOX FA7A
routing
IF PLACTYP1= 1/Free Standing Nursing Home, 4/NursingHomeUnitCCRC, 7/HospitalBasedSNF, or
17/Rehabilitation Facility, GO TO CCNINTRO.
ELSE GO TO FA12-BEDSNUM.
Does [FACILITY) have a CMS Certification Number, also referred to as a Medicare/Medicaid Provider Number,
OSCAR Provider Number, or Medicare Identification Number? The CMS Certification Number is a unique six-digit
number assigned to any facility certified to participate in Medicare and/or Medicaid.
CCNINTRO
FA11A
yes/no
[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.]
Code List
Routing
(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.]
(01) BOX FA6
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FA11 - FACRNAM2
(01) BOX FA7A
(-8) FA11 - FACRNAM2
(-9) FA11 - FACRNAM2
(01) [Continuous answer.]
(01) CLOSING6 - FINOTRES
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FA12 - BEDSNUM
(01) CCNDOC CASPER_LU-CCN
(-8) FA12 - BEDSNUM
(-9) FA12 - BEDSNUM
(00) NO
(01) YES
(02) NO BUT FACILITY IS CERTIFIED BY MEDICARE
AND/OR MEDICAID
(-8) Don't Know
(-9) Refused
(00) FA12 - BEDSNUM
(01) CASPER_LU- CCN
(02) CASPER_LU- CCN
(-8) FA12 - BEDSNUM
(-9) FA12 - BEDSNUM
(01) BOX FA6
(02) BOX FA6
(03) BOX FA6
(04) BOX FA6
(05) BOX FA6
(06) BOX FA6
(91) FA5A - EFOWNDOS
[IF NEEDED: The CMS Certification Number also used to be called the OSCAR Provider Number.]
Do you have a document that shows (FACILITY'S) CMS Certification Number?
CCNDOC
FA11B
yes/no
[IF NEEDED: The CMS Certification Number is also referred to as a Medicare/Medicaid Provider Number, OSCAR
Provider Number, or Medicare Identification Number.]
IF FACILITY RESPONDENT DOES NOT HAVE DOCUMENTATION, PROBE TO DETERMINE IF FACILITY IS
CERTIFIED BY MEDICARE AND/OR MEDICAID.
Please tell me the CMS Certification Number. It would be helpful if I could look at a document with the CMS
Certification Number on it, such as an MDS form or other document. These materials will ensure that I record the
number accurately.
[IF NEEDED: If you don't know the CCN CMS Certification Number I can look up the number using your Facility
name and address.]
[IF REFERENCING THE MDS : The CMS Certification Number can be found in section A0100 B. of the MDS form.]
CCN
CASPER_LU
lookup
(01) (value selected from lookup)
(-8) DON'T KNOW
START TYPING OR DOUBLE CLICK IN THE "CMS CERTIFICATION NUMBER" BOX TO LAUNCH THE LOOKUP.
(-9) REFUSED
(NF) NOT FOUND
IF THE FACILITY RESPONDENT DOES NOT KNOW THE CCN, PROBE TO CONFIRM THAT THE FACILITY IS
CERTIFIED BY MEDICARE AND/OR MEDICAID. AFTER YOU HAVE CONFIRMED THIS, YOU CAN SEARCH
THE LOOKUP USING A DIFFERENT IDENTIFIER, SUCH AS THE FACILITY’S NAME AND/ OR ADDRESS.
(01) BOX FA7B BOX FA7C
(-8) BOX FA7C
(-9) BOX FA7C
(NF) BOX FA7C
ACCORDING TO THE ADDRESS OF THIS FACILITY, THE FIRST TWO DIGITS OF THE CMS CERTIFICATION
NUMBER SHOULD BE [STATE PREFIX FILL].
[CMS CERTIFICATION NUMBER]
BOX FA7B
routing
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
Numeric
YOU SELECTED 'CCN NOT FOUND'. SELECT 01 TO CONTINUE WITHOUT A CCN. SELECT 02 TO RETURN
TO THE LOOKUP AND SELECT ANOTHER CCN.
IF CCN IN ('NF', MISSING, DK, RF), GO TO FA12-BEDSNUM.
ELSE GO TO BOX FA8.
How many beds does (FACILITY) have?
PRESS F1 FOR EXPANDED DEFINITION OF "BEDS".
