Rule 111-8-68-.07 - Services(1)Intake and Admission. Services shall be designed to meet the needs of the patient and must conform to the stated purposes and objectives of the facility. (a) Acceptance of a child or adolescent for inpatient treatment shall be based on the initial assessment, arrived at by a multidisciplinary team of clinical staff, and clearly explained to the patient, parent(s), and/or legal guardian. 1. Whether the family voluntarily requests services or the patient is referred by the court, the facility shall involve the family's participation to the fullest extent possible.2. Acceptance of the child or adolescent for treatment shall be based on the determination that the child or adolescent requires treatment of a comprehensive and intensive nature and is likely to benefit by the programs that the residential mental health facility has to offer.3. Admission shall be in keeping with stated policies of the facility and shall be limited to those patients for whom the facility has qualified staff, program and equipment available to give adequate care.4. Staff members who will be working with the patient, but who did not participate in the initial assessment, shall be oriented regarding the patient and the patient's anticipated admission prior to meeting the patient. When the patient is to be assigned to a group, the other patients in the group shall be prepared for the arrival of the new member. There shall be a specific staff member assigned to the new patient to observe the patient and help with the orientation period.5. The admission procedure shall include communication with parent(s) and/or legal guardian, and documentation of such communication, concerning: (i) responsibility for financial support including medical and dental care;(ii) consent for medical and surgical care and treatment;(iii) arrangements for appropriate family participation in the program, phone calls and visits when indicated;(iv) arrangements for clothing, allowances and gifts;(v) arrangements regarding the patient leaving the facility with or without medical consent;(vi) description of the facility's services and the daily routines of patients;(vii) the facility's policies and procedures for discipline and grievances;(viii) patient rights; and(ix) the facility's policy and procedures for the use of emergency safety interventions with written acknowledgment that the patient, parent(s), and/or legal guardian has been informed of these procedures and has been provided a copy of the procedures along with contact information for the Georgia protection and advocacy agency, currently designated as the Georgia Advocacy Office.6. Decisions for admission shall be based on the initial assessment of the patient made by the appropriate multidisciplinary team of clinical staff. This assessment shall be in writing and recorded on admission. The initial assessment shall clearly indicate the patient's needs as related to the services offered by the facility.7. The admission order must be written by a physician.(2)Assessment and Treatment Planning Including Discharge. The facility shall provide to families at the time of initial assessment a description of the treatment services it provides, including content, methods, equipment and personnel involved. Each patient's treatment program must be individualized, and must describe which of the offered services are needed and are to be provided. (a)Assessment. The facility is responsible for a complete assessment of the patient, some of which may be completed prior to admission, by reliable professionals acceptable to the facility's staff. The complete assessment shall include but is not limited to: 1. Physical examination, which includes at least a general physical examination and neurological assessment, performed within twenty-four (24) hours after admission by a licensed physician or a nurse practitioner or physician's assistant working under the direction of a licensed physician who is on staff at the facility. However, in lieu of performing the required physical examination; the staff physician, nurse practitioner or physician's assistant working under direction of the physician may examine and update the patient's physical condition within twenty-four (24) hours after admission where an appropriate physical examination completed by any licensed physician or a nurse practitioner or physician's assistant working under the direction of the licensed physician was performed within forty-eight (48) hours prior to admission.2. Assessment of motor development and functioning;4. Speech, hearing and language assessment;6. Review of immunization status and completion according to the U.S. Public Health Service Advisory Committee on Immunization Practices and the Committee on Control of Infectious Diseases of the American Academy of Pediatrics;7. Laboratory workup including routine blood work and urinalysis;8. Chest x-ray and/or tuberculin test;10. Follow-up testing and/or treatment by appropriately qualified and/or trained clinicians where any of the physical health assessments indicate the need for further testing or definitive treatment with any plans for treatments coordinated with the patient's overall treatment plan;11. Psychiatric/psychological examination, including but not limited to: (i) Direct psychiatric evaluation and behavioral appraisal, evaluation of sensory, motor functioning, a mental status examination appropriate to the age of the patient and a psychodynamic appraisal. A psychiatric history, including history of any previous treatment for mental, emotional or behavioral disturbances shall be obtained, including the nature, duration and results of the treatment, and the reason for termination. An initial and ongoing assessment of the patient's potential risks of harm to self and others is also required;(ii) Appropriate psychological testing;(iii) An initial and ongoing assessment of the need for safety supervision and monitoring.