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pdf2021 MCBS Facility Instrument
Variable Name
MR Screen Name
FQ-Facility Questionnaire
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
FACILITY QUESTIONNAIRE SECTION SPECIFICATIONS
CRITERIA
SAMPLE TYPE=ALL
SEASON=ALL
PLACEMENT
Start of Facility Interview
BOX FQ1
routing
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
(01) [Continuous answer.]
What is the exact name of the place where (SP) (is/was) physically located [on or around (PREVIOUS INTERVIEW
(-8) Don't Know
DATE)/on or around (ADMISSION DATE REPORTED BY A PREVIOUS SOURCE)]?
(-9) Refused
FADDROK
FQ2
yes/no
Next, I would like to verify the 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)].
I have it listed as [READ ADDRESS BELOW]. Is this correct?
ADDRESS
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
(01) FQ2 - FADDROK
(-8) FQ2 - FADDROK
(-9) FQ2 - FADDROK
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(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
ADDRCITY
FQ2A
address
CITY
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) FQ2A - ADDRSTAT
(-8) FQ2A - ADDRSTAT
(-9) FQ2A - ADDRSTAT
ADDRSTAT
FQ2A
address
STATE
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) FQ2A - ADDRZIP
(-8) FQ2A - ADDRZIP
(-9) FQ2A - ADDRZIP
ADDRZIP
FQ2A
address
ZIP
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) FQ3 - FADMNOK
(-8) FQ3 - FADMNOK
(-9) FQ3 - FADMNOK
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
(00) FQ3A - FACRNAM1
(01) FQ4 - MADDROK
(02) FQ4 - MADDROK
(-8) FQ4 - MADDROK
(-9) FQ4 - MADDROK
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
FQ4A
FQ4A
text
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) FQ4A - MAILCIT1
(-8) FQ4A - MAILCIT1
(-9) FQ4A - MAILCIT1
What is the correct address for your office?
PRESS F1 FOR STATE ABBREVIATIONS.
ADDRESS
MAILCIT1
MAILADD1
text
CITY
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) FQ4A - MAILSTA1
(-8) FQ4A - MAILSTA1
(-9) FQ4A - MAILSTA1
MAILSTA1
FQ4A
text
STATE
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) FQ4A - MAILZIP1
(-8) FQ4A - MAILZIP1
(-9) FQ4A - MAILZIP1
MAILZIP1
FQ4A
text
ZIP
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) FQ5 - FPHONOK
(-8) FQ5 - FPHONOK
(-9) FQ5 - FPHONOK
Page 1 of 11
2021 MCBS Facility Instrument
Variable Name
MR Screen Name
FQ-Facility Questionnaire
Question Type
Question Text/Description
Code List
Routing
(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) FQ5A - ADDRAREA
(01) BOX FQ7
(-8) BOX FQ7
(-9) BOX FQ7
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) FQ5A - ADDREXCH
(-8) FQ5A - ADDREXCH
(-9) FQ5A - ADDREXCH
FPHONOK
FQ5
yes/no
ADDRAREA
FQ5A
Numeric
ADDREXCH
FQ5A
Numeric
EXCHANGE
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) FQ5A - ADDRLOCL
(-8) FQ5A - ADDRLOCL
(-9) FQ5A - ADDRLOCL
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
IF BASELINE FQ, GO TO FAINTRO1 - FAINT1TC.
IF FALL ROUND OR ANNUAL FQ, GO TO FB0PRE - ANSWERFB.
ELSE GO TO FC1PRE - FC1PRECT.
FAINTRO1
code one
(01) Continue
(01) BOX FA1
FAINT1TC
What is the phone number?
AREACODE
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.
BOX FA1
routing
IF ADULT/GROUP HOME, GO TO FA5A - EFOWNDES.
ELSE GO TO FA1 - PLACTYP1.
PLACTYP1
FA1
code one
(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
(13) HOME OFFICE OR MANAGEMENT OFFICE FOR A
PRESS F1 FOR PLACE DEFINITIONS.
