CMS-P-0015A Questionaire Missing Data

2022 MCBS Facility Instrument

Variable Name

FQM-Facility Questionnaire Missing Data

MR Screen Name Question Type

Question Text/Description

Code List

Routing

(01) CONTINUE

(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

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.

FQMISSNG

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.
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.

I need to verify that our information about you is correct.

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.

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

Is (FACILITY) the exact name of this (facility/home)?

MSFADDR

FQM2A

Yes/No

ADDRESS

FQM2B

Address

ADDRCITY

FQM2B

Address

CITY

(01) [Continuous answer]

(01) FQM2B - ADDRSTAT

ADDRSTAT

FQM2B

Address

STATE

(01) [Continuous answer]

(01) FQM2B - ADDRZIP

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

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

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

MSMADDR

FQM2C

MAILADDR

FQM2D

Text

MAILCITY

FQM2D

Text

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?

What is the correct address for your office?
ADDRESS

CITY

Page 1 of 4

2022 MCBS Facility Instrument

Variable Name

FQM-Facility Questionnaire Missing Data

MR Screen Name Question Type

Question Text/Description

Code List

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

MAILSTAT

FQM2D

Text

STATE

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

MAILZIP

FQM2D

Text

ZIP

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

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

routing

IF (FQ3 - FADMNOK = DK OR RF) AND (FQM3A - MSFADMN = DK, EMPTY, OR NULL), GO TO FQM3A MSFADMN.
ELSE GO TO BOX FQM4.
(00) FQM3B - FACRNAMM
(01) BOX FQM4
(-8) BOX FQM4
(-9) BOX FQM4

BOX FQM3

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

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.

(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

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

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

MSFPHON

FQM4A

Yes/No

ADDRAREA

FQM4B

Numeric

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

2022 MCBS Facility Instrument

Variable Name

FQM-Facility Questionnaire Missing Data

MR Screen Name Question Type

Question Text/Description

Code List

Routing

MSPLACTY

FQM5A

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
PRESS F1 FOR PLACE DEFINITIONS.
(13) HOME OFFICE OR MANAGEMENT OFFICE FOR A
CHAIN OR GROUP OF OFF-SITE NURSING
IF RESPONDENT REPORTS CCRC OR RETIREMENT COMMUNITY, PROBE FOR TYPE OF PLACE FOR UNIT
FACILITIES
WHERE SP RESIDES. DO NOT ENTER "OTHER".
(15) MENTAL HEALTH CENTER/PSYCHIATRIC
SETTING
(16) INSTITUTION FOR THE INTELLECTUALLY
DISABLED/DEVELOPMENTALLY DISABLED
(17) REHABILITATION FACILITY
(91) OTHER
(-9) Refused

(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

MSPLTPOS

FQM5A

text

OTHER (SPECIFY)

(01) [Continuous answer]

(01) BOX FQM6

[PROBE: Do not count "independent living" beds or those that don’t provide 24-hour a day assistance or supervision (01) [Continuous answer.]
with daily living activities.]
(-8) Don't Know
(-9) Refused
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.

(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

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

FQM7A

Yes/No

BOX FQM8

routing

FQM8A

BOX FQM9

IF R MENTIONS:
-ICF (INTERMEDIATE CARE FACILITY), NOTE IN COMMENTS AND ENTER 1.
ICF/IID (INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES), NOTE IN
COMMENTS AND ENTER 0.

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

(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

IF (FA14 - CARECRT1 = DK OR RF) AND (FQM8A - MSCAREC1 = DK, EMPTY, OR NULL), GO TO FQM8A MSCAREC1.
ELSE GO TO BOX FQM9.

Yes/No

Is (FACILITY) certified by Medicare as a SNF?

routing

IF (FA15 - CAIDICF = DK OR RF) AND (FQM9A - MSCAIDIC = DK, EMPTY, OR NULL), GO TO FQM9A MSCAIDIC.
ELSE GO TO BOX FQM10.

Page 3 of 4

2022 MCBS Facility Instrument

Variable Name

MSCAIDIC

FQM-Facility Questionnaire Missing Data

MR Screen Name Question Type

FQM9A

BOX FQM10

Question Text/Description

Code List

Routing

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

(00) BOX FQM10
(01) BOX FQM10
(-8) BOX FQM10
(-9) 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.

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

(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?

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

MSHDPLOS

FQM10A

text

OTHER AGENCY (SPECIFY)

(01) [Continuous answer]

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

(00) NO, NOT LICENSED
(01) YES, LICENSED BY STATE HEALTH
Does (FACILITY) have any beds licensed as personal care, board and care, assisted living, or domiciliary care beds DEPARTMENT
by the (STATE) State Health Department or by some other state agency?
(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

BOX FQM11

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