N.J. Admin. Code § 10:37-9.8

Current through Register Vol. 56, No. 19, October 7, 2024

Section 10:37-9.8 - Utilization review (UR)

(a) Each QA program shall include a utilization review (UR) component which shall be described in the QA plan.

(b) The UR component of the QA program shall include a system, which shall include timeframes for review and which shall monitor the appropriateness of:

1. Admission, for at least 10 percent of all new clients each month; and

2. Continued stay, for at least 10 percent of the clients served by the PA during the previous year, with a representative sample from each program element.

(c) Written criteria shall be developed for admission and continued stay in each program element. These criteria shall be utilized during the UR activities described in (b) above.

(d) A written description for the processing of cases deemed inappropriate admissions and continued stays shall be developed. Action for inappropriate cases (those which do not meet criteria or receive approval by the medical reviewer) shall be effected through termination, transfer to an appropriate program or implementation of interventions necessary to facilitate termination.

(e) Criteria shall be developed for each program element for assessing length of stay. Level of functioning, severity of illness, diagnosis or other professionally accepted categories upon which length of stay norms are based shall reflect the clinical needs of the clients served by the PA and the PA's treatment philosophy.

(f) Continued service for a client who exceeds the identified length of stay norm shall be justified in the client's clinical record.

(g) Monthly UR statistical summaries shall be maintained and shall include the number of admission and continued stay reviews completed, as well as dispositions (for example, approvals, transfers, terminations).

(h) There shall be a written policy describing how UR findings and records are maintained to assure client and staff confidentiality. Client numbers and clinician codes are one acceptable method that can be used.

(i) There shall be a written conflict of interest policy that excludes a clinician who is involved in treatment of a client from making the determination of that client's appropriateness for continued stay.

(j) When the PA has developed the QA program, the PA should additionally document UR activities that address efficient use of staff and resources.

N.J. Admin. Code § 10:37-9.8