GG0130C5: Toileting Hygiene (OBRA/Interim Performance)

1. Review of Medical Records

• Objective: To determine the resident's ability to manage toileting hygiene.
• Process:
  • Nursing Notes: Review daily nursing notes for entries related to the resident's ability to perform toileting hygiene tasks.
  • Therapy Records: Examine occupational and physical therapy records for evaluations and progress notes regarding toileting hygiene.
  • Care Plan: Look at the resident’s care plan for documented goals and interventions related to toileting hygiene.
  • Direct Observation: If possible, conduct or review direct observations of the resident performing toileting hygiene tasks.

2. Understanding Definitions

• Toileting Hygiene: Refers to the ability to maintain perineal hygiene, adjust clothes before and after using the toilet, commode, bedpan, or urinal. This includes managing continence supplies like pads or briefs.
• OBRA/Interim Performance: Performance observed and documented during the OBRA (Omnibus Budget Reconciliation Act) assessment period or interim assessments.

3. Coding Instructions

• Code GG0130C5:
  • 06: Independent - Resident completes the activity by themselves with no assistance.
  • 05: Setup or clean-up assistance - Resident completes the activity but requires setup or clean-up help from another person.
  • 04: Supervision or touching assistance - Resident completes the activity with verbal cues or light touch assistance.
  • 03: Partial/moderate assistance - Resident does more than half of the effort, but helper does less than half.
  • 02: Substantial/maximal assistance - Helper does more than half of the effort.
  • 01: Dependent - Helper does all of the effort.
• Example: If the resident requires setup assistance to adjust their clothing before and after toileting but performs the actual hygiene tasks independently, code GG0130C5 as '05'.

4. Coding Tips

• Consistent Observations: Ensure that observations of the resident’s performance are consistent across different shifts and caregivers.
• Contextual Factors: Consider factors such as the resident's typical performance and any temporary conditions that might affect their abilities (e.g., recent surgery or illness).

5. Documentation

• Required Documentation:
  • Daily Nursing Notes: Detailed notes describing the level of assistance provided during toileting hygiene.
  • Therapy Notes: Progress notes from therapists detailing the resident's ability and any assistance needed.
  • Care Plan: Documented goals and interventions related to improving or maintaining toileting hygiene.
• Example: "During the assessment period from 05/01/2024 to 05/14/2024, the resident required setup assistance for adjusting clothing before and after using the toilet but was able to perform perineal hygiene independently."

6. Common Errors to Avoid

• Overestimating Independence: Avoid coding the resident as more independent than they are by not considering all aspects of the task.
• Inconsistent Documentation: Ensure that all staff are documenting the resident’s performance consistently to avoid discrepancies.
• Ignoring Variability: Consider the resident’s usual performance and not just isolated incidents.

7. Practical Application

• Scenario: A resident typically needs verbal cues to manage clothing before and after toileting and requires light touch assistance for perineal hygiene. This consistent need for assistance is documented by nursing staff and therapists. Therefore, for the assessment period, GG0130C5 is coded as '04'.

Please note that the information provided in this guide for MDS 3.0 Item set GG0130C5  was originally based on the CMS's RAI Version 3.0 Manual, October 2023 edition. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide. This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0. 

The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding. 

Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.