Utilization review

1. The hospice program must appoint a utilization review committee whose responsibilities are to provide an ongoing evaluation and review of the hospice program and to make recommendations to the administrator who shall report findings and recommendations to the governing body on a timely basis. The committee shall meet at least semiannually and provide the administrator with dated, signed minutes of the meetings. 2. There must be a written utilization review plan describing the process used to monitor the utilization of the hospice program service and to resolve identified problems. 3. There must be evidence that the plan is reviewed at least annually and revised as necessary. 4. The utilization review committee shall conduct regular, ongoing utilization review to include, but not be limited to, a random sample and defined number of hospice medical records to determine at least the following: a. The appropriateness of admission to the hospice program. b. Continued stay longer than six months. c. If the hospice program service plan was directly related to the identified physical and social needs of the patient and family. d. If the service, medication, and treatment prescribed were in accordance with the current hospice service plan. e. If the hospice program of care appropriately utilized inpatient hospice care on a short-term basis only, and maintained itself primarily as a home care program. 5. In addition to the medical record review, the following sources of information may be obtained and reviewed: a. Billing information. b. Quality assurance findings. c. Reimbursement. 6. When problems in the utilization of hospice program services are identified, there must be evidence that action is taken to correct the problems.