As PDPM implementation gets underway, daily coding decisions often lead to questions. This new section of Proactive’s blog will address commonly asked questions. Click here to see all these PDPM Coding Questions blogs.

Q:

Does GG have to be completed daily for 3 days? Would it be sufficient to only have it as part of our nursing admission assessment and therapy evaluation by day 3 and then nursing/MDS document a collaborative review of these assessments in writing?

A:

There is no specific requirement that the GG items need to be assessed by every party, every day. For example, therapy may have data at eval day 1 and nursing may have for day shift day 2-3 and night shift day 3 and we would determine usual performance from this available information.

I would be hesitant to have a strict “procedure” or system that could potentially limit GG data collection to one day for nursing (admission) and one day for therapy (eval), because the actual assessment period is “during the three-days” to determine the “usual performance” – Observing the resident’s interactions with others in different locations and circumstances…If the resident’s functional status varies, record the resident’s usual ability…(RAI GG-10).

By way of example:

  • Resident 1 has performed sit-to-stand 3 times on day of admission and was dependent each time. There is no variance and is enough to determine “usual”. Therefore I will not need the entire 3 days to assess.
  • Resident 2 has performed sit-to-stand 3 times on day of admission with assistance ranging from partial assist to dependent. I will need to continue to assess for “up to 3 days” to have enough occurrences to determine “usual”.

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Blog by Shelly Maffia, MSN, MBA, RN, LNHA, QCP, CHC, Director of Regulatory Services, Proactive Medical Review

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