(01) YES
(02) NO, GO BACK TO LOOKUP TO CHANGE
(01) CONTINUE WITHOUT CCN
(02) NO, GO BACK TO LOOKUP TO CHANGE
(01) BOX FA7C
(02) CASPER_LU-CCN
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) BOX FA8
(-8) BOX FA8
(-9) BOX FA8
Page 3 of 9
2019 MCBS Facility Instrument
Variable Name
MR Screen Name Question Type
BOX FA8
CAIDCRT1
FQ-Facility Questionnaire
FA13
routing
yes/no
Question Text/Description
IF FA12 - BEDSNUM < 3 AND FA12-BEDSNUM <> DK,RF, GO TO FACLOSE2 - LEAVINEL.
ELSE IF PLAC.PLACTYPE = 1/Free Standing Nursing Home, 4/NursingHomeorNHUnit, 7/HospitalBasedSNF, OR
17/RehabilitationFacility, GO TO FA13 - CAIDCRT1.
ELSE IF PLAC.PLACTYPE = 16/InstitutionForMentallyRetarded OR FA2 - HOSPKIND =
3/StateCountyHospitalForMentallyIll OR 5/StateHospitalForIndividualsWithIntellectualDisabilities 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.]
IF R MENTIONS:
ICF/IID (INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES), SAY
THAT YOU WILL ASK ABOUT THOSE IN A MOMENT.
CARECRT1
FA14
yes/no
CAIDICF
FA15
yes/no
HDEPTLIC
FA16
code one
HDEPTLOS
FA16
verbatim
HDEPTPCH
FA18
code one
HDEPTPOS
FA18
verbatim
BOX FA9
routing
NORMCARE
FA19
list
SUPRMEDI
FA19
list
HELPBATH
FA19
list
HELPDRES
FA19
list
HELPEAT
FA19
list
BOX FA13
routing
RNLPNSUP
FA19A
yes/no
CARESUP
FA20
yes/no
BOX FA16A
routing
Code List
Routing
(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
Does (FACILITY) have any beds certified by Medicare as SNF beds?
(-8) Don't Know
(-9) Refused
(00) NO
Does (FACILITY) have any beds certified by [(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID] as ICF/IID
(01) YES
(Intermediate Facilities For Individuals With Intellectual Disabilities) beds?
(-8) Don't Know
(-9) Refused
(00) NO, NOT LICENSED
(01) YES, LICENSED BY STATE HEALTH
Does (FACILITY) have any beds that are [not certified by (Medicaid and Medicare/Medicare/Medicaid) but are]
DEPARTMENT
licensed as nursing home beds by the (STATE) State Health Department or by some other State or Federal Agency? (02) YES, LICENSED BY SOME OTHER AGENCY
(-8) Don't Know
(-9) Refused
OTHER AGENCY (SPECIFY)
(01) [Continuous answer.]
(00) NO, NOT LICENSED
(01) YES, LICENSED BY STATE HEALTH
Does (FACILITY) have any beds licensed as personal care, board and care, assisted living, or domiciliary care beds DEPARTMENT
by the (STATE) State Health Department or by some other state or local government agency?
(02) YES, LICENSED BY SOME OTHER AGENCY
(-8) Don't Know
(-9) Refused
OTHER AGENCY (SPECIFY)
(01) [Continuous answer.]
IF CCN IN ('NF', MISSING, DK, RF), GO TO FA19 - NORMCARE.
ELSE GO TO BOX FA13.
(00) NO
In addition to room and board, does (FACILITY) routinely provide…
(01) YES
(-8) Don't Know
nursing or medical care?
(-9) Refused
(00) NO
(01) YES
supervision over medications?
(-8) Don't Know
(-9) Refused
(00) NO
(01) YES
help with bathing?
(-8) Don't Know
(-9) Refused
(00) NO
(01) YES
help with dressing?
(-8) Don't Know
(-9) Refused
(00) NO
(01) YES
help with eating?
(-8) Don't Know
(-9) Refused
IF FA13 - CAIDCRT1, FA14 - CARECRT1, OR FA15 - CAIDICF = 1/Yes, GO TO FA20 - CARESUP.
ELSE GO TO FA19A - RNLPNSUP.
(00) NO
(01) YES
Does (FACILITY) provide 24-hour a day, on-site supervision by an RN or LPN 7 days a week?
