Understanding and Coding MDS 3.0 Item GG0130H3: Putting on/Taking off Footwear (Discharge Performance)

Understanding and Coding MDS 3.0 Item GG0130H3: Putting on/Taking off Footwear (Discharge Performance)

Introduction

Purpose:
MDS Item GG0130H3 assesses a resident’s ability to put on and take off footwear at the time of discharge. This item evaluates the level of assistance required and provides critical information for discharge planning, ensuring that appropriate support is available in the next care setting.

What is MDS Item GG0130H3?

Explanation:
GG0130H3 captures how much assistance a resident needs to put on and remove footwear at discharge. This includes tasks like putting on socks, shoes, or orthotic devices. The goal is to determine the level of independence achieved by the resident at discharge and to identify areas where ongoing support may be needed.

Guidelines for Coding GG0130H3

Coding Instructions:
Code GG0130H3 using the standard six-point scale, reflecting the level of assistance required:

• 06 (Independent): The resident completes the task without any assistance.
• 05 (Setup or clean-up assistance): The resident performs the task independently, but requires someone to set up or retrieve items.
• 04 (Supervision or touching assistance): The resident can perform the task but requires supervision or light touch assistance for safety.
• 03 (Partial/moderate assistance): The resident completes more than half of the task but still requires help.
• 02 (Substantial/maximal assistance): The resident performs less than half of the task, with a helper doing most of the work.
• 01 (Dependent): The resident is completely dependent on the helper for the task.

Example Scenario:
Resident C can put on socks but needs assistance fastening their shoes. In this case, GG0130H3 should be coded as 03 (Partial/moderate assistance) since the resident completes part of the task independently but requires help with the final steps.

Best Practices for Accurate Coding

Documentation:

Record the resident's performance in putting on and taking off footwear during the last three days leading up to discharge. Ensure that observations are consistent and reflect the resident's usual performance during this period.

Communication:

Facilitate effective communication between the interdisciplinary team, including therapists and nursing staff, to ensure that the discharge assessment is accurate and consistent with the resident’s documented progress.

Training:

Ensure that all staff members involved in coding understand how to apply the six-point scale correctly and are trained to assess the resident’s abilities without influencing the resident’s performance.

Conclusion

Summary:
Accurate coding of GG0130H3 ensures that a resident’s discharge plan reflects their true level of independence in dressing activities. By assessing their ability to manage footwear tasks, care teams can tailor post-discharge support to meet individual needs and promote ongoing independence.

Click here to see a detailed Step-by-Step on how to complete this item set.

Reference

Refer to CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024, Chapter 3, Page GG-37, for detailed guidance on coding this item.

Disclaimer

This guide is based on the CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024. 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.