Section 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 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;(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.Haw. Code R. § 17-1737-35
[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 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)