(-8) Don't Know
(-9) Refused
(00) NO
(01) YES
Does (FACILITY) provide 24-hour a day, on-site supervision by a caregiver 7 days a week
(-8) Don't Know
(-9) Refused
GO TO BOX FA16.
(00) FA15 - CAIDICF
(01) FA15 - CAIDICF
(-8) FA15 - CAIDICF
(-9) FA15 - CAIDICF
(00) FA16 - HDEPTLIC
(01) FA16 - HDEPTLIC
(-8) FA16 - HDEPTLIC
(-9) FA16 - HDEPTLIC
(00) FA18 - HDEPTPCH
(01) FA18 - HDEPTPCH
(02) FA16 - HDEPTLOS
(-8) FA18 - HDEPTPCH
(-9) FA18 - HDEPTPCH
(01) FA18 - HDEPTPCH
(00) BOX FA9
(01) BOX FA9
(02) FA18 - HDEPTPOS
(-8) BOX FA9
(-9) BOX FA9
(01) BOX FA9
(00) FA19 - SUPRMEDI
(01) FA19 - SUPRMEDI
(-8) FA19 - SUPRMEDI
(-9) FA19 - SUPRMEDI
(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 - HELPEAT
(01) FA19 - HELPEAT
(-8) FA19 - HELPEAT
(-9) FA19 - HELPEAT
(00) BOX FA13
(01) BOX FA13
(-8) BOX FA13
(-9) BOX FA13
(00) BOX FA16A
(01) BOX FA16A
(-8) BOX FA16A
(-9) BOX FA16A
(00) BOX FA16A
(01) BOX FA16A
(-8) BOX FA16A
(-9) BOX FA16A
Page 4 of 9
2019 MCBS Facility Instrument
Variable Name
FQ-Facility Questionnaire
MR Screen Name Question Type
Question Text/Description
BOX FA16
IF FQ.ELIGSTAT = 1/FacilityEligible and CCN IN ('NF', MISSING, DK, OR RF), GO TO FA22 - ANSRFACQ.
IF FQ.ELIGSTAT = 1/FacilityEligible and (CCN=NON-MISSING AND CCN NOT EQUAL TO 'NF'), GO TO FA35 MIDNTRES.
ELSE IF FQ.ELIGSTAT = 2/FacilityIneligible, GO TO FACLOSE2 - LEAVINEL.
ELSE GO TO FA11 - FACRNAM2.
routing
ANSRFACQ
FA22
yes/no
FACRNAM3
FA23
roster
BOX FA17
routing
FA24PRE
code one
FA24PRCT
ANYBEDUL
FA24
yes/no
(00) NO
The next questions are about the number of nursing beds and residents by payer type and staffing. Can you answer (01) YES
these questions about (FACILITY)?
(-8) Don't Know
(-9) Refused
Who would be the best person to answer questions about (FACILITY)?
(01) [Continuous answer.]
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 longterm care beds?
PRESS F1 FOR DEFINITION OF "OTHERWISE IDENTIFIED".
ULBEDS
FA25
Numeric
BOX FA18
routing
MANDMBED
FA26
Numeric
MCAIDBED
FA27
Numeric
BOX FA20
routing
FA28
Numeric
BOX FA21
routing
FA29
Numeric
BOX FA22
routing
FA30
Numeric
BOX FA23
routing
FA31
Numeric
BOX FA24
routing
MCAREBED
MNORMBED
ICFMRBED
OTLTCBED
Code List
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/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 longterm care (only)?
IF CANNOT CALCULATE NUMBER OF REMAINING BEDS, GO TO FA35 - MIDNTRES.
ELSE, GO TO FA32 - NHBEDCOR.
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
Is that correct?
PLEASE ENTER A BRIEF EXPLANATION:
MIDNTRES
FA35
Numeric
How many residents were in (FACILITY) altogether at midnight last night?
ANSWERFB
FB0PRE
yes/no
Would you be able to answer some questions about the certification status and services offered at (FACILITY)?
That leaves (NUMBER OF BEDS LEFT) long-term care beds that are neither certified or licensed as nursing home
or other long-term care beds.
Routing
(00) FA23 - FACRNAM3
(01) BOX FA17
(-8) BOX FA17
(-9) FA23 - FACRNAM3
(01) CLOSING6 - FINOTRES
(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
(00) No
(01) Yes
(00) FA32VB - NHBEDEX
(01) FA35 - MIDNTRES
(01) [Continuous answer.]
