Step-by-Step Coding Guide for Item Set GG0170O1: 12 Steps (Admission Performance)

1. Review of Medical Records

Objective: Evaluate the resident's ability to navigate 12 steps at the time of admission by conducting a comprehensive review of medical records.

• Action Steps: Review physical therapy assessments, nursing documentation, and physician notes that provide insight into the resident's mobility, focusing on their ability to manage stairs. Note any documented use of assistive devices or specific conditions that could impact their stair navigation abilities.

2. Understanding Definitions

• 12 Steps: This item assesses the resident's capability to ascend and descend a series of 12 steps, with or without a rail or assistive device, highlighting their balance, strength, and coordination.
• Admission Performance: Reflects the resident's ability to perform the stair navigation task at the time of admission, establishing a baseline for their mobility status.

3. Coding Instructions

• Code 06 - Independent: The resident completes the task without any assistance, supervision, or verbal cues.
• Code 05 - Set-up or clean-up assistance: The resident requires assistance only in preparing for or concluding the task.
• Code 04 - Supervision or touching assistance: The resident needs verbal encouragement or light steadying support but no physical assistance.
• Code 03 - Partial/moderate assistance: The helper provides less than half the effort needed for the resident to complete the task.
• Code 02 - Substantial/maximal assistance: The helper contributes more than half the effort.
• Code 01 - Dependent: The resident is unable to participate in the task; full assistance is required.
• Code 07 - Resident refused: The resident declines to attempt the task.
• Code 09 - Not applicable: The resident's condition does not allow for performing the task due to functional limitations.
• Code 88 - Not attempted due to medical condition or safety concerns: Health or safety reasons preclude the attempt.

4. Coding Tips

• Use stairs that mimic real-life conditions and ensure the safety of the assessment area.
• Assess with the resident's regular use of an assistive device, documenting its necessity and how it's used.
• Observe the resident's approach, execution, and completion of the task, paying particular attention to their technique and any signs of struggle.

5. Documentation

• Detail the resident's performance in navigating the 12 steps, including any assistance required and the use of assistive devices.
• Describe observations related to the resident's gait, balance, and any difficulties encountered during the task.
• Note improvements or specific challenges compared to previous mobility assessments, if available.

6. Common Errors to Avoid

• Overlooking the need for supervision or verbal guidance as a form of assistance.
• Incorrectly assuming that using an assistive device automatically indicates dependence.
• Failing to fully document the assessment, especially details of how the resident interacts with the steps.

7. Practical Application

• Utilize the assessment outcomes to develop a targeted care plan aimed at improving stair navigation abilities.
• Coordinate with the interdisciplinary team for physical therapy interventions or modifications to living spaces to accommodate the resident's level of stair navigation ability.

The Step-by-Step Coding Guide for item GG0170O1 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.