(a) Each agency operating a specialty hospital shall have a utilization review committee and a written utilization review plan for evaluation of the need for services provided to individuals. The utilization review committee and the utilization review plan shall comply with the following minimum requirements:

1. (1) Committee composition.

   1. (i) The utilization review committee shall be composed of professionals (as defined in section 680.13 of this Part), including at least:

      1. (a) two physicians;
      2. (b) other professional staff (as described in section 680.13) who are representatives of the disciplines in the specialty hospital.
   2. (ii) No member of the utilization review committee shall participate in the committee's deliberations regarding any individual he or she is treating directly.
   3. (iii) No member of the utilization review committee shall participate in the committee's deliberations if they have a financial interest in any hospital.

2. (2) Utilization review plan.

   1. (i) Each agency must have a separate written utilization review plan approved by the medical staff, administrator and the governing body, and the OPWDD.
   2. (ii) The OPWDD is responsible for reviewing each agency's plan and certifying to the appropriate State and Federal agencies that the plan meets all regulatory requirements.
   3. (iii) The utilization review plans must provide that each recipient's record includes information needed for the utilization review committee to perform the required utilization review.
   4. (iv) The utilization review committee shall assure confidentiality with respect to clients and physicians in its minutes and in its reports. Clients will be identified by medical chart number and physicians by physician employee number.

   5. (v) The utilization review plan shall require the utilization review committee to perform the following reviews:

      1. (a) An admission review within three days of admission to ensure that any person admitted to the facility meets the admission criteria and that the facility services are at the appropriate level of care for the individual.
      2. (b) A continued stay review within 30 days of admission and every six months subsequent to the date of admission, to ensure that the individual meets the criteria for continued stay and that the facility's services are meeting the individual's needs.

(e) In addition to the requirements for admission and continued stay reviews, the specialty hospital's utilization review plan shall describe the methods the utilization review committee uses to select and conduct health and habilitation care evaluation studies. The purpose of such studies shall be to promote the most effective and efficient use of the specialty hospital's facilities and services consistent with individual needs and professionally recognized standards of health and habilitation care. Such studies shall emphasize identification and analysis of patterns of care and shall recommend appropriate changes that will maintain consistently high quality care along with effective and efficient use of services.

1. (1) The health and habilitation care evaluation plan shall outline the utilization review committee's determination of the methods to be used in selecting and conducting the evaluation studies in the hospital.

2. (2) Each health and habilitation care evaluation study shall document:

   1. (i) its results;
   2. (ii) an analysis of the results;
   3. (iii) how the results have been used to make changes to improve the quality of care and promote more effective and efficient use of the specialty hospital's facilities and services;
   4. (iv) the action taken as needed to correct or investigate further any deficiencies or problems in the review process for admission or continued stay; and
   5. (v) its recommendations for more effective and efficient specialty hospital care procedures.

3. (3) Each health and habilitation care evaluation shall:

   1. (i) identify and analyze the health, habilitation or administrative factors related to the specialty hospital's care; and

   2. (ii) include an analysis of at least the following:

      1. (a) admissions;
      2. (b) durations of stay;
      3. (c) ancillary services provided, including but not limited to drugs and biologicals;
      4. (d) professional services performed in the specialty hospital; and
      5. (e) if indicated, contain recommendations for changes beneficial to individuals, staff, the specialty hospital and the community.

4. (4) Data that the utilization review committee uses to perform the evaluation studies shall be obtained from one or more of the following sources:

   1. (i) individual records, both program and medical, or other appropriate specialty hospital data;
   2. (ii) external organizations that compile statistics, design profiles, and produce other comparative data; and

   3. (iii) cooperative endeavors with:

      1. (a) professional standard review organization;
      2. (b) fiscal agents;
      3. (c) other service providers; or
      4. (d) other appropriate agencies.
5. (5) The specialty hospital shall have at least one health and habilitation care evaluation study in progress at any given time and shall complete one study each calendar year.