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(01) FA35 - MIDNTRES
(01) FR1PRE - FR1PRECT
(-8) FR1PRE - FR1PRECT
(-9) FR1PRE - FR1PRECT
(00) FB19 - FACRNAM4
(01) FB1PRE - FB1PRECT
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4
Page 5 of 9
2019 MCBS Facility Instrument
FQ-Facility Questionnaire
Variable Name
MR Screen Name Question Type
FB1PRECT
FB1PRE
code one
BOX FA36
routing
CCNCNFRM
CCNINTRO
FB11A
FB11B
yes/no
yes/no
Question Text/Description
I would like to review with you some information that I collected about (FACILITY) the last time I was here.
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 AND NOT IN ( DK, RF, "NF") GO TO FB11A - CCNCNFRM.
IF BPRELOADPLAC.PLACTYP1= 1/Free Standing Nursing Home, 4/NursingHomeUnitCCRC,
7/HospitalBasedSNF, or 17/Rehabilitation Facility AND PRELOADED CMS CERTIFICATION NUMBER
(BPRELOADFQ.CCN) IN ("NF", 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
CMS Certification Number?
[IF NEEDED: The CMS Certification Number is also referred to as a Medicare/Medicaid Provider Number, OSCAR
Provider Number, Medicare Identification Number, or Provider Number. The CMS Certification Number is a unique
six-digit number assigned to any facility certified to participate in Medicaire and/or Medicaid.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.]
Does [FACILITY] have a CMS Certification Number, also referred to as a Medicare/Medicaid Provider Number,
OSCAR Provider Number, or Medicare Identification Number? The CMS Certification Number is a unique six-digit
number assigned to any facility certified to participate in Medicare and/or Medicaid.
[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.]
[IF NEEDED: The CMS Certification Number also used to be called the OSCAR Provider Number.]
Do you have a document that shows (FACILITY'S) CMS Certification Number?
CCNDOC
FB11C
yes/no
[IF NEEDED: The CMS Certification Number is also referred to as a Medicare/Medicaid Provider Number, OSCAR
Provider Number, or Medicare Identification Number.]
IF FACILITY RESPONDENT DOES NOT HAVE DOCUMENTATION, PROBE TO DETERMINE IF FACILITY IS
CERTIFIED BY MEDICARE AND/OR MEDICAID.
Code List
Routing
(01) Continue
(01) BOX FA36
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FB11B - CCNINTRO
(01) BOX FB1
(-8) FB11B - CCNINTRO
(-9) FB11B - CCNINTRO
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX FB1
(01) FB11C - CCNDOC CASPER_LU-CCN
(-8) BOX FB1
(-9) BOX FB1
(00) NO
(01) YES
(02) NO BUT FACILITY IS CERTIFIED BY MEDICARE
AND/OR MEDICAID
(-8) Don't Know
(-9) Refused
(00) BOX FB1
(01) CASPER_LU - CCN
(02) CASPER_LU - CCN
(-8) BOX FB1
(-9) BOX FB1
Please tell me the CMS Certification Number. It would be helpful if I could look at a document with the CMS
Certification Number on it, such as an MDS form or other document. These materials will ensure that I record the
number accurately.
[IF NEEDED: If you don't know the CCN CMS Certification Number I can look up the number using your Facility
name and address.]
[IF REFERENCING THE MDS : The CMS Certification Number can be found in section A0100 B. of the MDS form.]
CCN
CASPER_LU
lookup
(01) (value selected from lookup)
(-8) DON'T KNOW
START TYPING OR DOUBLE CLICK IN THE "CMS CERTIFICATION NUMBER" BOX TO LAUNCH THE LOOKUP.
(-9) REFUSED
(NF) NOT FOUND
IF THE FACILITY RESPONDENT DOES NOT KNOW THE CCN, PROBE TO CONFIRM THAT THE FACILITY IS
CERTIFIED BY MEDICARE AND/OR MEDICAID. AFTER YOU HAVE CONFIRMED THIS, YOU CAN SEARCH
THE LOOKUP USING A DIFFERENT IDENTIFIER, SUCH AS THE FACILITY’S NAME AND/ OR ADDRESS.
(01) BOX FA37
(-8) BOX FB1
(-9) BOX FB1
BOX FB1
(NF)
ACCORDING TO THE ADDRESS OF THIS FACILITY, THE FIRST TWO DIGITS OF THE CMS CERTIFICATION
NUMBER SHOULD BE [STATE PREFIX FILL].