CHAIN OR GROUP OF OFF-SITE NURSING
IF RESPONDENT REPORTS CCRC OR RETIREMENT COMMUNITY, PROBE FOR TYPE OF PLACE FOR UNIT FACILITIES
(15) MENTAL HEALTH CENTER/PSYCHIATRIC
WHERE SP RESIDES. DO NOT ENTER "OTHER".
SETTING
(16) INSTITUTION FOR THE INTELLECTUALLY
DISABLED/DEVELOPMENTALLY DISABLED
(17) REHABILITATION FACILITY
(91) OTHER
(-9) Refused
PLACTPO1
FA1
verbatim
OTHER (SPECIFY)
(01) [Continuous answer.]
(01) FA1A - FACHOME
FA1A
code one
IF ALREADY KNOWN, CODE WITHOUT ASKING:
Do you prefer that I call (FACILITY) a home or a facility?
(01) PREFERS HOME
(02) PREFERS FACILITY
(03) NO PREFERENECE
(01) BOX FA1A
(02) BOX FA1A
(03) BOX FA1A
BOX FA1A
routing
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
(04) VA HOSPITAL, VA MEDICAL CENTER
(05) STATE HOSPITAL FOR INDIVIDUALS WITH
INTELLECTUAL DISABILITIES
(06) CHRONIC DISEASE, REHABILITATION,
GERIATRIC, OR OTHER LONG-TERM CARE
HOSPITAL
(91) OTHER
(01) FA2A - LCNDBEDS
(02) FA2A - LCNDBEDS
(03) FA2A - LCNDBEDS
(04) FA2A - LCNDBEDS
(05) FA2A - LCNDBEDS
(06) FA2A - LCNDBEDS
(91) FA2 - HOSPKIOS
FACHOME
HOSPKIND
FA2
code one
HOSPKIOS
FA2
verbatim
LCNDBEDS
FA2A
yes/no
SHOW CARD FA3
You mentioned that (FACILITY) is a hospital. Please look at this card and tell me what kind of hospital it is.
(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
OTHER (SPECIFY)
(01) [Continuous answer.]
(01) FA2A - LCNDBEDS
Does (FACILITY) have any beds that are either certified or licensed as a nursing facility or certified or licensed as
an ICF/IID (Intermediate Care Facilities for Individuals with Intellectual Disabilities)?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX FA2A
(01) FA3 - FACLPART
(-8) BOX FA2A
(-9) BOX FA2A
PRESS F1 FOR SUGGESTED PROBES.
Page 2 of 11
2021 MCBS Facility Instrument
Variable Name
FACLPART
PLACTYP2
FQ-Facility Questionnaire
MR Screen Name
Question Type
BOX FA2A
routing
FA3
Yes/No
FA4
code one
Question Text/Description
IF FA2 - HOSPKIND = 1/AcuteCareHospital, GO TO FACLOSE2 - LEAVINEL.
ELSE GO TO FA3 - FACLPART.
Is (FACILITY) part of a larger facility or campus?
PRESS F1 FOR DEFINITION, EXAMPLES OF "LARGER" PLACES.
SHOW CARD FA1
What type of place is (FACILITY) part of?
PRESS F1 FOR HOSPITAL DEFINITIONS.
Code List
Routing
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FA5A - EFOWNDES
(01) FA4 - PLACTYP2
(-8) BOX FA6
(-9) BOX FA6
(03) CONTINUING CARE RETIREMENT COMMUNITY
(CCRC)
(05) RETIREMENT COMMUNITY
(06) HOSPITAL
(08) ASSISTED LIVING FACILITY
(09) BOARD AND CARE HOME
(10) DOMICILIARY CARE HOME
(11) PERSONAL CARE HOME
(12) REST HOME/RETIREMENT HOME
(91) OTHER
(-8) Don't Know
(-9) Refused
(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
PLACTPO2
FA4
verbatim
OTHER (SPECIFY)
(01) [Continuous answer.]
(01) FA5 - LGPLCNAM
LGPLCNAM
FA5
text
What is the name of the (CATEGORY SELECTED IN FA4 - PLACTYP2/place)?
(01) [Continuous answer.]
