CMS-P-0015A Facility Showcards

SHOWCARDS &
REFERENCE CARDS
Medicare Current Beneficiary Survey
Facility Component

Table of Contents: Showcards
FACILITY QUESTIONNAIRE (FQ)
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FA1
FA2
FA3
FA4

RESIDENCE HISTORY (RH)
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RH1

BACKGROUND QUESTIONNAIRE (BQ)
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BQ1AA
BQ1B
BQIC
BQ1
BQ1A
BQ2
BQ3

HEALTH STATUS (HS)
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HA1
HA3
HA4
HA5
HA6

USE OF SERVICES (US)
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US1
US2
US3
US4
US5
US6

FA1
Type of Place You Are Part Of...
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Continuing Care Retirement Community (CCRC)
Retirement Community
Hospital
Assisted Living Facility
Board and Home Care
Domiciliary Care Home
Rest Home/Retirement Home
Other

Updated October 27, 2014

FA2
Type of Place You Are Part Of...
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Free Standing Nursing Home
Nursing Home/Unit Within a CCRC or Retirement Center
Hospital
Hospital-Based SNF Unit
Assisted Living Facility
Board and Care Home
Domiciliary Care Home
Personal Care Home
Rest Home/Retirement Center
Home Office or Management Office for a Chain or Group of
Off-Site Nursing Facilities
Mental Health/Psychiatric Setting
Institution for the Intellectually Disabled/Developmentally
Disabled
Rehabilitation Facility
Other

Updated July 23, 2018

FA3
Types of Hospitals
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Acute Care Hospital
Private Psychiatric Hospital
State or County Hospital for the Mentally Ill
VA Hospital, VA Medical Center
State Hospital for Individuals with Intellectual Disabilities
Chronic Disease, Rehabilitation, Geriatric, or Other LongTerm Care Hospital
• Other

Updated July 23, 2018

FA4
Types of Ownership
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For Profit (Individual, Partnership, or Corporation)
Private Nonprofit (Religious Group, Nonprofit Corp., Etc.)
City/County Government
State Government
Veterans Administration
Other Federal Agency
Other

Updated October 27, 2014

RH1
Nursing Home or Rehabilitation Center:
• Nursing homes are licensed or certified facilities that provide nursing
services 24 hours a day to the residents. Rehabilitation centers provide
skilled nursing care or rehabilitation services and other related health
services.
Personal Care Home or Residential Care Facility:
• Personal care and residential care facilities or apartment buildings offer
residents help with activities, such as bathing and dressing, but do not
provide 24-hour nursing services. (Some residents at a personal care or
residential care facility may not require such assistance, but it must be
available to them.) These facilities are sometimes called assisted-living
communities, personal care homes, board and care homes, or
domiciliary homes.
CCRC or Retirement Home or Center:
• CCRC and retirement centers or homes may have nursing home
facilities on a campus or in one large building along with other housing
and services, such as apartments, board and care services, and often a
variety of community-based long-term care services.
Hospital
Private Home or Apartment
Other LTC Facility:
• Long-term care facilities provide a residence, some surveillance and
available living assistance for persons no longer willing or able to live on
their own for the long term.
Other

Updated October 27, 2014

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Updated October 27, 2014

BQ1AA
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Mexican, Mexican American, (Chicano/Chicana)
Puerto Rican
Cuban
Other Hispanic, Latino, Latina or Spanish Origin

Updated October 27, 2014

BQ1B
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Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other

Updated October 27, 2014

BQ1C
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Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander

Updated October 27, 2014

BQ1
Armed Forces Service
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Iraq or Afghanistan Conflict (2001 – Present)
Persian Gulf War (August 1990 – March 1991)
Vietnam Era (August 1964 - May 1975)
Korean Conflict (June 1950 - January 1955)
World War II (September 1940 - July 1947)
World War I (1917-1918)
Peace Time Only (All Other Times)

Updated October 27, 2014

BQ1A
Race
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American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Another

