Since the implementation of Section GG on the MDS in October 1, 2016, facilities have grappled with best practices on how to gather data for appropriate completion. While many organizations (in our experience) have opted to simply “have therapy complete this section” the updated RAI manual (V1.16) effective October 1, 2018, has implemented new items to this section. Thus, the issue of best practices to gather data for appropriate completion have resurfaced. This article will discuss our interpretation of the updated RAI manual as well as recommended best practices to gather data for appropriate section GG completion.
First, when discussing “steps for assessment,” the RAI manual V1.16 (Chapter three, section GG, page GG-9) discusses “…an interdisciplinary team of qualified clinicians is involved in assessing the resident during the three-day assessment period.” Additionally, this section of the manual discusses having documentation to support coding in the resident’s medical record. Thus, we contend that simply “having therapy complete this section” is not the best practice.
When reviewing individual items on section GG we recognize that there are certain areas that might be observed by nursing as well as therapy staff (e.g. rolling on side, transfers, etc.). However, there are other items where therapy only might have the opportunity to make observations (e.g. walking up and down stairs, picking up objects, walking on uneven surfaces, etc.). Here we recommend a combined approach where nursing might complete portions of section GG, daily for the three day observation (first three days of a PPS stay or last three days of a planned discharge from Medicare Part A). Additionally, while therapy would compete a full section GG on their evaluations, we recommend that the MDS Coordinator ultimately code the entire section GG on the MDS with consideration of the nursing as well as the therapy documentation to determine the resident’s “usual” function over the three day observation.
Specifically, we recommend the following items be completed by therapy only:
- GG0100: Prior functioning: Every day activities
- GG0110: Prior Device Use
- GG0170G: Car transfer
- GG0170I: Walk 10 feet
- GG0170J: Walk 50 feet with two turns
- GG0170K: Walk 150 feet
- GG0170L: Walking 10 feet on uneven surfaces
- GG0170M-O: Walking up and down steps (one step, four steps, 12 steps respectively)
- GG0170P: Picking up object
- GG0170 Q1-SS1: Wheelchair and scooter use
Next, recommended items for daily completion by Nursing (which may be documented on a User Defined Assessment [UDA] in the facility software system) are as follows:
- GG0130A-H: Eating, Oral hygiene, Toileting hygiene, Shower/ bathe self, Upper body dressing, lower body dressing, Putting on/ taking off footwear.
- GG0170A-F: Roll left and right, Sit to lying, Lying to sitting on side of bed, Sit to stand, Chair/ bed-to-chair transfer, and toilet transfer.