(01) FA5A - EFOWNDES
(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) BOX FA6
(02) BOX FA6
(03) BOX FA6
(04) BOX FA6
(05) BOX FA6
(06) BOX FA6
(91) FA5A - EFOWNDOS
(01) [Continuous answer.]
(01) BOX FA6
SHOW CARD FA4
EFOWNDES
FA5A
code one
EFOWNDOS
FA5A
verbatim
OTHER (SPECIFY)
BOX FA6
routing
GO TO BOX FA6A.
BOX FA6A
routing
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)?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FA11 - FACRNAM2
(01) BOX FA7A
(-8) FA11 - FACRNAM2
(-9) FA11 - FACRNAM2
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.
(01) [Continuous answer.]
(01) CLOSING6 - FINOTRES
routing
IF PLACTYP1= 1/Free Standing Nursing Home, 4/NursingHomeUnitCCRC, 7/HospitalBasedSNF, or
17/Rehabilitation Facility, GO TO CCNINTRO.
ELSE GO TO FA12A - TOTLBEDA.
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FA12A - TOTLBEDA
(01) CASPER_LU-CCN
(-8) FA12A - TOTLBEDA
(-9) FA12A - TOTLBEDA
BOX FA7A
Which one of the categories on this card best describes the ownership of (FACILITY)?
Does [FACILITY) have a CMS Certification Number, also referred to as a Medicare/Medicaid 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.]
[IF NEEDED: The CMS Certification Number also used to be called the OSCAR Provider Number.]
Page 3 of 11
2021 MCBS Facility Instrument
Variable Name
MR Screen Name
FQ-Facility Questionnaire
Question Type
Question Text/Description
Code List
Routing
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 CMS Certification Number I can look up the number using your Facility name
and address.]
CCN
CASPER_LUA
lookup
[IF REFERENCING THE MDS : The CMS Certification Number can be found in section A0100 B. of the MDS form.] (01) (value selected from lookup)
(-8) DON'T KNOW
START TYPING OR DOUBLE CLICK IN THE "CASPER_LU" 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 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].
SEARCH FOR THE FACILITY'S CCN BY TYPING THE CCN IN THE SEARCH BOX.WHEN YOU FIND THE
CORRECT CCN, HIGHLIGHT THE ROW AND PRESS THE SELECT BUTTON.
lookup
IF THE FACILITY RESPONDENT DOES NOT KNOW THE CCN, SEARCHTHE LOOKUP USING A DIFFERENT
IDENTIFIER, SUCH AS THE FACILITY'S NAME OR ADDRESS.
IF YOU CANNOT FIND THE FACILITY'S CCN, PRESS THE "NOT FOUND" BUTTON.
IF YOU NEED TO EXIT THE LOOKUP, PRESS THE "CLOSE" BUTTON.
BOX FA7C
routing
IF CCN IN ('NF', MISSING, DK, RF), GO TO FA12A - TOTLBEDA.
ELSE GO TO BOX FA8.
How many beds does (FACILITY) have that provide long-term care?
TOTLBEDA
FA12A
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 FA8
routing
FA13
yes/no
(01) BOX FA8
(-8) BOX FA8
(-9) BOX FA8
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FA14 - CARECRT1
(01) FA14 - CARECRT1
(-8) FA14 - CARECRT1
(-9) FA14 - CARECRT1
IF FA12A - TOTLBEDA < 3 AND FA12A - TOTLBEDA <> 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?
CAIDCRT1
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
[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
Does (FACILITY) have any beds certified by Medicare as SNF beds?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FA15 - CAIDICF
(01) FA15 - CAIDICF
(-8) FA15 - CAIDICF
(-9) FA15 - CAIDICF
CAIDICF
FA15
yes/no
Does (FACILITY) have any beds certified by [(PREFERRED NAME(S) FOR MEDICAID)/MEDICAID] as ICF/IID
(Intermediate Facilities For Individuals With Intellectual Disabilities) beds?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FA16 - HDEPTLIC
(01) FA16 - HDEPTLIC
(-8) FA16 - HDEPTLIC
(-9) FA16 - HDEPTLIC
code one
Does (FACILITY) have any beds that are [not certified by (Medicaid and Medicare/Medicare/Medicaid) but are]
licensed as nursing home beds by the (STATE) State Health Department or by some other State or Federal
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) FA18 - HDEPTPCH
(01) FA18 - HDEPTPCH
(02) FA16 - HDEPTLOS
(-8) FA18 - HDEPTPCH
(-9) FA18 - HDEPTPCH
HDEPTLIC
FA16
Page 4 of 11
2021 MCBS Facility Instrument
FQ-Facility Questionnaire
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
Routing
HDEPTLOS
FA16
verbatim
OTHER AGENCY (SPECIFY)
(01) [Continuous answer.]
