Hello. My name is Terri Mota. I am a nurse consultant with the Quality
Measurement & Value-Based Incentives Group within the Division of
Chronic and Post-Acute Care at the Centers for Medicare & Medicaid
Services. I am pleased to be able to provide you with this training
regarding Section GG of the Minimum Data Set, Version 3.0 (or MDS 3.0).
Section GG, Functional Abilities and Goals, is effective beginning
October 1st 2016. This training is intended to provide nursing home
staff with an overview of this very important section.
This training has been produced in four sections so that you are able to
view it in multiple sittings if that fits into your schedule better than
viewing it in its entirety.
When coding Section GG items, be sure to use the Resident Assessment
Instrument (or RAI) User's Manual and, if you have any questions, you
can contact your State RAI Coordinator to help you. You can locate your
State RAI Coordinator's name and contact information in Appendix B of
the RAI User's Manual. Here are our objectives for this training. It is
my hope that upon completion of the training, participants will be able
to: Describe the intent of Section GG, Define the look-back period for
each item, Explain the rationale for each item, Discuss the steps for
assessment for each item, and Accurately code Section GG scenarios.
Let's begin by answering the question "why are these items important?"
The Improving Medicare Post-Acute Care Transformation Act of 2014 (or
IMPACT Act of 2014) requires that CMS implement cross-setting quality
measures, and as many of you know, as part of the Skilled Nursing
Facility Quality Reporting Program (or SNF QRP), CMS has adopted an
application of the Long-Term Care Hospital process measure, titled
Application of Percent of Long-Term Care Hospital Patients with an
Admission and Discharge Functional Assessment and a Care Plan that
Addresses Function (NQF #2631). The items in this section are used to
calculate that quality measure. Section GG assesses a resident's need
for assistance with self-care and mobility activities.
The items focus on resident's self-care and mobility skills at specific
times in their SNF stay and on their discharge goals related to these
areas. The time frames associated with this section are really important
to understand, so I'll reinforce this as we go through the items
themselves. We're trying to get an understanding of the resident's
status at admission, which is a baseline assessment that reflects the
resident's usual performance at the time of admission; their status on
discharge, as well as an understanding of their discharge goals which
are established at the start of the SNF stay and are related to
self-care and mobility performance.
There are several items related to self-care and mobility that will be
assessed on admission to and discharge from the SNF. I will be covering
those items together, and the examples that I provide could be examples
related to admission or could be related to discharge. The coding to
reflect the resident's performance is the same for these two points in
time. The other group of items in Section GG relate to discharge goals.
The resident's discharge goals are coded on admission to the SNF and are
part of the treatment plan while the resident is in the SNF. CMS has
received questions about who can assess various items on the MDS 3.0.
CMS does not require specific staff to complete particular portions of
the RAI - rather, facility staff is advised to refer to facility,
Federal, and State policies and procedures to determine which SNF staff
members may complete an assessment. Resident assessments are to be done
in compliance with facility, Federal, and State requirements and may
relate to professional scope of practice. Physical therapists,
occupational therapists, speech language pathologists, and nurses are
the typical staff involved in the assessment of self-care and mobility
items. With Section GG, assessors are introduced to a new term: helper.
While the term helper is new, the definition of it will likely look
familiar to you as it is consistent with the definition of facility
staff in Section G of the MDS 3.0.
For the purposes of completing Section GG, a "helper" is defined as
facility staff who are direct employees or facility-contracted employees
- for example, rehabilitation staff, and nursing agency staff). Thus, it
does not include individuals hired, compensated or not, by individuals
outside of the facility's management and administration such as hospice
staff, nursing students or certified nursing assistant students, etc.
Therefore, when helper assistance is required because a resident's
performance is unsafe or of poor quality, only consider facility staff
when scoring the amount of assistance provided. The items in GG0130:
Self-Care are first completed on Admission or the start of the SNF PPS
Stay. You will note that there are two columns on this portion of the
item set. In Column 1, admission performance is documented and Column 2
captures the resident's discharge goal. The assessment period for the
admission performance is day one through day three of the SNF PPS Stay,
starting with the date in A2400B, which is the Start Date of the Most
Recent Medicare Stay. There are also GG0130: Self-Care items captured on
Discharge in order to reflect the resident's status at the end of SNF
PPS stay. The assessment period for these items is the last 3 days of
the SNF PPS stay ending on the date in A2400C, which is the End Date of
the Most Recent Medicare Stay. GG0130 is important because during a
Medicare Part A SNF stay, residents may have self-care limitations on
admission. In addition, residents may be at risk of further functional
decline during their stay in the SNF. Understanding the resident's
status on admission allows for individualized care planning aimed at
meeting self-care and mobility goals. There are several steps for
assessment associated with GG0130. Assessors should assess the
resident's self-care status based on direct observation, the resident's
self-report, family reports, and direct care staff reports documented in
the resident's medical record during the 3-day assessment period, which
again is days 1 through 3, starting with the date in A2400B, the Start
of the Most Recent Medicare stay.
Because promoting residents' ability to meet or maintain their highest
practicable level of functioning should be the goal of care, residents
should be allowed to perform activities as independently as possible, as
long as they are safe.
Just a few moments ago I defined a helper for the purposes of completing
Section GG - remember, when helper assistance is required because a
resident's performance is unsafe or of poor quality, only consider
facility staff when scoring the amount of assistance provided. So, for
example, if you are coding eating for a resident who has a swallowing
problem, and the person could theoretically eat, but it would be unsafe
because he eats quickly, and has a swallowing problem, you'd be very
concerned about him aspirating. To ensure he is safe, a staff person
actually sits with him, provides direct supervision and cues him to slow
down - this is the helper. However, if the resident's daughter is in to
visit each day at lunch and supper, any assistance she provides for the
resident while he eats and drinks is not considered when scoring this
item. Activities may be completed with or without assistive device(s).
