Current through Register Vol. 46, No. 39, September 25, 2024
(a) Each agency
operating a specialty hospital shall have a utilization review committee and a
written utilization review plan for evaluation of the need for services
provided to individuals. The utilization review committee and the utilization
review plan shall comply with the following minimum requirements:
(1) Committee composition.
(i) The utilization review committee shall be
composed of professionals (as defined in section
680.13 of
this Part), including at least:
(a) two
physicians;
(b) other professional
staff (as described in section
680.13) who
are representatives of the disciplines in the specialty hospital.
(ii) No member of the utilization
review committee shall participate in the committee's deliberations regarding
any individual he or she is treating directly.
(iii) No member of the utilization review
committee shall participate in the committee's deliberations if they have a
financial interest in any hospital.
(2) Utilization review plan.
(i) Each agency must have a separate written
utilization review plan approved by the medical staff, administrator and the
governing body, and the OPWDD.
(ii)
The OPWDD is responsible for reviewing each agency's plan and certifying to the
appropriate State and Federal agencies that the plan meets all regulatory
requirements.
(iii) The utilization
review plans must provide that each recipient's record includes information
needed for the utilization review committee to perform the required utilization
review.
(iv) The utilization review
committee shall assure confidentiality with respect to clients and physicians
in its minutes and in its reports. Clients will be identified by medical chart
number and physicians by physician employee number.
(v) The utilization review plan shall require
the utilization review committee to perform the following reviews:
(a) An admission review within three days of
admission to ensure that any person admitted to the facility meets the
admission criteria and that the facility services are at the appropriate level
of care for the individual.
(b) A
continued stay review within 30 days of admission and every six months
subsequent to the date of admission, to ensure that the individual meets the
criteria for continued stay and that the facility's services are meeting the
individual's needs.
(b) There shall be at least a semiannual
independent utilization review and an annual independent professional review of
the individual at the specialty hospital performed by professionally qualified
persons selected and funded by OPWDD.
(c) Each specialty hospital facility shall
provide the information required for these reviews, on forms and in the format
prescribed by OPWDD.
(d) In
addition to the internal utilization review required in this section, there
shall be at least a semiannual independent utilization review and an annual
independent professional review of the population. More frequent reviews may be
performed as determined by OPWDD. Such reviews will be performed by
professionally qualified persons selected and funded by OPWDD. Each specialty
hospital shall provide information required by these reviews, on the forms and
in the manner prescribed by OPWDD.
(e) In addition to the requirements for
admission and continued stay reviews, the specialty hospital's utilization
review plan shall describe the methods the utilization review committee uses to
select and conduct health and habilitation care evaluation studies. The purpose
of such studies shall be to promote the most effective and efficient use of the
specialty hospital's facilities and services consistent with individual needs
and professionally recognized standards of health and habilitation care. Such
studies shall emphasize identification and analysis of patterns of care and
shall recommend appropriate changes that will maintain consistently high
quality care along with effective and efficient use of services.
(1) The health and habilitation care
evaluation plan shall outline the utilization review committee's determination
of the methods to be used in selecting and conducting the evaluation studies in
the hospital.
(2) Each health and
habilitation care evaluation study shall document:
(i) its results;
(ii) an analysis of the results;
(iii) how the results have been used to make
changes to improve the quality of care and promote more effective and efficient
use of the specialty hospital's facilities and services;
(iv) the action taken as needed to correct or
investigate further any deficiencies or problems in the review process for
admission or continued stay; and
(v) its recommendations for more effective
and efficient specialty hospital care procedures.
(3) Each health and habilitation care
evaluation shall:
(i) identify and analyze the
health, habilitation or administrative factors related to the specialty
hospital's care; and
(ii) include
an analysis of at least the following:
(a)
admissions;
(b) durations of
stay;
(c) ancillary services
provided, including but not limited to drugs and biologicals;
(d) professional services performed in the
specialty hospital; and
(e) if
indicated, contain recommendations for changes beneficial to individuals,
staff, the specialty hospital and the community.
(4) Data that the utilization
review committee uses to perform the evaluation studies shall be obtained from
one or more of the following sources:
(i)
individual records, both program and medical, or other appropriate specialty
hospital data;
(ii) external
organizations that compile statistics, design profiles, and produce other
comparative data; and
(iii)
cooperative endeavors with:
(a) professional
standard review organization;
(b)
fiscal agents;
(c) other service
providers; or
(d) other appropriate
agencies.
(5)
The specialty hospital shall have at least one health and habilitation care
evaluation study in progress at any given time and shall complete one study
each calendar year.