(iv) Developmental/social assessment, including but not limited to:(I) The developmental history of the patient including the prenatal period and from birth until present, the rate of progress, developmental milestones, developmental problems, and past experiences that may have affected the development. The assessment shall include an evaluation of the patient's strengths as well as problems. Consideration shall be given to the healthy developmental aspects of the patient, as well as to the pathological aspects, and the effects that each has on the other shall be assessed. There shall be an assessment of the patient's current age, appropriate developmental needs, which shall include a detailed appraisal of his peer and group relationships and activities.(II) A social assessment including evaluation of the patient's relationships within the structure of the family and with the community at large, an evaluation of the characteristics of the social, peer group, and institutional settings from which the patient comes. Consideration shall be given to the patient's family circumstances, including the constellation of the family group, their current living situation, and all social, religious, ethnic, cultural, financial, emotional and health factors. Other factors that shall be considered are past events and current problems that have affected the patient and family; potentialities of the family's members meeting the patient's needs; and their accessibility to help in the treatment and rehabilitation of the patient. The expectations of the family regarding the patient's treatment, the degree to which they expect to be involved, and their expectations as to the length of time and type of treatment required shall also be assessed.12. Nursing. The nursing assessment includes, but is not limited to the evaluation of: (i) Self-care capabilities including bathing, sleeping, eating;(ii) Hygienic practices such as routine dental and physical care and establishment of healthy toilet habits;(iii) Dietary habits including a balanced diet and appropriate fluid and caloric intake;(iv) Responses to physical diseases such as acceptance by the patient of a chronic illness as manifested by his compliance with prescribed treatment;(v) Responses to physical handicaps such as the use of prostheses or coping patterns used by the visually handicapped; and(vi) Responses to medications such as allergies or dependence.13. Educational/Vocational. The patient's current educational/vocational needs in functioning, including deficits and strengths, shall be assessed. Potential educational impairment and current and future educational/vocational potential shall be evaluated using, as indicated, specific educational testing and special educators or others.14. Recreational. The patient's work and play experiences, activities, interests and skills shall be evaluated in relation to planning appropriate recreational activities.(b)Treatment Planning. An initial treatment plan shall be formulated, written, and interpreted to the staff and patient within forty-eight (48) hours of admission. The comprehensive treatment plan shall be formulated for each patient by a multidisciplinary staff, written, implemented, and placed in the patient's records within fourteen (14) days of admission. This plan must be reviewed at least monthly, or more frequently to meet the needs of the patients or if the objectives of the program indicate. Review shall be noted in the record. A psychiatrist as well as multidisciplinary professional staff must participate in the preparation of the plan and any major revisions. 1. The initial treatment plan shall be based on screening and initial assessments and shall reflect the reasons for admission, significant problems, and preliminary treatment and medication modalities to be used pending completion of the comprehensive treatment plan.2. The comprehensive treatment plan shall outline an active treatment program and be based on the assessment of the physical; developmental; psychological; chronological and developmental age; family; educational; vocational; social; and recreational needs of the patient. The reason for admission should be specified as should specific treatment goals, stated in measurable terms, including a projected timeframe; treatment modalities to be used; staff who are responsible for coordinating and carrying out the treatment; and expected length of stay and designation of the person or agency to whom the patient will be discharged. The comprehensive treatment plan shall be reviewed and revised at least monthly or more frequently to meet the needs of the patients.3. The degree of the patient's family's involvement (parent or parent surrogates) shall be defined in the treatment plan.4. Collaboration with resources and significant others shall be included in treatment planning, when appropriate.(c)Discharge. Discharge planning begins at the time of admission. A discharge date shall be projected in the treatment plan. Discharge planning shall include a period of time for transition into the community, e.g., home visits gradually lengthened, schools, etc. for those patients who have been in the facility for an extended period of time. The facility shall provide clinical or other patient information as required for the receiving organization to provide appropriate follow-up care.(3)Staff Coverage. There shall be a master clinical staffing plan which provides for the continuous provision of sufficient regular, special, and emergency supervision and observation of all patients twenty-four (24) hours a day to meet their physical, mental, social, and safety needs.(a) There shall be a registered nurse on duty at all times. Services of a registered nurse shall be available for all patients at all times. An exception may be permitted in facilities having less than a daily average of twenty (20) patients or less than twenty-five (25) beds, in that a registered nurse will not be required to be on duty at all times. In such cases, a licensed practical nurse shall be on duty and shall be assigned responsibility for the care of the patient, and a physician or registered nurse shall be on call and available for emergencies.(b) A physician shall be on call twenty-four (24) hours a day and accessible to the facility within sixty (60) minutes. The physician's name and contact information shall be clearly posted in accessible places for all staff.