If the person uses a device, then the person should be assessed using
that device. Use of assistive device(s) to complete an activity should
not affect coding of the activity.
Residents should be coded performing activities based on their "usual
performance," or baseline performance, which is identified as the
resident's usual activity or performance for any of the self-care or
mobility activities, not the most independent or dependent performance
over the assessment period. Therefore, if there's fluctuation in the
performance of activities during the three-day assessment, the
performance wouldn't be the worst, and it wouldn't be the best, but it
would be what's "usual" for that individual. The items in GG0130 are
assessed at admission, but are assessed again at discharge. They are
completed on admission only if A0310B is coded 01 indicating that the
assessment is a PPS 5-Day assessment or on discharge if A0310G and
A0310H are both coded 1, indicating that the assessment refers to a
planned, Part A PPS Discharge.
Let's now turn to the code responses used in item GG0130. The code
responses used in this item are exactly the same for admission and
discharge. There is a six-point scale used to code the self-care items,
starting with Code 06 which refers to when a resident is independent.
The code of independent would be used when the resident completes the
activity by him or herself with no assistance from a helper. And no
assistance means, no supervision, no cueing, and no physical help.
Code 05 is used when the resident requires only set-up or clean-up
assistance. Setup or clean-up assistance means that the resident
completes the activity; the helper assists only with setting up for or
cleaning up from the activity, but doesn't actually help with the
activity. An example for the item Eating might be that the helper opens
drink containers and cuts meat for a resident but, after that's done,
the helper can leave and then the resident is able to eat by herself.
Code 04 indicates that the resident requires supervision or touching
assistance. Code 04 is defined as the helper provides verbal cueing,
touching, or steadying assistance as the resident completes the
activity. Assistance may be provided throughout the activity, or
intermittently.
Code 03, which is used when "partial or moderate assistance" is required
to complete the activity, indicating that the helper is providing some
physical lifting assistance. What this means is that the helper does
less than half of the effort and the resident is doing more than half of
the effort to complete the activity. The helper lifts, holds, or
supports the trunk or limb but provides less than half of the effort to
do so.
Code 02 is coded when the resident requires substantial or maximal
assistance and the helper does more than half of the effort. This code
indicates that the helper needs to assist the resident by lifting or
holding the trunk or limbs, and provides more than half of the effort to
do so. Code 1 is "dependent" and this code indicates that the helper
does all the effort and the resident is unable to assist in completing
the activity, or the assistance of two or more helpers is required in
order for the activity to occur. There is significant staff assistance
required if there are two or more staff assisting the resident so this
is always coded as Code 1. An example of this is that one helper is
physically helping a resident walk and the second helper is pushing a
wheelchair close behind while the resident walks. In this case, two
helpers are needed, and it would be appropriate to use Code 1.
We recognize that some residents may be too ill, or in some cases, may
refuse to do an activity, or it may be that some items are not
applicable. Therefore, there are three codes to report that type of
information. The first Code is 07, resident refused. And this is used if
the resident refuses to do the activity. This potentially could be used
in the mobility items, perhaps related to walking if the resident
doesn't want to get out of bed during the assessment period.
Code 09 is not applicable, and that is reported if the resident did not
perform the activity prior to the current illness, exacerbation, or
injury.
Code 88 will probably be the most frequently used of these codes in the
SNF setting. This code is used to indicate that the activity was not
attempted due to the medical condition of the resident, or for safety
concerns. An example of this in the area of self-care would be if there
is a resident with a very severe swallowing problem, who receives all of
his or her nutrition via a gastrostomy or G-tube; in this case, eating
would be coded as 88. In this example, eating by mouth did not occur,
and the definition of eating is very specifically focused on eating by
mouth. So administration of G-tube feeding would not count as eating in
Section GG, and if the person does not eat by mouth, this would be coded
as 88. In order to code Section GG, the assessor would be reviewing the
documentation in the medical record. They would also likely talk to
direct care staff if the information, needs to be clarified. Asking
probing questions will help the assessor to clarify the performance of
the resident. Here are some example questions that the assessor can
consider when scoring the self-care items: Does the resident need
assistance, such as physical help, verbal or non-verbal cueing, or help,
with setup/clean-up to complete the self-care activity? If no, Code 06,
Independent If yes, continue by asking: Does the resident need only
setup or clean-up assistance? If yes, Code 05, Setup or clean-up If no,
continue on with the following questions. Does the resident need only
verbal/non-verbal cueing, or steadying/touching assistance? If yes, Code
04, Supervision or touching assistance If no, ask if the resident needs
lifting assistance or trunk support with the helper providing less than
half of the effort? If yes, Code 03, Partial/moderate assistance If no
continue with the next question. Does the resident need lifting
assistance or trunk support with the helper providing more than half of
the effort? If yes, Code 02, Substantial/maximal assistance If no, ask
if the helper provides all of the effort to complete the activity OR if
the assistance of two or more helpers is required? If yes, Code 01,
Dependent If the activity was not attempted, asking direct caregivers
probing questions will help the assessor to determine why. Ask if the
resident refused to complete the activity, if so, Code 07. If the
resident did not perform this activity prior to the current illness,
exacerbation, or injury Code 09, Not applicable. And if the activity was
not attempted due to medical condition or safety concerns, code 88.
Asking specific probing questions such as these will help you determine
the appropriate level of performance to code for the resident for each
item in Section GG.
This is the end of segment one of the training. With segment two, I will
pick up with coding tips for Section GG.