Haw. Code R. § 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.
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