[CMS CERTIFICATION NUMBER]
BOX FA37
routing
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 FB1
routing
YOU SELECTED 'CCN NOT FOUND'. SELECT 01 TO CONTINUE WITHOUT A CCN. SELECT 02 TO RETURN
TO THE LOOKUP AND SELECT ANOTHER CCN.
IF PreloadFQ.CAIDCERT = EMTPY, GO TO BOX FB3.
ELSE GO TO FB2 - CAIDCERT.
CAIDCERT
FB2
yes/no
Is (FACILITY) (still) certified by Medicaid as a Nursing Facility (NF)?
CARECERT
FB5
yes/no
Is (FACILITY) (still) certified by Medicare as a Skilled Nursing Facility (SNF)?
BOX FB3
routing
IF PreloadFQ.FMRCERT <> EMPTY, GO TO FB9 - FMRCERT.
ELSE GO TO BOX FB4.
(01) YES
(02) NO, GO BACK TO LOOKUP TO CHANGE
(01) CONTINUE WITHOUT CCN
(02) NO, GO BACK TO LOOKUP TO CHANGE
(01) BOX FB1
(02) CASPER_LU-CCN
(01) BOX FB1
(02) CASPER_LU-CCN
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FB5 - CARECERT
(01) FB5 - CARECERT
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4
(00) BOX FB3
(01) BOX FB3
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4
Page 6 of 9
2019 MCBS Facility Instrument
Variable Name
FMRCERT
FQ-Facility Questionnaire
MR Screen Name Question Type
Question Text/Description
Code List
Routing
FB9
yes/no
Is (FACILITY) (still) certified by Medicaid as an Intermediate Care Facilities for Individuals with Intellectual
Disabilities (ICF/IID)?
(00) BOX FB4
(01) BOX FB4
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4
BOX FB4
routing
IF PreloadFQ.HDLICEN <> EMPTY, GO TO FB11 - HDLICEN.
ELSE GO TO FB14 - PCHLICEN.
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
HDLICEN
FB11
code one
HDLICOS
FB11
verbatim
PCHLICEN
FB14
code one
PCHLICOS
FB14
verbatim
BOX FB4A
routing
NURSCARE
FB15
List
MEDISUPR
FB15
List
BATHHELP
FB15
List
DRESHELP
FB15
List
EATHELP
FB15
List
BOX FB5AA
routing
BOX FB5
routing
(00) NO, NOT LICENSED
(01) YES, LICENSED BY STATE HEALTH
Does (FACILITY) (still have/have any) beds that are [not certified by (Medicaid and Medicare/Medicare/Medicaid)
DEPARTMENT
but are] licensed as nursing (facility/home) beds by the (STATE) State Health Department or by some other State or
(02) YES, LICENSED BY SOME OTHER AGENCY
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, domiciliary care DEPARTMENT
home or rest home by the (STATE) State Health Department or by some other state or local government agency?
(02) YES, LICENSED BY SOME OTHER AGENCY
(-8) Don't Know
(-9) Refused
OTHER AGENCY (SPECIFY)
(01) [Continuous answer.]
IF CCN= MISSING, DK, RF, NF GO TO FB15 - NURSCARE
ELSE GO TO BOX FB5.
(00) NO
In addition to room and board, does (FACILITY) routinely provide…
(01) YES
(-8) Don't Know
nursing or medical care?
(-9) Refused
(00) NO
(01) YES
supervision over medications?
(-8) Don't Know
(-9) Refused
(00) NO
(01) YES
help with bathing?
(-8) Don't Know
(-9) Refused
(00) NO
(01) YES
help with dressing?
(-8) Don't Know
(-9) Refused
(00) NO
(01) YES
help with eating?
(-8) Don't Know
(-9) Refused
IF ANY ITEM IN FB15 = DK OR RF, GO TO FB19 - FACRNAM4.
ELSE GO TO BOX FB5.
FB15A
yes/no
Does (FACILITY) provide 24-hour a day, on-site supervision by an RN or LPN 7 days a week?
