PDPM Coding Question – If someone comes in at a more dependent level, such as 01 – total assist for majority of things, then seems to improve to 02 – max assist on the second day, are we supposed to continue doing GG for the full 3 days?

If someone comes in at a more dependent level, such as 01 – total assist for majority of things, then seems to improve to 02 – max assist on the second day, are we supposed to continue doing GG for the full 3 days?

A:

The RAI Steps for Assessment (pg. GG-10) state that the assessment should be completed during the three-day assessment period – which infers we may not need the entire 3 days to determine usual performance for some residents. Furthermore, the RAI explains, “The admission functional assessment, when possible, should be conducted prior to the resident benefitting from treatment interventions in order to reflect the resident’s true admission baseline functional status. If treatment has started, for example, on the day of admission, a baseline functional status assessment can still be conducted. Treatment should not be withheld in order to conduct the functional assessment.”

When to stop the admission GG assessment will be specific to the individual resident and based on IDT collaboration. For example, using the scenario above, we would need to determine:

1. 1. • Did the resident directly benefit from treatment (i.e., therapy) on day 2 which accounts for the improvement? – If yes, we might no longer assess this item(s) as no longer representative of baseline status; OR
      • Is the resident showing variances in performance due to when and where the item(s) is being assessed and has NOT yet benefitted from direct treatment? – In this case we might continue to assess the item(s) up to and through day 3 or until the resident has benefitted from treatment to gather more information to accurately code usual performance.

Ultimately, we need to ensure we’re assessing appropriately for ‘usual performance’, not the resident’s best or worst performance.