Q&A: How do we establish section GG goals when a resident is not on therapy’s caseload?

Posted By: Carol Maher, RN-BC, CPC, RAC-MT
Post Date: 11/12/2018

Question: We have a Medicare Part A resident who was readmitted following an acute exacerbation of COPD. Therapy did not pick him up because he was evaluated to be independent. Section GG, therefore, did not have any goals and we received warnings on the Validation Report. If therapy does not pick up a resident, how are we to establish section GG goals?  

Answer: Section GG is not dependent on therapy. Nursing is also responsible for assessing and setting goals. The RAI User’s Manual articulates that GG should be completed by an interdisciplinary approach. On page GG-28, the RAI User’s Manual reviews discharge goals, explaining that goals may be for improvement (higher than the 5-day), the same (maintain function), or decline (lower than the 5-day if the resident has a progressive condition and goals are to slow the decline of function, but decline is expected). If the resident is already independent and not expected to improve or decline, your goal may be to maintain their function in one or more area(s). 

On page GG-28, the RAI User’s Manual reviews discharge goals, explaining that goals may be for improvement (higher than the 5-day), the same (maintain function), or decline (lower than the 5-day if the resident has a progressive condition and goals are to slow the decline of function, but decline is expected).  If the resident is already independent and not expected to improve or decline, your goal may be to maintain their function in one or more area(s).

 


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