Updated October 27, 2014

BQ2
In This Facility
Other Nursing Home or Rehabilitation Center:
• Nursing homes are licensed or certified facilities that provide nursing services
24 hours a day to the residents. Rehabilitation centers provide skilled nursing
care or rehabilitation services and other related health services.
Personal Care Home/Other Residential Care Facility:
• Personal care and residential care facilities or apartment buildings offer
residents help with activities, such as bathing and dressing, but do not provide
24-hour nursing services. (Some residents at a personal care or residential
care facility may not require such assistance, but it must be available to
them.) These facilities are sometimes called assisted-living communities,
personal care homes, board and care homes, or domiciliary homes.
CCRC or Retirement Home or Center:
• CCRC and retirement centers or homes may have nursing home facilities on
a campus or in one large building along with other housing and services, such
as apartments, board and care services, and often a variety of communitybased long-term care services.
Hospital
Private Home or Apartment
Spouse Deceased
Other LTC Facility:

•

Long-term care facilities provide a residence, some surveillance and available
living assistance for persons no longer willing or able to live on their own for
the long term.

Updated October 27, 2014

BQ3
Total Yearly Income (Before Taxes or Deductions) Received
From:
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Jobs
Businesses
Interest
Social Security
Railroad Retirement
Supplemental Security Income (SSI)
Pensions
Other Sources

Updated October 27, 2014

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Updated October 27, 2014

HA1
Level of Self-Performance
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Independent
Supervision
Limited Assistance
Extensive Assistance
Total Dependence
Activity Occurred Only Once or Twice
Activity Did Not Occur

Updated October 27, 2014

HA3
Diagnoses
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Alzheimer's Disease
Anemia
Anxiety Disorder
Aphasia
Arthritis
Asthma, COPD, or Chronic Lung Disease
Atrial Fibrillation or Other Dysrhythmias
Benign Prostatic Hyperplasia
Cancer
Cataracts, Glaucoma, or Macular Degeneration
Cerebral Palsy
Cerebrovascular Accident (CVA), Transient Ischemic Attack (TIA), or
Stroke
Cirrhosis
Coronary Artery Disease (E.G., Angina, MI, and ASHD)
Deep Veneous Thrombosis (DVT), Pulmonary Embolus (PE) or
Pulmonary Thrombo-Embolism (PTE)
Dementia other than Alzheimer's
Depression
Diabetes Mellitus (E.G., Diabetic Retinopathy, Nephropathy, and
Neuropathy)
Gastroesophageal Reflux Disease (GERD) or Ulcer
Heart Failure (Congestive Heart Failure (CHF) and Pulmonary Edema)
Hemiplegia/Hemiparesis
Hip Fracture
Huntington’s Disease
Hyperkalemia

(continued)
Updated October 27, 2014

HA3
Diagnoses Continued
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Hyperlipidemia (Hypercholesterolemia)
Hypertension
Hyponatremia
Malnutrition or at Risk for Malnutrition
Manic Depression (Bipolar Disease)
Multiple Sclerosis
Neurogenic Bladder
Obstructive Uropathy
Orthostatic Hypotension
Osteoporosis
Other Fracture
Paraplegia
Parkinson's Disease
Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)
Post-Traumatic Stress Disorder (PTSD)
Psychotic Disorder (Other than Schizophrenia)
Quadriplegia
Renal Insufficiency, Renal Failure, or End-Stage Renal Disease (ESRD)
Respiratory Failure
Schizophrenia
Seizure Disorder or Epilepsy
Thyroid Disorder
(Hypothyroidism, Hyperthyroidism, and Hashimoto's Thyroiditis)
Tourette's Syndrome
Traumatic Brain Injury
Ulcerative Colitis, Crohn's Disease, or Inflammatory Bowel Disease
Other
• None of the Above

