P-0015A COVID-19 Facility-Level Supplement

2022 MCBS Facility Instrument

Variable Name

FC-COVID-19 Facility-Level Supplement

MR Screen Name Question Type

Question Text/Description

Code List

Routing

COVID-19 FACILITY-LEVEL SUPPLEMENT SECTION SPECIFICATIONS
CRITERIA
SAMPLE TYPE= CFR, CFC, FFC, FCF, IPR
SEASON
If SAMPLE TYPE= CFR, then SEASON=FALL
If SAMPLE TYPE in (CFC, FFC, FCF), then SEASON= ALL
If SAMPLE TYPE= IPR, then SEASON= FALL
Administered in flexible order after FQ and RH sections are completed.

PLACEMENT

FC1PRECT

FC1PRE

No Entry

I am now going to ask you some information about (FACILITY)'s experiences during the coronavirus pandemic, also
known as COVID-19 or SARS-CoV-2. Given the impact the coronavirus pandemic has had on facilities, the next
(01) Continue
questions aim to capture the experiences and challenges facilities such as your own have faced due to the
pandemic.

TELSERV

FC39

Yes/No

As of today, are any services provided through telehealth by (FACILITY)?

The next questions ask about telehealth services this facility is currently providing.

[IF NEEDED: Telehealth visits include visits by telephone or video.]

(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED

[As of today] are doctor or other health professional visits outside this facility currently offered through telehealth?
Please include outside visits for both primary and specialty care.

OUTDRTEL

FC40

code one

(00) NO
(01) YES
VISITS SHOULD INCLUDE BOTH PRIMARY AND SPECIALTY CARE. IF SERVICES ARE OFFERED THROUGH
(02) NOT APPLICABLE
TELEHEALTH FOR EITHER PRIMARY OR SPECIALTY CARE OUTSIDE THE FACILITY ANSWER “YES”.
(-8) DON’T KNOW
(-9) REFUSED
[IF NEEDED: “Outside” refers to telehealth visits with off-site primary and specialty care doctors or other health
professionals.]
[As of today] are doctor or other health professional visits inside this facility currently offered through telehealth?
Please include inside visits for both primary and specialty care.

INDRTEL

FC41

code one

TELDENTN

FC42

List

TELMHN

TELPODN

FC42

FC42

List

List

TELEDHBN

FC42

List

TELOTHN

FC42

List

(01) FC39 - TELSERV

(00) FC17 - ACTINTRO
(01) FC40 - OUTDRTEL
(-8) FC17 - ACTINTRO
(-9) FC17 - ACTINTRO

(00) FC41 - INDRTEL
(01) FC41 - INDRTEL
(02) FC41 - INDRTEL
(-8) FC41 - INDRTEL
(-9) FC41 - INDRTEL

(00) NO
(01) YES
VISITS SHOULD INCLUDE BOTH PRIMARY AND SPECIALTY CARE. IF SERVICES ARE OFFERED THROUGH
(02) NOT APPLICABLE
TELEHEALTH FOR EITHER PRIMARY OR SPECIALTY CARE INSIDE THE FACILITY ANSWER “YES”.
(-8) DON’T KNOW
(-9) REFUSED
[IF NEEDED: "Inside” refers to telehealth visits with primary and specialty care doctors or other health professionals
from this facility.]

(00) FC42 - TELDENTN
(01) FC42 - TELDENTN
(02) FC42 - TELDENTN
(-8) FC42 - TELDENTN
(-9) FC42 - TELDENTN

[As of today] which of the following services, both inside and outside this facility, are currently offered through
telehealth?

(00) NO
(01) YES
(02) NOT APPLICABLE
(-8) DON’T KNOW
(-9) REFUSED

(00) FC42- TELMHN
(01) FC42- TELMHN
(02) FC42- TELMHN
(-8) FC42- TELMHN
(-9) FC42- TELMHN

b. Psychiatrist or other mental health professional visits

(00) NO
(01) YES
(02) NOT APPLICABLE
(-8) DON’T KNOW
(-9) REFUSED

(00) FC42 - TELPODN
(01) FC42 - TELPODN
(02) FC42 - TELPODN
(-8) FC42 - TELPODN
(-9) FC42 - TELPODN

c. Podiatrist visits

(00) NO
(01) YES
(02) NOT APPLICABLE
(-8) DON’T KNOW
(-9) REFUSED

(00) FC42 - TELEDHBN
(01) FC42 - TELEDHBN
(02) FC42 - TELEDHBN
(-8) FC42 - TELEDHBN
(-9) FC42 - TELEDHBN

d. Educational or habilitational services

(00) NO
(01) YES
(02) NOT APPLICABLE
(-8) DON’T KNOW
(-9) REFUSED

(00) FC42 - TELOTHN
(01) FC42 - TELOTHN
(02) FC42 - TELOTHN
(-8) FC42 - TELOTHN
(-9) FC42 - TELOTHN

(00) NO
(01) YES
(02) NOT APPLICABLE
(-8) DON’T KNOW
(-9) REFUSED

(00) FC17 - ACTINTRO
(01) FC42-TELOTHNS
(02) FC17 - ACTINTRO
(-8) FC17 - ACTINTRO
(-9) FC17 - ACTINTRO

a. Dental visits

e. Any other types of services
[IF NEEDED: Other types of services inside or outside the facility may include dieticians, nurse practitioners,
physician’s assistants, registered nurses, or social workers.]

Page 1 of 3

2022 MCBS Facility Instrument

FC-COVID-19 Facility-Level Supplement

Variable Name

MR Screen Name Question Type

Question Text/Description

Code List

Routing

TELOTHNS

FC42

verbatim

OTHER (SPECIFY)

(01) [Continuous answer.]

