On October 1, 2016, completion of section GG (Functional Abilities and Goals) will be required as part of the admission (Start of SNF PPS Stay) and Discharge assessment (End of SNF PPS Stay) for all traditional Medicare Part A SNF stays. Data from Section GG will be used to calculate the Skilled Nursing Facility Quality Reporting Program (SNF QRP) quality measure (QM) for the percent of residents with an admission and discharge functional assessment and a care plan that addresses function.
Section GG will be used to document the resident’s “usual performance” for days 1-3 of the SNF PPS stay and establish discharge goals for three self-care activities and nine mobility activities, using a new 6-point scale, which is very different from the scale staff are accustomed to for coding functional status in Section G of the MDS. At the end of the SNF PPS stay, discharge performance will be recorded in Section GG by assessing the resident’s “usual performance” during the last 3 days of the stay.
The self-care and mobility items assessed in the new Section GG will include:
• Eating: Ability to use suitable utensils to bring food to the mouth & swallow food once the meal is presented on a table/tray. (This does include tube feeding).
• Oral Hygiene: Ability to use suitable items to clean teeth. For dentures, the ability to remove and replace dentures from and to the mouth & manage equipment for soaking them.
• Toileting Hygiene: Ability to maintain perineal hygiene, adjust clothes before and after using the toilet, commode, bedpan, or urinal.
• Sit to lying: Ability to move from sitting on side of bed to lying flat on bed.
• Lying to sitting on side of bed: Ability to safely move from lying on the back to sitting on the side of the bed with feet flat on the floor and with no back support.
• Sit to stand: Ability to safely come to a standing position from sitting in a chair or on the side of the bed.
• Chair/bed-to-chair transfers: Ability to safely transfer to and from a bed to a chair or wheelchair.
• Toilet transfer: Ability to safely get on and off a toilet or commode.
• Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns. (Not completed if resident does not walk and a walking goal is not clinically indicated)
• Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space. (Not completed if resident does not walk and a walking goal is not clinically indicated)
• Wheel 50 feet with two turns: Once seated in wheelchair/scooter, ability to wheel at least 50 feet and make two turns. (Only completed if resident uses a wheelchair/scooter)
• Wheel 150 feet: Once seated in wheelchair/scooter, ability to wheel at least 150 feet in a corridor or similar space. (Only completed if resident uses a wheelchair/scooter)
The resident’s usual performance on admission and discharge for each self-care and mobility activity will be recorded in Section GG using the following 6-point scale:
• 06, Independent: if the resident completes the activity by him/herself with no assistance from a helper.
• 05, Setup or clean-up assistance: if the helper SETS UP or CLEANS UP; resident completes activity. Helper assists only prior to or following the activity, but not during the activity. For example, the resident requires assistance cutting up food or opening container, or requires setup of hygiene item(s) or assistive device(s).
• 04, Supervision or touching assistance: if the helper provides VERBAL CUES or TOUCHING/ STEADYING assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. For example, the resident requires verbal cueing, coaxing, or general supervision for safety to complete activity; or resident may require only incidental help such as contact guard or steadying assist during the activity.
• 03, Partial/moderate assistance: if the helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.
• 02, Substantial/maximal assistance: if the helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.
• 01, Dependent: if the helper does ALL of the effort. Resident does none of the effort to complete the activity; or the assistance of two or more helpers is required for the resident to complete the activity.
Some key points that facilities must consider prior to the implementation of Section GG on October 1 include:
1. Beginning in October, Section GG reporting will impact the SNF Quality Reporting Function domain, which is one of three SNF QRP QMs (the other QMs are short stay new or worsened pressure ulcer and long stay falls with major injury). For fiscal year 2018 payment determination, CMS will collect data on residents admitted to SNFs Part A stay on or after October 1, 2016 and discharged from SNF Part A stay on or before December 31, 2016. Facilities must have 100% of the data elements required to calculate all three of the new QRP QMs on 80% of their Medicare assessments or they will have their annual payment update reduced by 2%. Measures cannot be calculated where there is use of a dash (-) on the MDS assessment for questions impacting the QM. For Section GG admission and discharge performance, CMS is giving providers additional coding choices instead of using a dash to code why an item was not assessed. These additional coding choices include:
• 07 (resident refused): Used if resident refused to complete the activity
• 09 (not applicable): Used if resident did not perform activity prior to current illness, exacerbation, or injury
• 88 (not attempted due to medical condition or safety concern): Used if activity was not attempted due to medical condition or safety concern
These additional codes only apply to performance and cannot be used for the discharge goal. To calculate the QM for the percent of residents who have their functional status assessed upon admission and discharge and have a care plan addressing function, only one of the 12 self-care or mobility goals must be set per resident stay. It will not exclude the assessment from the calculation of the SNF QRP QMs if dashes are coded for the discharge goal, as long as at least one discharge goal is coded using the six-point scale.
2. Section GG will be completed at the start of a Part A stay on the 5-day PPS assessment and at the end of the Part A stay on the new Part A PPS Discharge assessment for all planned discharges that meet specific requirements. For the 5-Day PPS assessment, the assessment period for Section GG is days 1-3 of the Part A stay and for the PPS Discharge assessment, the assessment period for Section GG is the last three days of the SNF PPS stay. Because of the limited time period for assessing these areas, facilities must begin establishing processes for how they will collect this data and establish care plans for discharge goals within the defined time frames, including what disciplines will participate in collecting the data (ie. Nursing, therapy, or combination of both) and determining how the information will be assessed (ie. Will software vendor have documentation capabilities or does facility need to establish documentation form).
3. Staff will require education on the coding requirements for Section GG and the different levels of assistance included in the 6-point scoring system. This education needs to be completed prior to the implementation of Section GG and facilities should allow ample time for staff to begin practice coding prior to the October 1 implementation date. Failing to proactively prepare for the upcoming changes could result in a payment reduction for FY 2018.
A draft version of the new MDS 3.0 Manual Version 1.14 was released by CMS in May and is available at:
Proactive Medical Review offers specialized clinical risk management consulting services to support the proactive management, prevention, and mitigation of risk through Quality Assurance and Performance Improvement (QAPI) efforts designed to achieve and sustain quality outcomes.
For more information on how Proactive Medical Review can assist you to prepare for SNF Quality Reporting and the upcoming changes to the RAI manual, please contact us at 812-471-7777.