(c) Assessments of staffing needs shall be made on an ongoing basis but minimally every twenty-four (24) hours. Staffing patterns shall be adjusted to meet the assessed needs of patients. Special attention shall be given to times which probably indicate the need for increased direct care, e.g., weekends, evenings, during meals, transition between activities, awaking hours, numbers of patients requiring special observations, etc.(d) Staff interaction shall ensure that there is adequate communication of information regarding patients, e.g., between working shifts or change of personnel, with consulting professional staff at routine planning and patient review meetings, etc. These shall be documented in writing.(4)Program Activities. Program goals of the facility shall include those activities designed to promote the "normal" growth and development of the patients, regardless of pathology or age level. There should be positive relationships with general community resources, and the facility staff shall enlist the support of these resources to provide opportunities for patients to participate in normal community activities as they are able. All labeling of vehicles used for transportation of patients shall be such that it does not call unnecessary attention to the patients.
(a)Group Size. The size and composition of each living group shall be therapeutically planned and depend on the age, developmental level, sex and clinical conditions. It shall allow for appropriate staff-patient interaction, security, close observation and support.(b)Daily Routine. A basic routine shall be delineated in a written plan which shall be available to all personnel. The daily program shall be planned to provide a consistent well structured yet flexible framework for daily living and shall be periodically reviewed and revised as the needs of individual patients or the living group change. A basic daily routine shall be coordinated with special requirements of the patient's treatment plan.(c)Social and Recreation Activities. Programs of recreational, physical, and social activities shall be provided for all patients for daytime, evenings, and weekends, to meet the needs of the patients and goals of the program. Programs should be designed to assist patients to develop a sense of confidence, individuality, self-esteem, and establish appropriate skills for living within the community. There shall be documentation of these activities as well as schedules maintained of any planned activities.(d)Religious Activities. Opportunity shall be provided for all patients to participate in religious services and other religious activities within the framework of their individual and family interests and clinical status. The option to celebrate holidays in the patient's traditional manner shall be provided and encouraged.(e)Education. The facility shall arrange for or provide an educational program for all patients receiving services in that facility. The particular educational needs of each patient shall be considered in both placement and programming.(f)Vocational Programs. The facility shall arrange for or provide some degree of vocational and/or prevocational training for patients in the facility for whom it is indicated.1. If there are plans for work experience developed as part of the patient's overall treatment plan the work shall be in the patient's interest with payment where appropriate, and never solely in the interest of the facility's goals or needs.2. Patients shall not be responsible for any major phase of the facility's operation or maintenance, such as cooking, laundering, housekeeping, farming and repairing. Patients shall not be considered as substitutes for employed staff.3. Adequate attention shall be paid to federal wage and hour laws.(5)Nutrition. Food services must comply with the Rules and Regulations for Food Service, Chapter 290-5-14. There must be a provision for planning and preparation of special diets as needed. Menus shall be evaluated by a consultant dietitian relative to nutritional adequacy at least monthly, with observation of food intake and changes seen in the patient.(6)Physical Care. The facility shall have available, either within its own organizational structure or by written arrangements with outside clinicians or facilities, a full range of services for the treatment of illnesses and the maintenance of general health. The facility's written plan for clinical services shall delineate the ways the facility obtains or provides all general and specialized medical, surgical, nursing and dental services. Definite arrangements shall be made for a licensed physician to provide medical care for the patients. This shall include arrangements for necessary visits to the facility as well as office visits. Each patient shall have a primary physician who maintains familiarity with the patient's physical health status. (a) Patients who are physically ill shall be cared for in surroundings that are familiar to them as long as this is medically feasible. If medical isolation is necessary, there shall be sufficient and qualified staff available to give appropriate care and attention.(b) Arrangements shall be made in writing for patients from the facility to receive care from outside clinicians and at appropriate hospital facilities in the event a patient requires services that the facility cannot properly handle.(c) Every patient shall have a complete physical examination annually and more frequently if indicated. This examination shall be as inclusive as the initial examination. Efforts shall be made by the facility to have physical defects of the patients corrected through proper medical care. Immunizations shall be kept current (DPT, polio, measles, rubella), appropriate to the patient's age.(d) Each member of the staff shall be able to recognize common symptoms of the illnesses of patients, and to note any marked defects of patients. Staff shall be able to provide nursing care under the supervision of a registered nurse.