(01) FA18 - HDEPTPCH
(00) BOX FA9
(01) BOX FA9
(02) FA18 - HDEPTPOS
(-8) BOX FA9
(-9) BOX FA9
HDEPTPCH
FA18
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 or local government 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
HDEPTPOS
FA18
verbatim
OTHER AGENCY (SPECIFY)
(01) [Continuous answer.]
(01) BOX FA9
BOX FA9
routing
IF CCN IN ('NF', MISSING, DK, RF), GO TO FA19 - NORMCARE.
ELSE GO TO BOX FA13.
NORMCARE
FA19
list
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FA19 - SUPRMEDI
(01) FA19 - SUPRMEDI
(-8) FA19 - SUPRMEDI
(-9) FA19 - SUPRMEDI
SUPRMEDI
FA19
list
b. supervision over medications?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FA19 - HELPBATH
(01) FA19 - HELPBATH
(-8) FA19 - HELPBATH
(-9) FA19 - HELPBATH
HELPBATH
FA19
list
c. help with bathing?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FA19 - HELPDRES
(01) FA19 - HELPDRES
(-8) FA19 - HELPDRES
(-9) FA19 - HELPDRES
HELPDRES
FA19
list
d. help with dressing?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FA19 - HELPEAT
(01) FA19 - HELPEAT
(-8) FA19 - HELPEAT
(-9) FA19 - HELPEAT
HELPEAT
FA19
list
e. help with eating?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX FA13
(01) BOX FA13
(-8) BOX FA13
(-9) BOX FA13
BOX FA13
routing
IF FA13 - CAIDCRT1, FA14 - CARECRT1, OR FA15 - CAIDICF = 1/Yes, GO TO FA20 - CARESUP.
ELSE GO TO FA19A - RNLPNSUP.
RNLPNSUP
FA19A
yes/no
Does (FACILITY) provide 24-hour a day, on-site supervision by an RN or LPN 7 days a week?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX FA16A
(01) BOX FA16A
(-8) BOX FA16A
(-9) BOX FA16A
CARESUP
FA20
yes/no
Does (FACILITY) provide 24-hour a day, on-site supervision by a caregiver 7 days a week
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX FA16A
(01) BOX FA16A
(-8) BOX FA16A
(-9) BOX FA16A
BOX FA16A
routing
GO TO BOX FA16.
BOX FA16
routing
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.
ANSRFACQ
FA22
yes/no
The next questions are about the number of nursing beds and residents by payer type and staffing. Can you
answer these questions about (FACILITY)?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FA23 - FACRNAM3
(01) BOX FA17
(-8) BOX FA17
(-9) FA23 - FACRNAM3
FACRNAM3
FA23
roster
(01) [Continuous answer.]
(01) CLOSING6 - FINOTRES
BOX FA17
routing
(01) Continue
(01) BOX FA18
In addition to room and board, does (FACILITY) routinely provide…
a. nursing or medical care?
Who would be the best person to answer questions about (FACILITY)?
SELECT A RESPONSE BELOW OR ADD TO THE PERSON ROSTER.
IF FA12A - TOTLBEDA <> DK OR RF, GO TO FA24PRE - FA24PRCT.
ELSE GO TO BOX FA18.
From information I collected earlier, I understand that (FACILITY) has a total of (NUMBER OF BEDS IN FACILITY)
beds.
FA24PRCT
FA24PRE
code one
[IF NECESSARY: We are concerned only with the place where (SP) is physically located.]
PRESS "1" TO CONTINUE.
