CMS-P-0015A Questionaire

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

Fac2019_Facility_Questionnaire_FQ

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

OMB: 0938-0568

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2019 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 Typeapplication/pdf
AuthorSamantha Rosner
File Modified2019-03-21
File Created2019-03-21

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