CGIVSUP
FB16
yes/no
Does (FACILITY) provide 24-hour a day, on-site supervision by a caregiver 7 days a week?
routing
BOX FB9
routing
SAMEBEDS
FB17
Yes/No
TOTELBED
FB18
Numeric
FACRNAM4
FB19
Roster
(01) FB14 - PCHLICEN
(00) BOX FB4A
(01) BOX FB4A
(02) FB14 - PCHLICOS
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4
(01) BOX FB4A
(00) FB15 - MEDISUPR
(01) FB15 - MEDISUPR
(-8) FB15 - MEDISUPR
(-9) FB15 - MEDISUPR
(00) FB15 - BATHHELP
(01) FB15 - BATHHELP
(-8) FB15 - BATHHELP
(-9) FB15 - BATHHELP
(00) FB15 - DRESHELP
(01) FB15 - DRESHELP
(-8) FB15 - DRESHELP
(-9) FB15 - DRESHELP
(00) FB15 - EATHELP
(01) FB15 - EATHELP
(-8) FB15 - EATHELP
(-9) FB15 - EATHELP
(00) BOX FB5AA
(01) BOX FB5AA
(-8) BOX FB5AA
(-9) BOX FB5AA
IF FB2-CAIDCERT = 1/Yes OR FB5-CARECERT = 1/Yes OR FB9-FMRCERT = 1/Yes, GO TO FB16 - CGIVSUP.
ELSE GO TO FB15A - NURSSUP.
NURSSUP
BOX FB8
(00) FB14 - PCHLICEN
(01) FB14 - PCHLICEN
(02) FB11 - HDLICOS
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4
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.
IF PreloadFQ.TOTELBED = DK, RF AND CCN in ('NF', MISSING, DK, RF), GO TO FB18 - TOTELBED.
ELSE IF CCN IN ('NF', MISSING, DK, RF), GO TO FB17 - SAMEBEDS.
ELSE GO TO FB27-MIDNTCNT.
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) NO
I have recorded that (FACILITY) has [PREVIOUS TOTAL # LTC BEDS] beds that provide long-term care. Is this still (01) YES
the number of beds providing long-term care in (FACILITY)?
(-8) Don't Know
(-9) Refused
How many beds does (FACILITY) have that provide long-term care?
(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 supervision
(-9) Refused
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.
(00) BOX FB8
(01) BOX FB8
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4
(00) BOX FB8
(01) BOX FB8
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4
(00) FB18 - TOTELBED
(01) BOX FB11
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4
(01) BOX FB11
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4
(01) CLOSING6B - FINOTRSB
Page 7 of 9
2019 MCBS Facility Instrument
Variable Name
CANDCBED
CAIDBEDS
CAREBEDS
HDLICBED
FMRBEDS
PCHBED
FBBEDCOR
FQ-Facility Questionnaire
MR Screen Name Question Type
BOX FB11
routing
FB20
Numeric
BOX FB12
routing
FB21
Numeric
BOX FB13
routing
Question Text/Description
Code List
Routing
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) BOX FB12
(-8) BOX FB12
(-9) BOX FB12
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) BOX FB13
(-8) BOX FB13
(-9) BOX FB13
(01) [Continuous answer.]
[I have recorded that (FACILITY) contains beds that are certified by Medicare as Skilled Nursing Facility beds.] How
(-8) Don't Know
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 by
(01) [Continuous answer.]
[(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID] or Medicare. How many beds are licensed but not certified (-8) Don't Know
as nursing home beds (only)?
(-9) Refused
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/IID (Intermediate Care Facilities for Individuals with Intellectual Disabilities) beds.
(-8) Don't Know
How many beds are certified as ICF/IID beds (only)?
(-9) Refused
(01) BOX FB14
(-8) BOX FB14
(-9) BOX FB14
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
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)?
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
MEDICAID)/MEDICAID] as Nursing Facility beds.] How many beds are certified under [(PREFERRED NAME(S)
FOR MEDICAID)/MEDICAID] (only)?
IF FB5-CARECERT = 1/Yes, GO TO FB22 - CAREBEDS.
ELSE, GO TO BOX FB14.
FB22
Numeric
BOX FB14
routing
FB23
Numeric
BOX FB15
routing
FB24
Numeric
BOX FB16
routing
IF FB14-PCLICEN = 1/YesStatHealthDept OR 2/YesOtherAgency, GO TO FB25 - PCHBED.
ELSE GO TO BOX FB17.
FB25
Numeric
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 longterm care (only)?
