Current through Register Vol. 54, No. 7, April 4, 2022
(a) Each QA
program shall include a utilization review (UR) component which shall be
described in the QA plan.
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
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
criteria shall be developed for admission and continued stay in each program
element. These criteria shall be utilized during the UR activities described in
(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
(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.
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.