Current through Register 1531, September 27, 2024
(A) Facilities
providing Level I or II care shall review the services, quality of care and
utilization of their facilities.
(B) The utilization review process or
activity shall include a review of all or a sample of residents to determine
appropriateness of admissions, duration of stays by level of care, professional
services and other relevant aspects of care and services provided by the
facility.
(C) Utilization review
shall be conducted by one or a combination of the following:
(1) By a utilization review committee, which
is multidisciplinary and consists of at least two physicians or
physician-physician assistant teams or physician-nurse practitioner teams, a
registered nurse and, where feasible, other health professionals.
(2) By a committee or group outside the
facility that may be established by the following on the approval of the
Department:
(a) By a medical
society.
(b) By some or all of the
hospitals and long-term care facilities in the locality.
(c) By other health care facilities in the
locality in conjunction with at least one hospital.
(3) When the above alternatives are not
feasible, by a committee sponsored and organized in such a manner as to be
approved by the Department.
(4) No
member of the utilization review committee shall have a proprietary interest in
the facility.
(D)
Medical Care Evaluation Reviews (Special Studies).
(1) Reviews shall be made on a continuing
basis of all or a sample of residents to determine the quality and necessity of
care and services provided and to promote efficient use of health facilities
and services. Such studies shall be of appropriate type and duration, and at
least one study shall be in progress at all times.
(2) Such studies shall emphasize
identification and analysis of patterns of care and services.
(3) The reviews of professional services
furnished shall include such studies as types of services provided, proper use
of consultation, promptness of initiation of required nursing and related care,
delivery of services and other such studies.
(4) Data and information needed to perform
such studies may be obtained from statistical services, fiscal intermediaries,
the facility's records and other such sources.
(5) Studies and service shall be summarized
and recommendations formulated and presented to the administration and other
appropriate authorities.
(6) An
initial review of resident needs and length of stay by level of care shall be
made at an appropriate interval after admission. This interval shall not be
longer than 30 days following admission for facilities providing Level I or II
care and 90 days following admission for facilities providing Level III care.
Subsequent reviews shall be made periodically at designated intervals
reasonable and consonant with the diagnosis and overall condition of the
resident.
(7) No physician or
physician-physician assistant team or physician-nurse practitioner team shall
have review responsibility for any case in which he or she was professionally
involved.
(8) If physician or
physician-assistant team or physician-nurse practitioner team members of the
committee decide, after opportunity for consultation with the primary care
provider, further stay in a given level of care is not medically necessary,
there shall be prompt notification (within 48 hours) in writing to the
facility, the resident's primary care provider and the resident or his or her
guardian.
(E) To
facilitate review, the utilization review committee shall use the complete
medical record or a summary of the record and shall use such methods as a
utilization review check list and interviews with the primary care provider as
indicated.
(F) The facility shall
have in effect a written plan for utilization review that applies to all
residents in the facility.
(1) The plan shall
be approved by the governing body.
(2) The development of the plan shall be a
responsibility of the medical staff and the administration.
(3) A written plan for utilization review
activities shall include:
(a) The
organization, objectives and composition of the committee(s) responsible for
utilization review;
(b) Frequency
of meetings;
(c) The type and
content of records to be kept;
(d)
Description of the method to be used in selecting cases for special
studies;
(e) A description of the
method utilized to determine periodic reviews;
(f) Procedures to be followed for preparing
committee reports and recommendations including their dissemination and
implementation.
(G)
Administrative
Responsibilities.
(1) The
administration shall provide support and assistance to the utilization review
committee.
(2) The administration
shall act appropriately upon recommendations made by the utilization review
committee.
(H) Records,
reports and minutes shall be kept of the activities of the utilization review
committee, and they shall be complete, accurate, current and available within
the facility.
(1) The minutes of each meeting
shall include:
(a) A summary of the number and
types of cases reviewed and findings.
(b) Committee actions and recommendations on
extended stay cases and other types of cases.
(c) Interim reports, final conclusions and
recommendations resulting from medical care evaluation reviews (special
studies).
(2) Reports
shall regularly be made by the committee to the medical staff (if any), the
administration and the governing body. Information and reports shall be
submitted to the Department upon request.
