CMS-P-0015A Questionaire Missing Data

2021 MCBS Facility Instrument

Variable Name

MR Screen Name

FQM- Facility Questionnaire Missing Data

Question Type

Question Text/Description

Code List

Routing

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

BOX FQMBEG

routing

GO TO FQMISS1 - FQMISSNG.

FQMISS1

code one

THE FOLLOWING ITEMS ARE MISSING FROM FQ. CONFIRM THAT THE RESPONDENT CAN ANSWER AT
LEAST ONE QUESTION.
(01) CONTINUE
PRESS "1" TO CONTINUE.

BOX FQM1

routing

IF (FQ1A - PLACNAME = DK OR RF) AND (FQM1A - MSFNAME = DK, EMPTY, OR NULL), GO TO FQM1A MSFNAME.
ELSE GO TO BOX FQM2.

MSFNAME

FQM1A

Yes/No

ADDRNAME

FQM1B

text

What is the exact name of the place where (SP) was physically located on (REFERENCE DATE)?

BOX FQM2

routing

IF (FQ2 - FADDROK = DK OR RF) AND (FQM2A - MSFADDR = DK, EMPTY, OR NULL), GO TO FQM2A MSFADDR.
ELSE GO TO BOX FQM2A1.

MSFADDR

FQM2A

Yes/No

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

ADDRESS

FQM2B

Address

ADDRCITY

FQM2B

Address

ADDRSTAT

FQM2B

ADDRZIP

FQMISSNG

(01) BOX FQM1

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

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

(01) [Continuous answer]

(01) BOX FQM2

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

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

(01) [Continuous answer]

(01) FQM2B - ADDRCITY

CITY

(01) [Continuous answer]

(01) FQM2B - ADDRSTAT

Address

STATE

(01) [Continuous answer]

(01) FQM2B - ADDRZIP

FQM2B

Address

ZIP

(01) [Continuous answer]

(01) BOX FQM2A1

BOX FQM2A1

routing

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

(00) NO
(01) YES
(-9) Refused

(00) FQM2D - MAILADDR
(01) BOX FQM3
(-9) BOX FQM3

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

(01) FQM2D - MAILCITY
(-8) FQM2D - MAILCITY
(-9) FQM2D - MAILCITY

MSMADDR

FQM2C

MAILADDR

FQM2D

I need to verify that our information about you is correct.
Is (FACILITY) the exact name of this (facility/home)?

What is the correct address of the place where (SP) was physically located on (REFERENCE DATE)?
ADDRESS

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

Text

What is the correct address for your office?
ADDRESS

Page 1 of 4

2021 MCBS Facility Instrument

Variable Name

MR Screen Name

FQM- Facility Questionnaire Missing Data

Question Type

Question Text/Description

Code List

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

MAILCITY

FQM2D

Text

CITY

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

MAILSTAT

FQM2D

Text

STATE

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

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

MAILZIP

FQM2D

Text

ZIP

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

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

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

[Is (ADMINISTRATOR'S NAME)/Are you] (still) the current administrator of (FACILITY)?

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

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

FACRNAMM

FQM3B

text

What is the current administrator's name?
SELECT A RESPONSE BELOW OR ADD TO THE PERSON ROSTER.

(01) [Continuous answer]

(01) BOX FQM4

BOX FQM4

routing

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

MSFPHON

FQM4A

Yes/No

(VERIFY PHONE NUMBER IS FOR FQ RESPONDENT. DO NOT READ ALOUD.)
Is (FACILITY AREA CODE AND PHONE NUMBER) the correct phone number for (FACILITY)?

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

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

ADDRAREA

FQM4B

Numeric

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

(01) FQM4B - ADDREXCH
(-8) FQM4B - ADDREXCH
(-9) FQM4B - ADDREXCH

ADDREXCH

FQM4B

Numeric

EXCHANGE

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

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

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.

What is the phone number?
AREA CODE

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2021 MCBS Facility Instrument

Variable Name

MR Screen Name

FQM- Facility Questionnaire Missing Data

Question Type

Question Text/Description

SHOW CARD FA2
MSPLACTY

FQM5A

code one

What type of place is (FACILITY)?
PRESS F1 FOR PLACE DEFINITIONS.
IF RESPONDENT REPORTS CCRC OR RETIREMENT COMMUNITY, PROBE FOR TYPE OF PLACE FOR
UNIT WHERE SP RESIDES. DO NOT ENTER "OTHER".

