(a) Each
diagnostic and research clinic shall have a utilization review committee and a
written utilization review plan for evaluation of the need for services
provided to persons with developmental disabilities. The same utilization
review plan and the utilization review committee for internal utilization
reviews shall address and review the diagnostic and research clinic's
nonresidential component and its residential unit (i.e., the ICF/DD), so as to
review the person's eligibility for services (resident/nonresident) at this
level of care. The utilization review committee and the utilization review plan
shall comply with the following requirements:
(1) Committee composition.
(i) The utilization review committee shall be
composed of professionals including at least:
(a) one physician;
(b) one person who is a qualified
intellectual disability professional; or
(c) other professional staff representing the
disciplines at the diagnostic and research clinic.
(ii) Additionally, the committee may and is
encouraged to include:
(a) a representative
of the local director of community services; and
(b) representative(s) from other programs
affiliated with the diagnostic and research clinic and/or other programs giving
services to persons being assessed by the clinic.
(iii) No member of the utilization review
committee shall participate in the committee's deliberations regarding any
person he or she is directly treating.
(2) Utilization review plan.
(i) Each diagnostic and research clinic shall
have a separate written utilization review plan approved by the director and/or
governing body, and by the bureau of utilization review of OPWDD.
(ii) The bureau of utilization review shall
be responsible for reviewing each diagnostic and research clinic's plan and
certifying to the appropriate State and Federal agencies that the plan meets
all regulatory requirements.
(iii)
The utilization review committee shall develop a plan for review to indicate at
least:
(a) the criteria for providing each
service;
(b) the methods for
conducting review of admission appropriateness, authorization of specialized
medical and clinical laboratory services, residential services, team planning
conferences, and other optional services; or
(c) the requirements for conducting admission
reviews prior to giving any services, and the requirements for conducting
continued treatment reviews after services authorized at the intake screening
have been delivered, and subsequent treatment reviews after corollary or
supplemental services are given at follow-up visits to the clinic.
(iv) The utilization review plan
shall require the utilization review committee to use the forms and criteria
prescribed by OPWDD in accordance with instructions provided by the
commissioner.
(v) The utilization
review plan shall include requirements for a monthly report submitted to the
commissioner of OPWDD. This report shall:
(a)
summarize the activities of the utilization review committee; and
(b) include a copy of each notice of
alternative care.
(vi)
The utilization review committee shall keep minutes of its meetings
sufficiently detailed to document its decisions and the basis for them so as to
enable auditing by the local commissioner of social services or his or her
designee, by any other authorized person or agency, or by OPWDD.
