Q:

Is it correct that CNA’s are not allowed to complete section GG? Is it possible to have CNAs submit documentation to an RN who then completes the assessment for GG?

A:

As per the RAI – assess the resident’s self-care and mobility performance based on direct observation, incorporating resident self-reports and reports from qualified clinicians, care staff, or family documented in the medical record during the three-day assessment period. As CNA’s are “care staff”, their reports should be incorporated into the assessment process. The RAI defines a “qualified clinician” as – Healthcare professionals practicing within their scope of practice and consistent with Federal, State, and local law and regulations. (See Chapter 3, GG-10). https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual

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Blog by Eleisha Wilkes, RN, RAC-CT, RAC-CTA, Proactive Medical Review

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