Section 150.014 - Utilization Review(A) Facilities providing Level I or II care shall review the services, quality of care and utilization of their facilities.(B) The utilization review process or activity shall include a review of all or a sample of residents to determine appropriateness of admissions, duration of stays by level of care, professional services and other relevant aspects of care and services provided by the facility.(C) Utilization review shall be conducted by one or a combination of the following: (1) By a utilization review committee, which is multidisciplinary and consists of at least two physicians or physician-physician assistant teams or physician-nurse practitioner teams, a registered nurse and, where feasible, other health professionals.(2) By a committee or group outside the facility that may be established by the following on the approval of the Department:(a) By a medical society.(b) By some or all of the hospitals and long-term care facilities in the locality.(c) By other health care facilities in the locality in conjunction with at least one hospital.(3) When the above alternatives are not feasible, by a committee sponsored and organized in such a manner as to be approved by the Department.(4) No member of the utilization review committee shall have a proprietary interest in the facility.(D)Medical Care Evaluation Reviews (Special Studies). (1) Reviews shall be made on a continuing basis of all or a sample of residents to determine the quality and necessity of care and services provided and to promote efficient use of health facilities and services. Such studies shall be of appropriate type and duration, and at least one study shall be in progress at all times.(2) Such studies shall emphasize identification and analysis of patterns of care and services.(3) The reviews of professional services furnished shall include such studies as types of services provided, proper use of consultation, promptness of initiation of required nursing and related care, delivery of services and other such studies.(4) Data and information needed to perform such studies may be obtained from statistical services, fiscal intermediaries, the facility's records and other such sources.(5) Studies and service shall be summarized and recommendations formulated and presented to the administration and other appropriate authorities.(6) An initial review of resident needs and length of stay by level of care shall be made at an appropriate interval after admission. This interval shall not be longer than 30 days following admission for facilities providing Level I or II care and 90 days following admission for facilities providing Level III care. Subsequent reviews shall be made periodically at designated intervals reasonable and consonant with the diagnosis and overall condition of the resident.(7) No physician or physician-physician assistant team or physician-nurse practitioner team shall have review responsibility for any case in which he or she was professionally involved.(8) If physician or physician-assistant team or physician-nurse practitioner team members of the committee decide, after opportunity for consultation with the primary care provider, further stay in a given level of care is not medically necessary, there shall be prompt notification (within 48 hours) in writing to the facility, the resident's primary care provider and the resident or his or her guardian.(E) To facilitate review, the utilization review committee shall use the complete medical record or a summary of the record and shall use such methods as a utilization review check list and interviews with the primary care provider as indicated.(F) The facility shall have in effect a written plan for utilization review that applies to all residents in the facility.(1) The plan shall be approved by the governing body.(2) The development of the plan shall be a responsibility of the medical staff and the administration.(3) A written plan for utilization review activities shall include:(a) The organization, objectives and composition of the committee(s) responsible for utilization review;(b) Frequency of meetings;(c) The type and content of records to be kept;(d) Description of the method to be used in selecting cases for special studies;(e) A description of the method utilized to determine periodic reviews;(f) Procedures to be followed for preparing committee reports and recommendations including their dissemination and implementation.(G)Administrative Responsibilities.(1) The administration shall provide support and assistance to the utilization review committee.(2) The administration shall act appropriately upon recommendations made by the utilization review committee.(H) Records, reports and minutes shall be kept of the activities of the utilization review committee, and they shall be complete, accurate, current and available within the facility.(1) The minutes of each meeting shall include:(a) A summary of the number and types of cases reviewed and findings.(b) Committee actions and recommendations on extended stay cases and other types of cases.(c) Interim reports, final conclusions and recommendations resulting from medical care evaluation reviews (special studies).(2) Reports shall regularly be made by the committee to the medical staff (if any), the administration and the governing body. Information and reports shall be submitted to the Department upon request.Amended by Mass Register Issue 1361, eff. 3/23/2018.