Step-by-Step Coding Guide for Item Set GG0170M1: 1 STEP (Curb) (Admission Performance)

1. Review of Medical Records

Objective: Assess the resident's ability to navigate a single step or curb at the time of admission.

• Thoroughly review physical therapy evaluations, nursing assessments, and physician's notes for details on the resident's mobility, specifically their ability to manage steps or curbs.
• Document any previous use of assistive devices or accommodations for step navigation.

2. Understanding Definitions

• 1 STEP (Curb): This task assesses the resident's ability to step over a curb or a single step, which can include stepping up or down. This is a crucial aspect of mobility and balance.
• Admission Performance: Represents the resident's capability to perform the task upon admission, offering a baseline for care and therapy planning.

3. Coding Instructions

• Code 06 - Independent: Resident steps over the curb without any assistance, including without the use of handrails or physical support.
• Code 05 - Set-up or clean-up assistance: Resident needs help only before or after the task, such as positioning at the start.
• Code 04 - Supervision or touching assistance: Resident requires verbal cues, supervision, or light touch to maintain balance or direction.
• Code 03 - Partial/moderate assistance: Helper provides less than half the effort.
• Code 02 - Substantial/maximal assistance: Helper provides more than half the effort.
• Code 01 - Dependent: Resident is unable to participate in stepping over the curb; full assistance is needed.
• Code 07 - Resident refused: The task was not attempted due to the resident's refusal.
• Code 09 - Not applicable: The resident's condition prevents them from attempting the task.
• Code 88 - Not attempted due to medical condition or safety concerns: Task not attempted due to health or safety risks.

4. Coding Tips

• Assess in a controlled environment, using a simulation of a curb if the actual curb is not available.
• Ensure the resident is wearing appropriate footwear and using their customary assistive device if applicable.
• Observe and evaluate the entire process, including the approach, step over, and departure from the curb.

5. Documentation

• Clearly document the method of assessment, the resident's performance, and any assistive device used.
• Note observations about the resident's balance, effort, and any verbal cues required.
• Record any comparison to baseline abilities or changes from prior assessments if available.

6. Common Errors to Avoid

• Assuming the use of an assistive device means the resident cannot be considered independent.
• Not recognizing the need for verbal cues or light touch assistance as a form of support.
• Inadequate assessment setup that does not accurately simulate stepping over a curb.

7. Practical Application

• Use assessment results for care planning, including fall prevention strategies and mobility enhancement programs.
• Share findings with the interdisciplinary team to inform therapy goals and discharge planning.

The Step-by-Step Coding Guide for item GG0170M1 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. 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.