GG0130. Self-Care (Assessment period is the first 3 days of the stay)

Step-By-Step Coding Guide for GG0130: Self-Care

Objective: Introduce and explain the significance of GG0130, Self-Care. Key Points:

• GG0130, Self-Care, assesses the resident's ability to perform tasks of daily living such as eating, oral hygiene, toileting hygiene, showering/bathing self, upper body dressing, lower body dressing, and putting on/taking off footwear.
• This section is crucial for developing care plans that address the resident's self-care needs and for tracking changes in ability over time.

Understanding the Components

Objective: Break down the components or levels of GG0130, Self-Care. Key Points:

• Each self-care activity is rated based on the resident's ability and level of independence, ranging from independent (Code 06) to dependent (Code 01), including the use of helper(s) and how much assistance is required.
• Not Attempted Codes, such as Code 07 (resident refused), Code 09 (not applicable), and Code 10 (not attempted due to environmental limitations), are used when the activity was not performed during the assessment period.

The Assessment Process

Objective: Outline the process of assessing and implementing GG0130, Self-Care.

Key Points:

• Perform the assessment during the first 3 days of the resident's stay.
• Observe the resident performing each self-care activity, consult with direct care staff, and review the resident's medical records for information on self-care performance.
• Consider all attempts to perform each activity during the 3-day assessment period.

Coding and Documentation

Objective: Teach accurate coding and documentation for GG0130, Self-Care.

Key Points:

• Code the resident's self-care ability based on the usual performance for each activity during the 3-day assessment period.
• Document any discrepancies, resident refusals, or reasons why an activity was not attempted in the resident's medical record.

Common Errors and Best Practices

Objective: Highlight common errors and provide best practices.

Key Points:

• Common errors include coding based on a single attempt rather than usual performance, overlooking helper assistance, and misinterpreting the coding levels.
• Best practices involve thorough observation over the 3-day period, consulting with interdisciplinary team members, and accurately documenting each self-care activity's assessment.

Practical Applications

Objective: Apply knowledge through practical examples and simulations.

Key Points:

• Engage in role-playing scenarios where staff members simulate assessment situations.
• Use case studies of residents with varying levels of self-care abilities to practice coding.

Resources for Further Learning

Objective: Direct learners to additional resources for deeper understanding.

Key Points:

• CMS's RAI Version 3.0 Manual, especially the latest version for any updates.
• Online resources, webinars, and workshops offered by professional organizations.

Q&A and Interactive Session

Objective: Clarify doubts and answer specific questions.

Interactive Discussion: Engage with participants to address their queries regarding GG0130 coding.

The Step-by-Step Coding Guide for item GG0130 in MDS 3.0 Section GG is based on the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.18.11, dated October 2023. Please note that healthcare guidelines, policies, and regulations can undergo frequent updates. Therefore, healthcare professionals must ensure they are referencing the most current version of the MDS 3.0 manual. This guide aims to assist with understanding and applying the coding procedures as outlined in the referenced manual version. However, in cases where there are updates or changes to the manual after the mentioned date, users should refer to the latest version of the manual for the most accurate and up-to-date information. The guide should not substitute for professional judgment and the consultation of the latest regulatory guidelines in the healthcare field.