​Although keeping it simple is often the easiest and most tempting way to complete a task, sometimes it is not the correct way. To ensure the accuracy of section GG’s self-care and mobility items, interdisciplinary team (IDT) involvement and a process to determine usual performance are essential. It may seem preferable to streamline the process and assign the nurse assessment coordinator or therapist to complete this section, but it will likely lead to an inaccurate result.

The Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual (RAI User’s Manual) specifies that facility staff must: “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. The Centers for Medicare & Medicaid Services [CMS] anticipates that an interdisciplinary team of qualified clinicians is involved in assessing the resident during the assessment period.” (CMS, 2023, p. GG-15)

The four tips described here will help facility teams develop a process to ensure the accuracy of section GG items.

Tip 1: Distinguish between data collection and determination of usual performance.
Section GG requires a qualified clinician to complete the assessment of usual performance. This statement refers to the assessment of section GG for the determination of usual performance rather than the data collection used to make the determination. Documentation of a particular episode of care reflects only what occurred during that episode. It doesn’t require an assessment and may be documented by nurse aides, nurses, therapists, and other IDT members involved in the resident’s care. CMS also does not mandate how this information is documented. Facilities may create their own systems to complete the requirement. 

As noted earlier, the determination of usual performance is considered an assessment and can only be completed by a qualified clinician as defined by state and federal laws. When episode documentation supports observations that the resident performed at the same level during the entire three-day window, the team may only need to state the determination of usual performance in this area. But in situations where fluctuations are observed or the resident may have benefited from services at the start of the Medicare stay, additional documentation may be needed to support the rationale of the coding decisions.

Tip 2: Involve the interdisciplinary team.
To achieve a comprehensive understanding of the resident’s performance, he or she must be observed in different locations and circumstances. Involving the IDT and asking the resident or family about performance helps achieve this goal. Establishing a process to collect and use all this data is essential to code section GG accurately.

The IDT’s participation is also key to establish if the resident benefited from services during the first three days of the Medicare stay on the five-day assessment. To make this determination, the team must identify which services were implemented by the team and if the resident benefited in his or her performance of self-care or mobility items because of these services. 

Tip 3: Don’t rely on only one staff member to complete section GG.
Limiting the data used to determine usual performance to just one discipline or staff member prevents section GG from presenting a holistic view of the resident’s performance during the three-day window. If the facility relies solely on the therapy team to inform section GG, the supporting documentation will only represent a small snapshot of time when the therapist was observing or evaluating the resident. For example, the therapist may observe one meal, although the resident may have received up to nine meals during the window. Likewise, the therapist may have transferred the resident a few times, whereas the direct care staff assisted the resident with multiple transfers on all shifts during the window. 

Yet when the resident is on the therapy caseload, assessments and evaluations made by therapy must be included. How the resident performs during therapy is part of the overall picture of performance during the window. Thus to be accurate, section GG should reflect how the resident usually performed across all shifts. 

Some GG items are more likely to be completed by therapy without nursing involvement; others may not include therapy at all. For example, the resident may only use the stairs in the therapy gym during treatment. If this represents the only occurrence of stair use, it would be used to complete steps/stair items in section GG. Also, therapy may not participate in oral hygiene or bathing the resident. If the nurse aides were the only staff members assigned to these tasks, the information to support section GG must come from them. 

Tip 4: Remember that the clinical judgment of qualified clinicians is part of the process.
How a resident performs self-care and mobility items throughout the day may depend on a variety of factors, as well as the staff involved in the care. The performance may depend on the resident’s overall condition and stamina. He or she may be able to perform tasks in the morning with less assistance than in the afternoon due to the fatigue of the daily activities. Additionally, the resident may perform at a higher level or with less assistance in therapy due to the expertise and techniques of the clinicians. Likewise, the resident may need more assistance with toileting at night than during the day. When the performance of tasks fluctuates, the RAI User’s Manual instructs the assessor to use clinical judgment to determine the usual performance, not the worst or the best performance, but the clinical judgment of qualified clinicians of what constitutes the usual performance. Documentation of this clinical judgment will help support the coding decisions made for section GG.

Conclusion
Coding section GG can be challenging, and any attempts to oversimplify it will likely result in an incomplete evaluation of usual performance and an inaccurate MDS assessment. Following the tips offered here and the steps for assessment listed in the RAI User’s Manual will help the IDT establish a process that assesses self-care and mobility items appropriately and supports the coding decisions for section GG. 

Reference
Centers for Medicare & Medicaid Services (CMS). (2023). Long-term care facility resident assessment instrument 3.0 user’s manual, version 1.18.11.

Jessie McGill, RN, BSN, RAC-MT, RAC-MTA, is curriculum development specialist for the American Association of Post-Acute Care Nursing (AAPACN).