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pdf2021 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
Page 2 of 4
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
File Type | application/pdf |
File Title | Medicare Current Beneficiary Survey Section Specifications for FQM |
Subject | Medicare beneficiaries, MCBS facility instrument, 2021, Facility Questionnaire Missing Data, FQM |
Author | NORC |
File Modified | 2021-09-08 |
File Created | 2021-09-03 |