Page 5 of 11
2021 MCBS Facility Instrument
Variable Name
Question Type
Question Text/Description
BOX FA18
routing
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.
MANDMBED
FA26
Numeric
MCAIDBED
FA27
MCAREBED
MNORMBED
ICFMRBED
OTLTCBED
MR Screen Name
FQ-Facility Questionnaire
Code List
Routing
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)?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) FA27 - MCAIDBED
(-8) FA27 - MCAIDBED
(-9) FA27 - MCAIDBED
Numeric
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)?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) BOX FA20
(-8) BOX FA20
(-9) BOX FA20
BOX FA20
routing
IF FA14 - CARECRT1 = 1/Yes, GO TO FA28 - MCAREBED.
ELSE GO TO BOX FA21.
FA28
Numeric
(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
(01) BOX FA21
(-8) BOX FA21
(-9) BOX FA21
BOX FA21
routing
IF FA16 - HDEPTLIC = 1/YesStateHealthDept OR 2/YesOtherAgency, GO TO FA29 - MNORMBED.
ELSE GO TO BOX FA22.
FA29
Numeric
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
BOX FA22
routing
IF FA15 - CAIDICF = 1/Yes, GO TO FA30 - ICFMRBED.
ELSE GO TO BOX FA23.
FA30
Numeric
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/IID beds (only)?
BOX FA23
(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
routing
IF FA18 - HDEPTPCH = 1/YesStateHealthDept OR 2/YesOtherAgency, GO TO FA31 - OTLTCBED.
ELSE GO TO BOX FA24.
FA31
Numeric
I recorded earlier that (FACILITY) contains beds that are licensed as personal care, board and care, assisted living, (01) [Continuous answer.]
domiciliary care, or other type of long-term care beds. How many beds are licensed as one of these types of long- (-8) Don't Know
term care (only)?
(-9) Refused
(01) BOX FA24
(-8) BOX FA24
(-9) BOX FA24
BOX FA24
routing
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
(00) No
That leaves (NUMBER OF BEDS LEFT) long-term care beds that are neither certified or licensed as nursing home (01) Yes
or other long-term care beds.
(00) FA32VB - NHBEDEX
(01) FA35 - MIDNTRES
Is that correct?
PLEASE ENTER A BRIEF EXPLANATION:
(01) [Continuous answer.]
(01) FA35 - MIDNTRES
(01) FR1PRE - FR1PRECT
(-8) FR1PRE - FR1PRECT
(-9) FR1PRE - FR1PRECT
MIDNTRES
FA35
Numeric
How many residents were in (FACILITY) altogether at midnight last night?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
ANSWERFB
FB0PRE
yes/no
Would you be able to answer some questions about the certification status and services offered at (FACILITY)?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FB19 - FACRNAM4
(01) FB1PRE - FB1PRECT
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4
FB1PRECT
FB1PRE
code one
(01) Continue
(01) BOX FA36
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.
BOX FA36
routing
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.
Page 6 of 11
2021 MCBS Facility Instrument
Variable Name
MR Screen Name
FQ-Facility Questionnaire
Question Type
Question Text/Description
You previously told me that (FACILITY)'s CMS Certification Number is [(BPRELOADFQ.CCN]. Is that still your
CMS Certification Number?
CCNCNFRM
CCNINTRO
FB11A
FB11B
yes/no
yes/no
[IF NEEDED: The CMS Certification Number is also referred to as a Medicare/Medicaid 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.]
Code List
Routing
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FB11B - CCNINTRO
(01) BOX FB1
(-8) FB11B - CCNINTRO
(-9) FB11B - CCNINTRO
Does [FACILITY) have a CMS Certification Number, also referred to as a Medicare/Medicaid 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.
(00) NO
(01) YES
[IF NEEDED: The CMS Certification Number is not the same as the National Provider Identifier (NPI), which is a
(-8) Don't Know
unique 10-digit identification number issued to health care providers.]
(-9) Refused
(00) BOX FB1
(01) CASPER_LU-CCN
(-8) BOX FB1
(-9) BOX FB1
[IF NEEDED: The CMS Certification Number also used to be called the OSCAR Provider Number.]