Updated October 27, 2014

HA4
Infections
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Multidrug-Resistant Organism (MDRO)
Pneumonia
Septicemia
Tuberculosis
Urinary Tract Infection in Last 30 Days
Viral Hepatitis
Wound Infection (Other Than Foot)
None of the Above

Updated October 27, 2014

HA5
Other Diagnoses
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Agitation
Alcohol Dependency
Allergies
Anorexia
Aortic Stenosis
Ataxia
Atypical Psychosis
Blindness
Breast Disorders
Cataracts
Cerebral Degeneration
Clinical Obesity
Clostridium Difficile (C.DIFF.)
Conjunctivitis
Constipation
Degenerative Joint Disease
Diaphragmatic Hernia (Hiatal Hernia)
Diverticula of Colon
Down's Syndrome
Dysphagia (Swallowing Difficulties)
Edema (Other Than Pulmonary)
Gastritis/Duodenitis
Gastroenteritis, Noninfectious
(continued)
Updated October 27, 2014

HA5
Other Diagnoses Continued
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Gastrointestinal Hemorrhage
Gout
Hemorrhage of Esophagus
HIV Infection
Hyperplasia of Prostate
Hypopotassemia/Hypokalemia
Hypotension (Other Than Orthostatic)
Insomnia
Kyphosis
Missing Limb (E.G., Amputation)
Nonpsychotic Brain Syndrome
Organic Brain Syndrome
Osteoarthritis
Pathological Bone Fracture
Renal Ureteral Disorder
Respiratory Infection
Scoliosis
Sexually Transmitted Diseases
Spinal Stenosis
Ulcer of Leg, Chronic
Urinary Retention
Vertigo

Updated October 27, 2014

HA6
IADLs
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No Difficulty at All
A Little Difficulty
Some Difficulty
A Lot of Difficulty
Not Able To Do It

Updated October 27, 2014

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Updated October 27, 2014

US1
How Often Each Week...
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Less Than Once a Week
Once or Twice a Week
3 to 5 Times a Week
More Than 5 Times a Week
One-Time Evaluation

Updated October 27, 2014

US2
How Long a Period...
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Less Than 1 Week
1 to 3 Weeks
4 to 8 Weeks
More Than 8 Weeks but Not the Whole Time
About the Whole Time

Updated October 27, 2014

US3
Other Certified or Licensed Health Care Providers
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Audiologist
Dietician
Laboratory Technician
Nurse Practitioner
Ophthalmologist
Optometrist
Physician’s Assistant
Recreational Therapist
Registered Nurse
Social Worker
X-Ray Technician
Other

Updated October 27, 2014

US4
Supplies and Medical Services
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Ambulance Service
Cloth Diapers
Diabetic Equipment or Supplies
Disposable Diapers
Equipment or Supplies for Kidney Dialysis
Eye Glasses or Contact Lenses
Hearing Aid or Other Communication Device
Orthopedic Items
Ostomy Supplies
Oxygen
Prosthesis
None of the Above

Updated October 27, 2014

US5
Other Medical Device or Equipment
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Bedside Commode
Bed Pads (Cloth or Disposable)
Catheter and Catheter Supplies
Feeding Supplies (Include Pumps, Syringes, Tubes)
G Tube and Supplies
Geri Chair
Hospital Bed
IV Supplies
Nebulizer
Special Mattress, Cushions or Mattress Pads (Include Egg
Crate, Air)
Suction Machine and Supplies
TED Hose and Supplies
Wheelchair/Walker
Some Other Type of Device or Equipment
None of the Above

Updated October 27, 2014

US6
Other Necessary Medical Items or Services
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Applying/Changing Dressings Including Band-Aids
Applying/Monitoring Hot Packs
Catheterization and Irrigation
Feeding (With Spoon, Syringe, Pump or Other Device)
G Tube Use and Care
Incontinence
IV Use and Care
Pacemaker Check
Skin Treatments for Prevention/Treatment of Skin Ulcers
Some Other Kind of Item or Service
Suctioning
None of the Above

Updated October 27, 2014