BOX FB17
routing
FB26
yes/no
(01) BOX FB15
(-8) BOX FB15
(-9) BOX FB15
(01) BOX FB16
(-8) BOX FB16
(-9) BOX FB16
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) BOX FB17
(-8) BOX FB17
(-9) BOX FB17
(00) NO
(01) YES
(00) FB26VB - FBBEDEX
(01) FB27 - MIDNTCNT
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).
[REVIEW NUMBER OF BEDS BY TYPE.]
Is that correct?
FBBEDEX
FB26VB
verbatim
PLEASE ENTER A BRIEF EXPLANATION:
(01) [Continuous answer.]
(01) FB27 - MIDNTCNT
MIDNTCNT
FB27
Numeric
How many residents were in (FACILITY) altogether at midnight last
night?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(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)
(01) Continue
residents.
(01) FR2 - RATEPRB
[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?
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".
HIGHPER
FR3
code one
HIGH RATE UNIT
HIGHPROS
FR3
verbatim
OTHER (SPECIFY)
LOWRATE
FR4
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".
LOWPER
FR4
code one
LOW RATE UNIT
LOPEROS
FR4
verbatim
OTHER (SPECIFY)
(00) NO
(01) YES
(-8) Don't Know
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) DAY
(02) WEEK
(03) MONTH
(91) OTHER
(01) [Continuous answer.]
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) DAY
(02) WEEK
(03) MONTH
(91) OTHER
(01) [Continuous answer.]
(00) FR5 - SINGRATE
(01) FR3-HIGHRATE
(-8) FR5 - SINGRATE
(01) FR3 - HIGHPER
(-8) FR4-LOWRATE
(-9) BOX FR2
(01) FR4 - LOWRATE
(02) FR4 - LOWRATE
(03) FR4 - LOWRATE
(91) FR3 - HIGHPROS
(01) FR4 - LOWRATE
(01) FR4 - LOWPER
(-8) BOX FR2
(-9) BOX FR2
(01) BOX FR2
(02) BOX FR2
(03) BOX FR2
(91) FR4 - LOWPEROS
(01) BOX FR2
Page 8 of 9
2019 MCBS Facility Instrument
FQ-Facility Questionnaire
Variable Name
MR Screen Name Question Type
Question Text/Description
SINGRATE
FR5
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".
SINGPER
FR5
code one
SINGLE RATE UNIT
SINGPEROS
FR5
BOX FR2
verbatim
routing
RETURNAV
CLOSING1
code one
OTHER (SPECIFY)
GO TO CLOSING1 - RETURNAV.
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.
THE FACILITY-LEVEL QUESTIONS FOR THIS CASE ARE COMPLETE FOR THIS ROUND.
LEAVINEL
FACLOSE2
code one
LEVINEL2
FBCLOSE2
code one
PRESS "1" TO RETURN TO FACILITY NAVIGATION SCREEN.
YOU ARE ABOUT TO LEAVE FQ BECAUSE THE FACILITY IS INELIGIBLE.
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.
Code List
Routing
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) DAY
(02) WEEK
(03) MONTH
(91) OTHER
(01) [Continuous answer.]
(01) FR5 - SINGPER
(-8) BOX FR2
(-9) BOX FR2
(01) BOX FR2
(02) BOX FR2
(03) BOX FR2
(91) FR5 - SINGPEROS
(01) BOX FR2
(01) Continue
(01) BOX FACEND
(01) Continue
(01) BOX FACEND
(01) Continue
(01) BOX FACEND
(01) Continue
(01) BOX FACEND
(01) Continue
(01) BOX FACEND
(01) Continue
(01) BOX FACEND
(01) Continue
(01) BOX FACEND
YOU ARE ABOUT TO LEAVE FQ BECAUSE THIS IS A "HOME OFFICE" WITH NO RESIDENTS.
LVNORES
FINOTRES
FINOTRSB
NOTRESP
FACLOSE5
CLOSING6
CLOSING6B
code one
code one
code one
FQCLOSE7
code one
BOX FACEND
routing
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.
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.
YOU ARE ABOUT TO LEAVE FQ BECAUSE THE RESPONDENT IS NOT ABLE TO VERIFY INFORMATION
ABOUT THE FACILITY.
IF THIS IS NOT RIGHT, BACK UP TO MAKE APPROPRIATE CORRECTIONS. OTHERWISE, PRESS "1" TO
RETURN TO FACILITY NAVIGATION SCREEN.
GO TO NAVIGATOR
Page 9 of 9
| File Type | application/pdf |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |