GG0130I5: Personal Hygiene (OBRA/Interim Performance), Step-by-Step

Step-by-Step Coding Guide for Item Set GG0130I5: Personal Hygiene (OBRA/Interim Performance)

1. Review of Medical Records

• Objective: To accurately assess and code the resident's ability to manage personal hygiene tasks based on their performance during the observation period specified by OBRA.
• Process:
  • Examine nursing and therapy notes detailing the resident's daily routines and assistance required with personal hygiene tasks, including washing face, hands, brushing teeth, and managing grooming.
  • Review assessments from occupational therapists who may have evaluated the resident's functional capacity in performing personal hygiene tasks.
  • Consult with caregiving staff who assist residents with their daily personal care activities for firsthand insights.

2. Understanding Definitions

• Personal Hygiene: Involves activities related to maintaining one’s body cleanliness and appearance. Tasks may include washing the face and hands, brushing teeth, hair grooming, and shaving.

3. Coding Instructions

• Code GG0130I5:
  • 06: Independent - Resident completes the task by themselves without any assistance.
  • 05: Setup or clean-up assistance - Resident completes the task but requires setup or cleaning afterward.
  • 04: Supervision or touching assistance - Resident requires verbal cues or minor physical help.
  • 03: Partial/moderate assistance - Resident does more than half of the effort.
  • 02: Substantial/maximal assistance - Resident does less than half of the effort.
  • 01: Dependent - Helper does all of the task, resident does none of the effort.
• Example: If the resident requires help with setting up toiletries and reminders to wash thoroughly but performs most of the task themselves, code GG0130I5 as '05'.

4. Coding Tips

• Observe the resident performing these tasks over multiple days to ensure consistent and accurate coding.
• Consider the use of adaptive devices or environmental modifications that might influence the level of independence.

5. Documentation

• Required Documentation:
  • Detailed descriptions of the resident’s performance in personal hygiene activities, including the type of assistance needed.
  • Occupational therapy assessment reports if available, highlighting capabilities and limitations related to personal hygiene.
  • Caregiver and nursing notes that corroborate the coding decision with specific observations.
• Documentation should clearly describe the resident’s dependency level and any changes in their ability to perform these tasks.

6. Common Errors to Avoid

• Not considering adaptive tools or environmental aids that could impact the resident's ability to perform hygiene tasks independently.
• Inconsistencies between observed performance and documentation that could lead to inaccuracies in coding.
• Overlooking the resident's potential for variability in performance from day to day.

7. Practical Application

• Scenario: A resident recently underwent shoulder surgery which has temporarily limited their ability to perform some personal hygiene tasks independently. During the assessment period, the resident demonstrates the ability to brush their teeth and comb their hair using adaptive devices. However, they need help to set up these devices and occasionally need physical assistance to complete the task. After observing and documenting these details over several days, the interdisciplinary team agrees to code GG0130I5 as '05', reflecting the setup assistance and occasional physical help the resident requires.

Please note that the information provided in this guide for MDS 3.0 Item set GG0130I5 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.