MDS Update: Gearing up for Section GG charting

As facilities gear up for the new Minimum Data Set (MDS) section GG, which captures residents’ functional abilities and goals, they must examine how to change their charting workflows and systems in order to meet the new supporting documentation requirements. Not all software vendors have developed and integrated section GG modules into the electronic health record system, which creates a challenge for many providers. However, even after software vendors develop a section GG charting module, determining which staff members should complete the new MDS section items—and when—is still an open question for many facilities. In order to prepare for the October 1 start date, facility leaders need to decide who will complete each section and which portions, if any, can be auto-filtered with software.

The new section GG, column 1, asks the assessor to determine the resident’s “usual performance” during the resident’s first and last three days of a Medicare stay for eating, oral hygiene, toileting, and mobility. According to the draft copy of the RAI User’s Manual v1.14, released in June, information to code section GG can come from “direct observation, the resident’s self-report, family reports, and direct care staff reports documented in the resident’s medical record during the three-day assessment period, which is days 1 through 3, starting with the date in A2400B, Start of most recent Medicare stay.” The ability of the MDS coordinator or therapist to accurately complete this section of the MDS will be greatly enhanced if nursing assistants are able to chart the care they provide to the resident in the above-mentioned activities of daily living (ADLs).

As staff begin to complete both sections G and GG, the potential for confusion in scoring is a grave concern for many facility managers. The scoring methodology for section GG includes a six-point scale: Independent (6), Setup or clean-up assistance (5), Supervision or touching assistance (4), Partial/moderate assistance (3), Substantial/maximal assistance (2), and Dependent (1). This new scoring scale is the reverse of the scale in section G. For example, in section GG, Dependent is scored as a 1; in section G, Total dependence is scored as a 4.

Assessing charting competency

Is it feasible or advantageous to train nursing assistants to score residents for ADLs based on the new six-point scale? That depends. Facility management needs to assess nursing assistants’ competency to chart effectively. A variety of challenges may prevent accurate charting by nursing assistants:

• Nursing assistants may not understand the ADL charting questions due to a lack of knowledge of the definitions and what is included in each item.
• Charting might be done at the beginning of the shift before care is completed.
• Charting might be done at the end of the shift but may not capture all the activities that occurred during the shift.

Licensed nursing staff and therapists also should be involved as much as possible in the charting process and determination of the section GG scoring. All those tasked with charting will need training and clear instructions on their role in the process.

Preparing staff for section GG is a tall order, particularly if software vendors don’t have the modules developed in time for facility staff training or if the final software module is not as user-friendly as staff members need. Many years went into developing the MDS section G software charting systems, which include pictures of each item being completed, cueing the nursing assistant to chart the appropriate level of care provided. Since section GG is so new, facility staff should take a good look at how the software module displays the charting items and be sure that it meets their needs.

Preparation tips

These ongoing problems won’t magically go away when staff begin capturing section GG information on October 1, 2016. Developing a comprehensive project plan to get facility staff ready is essential. Consider including the following steps in your preparations:

• Determine if and when the software vendor will open a section GG charting module.
• Review and test the module to see if it is user-friendly and has clear charting instructions.
• If the electronic health record system won’t support section GG charting, consider implementing a paper-based charting tool.
• Designate and train charting super-users to assist others assigned to charting roles.
• Decide which staff role will complete the charting (e.g. nursing assistant, nurse, MDS nurse, or therapist).
• Consider having nursing assistants chart their episodes of care during the look-back periods for later use, when the MDS assessor (the MDS nurse or therapist) determines the “usual performance” that will go on the MDS.
• Determine how the licensed nurse and therapist will collaborate to code the discharge goal for the resident required in section GG, column 2.
• Conduct staff training well in advance of the October 1 implementation deadline.
• Work with the software vendor to allow system testing and integration testing (and make sure that it works well before October 1).
• Ensure that the workflow developed to complete section GG is a collaborative process between nursing and therapy.

Change is never easy. Adopting new charting and assessment processes to meet section GG requirements will be a challenge. Taking time now to map out the workflows from beginning to end will set the facility up for greater success come October 1. To help with this transition, remind your staff of the big why. Section GG establishes a resident functional baseline, determines goals for improvement, and then assesses whether the resident has met those goals. Tracking improvement in resident condition will allow you to let everyone know about the great care your facility provides.

Judi Kulus is Vice President of Curriculum Development at the Amwerican Association of Nurse Assessment Coordination  (AANAC).

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