HAR §17-1737-35. Utilization control for ICF-MRs

(a) This section defines the utilization control process which shall be administered in accordance with state and federal regulations to achieve optimal quality control of the utilization of services provided under the state plan. (b) The provisions for the utilization control for ICF-MRs are as follows: (1) A written certification or recertification statement that the client require a specific level of care is required as follows: (A) Admission certification shall be provided by a physician or a nurse practitioner or a clinical nurse specialist who is not an employee of the facility but is working in collaboration with a physician, on admission or not more than sixty days prior to authorization of medicaid payment for the provision of long-term institutional services to the client; (B) A recertification statement shall be provided by a physician or a physician assistant under the supervision of a physician or a nurse practitioner or a clinical nurse specialist who is not an employee of the facility but is working in collaboration with a physician, no more than twelve months following certification and thereafter no more than twelve months intervals until discharge from the ICF-MR; (C) The written certification and recertification statements shall be placed on a form designed either by the facility or the department specifically for certification and recertification documentations, and said form shall be placed in each client's active medical record; and (D) The written certification and recertification statements shall clearly UNOFFICIAL 1737-37 indicate the client's need for a specific level of care, and shall include: (i) A physician's signature or initials clearly identified with the acronym "M.D." for medical doctor, or "D.O." for doctor of osteopathy; (ii) A physician assistant's signature or initials, clearly identified with the acronym "P.A." for physician assistant; (iii) A nurse practitioner's signature or initials, clearly identified with the acronym "R.N.C."or "R.N." whichever is appropriate; or (iv) A clinical nurse specialist's signature or initials clearly identified with the acronym "R.N.M.S." or "R.N.C.S." whichever is appropriate; and (v) The date of certification or recertification statement is signed or initialed by a physician or a physician assistant or a nurse practitioner or a clinical nurse specialist; (2) The facility shall have in effect a written utilization review plan approved by the department which shall include the following methods and procedures: (A) Use of cross reference file numbers in all UR related documentation to assure the anonymity of the medicaid client; (B) Identification of the administrative entity and sub-group of the entity responsible for the performance of UR and the medical staff of a medical institution; (C) Development and selection and adoption of forms utilized for the UR process; (D) Review of documentation necessary to verify justification for continued stay cases. The information shall be an integral part of the client's medical record and shall include the following: (i) Name of the attending physician; (ii) Date of admission to the facility; (iii) Date of application if made after admission to the facility; UNOFFICIAL 1737-38 (iv) The written plan of care; (v) The reasons for and the plan for continued stay when deemed necessary by the attending physician; and (vi) As necessary, other documented material to support the utilization review committee's decision; (E) Utilization review committee members shall not be involved in the care of a client whose case is being reviewed and shall not be employed by, or have a financial interest in any facility in which the URC functions; (F) URC members must include at least one physician and one other professional responsible for review of continued stay cases and at least one member shall be a QMRP; (G) Development and adoption of inhouse criteria by which continued stay cases shall be reviewed at least once in a six month period; (H) Review by a physician member of the URC of cases not meeting the applicable in-house ICF-MR criteria for continued stay; and (I) Notification of continued stay denial to the affected client shall be as follows: (i) The client's QMRP shall be notified within one working day, and an allowance of two working days shall be afforded to the QMRP to respond to the URC's continued stay denial before it becomes final; and (ii) Written notification of continued stay denial by the URC within two working days after the final URC determination shall be given to the facility administrator, the client, and the client's next of kin; and (3) The facility shall operate and provide services in compliance with all state, federal and local laws, regulations, and codes and with accepted professional standards and principles that apply to professionals providing services in the facility. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §§430.10, 431.10, 456.1, 483.410; 42 U.S.C. §§1395, 1396) (Imp: 42 UNOFFICIAL 1737-39 C.F.R. §§456.350, 456.351, 456.360, 456.370, 456.380, 456.381, 456.400, 456.401, 456.405 - 456.407, 456.411 - 456.413, 456.431 - 456.438) §17-1737-36 Inspection of care (IOC) reviews in ICF-MR facilities. The department shall be responsible for conducting periodic inspection of care review in ICF-MRs to evaluate the utilization of care and services provided to the client: (1) Inspection of care team members shall be employees of the department, and may consist of a physician or a registered nurse, and a social worker. One of the team members shall be a QMRP. If a physician is not on the team, a physician shall be available to provide consultation to the team; (2) Frequency of inspection shall be based on the quality of care and services provided by the facility, and on the condition of clients in the facility. However, at the minimum, each client shall be evaluated once annually; (3) No facility shall be notified of the time of inspection more than forty-eight hours before the scheduled arrival of the team; (4) Method of inspection shall be by personal contact with and observation of each client, and review of each client's medical record to determine the following: (A) Whether the facility services are adequate to meet the health needs of each client, the rehabilitative and social needs of each client and to promote maximum physical, mental, and psychosocial functioning; (B) Whether continued stay in the facility is necessary and desirable; (C) Whether it is feasible to meet the client's health needs, and in an ICF-MR the client's rehabilitative needs through alternative institutional or noninstitutional services; and (D) Whether each client is receiving active treatment in accordance with the provisions of section 17-1737-30; (5) The determinations on adequacy of services and related matters stipulated in paragraph (4) shall be based on, but not limited to, such items as whether: UNOFFICIAL 1737-40 (A) The medical evaluation, any required social and psychological evaluations, and the Individual Program Plans, where required, are followed; and all ordered services, including dietary orders, are provided and properly recorded; (B) The attending physician reviews prescribed medications at least quarterly; (C) Tests or observations of each client indicated by his medication regimen are made at appropriate times and are properly recorded; (D) The individual program plan must be reviewed at least every ninety days by the QMRP and revised as necessary; (E) For those clients certified as not needing a medical care plan, a review of their health status must be a direct physical examination by a licensed nurse on a quarterly or more frequent basis depending on client need and the result of any action (including referral to a physician to address client health problems) shall be recorded in the client's record; (F) Progress notes by physicians, nurses, social workers, and other professionals are made as indicated and are reflective of the need for the specific professional's intervention consistent with the observed condition of the client, and support the need for continued stay at the ICF-MR; (G) Progress notes shall be dated and signed followed by the professional's professional acronym; (H) The client receives adequate services, based on such observations as cleanliness, absence of bedsores, absence of signs of malnutrition or dehydration, and apparent maintenance of maximum physical, mental, and psychosocial function; (I) The client receives active treatment as defined in section 17-1737-30; (J) The client needs any service that is not furnished by the facility through arrangements with others; and UNOFFICIAL 1737-41 (K) The client needs continued placement in the facility or there is an appropriate plan to transfer the patient to an alternate method of care; (6) The inspection of care team shall prepare a report promptly after each inspection. The report shall contain: (A) The observations, conclusions, and recommendations of the team concerning the adequacy, appropriateness, and quality of all services provided in the facility or through other arrangements, including physician services to client's, and specific findings about individual clients in the facility; and (B) The dates of the inspection and the names and qualifications of the members of the team; and (7) The department shall send a copy of each inspection report to the facility inspected, the facility's utilization review committee, and the state department of health. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §§430.10, 431.10) (Imp: 42 C.F.R. §§456.600 - 456.613)