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 CMS Certification Number I can look up the number using your Facility name
and address.]
CCN
CASPER_LUB
lookup
[IF REFERENCING THE MDS : The CMS Certification Number can be found in section A0100 B. of the MDS form.] (01) (value selected from lookup)
(-8) DON'T KNOW
START TYPING OR DOUBLE CLICK IN THE "CASPER_LU" 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 FB1
(-8) BOX FB1
(-9) BOX FB1
(NF) BOX FB1
ACCORDING TO THE ADDRESS OF THIS FACILITY, THE FIRST TWO DIGITS OF THE CMS CERTIFICATION
NUMBER SHOULD BE [STATE PREFIX FILL].
SEARCH FOR THE FACILITY'S CCN BY TYPING THE CCN IN THE SEARCH BOX.WHEN YOU FIND THE
CORRECT CCN, HIGHLIGHT THE ROW AND PRESS THE SELECT BUTTON.
lookup
IF THE FACILITY RESPONDENT DOES NOT KNOW THE CCN, SEARCH THE LOOKUP USING A
DIFFERENT IDENTIFIER, SUCH AS THE FACILITY'S NAME OR ADDRESS.
IF YOU CANNOT FIND THE FACILITY'S CCN, PRESS THE "NOT FOUND" BUTTON.
IF YOU NEED TO EXIT THE LOOKUP, PRESS THE "CLOSE" BUTTON.
BOX FB1
routing
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)?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FB5 - CARECERT
(01) FB5 - CARECERT
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4
CARECERT
FB5
yes/no
Is (FACILITY) (still) certified by Medicare as a Skilled Nursing Facility (SNF)?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX FB3
(01) BOX FB3
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4
BOX FB3
routing
IF PreloadFQ.FMRCERT <> EMPTY, GO TO FB9 - FMRCERT.
ELSE GO TO BOX FB4.
FB9
yes/no
Is (FACILITY) (still) certified by Medicaid as an Intermediate Care Facilities for Individuals with Intellectual
Disabilities (ICF/IID)?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(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.
FMRCERT
Page 7 of 11
2021 MCBS Facility Instrument
Variable Name
MR Screen Name
FQ-Facility Questionnaire
Question Type
Question Text/Description
Code List
Routing
(00) FB14 - PCHLICEN
(01) FB14 - PCHLICEN
(02) FB11 - HDLICOS
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4
HDLICEN
FB11
code one
Does (FACILITY) (still have/have any) beds that are [not certified by (Medicaid and Medicare/Medicare/Medicaid)
but are] licensed as nursing (facility/home) beds by the (STATE) State Health Department or by some other State
or Federal 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
HDLICOS
FB11
verbatim
OTHER AGENCY (SPECIFY)
(01) [Continuous answer.]
(01) FB14 - PCHLICEN
Is (FACILITY) (still) licensed as a personal care home, board and care home, assisted living facility, domiciliary
care home or rest home by the (STATE) State Health Department or by some other state or local government
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 FB4A
(01) BOX FB4A
(02) FB14 - PCHLICOS
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4
(01) [Continuous answer.]
(01) BOX FB4A
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FB15 - MEDISUPR
(01) FB15 - MEDISUPR
(-8) FB15 - MEDISUPR
(-9) FB15 - MEDISUPR
PCHLICEN
FB14
code one
PCHLICOS
FB14
verbatim
OTHER AGENCY (SPECIFY)
BOX FB4A
routing
IF CCN= MISSING, DK, RF, NF GO TO FB15 - NURSCARE
ELSE GO TO BOX FB5.
NURSCARE
FB15
List
MEDISUPR
FB15
List
b. supervision over medications?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FB15 - BATHHELP
(01) FB15 - BATHHELP
(-8) FB15 - BATHHELP
(-9) FB15 - BATHHELP
BATHHELP
FB15
List
c. help with bathing?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FB15 - DRESHELP
(01) FB15 - DRESHELP
(-8) FB15 - DRESHELP
(-9) FB15 - DRESHELP
DRESHELP
FB15
List
d. help with dressing?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FB15 - EATHELP
(01) FB15 - EATHELP
(-8) FB15 - EATHELP
(-9) FB15 - EATHELP
EATHELP
FB15
List
e. help with eating?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX FB5AA
(01) BOX FB5AA
(-8) BOX FB5AA
(-9) BOX FB5AA
BOX FB5AA
routing
IF ANY ITEM IN FB15 = DK OR RF, GO TO FB19 - FACRNAM4.
