CMS-P-0015A Questionaire Missing Data

2019 MCBS Facility Instrument

Variable Name

FQM-Facility Questionnaire Missing Data

MR Screen Name Question Type

Question Text/Description

Code List

Routing

(01) CONTINUE

(01) BOX FQM1

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

(00) FQM1B - ADDRNAME
(01) BOX FQM2
(-8) BOX FQM2
(-9) BOX FQM2
(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) FQM2B - ADDRCITY

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

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

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

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

FACILITY QUESTIONNAIRE MISSING DATA SECTION SPECIFICATIONS
CRITERIA
SAMPLE TYPE= ALL and at least one key FQ variable is DK, RF, or NULL
SEASON=ALL

FQMISSNG

BOX FQMBEG

routing

FQMISS1

code one

BOX FQM1

routing

MSFNAME

FQM1A

Yes/No

ADDRNAME

FQM1B

text

BOX FQM2

routing

MSFADDR

FQM2A

Yes/No

ADDRESS

FQM2B

Address

ADDRCITY
ADDRSTAT
ADDRZIP

FQM2B
FQM2B
FQM2B

Address
Address
Address

BOX FQM2A1

routing

PLACEMENT
Administered in flexible order after FQ and RH sections are completed.
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.
IF (FQ1A - PLACNAME = DK OR RF) AND (FQM1A - MSFNAME = DK, EMPTY, OR NULL), GO TO FQM1A MSFNAME.
ELSE GO TO BOX FQM2.
I need to verify that our information about you is correct.
Is (FACILITY) the exact name of this (facility/home)?
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)?
ADDRESS
CITY
STATE
ZIP
IF (FQ4 - MADDROK = RF) AND (FQM2C - MSMADDR = EMPTY, OR NULL), GO TO FQM2C - MSMADDR.
ELSE GO TO BOX FQM3.

MSMADDR

FQM2C

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

MAILADDR

FQM2D

Text

MAILCITY

FQM2D

Text

CITY

MAILSTAT

FQM2D

Text

STATE

MAILZIP

FQM2D

Text

ZIP

BOX FQM3

routing

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

MSFADMN

FQM3A

Yes/No

FACRNAMM

FQM3B

text

BOX FQM4

routing

MSFPHON

FQM4A

Yes/No

ADDRAREA

FQM4B

Numeric

ADDREXCH

FQM4B

Numeric

What is the correct address for your office?
ADDRESS

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

Page 1 of 3

2019 MCBS Facility Instrument

FQM-Facility Questionnaire Missing Data

Variable Name

MR Screen Name Question Type

Question Text/Description

Code List

Routing

ADDRLOCL

FQM4B

Numeric

LOCAL

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

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

BOX FQM5

routing

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

MSPLACTY

FQM5A

code one

MSPLTPOS

FQM5A

text

FQM6
MSBEDSNU

FQM6A

BOX FQM7

Numeric

routing

(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
SHOW CARD FA2
(10) DOMICILIARY CARE HOME
(11) PERSONAL CARE HOME
What type of place is (FACILITY)?
(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)
IF (FA12 - BEDSNUM = DK OR RF AND CCN='NF', MISSING, DK, RF), GO TO FQM6A - MSBEDSNU.
ELSE GO TO BOX FQM7.
How many beds does (FACILITY) have?
PRESS F1 FOR EXPANDED DEFINITIONS OF "BEDS".
NO. OF BEDS
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

MSCAREC1

MSCAIDIC

FQM7A

Yes/No

BOX FQM8

routing

IF R MENTIONS:
-ICF (INTERMEDIATE CARE FACILITY), NOTE IN COMMENTS AND ENTER 1.
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.

FQM8A

Yes/No

Is (FACILITY) certified by Medicare as a SNF?

BOX FQM9

routing

IF (FA15 - CAIDICF = DK OR RF) AND (FQM9A - MSCAIDIC = DK, EMPTY, OR NULL), GO TO FQM9A MSCAIDIC.
ELSE GO TO BOX FQM10.

Yes/No

Does (FACILITY) have any beds certified by [(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID] as ICF/IID
(Intermediate Care Facilities for Individuals with Intellectual Disabilities) beds?

routing

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.

FQM9A

BOX FQM10

MSHDEPTL

FQM10A

code one

MSHDPLOS

FQM10A

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.

(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

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

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

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

(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

Page 2 of 3

2019 MCBS Facility Instrument

Variable Name

FQM-Facility Questionnaire Missing Data

MR Screen Name Question Type

MSHDEPTP

FQM11A

code one

MSHDPPOS

FQM11A
BOX FQMCOMP

routing

FQMSEND

FQMEND

code one

BOX FQMEND

routing

Question Text/Description

Code List

(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 agency?
(02) YES, LICENSED BY SOME OTHER AGENCY
(-8) Don't Know
(-9) Refused
OTHER AGENCY (SPECIFY)
(01) [Continuous answer]
GO TO FQMEND - FQMSEND.
YOU HAVE REACHED THE END OF THE SECTION FOR FACILITY LEVEL MISSING DATA.
(01) CONTINUE
PRESS "1" TO RETURN TO FACILITY NAVIGATION SCREEN.
GO TO NAVIGATOR

Routing
(00) BOX FQMCOMP
(01) BOX FQMCOMP
(02) FQM11A - MSHDPPOS
(-8) BOX FQMCOMP
(-9) BOX FQMCOMP
(01) BOX FQM11
(01) BOX FQMEND

Page 3 of 3