MSPLTPOS

FQM5A

text

OTHER (SPECIFY)

Code List
(01) FREE STANDING NURSING HOME
(04) NURSING HOME UNIT WITHIN A CCRC OR
RETIREMENT CENTER
(06) HOSPITAL
(07) HOSPITAL-BASED SNF UNIT
(08) ASSISTED LIVING FACILITY
(09) BOARD AND CARE HOME
(10) DOMICILIARY CARE HOME
(11) PERSONAL CARE HOME
(12) REST HOME/RETIREMENT HOME
(13) HOME OFFICE OR MANAGEMENT OFFICE FOR
A CHAIN OR GROUP OF OFF-SITE NURSING
FACILITIES
(15) MENTAL HEALTH CENTER/PSYCHIATRIC
SETTING
(16) INSTITUTION FOR THE INTELLECTUALLY
DISABLED/DEVELOPMENTALLY DISABLED
(17) REHABILITATION FACILITY
(91) OTHER
(-9) Refused

Routing

(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

IF (FA12A - TOTLBEDA = DK OR RF AND CCN='NF', MISSING, DK, RF), GO TO FQM6B-MSTOTLBA.
ELSE GO TO BOX FQM7.

FQM6

How many beds does (FACILITY) have that provide long-term care?
MSTOTLBA

FQM6B

Numeric

[PROBE: Do not count "independent living" beds or those that don’t provide 24-hour a day assistance or
supervision with daily living activities.]
IF THIS FACILITY CONTAINS BEDS THAT ARE CERTIFIED AS ICF/IID (INTERMEDIATE CARE FACILITIES
FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES), THEN COUNT ICF/IID BEDS IN THE TOTAL.

BOX FQM7

routing

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

Is (FACILITY) certified by [(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID] as a Nursing Facility (NF)?
MSCAIDC1

MSCAREC1

MSCAIDIC

(00) NO
IF R MENTIONS:
(01) YES
-ICF (INTERMEDIATE CARE FACILITY), NOTE IN COMMENTS AND ENTER 1.
(-8) Don't Know
ICF/IID (INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES), NOTE (-9) Refused
IN COMMENTS AND ENTER 0.

FQM7A

Yes/No

BOX FQM8

routing

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.

FQM9A

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?

(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

Page 3 of 4

2021 MCBS Facility Instrument

Variable Name

FQM- Facility Questionnaire Missing Data

MR Screen Name

Question Type

Question Text/Description

BOX FQM10

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.

Code List

Routing

(00) NO, NOT LICENSED
(01) YES, LICENSED BY STATE HEALTH
DEPARTMENT
(02) YES, LICENSED BY SOME OTHER AGENCY
(-8) Don't Know
(-9) Refused

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

(01) [Continuous answer]

(01) BOX FQM11

MSHDEPTL

FQM10A

code one

Is (FACILITY) licensed as a nursing (facility/home) by the (STATE) State Health Department or by some other
agency?

MSHDPLOS

FQM10A

text

OTHER AGENCY (SPECIFY)

BOX FQM11

routing

IF (FA18 - HDEPTPCH = DK OR RF) AND (FQM11A - MSHDEPTP = DK, EMPTY, OR NULL), GO TO FQM11A MSHDEPTP.
ELSE GO TO BOX FQMCOMP.

code one

Does (FACILITY) have any beds licensed as personal care, board and care, assisted living, or domiciliary care
beds by the (STATE) State Health Department or by some other state agency?

(00) NO, NOT LICENSED
(01) YES, LICENSED BY STATE HEALTH
DEPARTMENT
(02) YES, LICENSED BY SOME OTHER AGENCY
(-8) Don't Know
(-9) Refused

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

OTHER AGENCY (SPECIFY)

(01) [Continuous answer]

(01) BOX FQM11

(01) CONTINUE

(01) BOX FQMEND

MSHDEPTP

FQM11A

MSHDPPOS

FQM11A

FQMSEND

BOX FQMCOMP

routing

FQMEND

code one

BOX FQMEND

routing

GO TO FQMEND - FQMSEND.
YOU HAVE REACHED THE END OF THE SECTION FOR FACILITY LEVEL MISSING DATA.
PRESS "1" TO RETURN TO FACILITY NAVIGATION SCREEN.
GO TO NAVIGATOR

Page 4 of 4