(01) FC17 - ACTINTRO

No Entry

Now I would like to ask you about vaccine policies this facility may have to prevent the spread of the flu and COVID(01) CONTINUE
19.

ACTINTRO

FC17

What is (FACILITY)’s policy about the flu shot for health care personnel?
HCPFLUVC

FC22

code one

READ RESPONSE OPTIONS ALOUD:
• Flu shot is required
• Flu shot is recommended
• Neither
What (is/will be) (FACILITY)’s policy about the COVID-19 vaccine for health care personnel?

HCPCOVVC

FC23

code one

READ RESPONSE OPTIONS ALOUD:
• Vaccine (is/will be) required
• Vaccine (is/will be) recommended
• Neither
• Don't know
What is (FACILITY)’s policy about the flu shot for residents?

RESFLUVC

FC25

code one

READ RESPONSE OPTIONS ALOUD:
• Flu shot is required
• Flu shot is recommended
• Neither
What (is/will be) (FACILITY)’s policy about the COVID-19 vaccine for residents?

RESCOVVC

FC26

code one

PREMHS

FC30

No Entry

READ RESPONSE OPTIONS ALOUD:
• Vaccine (is/will be) required
• Vaccine (is/will be) recommended
• Neither
• Don't know
The next questions are about mental health services.
Does this facility offer…

FACMHITS

FC31

List

a. Individual Therapy Sessions
FOR EACH ITEM INCLUDE SERVICES OFFERED BY THE FACILITY AND/OR COORDINATED BY THE
FACILITY.

(01) HCPFLUVC

(01) VACCINE IS REQUIRED
(02) VACCINE IS RECOMMENDED
(03) NEITHER
(-8) DON’T KNOW
(-9) REFUSED

(01) FC23 - HCPCOVVC
(02) FC23 - HCPCOVVC
(03) FC23 - HCPCOVVC
(-8) FC23 - HCPCOVVC
(-9) FC23 - HCPCOVVC

(01) VACCINE (IS/WILL BE) REQUIRED
(02) VACCINE (IS/WILL BE) RECOMMENDED
(03) NEITHER
(-8) DON’T KNOW
(-9) REFUSED

(01) FC25 - RESFLUVC
(02) FC25 - RESFLUVC
(03) FC25 - RESFLUVC
(-8) FC25 - RESFLUVC
(-9) FC25 - RESFLUVC

(01) VACCINE IS REQUIRED
(02) VACCINE IS RECOMMENDED
(03) NEITHER
(-8) DON’T KNOW
(-9) REFUSED

(01) FC26 -RESCOVVC
(02) FC26 - RESCOVVC
(03) FC26 - RESCOVVC
(-8) FC26 - RESCOVVC
(-9) FC26 - RESCOVVC

(01) VACCINE (IS/WILL BE) REQUIRED
(02) VACCINE (IS/WILL BE) RECOMMENDED
(03) NEITHER
(-8) DON’T KNOW
(-9) REFUSED

(01) FC30 - PREMHS
(02) FC30 - PREMHS
(03) FC30 - PREMHS
(-8) FC30 - PREMHS
(-9) FC30 - PREMHS

(01) CONTINUE

(01) FC31 - FACMHITS

(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED

(00) FC31 - FACMHGTS
(01) FC31 - FACMHGTS
(-8) FC31 - FACMHGTS
(-9) FC31 - FACMHGTS

FACMHGTS

FC31

List

b. Group Therapy Sessions

(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED

(00) FC31 - FACMHSG
(01) FC31 - FACMHSG
(-8) FC31 - FACMHSG
(-9) FC31 - FACMHSG

FACMHSG

FC31

List

c. Support Groups

(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED

(00) FC31 - FACMHAT
(01) FC31 - FACMHAT
(-8) FC31 - FACMHAT
(-9) FC31 - FACMHAT

FACMHAT

FC31

List

d. Art Therapy

(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED

(00) FC31 - FACMHOTH
(01) FC31 - FACMHOTH
(-8) FC31 - FACMHOTH
(-9) FC31 - FACMHOTH

FACMHOTH

FC31

List

e. Any Other Types of Mental Health Services

(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED

(00) FC34 - SOCINTRO
(01) FC34 - SOCINTRO
(-8) FC34 - SOCINTRO
(-9) FC34 - SOCINTRO

SOCINTRO

FC34

No Entry

The next questions are about social and recreational activities.

(01) CONTINUE

(01) FC35 - ACTINFAC

Does this facility provide social and recreational activities within the facility?

(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED

(00) FC36 - ACTOUTFC
(01) FC36 - ACTOUTFC
(-8) FC36 - ACTOUTFC
(-9) FC36 - ACTOUTFC

(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED

(00) FCEND - FCENDCT
(01) FCEND - FCENDCT
(-8) FCEND - FCENDCT
(-9) FCEND - FCENDCT

ACTINFAC

FC35

Yes/No

ACTOUTFC

FC36

Yes/No

Does this facility provide social and recreational activities outside the facility?
“OUTSIDE THE FACILITY” REFERS TO ACTIVITIES THAT OCCUR OFF THE FACILITY PREMISES.

Page 2 of 3

2022 MCBS Facility Instrument

Variable Name
FCENDCT

FC-COVID-19 Facility-Level Supplement

MR Screen Name Question Type

Question Text/Description

Code List

Routing

FCEND

code one

YOU HAVE COMPLETED THE COVID-19 FACILITY-LEVEL SUPPLEMENT SECTION.
PRESS "1" TO RETURN TO NAVIGATION SCREEN.

(01) CONTINUE

(01) BOX FCEND

BOX FCEND

routing

GO TO NAVIGATOR

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