ELSE GO TO BOX FB5.
BOX FB5
routing
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
FB15A
yes/no
Does (FACILITY) provide 24-hour a day, on-site supervision by an RN or LPN 7 days a week?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX FB8
(01) BOX FB8
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4
CGIVSUP
FB16
yes/no
Does (FACILITY) provide 24-hour a day, on-site supervision by a caregiver 7 days a week?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX FB8
(01) BOX FB8
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4
BOX FB8
routing
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.
BOX FB9
routing
IF PreloadFQ.TOTELBED = DK, RF AND CCN in ('NF', MISSING, DK, RF), GO TO FB18 - TOTELBED.
ELSE IF CCN IN ('NF', MISSING, DK, RF) AND PreloadFQ.TOTELBED<>DK and PreloadFQ.TOTELBED<>REF,
GO TO FB17 - SAMEBEDS.
ELSE GO TO FB27-MIDNTCNT.
In addition to room and board, does (FACILITY) routinely provide…
a. nursing or medical care?
Page 8 of 11
2021 MCBS Facility Instrument
Variable Name
SAMEBEDS
MR Screen Name
FB17
FQ-Facility Questionnaire
Question Type
Yes/No
Question Text/Description
Code List
Routing
I have recorded that (FACILITY) has [PREVIOUS TOTAL # LTC BEDS] beds that provide long-term care. Is this
still the number of beds providing long-term care in (FACILITY)?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) FB18 - TOTELBED
(01) BOX FB11
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) BOX FB11
(-8) FB19 - FACRNAM4
(-9) FB19 - FACRNAM4
(01) [Continuous answer.]
(01) CLOSING6B - FINOTRSB
(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.]
(-8) Don't Know
(-9) Refused
(01) BOX FB14
(-8) BOX FB14
(-9) BOX FB14
(01) BOX FB15
(-8) BOX FB15
(-9) BOX FB15
How many beds does (FACILITY) have that provide long-term care?
TOTELBED
FB18
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.
FACRNAM4
CANDCBED
CAIDBEDS
CAREBEDS
HDLICBED
FB19
Roster
Who would be the best person to answer these questions about (FACILITY)?
SELECT A RESPONSE BELOW OR ADD TO THE PERSON ROSTER.
BOX FB11
routing
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.
FB20
Numeric
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)?
BOX FB12
routing
IF FB2-CAIDCERT = 1/Yes, GO TO FB21 - CAIDBEDS.
ELSE GO TO BOX FB13.
FB21
Numeric
[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)?
BOX FB13
routing
IF FB5-CARECERT = 1/Yes, GO TO FB22 - CAREBEDS.
ELSE, GO TO BOX FB14.
FB22
Numeric
[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)?
BOX FB14
routing
IF FB11-HDLICEN = 1/YesStateHealthAgency or 2/YesOtherAgency, GO TO FB23 - HDLICBED.
ELSE GO TO BOX FB15.
FB23
Numeric
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
BOX FB15
routing
IF FB9-FMRCERT = 1/Yes, GO TO FB24 - FMRBEDS.
ELSE GO TO BOX FB16.
FB24
Numeric
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/IID beds (only)?
BOX FB16
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) BOX FB16
(-8) BOX FB16
(-9) 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, (01) [Continuous answer.]
domiciliary care, or other type of long-term care beds. How many beds are licensed as one of these types of long- (-8) Don't Know
term care (only)?
(-9) Refused
(01) BOX FB17
(-8) BOX FB17
(-9) BOX FB17
BOX FB17
routing
IF CANNOT CALCULATE NUMBER OF REMAINING BEDS, GO TO FB27 - MIDNTCNT.
ELSE GO TO FB26 - FBBEDCOR.
