Condition of participation: Utilization review plan.

42 CFR § 485.66

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42 CFR § 485.66

Condition of participation: Utilization review plan. The facility must have in effect a written utilization review plan that is implemented annually, to assess the necessity of services and promotes the most efficient use of services provided by the facility.

(a)

Standard: Utilization review committee. The utilization review committee, consisting of the group of professional personnel specified in § 485.56(c), a committee of this group, or a group of similar composition, comprised by professional personnel not associated with the facility, must carry out the utilization review plan.

(b)

Standard: Utilization review plan. The utilization review plan must contain written procedures for evaluating—

(1)

Admissions, continued care, and discharges using, at a minimum, the criteria established in the patient care policies;

(2)

The applicability of the plan of treatment to established goals; and

(3)

The adequacy of clinical records with regard to—

(i)

Assessing the quality of services provided; and

(ii)

Determining whether the facility's policies and clinical practices are compatible and promote appropriate and efficient utilization of services.

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