Current through Register Vol. 46, No. 39, September 25, 2024
(a) Each residential treatment
facility shall have an organized utilization review program designed to monitor the
appropriateness of continued stay and to identify the overutilization or
underutilization of services.
(b) Each
residential treatment facility shall prepare a written utilization review plan
designed to ensure that there will be an ongoing utilization review program. This
utilization review plan shall be subject to approval by the Office of Mental Health.
The written utilization review plan shall address at a minimum:
(1) the establishment of a utilization review
committee that shall be composed of at least three members of the clinical staff who
meet the qualifications provided in section 584.10(d) of this Part, at least two of
whom shall be physicians. The utilization review committee shall include at least
one physician who is knowledgeable in the diagnosis and treatment of mental
illness;
(2) the operating procedures of
the utilization review committee, including convening meetings as often as necessary
to execute its functions, but in no event less often than quarterly; maintaining
written minutes of meetings; and submitting reports to the director. Utilization
review committee members who are directly involved in the care of a resident whose
care is being reviewed shall be excluded from the committee's
deliberations;
(3) the integration of
the utilization review program into the quality assurance program provided for in
section 584.17 of this Part.
(c) The utilization review committee shall review
each resident's continued stay in accordance with the following requirements:
(1) An initial continued stay review shall be
completed by the utilization review committee or commissioner's designee no later
than 30 days after admission.
(2)
Subsequent continued stay reviews shall be completed by the utilization review
committee or commissioner's designee 90 days after the initial continued stay review
and every 90 days thereafter.
(3) Review
of each alternate care determination by the utilization review committee or a
subcommittee of the utilization review committee which includes at least one
physician.
(4) Notification of the
physician on the resident's interdisciplinary treatment team of an alternative
determination. Additional information provided by such physician shall be considered
by the utilization review committee that includes at least two physicians.
(5) Notification of the director of final adverse
decisions.