FBBEDCOR
FB26
yes/no
[REVIEW NUMBER OF BEDS BY TYPE.]
FBBEDEX
FB26VB
verbatim
PLEASE ENTER A BRIEF EXPLANATION:
FMRBEDS
PCHBED
So, there are a total of (TOTAL # LTC BEDS) LTC beds in the (facility/home).
(00) NO
(01) YES
(00) FB26VB - FBBEDEX
(01) FB27 - MIDNTCNT
(01) [Continuous answer.]
(01) FB27 - MIDNTCNT
Is that correct?
Page 9 of 11
2021 MCBS Facility Instrument
FQ-Facility Questionnaire
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
Routing
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?
(00) NO
(01) YES
(-8) Don't Know
(00) FR5 - SINGRATE
(01) FR3-HIGHRATE
(-8) FR5 - SINGRATE
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".
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) FR3 - HIGHPER
(-8) FR4-LOWRATE
(-9) BOX FR2
HIGHPER
FR3
code one
HIGH RATE UNIT
(01) DAY
(02) WEEK
(03) MONTH
(91) OTHER
(01) FR4 - LOWRATE
(02) FR4 - LOWRATE
(03) FR4 - LOWRATE
(91) FR3 - HIGHPROS
HIGHPROS
FR3
verbatim
OTHER (SPECIFY)
(01) [Continuous answer.]
(01) FR4 - LOWRATE
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".
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) FR4 - LOWPER
(-8) BOX FR2
(-9) BOX FR2
LOWPER
FR4
code one
LOW RATE UNIT
(01) DAY
(02) WEEK
(03) MONTH
(91) OTHER
(01) BOX FR2
(02) BOX FR2
(03) BOX FR2
(91) FR4 - LOWPEROS
LOPEROS
FR4
verbatim
OTHER (SPECIFY)
(01) [Continuous answer.]
(01) BOX FR2
(01) FR5 - SINGPER
(-8) BOX FR2
(-9) BOX FR2
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".
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
SINGPER
FR5
code one
SINGLE RATE UNIT
(01) DAY
(02) WEEK
(03) MONTH
(91) OTHER
(01) BOX FR2
(02) BOX FR2
(03) BOX FR2
(91) FR5 - SINGPEROS
(01) [Continuous answer.]
(01) BOX FR2
SINGPEROS
FR5
verbatim
OTHER (SPECIFY)
BOX FR2
routing
GO TO CLOSING1 - RETURNAV.
Thank you. Those are all the facility-level questions I have for you at the moment. Next we will move on to questions
about (SP). Someone from my office may call you to verify some of the data I have collected. We appreciate your
help on this important study.
RETURNAV
CLOSING1
code one
THE FACILITY-LEVEL VERIFICATION AND/OR CERTIFICATION STATUS QUESTIONS FOR THIS CASE ARE (01) Continue
COMPLETE FOR THIS ROUND. FACILITY-LEVEL QUESTIONS ABOUT THE FACILITY’S COVID-19 PANDEMIC
EXPERIENCES WILL BE ASKED IN A LATER SECTION.
(01) BOX FACEND
PRESS "1" TO RETURN TO FACILITY NAVIGATION SCREEN.
LEAVINEL
FACLOSE2
code one
LEVINEL2
FBCLOSE2
code one
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.
(01) Continue
(01) BOX FACEND
(01) Continue
(01) BOX FACEND
Page 10 of 11
2021 MCBS Facility Instrument
Variable Name
MR Screen Name
FQ-Facility Questionnaire
Question Type
Question Text/Description
Code List
Routing
(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
FACLOSE5
code one
FINOTRES
CLOSING6
code one
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.
FINOTRSB
CLOSING6B
code one
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.
NOTRESP
FQCLOSE7
code one
BOX FACEND
routing
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 11 of 11
| File Type | application/pdf |
| File Title | Medicare Current Beneficiary Survey Section Specifications for FQ |
| Subject | Medicare beneficiaries, MCBS facility instrument, 2021, Facility Questionnaire, FQ |
| Author | NORC |
| File Modified | 2021-09-16 |
| File Created | 2021-09-09 |