What is the best practice for Section GG documentation?
As with most processes, the provider must determine the process that is most suitable for their facility policy, while also adhering to Federal and State requirements. According to a CMS FAQ Document, CMS does not impose specific documentation procedures, but that qualified clinician(s) will complete the assessment of usual performance based on all available data collected during the assessment period.
An example of a system for collecting resident usual performance data may include but is not limited to the following:
- Direct care staff (e.g., CNA’s) may document their observations of self-care and mobility activities using the facility approved electronic or paper-based form which will then be used in part to form the assessment completed by qualified clinician(s).
- Data may also be collected during an interview with direct care staff by a qualified clinician (e.g., Nurse, MDS nurse, etc.), or during direct observation incorporating resident self-reports and reports from qualified clinicians, direct care staff, or family documented in the resident’s medical record during the assessment period.
- Qualified clinicians may ask probing questions about documentation in order to better understand how the resident did performing a task.
- The restorative nurse may also be uniquely poised to assess and complete resident, family, and staff interviews.
- At the conclusion of the 3-day assessment period, the nurse assessment coordinator will collect documentation from the direct care and therapy staff used to collaborate with the interdisciplinary team.
- Ultimately, assessment of usual performance involves the review of data collection forms and talking with direct care staff from each shift that has cared for the resident to learn what the resident does for themself during each activity as well as the type and level of staff assistance provided.
- As a best practice, the interdisciplinary team will enter a collaborative note in the medical record to clarify variances in performance and provide the rationale for usual performance coding decisions when necessary.
Other key tips:
- Observing the resident’s interactions with others in different locations and circumstances is important for a comprehensive understanding of the resident’s functional status.
- For the admission performance, MDS coding should be based on the patient’s usual performance prior to benefitting from treatment intervention, or prior to the provision of any care by facility staff that would result in more independent performance or coding.
- Keep in mind the importance for each person involved in the Section GG process to be familiar with the definition of each activity, especially considering the vast differences from Section G items.
- IDT collaborative notes are especially helpful when the data collection doesn’t reveal a clear usual performance, but rather a mix of touching, partial, and substantial assistance for a particular activity. A narrative note that provides a rationale for final coding decisions will be extremely helpful in the event of an audit. Additionally, the clinician can provide a narrative to explain situations where not all information collected during the assessment period was used (e.g., the resident benefited from services provided at the start of the Medicare stay). For example, the patient benefits from transfer interventions after Medicare covered day 1 and data collection for that activity is ceased, but for all other activities, the assessor or IDT determines the entire 3 day assessment period is needed to establish the usual performance.
Stacy Baker, OTR/L, CHC, RAC-CT
Director of Audit Services
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