Section GG remains a popular discussion topic among the Nurse Assessment Coordinator (NAC) and other members of the interdisciplinary team (IDT). Many have questioned their own practices and processes, designed to support coding this section of the MDS.
CMS states in its Participant Questions from the Skilled Nursing Facility MDS 3.0 RAI v1.18.11 Guidance Training Program (June 21, 2023 – current as of August 2023) that: While CMS does not impose specific documentation procedures on nursing homes in completing the RAI, documentation that contributes to identification and communication of a resident’s problems, needs, and strengths, that monitors their condition on an on-going basis, and that records treatment and response to treatment, is a matter of good clinical practice and an expectation of trained and licensed health care professionals. As such, nursing home teams can determine the documentation that they feel is necessary to support coding items on the MDS 3.0, including to code the items in GG0130. Self-Care and GG0170. Mobility, according to their facility policy and procedure and in compliance with any Federal and State requirements.
GG items are captured on ALL MDS assessments, including unplanned discharges.
Who documents section GG?
Facilities around the country continue to ask, “Whose responsibility is it to document section GG items for self-care and mobility?” Per the RAI manual:
Assess the resident’s self-care performance based on direct observation, incorporating resident self-reports and reports from qualified clinicians, care staff, or family documented in the resident’s medical record during the assessment period. CMS anticipates that an interdisciplinary team of qualified clinicians is involved in assessing the resident during the assessment period.
The key takeaway is “qualified clinicians” – which the RAI manual defines as “healthcare professionals practicing within their scope of practice and consistent with Federal, State, and local law and regulations.”
Is there a process for GG documentation?
Facilities are looking for guidance on developing an effective process for GG documentation within their organization. Most software/vendors can often assist the facility with software development and creation of specific GG assessments and tools for documentation of GG items.
One potential area of focus is your organization’s software and charting burden.
Have you reviewed the ability to “turn off” Point of Care (POC), where CNAs (Certified Nursing Assistants) document data element items in the software? By “turning off” a POC item in the software, it would no longer be visible for assigned staff to complete for a specific resident. In many software systems, this can be accomplished on a facility level for all residents, and/or on an item-by-item individual level for section GG data elements. Any modifications should involve the Software Champion in the facility and the MDS Coordinator, along with staff who would be impacted by any changes.
Some examples of potential modifications:
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- A resident does not ambulate due to CVA and has left side paralysis, thus uses a WC for locomotion. Is staff charting that the resident does not ambulate, does not pick up an object from a standing position, or cannot go up or down step(s) (Code 9 – Not Applicable)? Could these items be turned off for this resident to reduce the charting burden?
- A resident transfers with a Hoyer, uses a WC for locomotion. Are any of the bed mobility items such as sitting to lying, lying to sitting, and sit to stand coded 9 – Not Applicable? Could these items as well as the items in the prior example be turned off in POC to reduce charting burden?
- Consider the MDS Coordinator and the IDT’s collaboration of documentation indicating the resident’s usual performance during the observation/look-back period. This documentation could likewise include Not Applicable data elements.
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When GG items that are not applicable to a particular resident are removed/turned off, staff POC charting on remaining items may improve and reflect more accurate individual resident needs and abilities. Therefore, when the RAI team reviews what needs to be documented where and by whom, conversations about items that could be “turned off” should be included.
If your software has not made the transition to GG and you are using paper documentation, you should complete a review that answers these same questions.
What Should We Be Doing Now?
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- Identify team members that will be involved in supporting documentation of “Usual Performance” for coding the MDS as determined by the IDT. Examine each resident’s ability to participate in each GG item. Identify residents that may have “not applicable” self-care or mobility performance data items.
- Assign a facility point person for determining when there is a change in the resident’s functional status to review the documentation in the software that pertains to each individualized resident.
- Review your policies, procedures and practices to ensure alignment with steps to assessment and coding instructions of the RAI manual and update as needed. Ensure team members have reviewed the decision tree in the RAI manual.
- Develop a facility process for GG documentation and monitor the process through the facility’s QAA/QAPI.
- Educate the team (as appropriate) regarding steps to assessment and coding tips. One item that is often overlooked is the instruction to code Dependent when two or more assistants are required for a resident to accomplish a GG self-care or mobility task.
- Communicate with the facility’s software vendor consistently regarding practices, updates, and issues.
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Section GG completion continues to be discussed, and questions on how to complete it still arise. Because section GG completion is important to the resident and facility – affecting resident care planning, resident PDPM score, facility SNF QRP (Quality Reporting Program), facility Quality Measures, and facility Five-Star ratings (to name a few) – a solid process to support accurate data capture is imperative.