(e) Staff shall have knowledge of basic health needs and health problems of patients, such as mental health, physical health and nutritional health. Staff shall teach attitudes and habits conducive to good health through daily routines, examples and discussion, and shall help the patients to understand the principles of health.(f) Each facility shall have a definitely planned program of dental care and dental health which shall be consistently followed. Each patient shall receive a dental examination by a qualified dentist and prophylaxis at least twice a year. Reports of all examinations and treatment should be included in the patient's clinical record.(7)Emergency Services. All clinical staff shall have training in matters related to handling emergency situations.(a) Policies and procedures shall be written regarding handling and reporting of emergencies and these shall be reviewed at least quarterly by all staff.(b) All patient care staff must have an up-to-date first-aid certificate and certification in basic cardiopulmonary resuscitation (CPR). The facility must maintain suction equipment and an automatic external defibrillator (AED). All patient care staff must have training in the use of oral suction and the use of an AED.(c) There shall be an emergency kit made up under the supervision of a physician and inspected regularly with documentation of inspections. This kit shall include emergency drugs, equipment, etc. This kit shall be stored in a locked area, easily accessible to appropriate staff.(d) There shall be an adequate number of appropriately equipped first aid kits stored with appropriate safeguards but accessible to staff in appropriate locations such as living units, recreation and special purpose areas, buses, vans, etc.(8)Pharmaceutical Services. Policies and procedures related to pharmaceutical services shall include but are not limited to:(a) The facility shall have a pharmacy or drug room onsite that shall be directed by a registered pharmacist. 1. The pharmacy or drug room shall be under competent supervision.2. The pharmacist shall be responsible to the administration of the facility and for developing, supervising and coordinating all activities of the pharmacy.(b) If there is a drug room with no pharmacist, prescription medication shall be dispensed by a qualified pharmacist elsewhere and only storage and distribution shall be done at the facility. A designated person shall have responsibility for the day-to-day operation of the drug room. A consulting pharmacist shall assist in developing policies and procedures for the distribution of drugs, and shall visit the facility as needed.(c) Special locked storage space shall be maintained at the facility to meet the legal requirements for storage of narcotics and other prescribed drugs.(d) Written arrangements with outside pharmacies, clinicians or facilities shall be made for emergency pharmaceutical service.(e) Establishment and maintenance of a satisfactory system of records and bookkeeping in accordance with the policies of the facility.(f) An automatic stop order on all prescribed drugs not specifically prescribed as to time and number of doses. These stop orders shall be in accordance with federal and state laws. Individual drug plans shall be reviewed by a physician weekly or more frequently as needed.(g) A drug formulary accepted for use in the facility which is developed and amended at regular intervals by medical staff in cooperation with the pharmacist.(h) Drugs may be administered only by a licensed nurse, in accordance with the Nurse Practice Act, O.C.G.A. § 43-26-12et seq. relating to the practice of nursing in Georgia.(i) Intravenous medications and fluids shall be administered in accordance with Georgia law. If administered by licensed nurses, they shall be administered only by those who have been trained and determined competent to perform this duty.(j) Each facility shall provide pharmaceutical services in compliance with State and federal laws and regulations.(9)Medical orders shall be in writing and signed by the physician. Telephone/verbal orders shall be used sparingly and given only to a licensed nurse or otherwise qualified individual as determined by the medical staff in accordance with State law. The individual receiving the telephone/verbal order shall immediately repeat the order and the prescribing physician shall verify that the repeated order is correct. The individual receiving the order shall document, in the patient's clinical record that the order was repeated and verified. Telephone/verbal orders must be signed by the physician within the timeframe designated in the facility's policies and procedures which ensure that it is done as soon as possible. Where telephone/verbal orders are routinely not being signed within the timeframe designated in the policy, the facility will take appropriate corrective action.(10)Laboratory and Pathology Services. Provision shall be made for those services within the facility or with an outside facility to meet the needs of the patient. These services shall be provided by a CLIA certified facility. Laboratory and pathology tests to be performed require an order from a qualified physician and reports from such tests shall be part of the patient's clinical records. Abnormal laboratory and pathology reports shall be followed up appropriately.(11)Patients' Rights. Every effort shall be made to safeguard the legal and civil rights of patients and to make certain that they are kept informed of their rights, including the right to legal counsel and all other requirements of due process when necessary. (a)Treatment. Each patient shall be provided treatment and care in the least restrictive environment as possible; each patient, parent(s), and/or legal guardian shall be encouraged to participate in the development of the patient's individualized treatment plan; and each patient shall be provided treatment and care in a manner that respects the patient's personal privacy and dignity.(b)Visitors. Policies shall allow visitation of patient's family and significant others unless clinically contraindicated. Appropriate places for visits shall be provided.(c)Telephone and Mail. Patients shall be allowed to conduct private telephone conversations with family and friends and to send and receive mail. When restrictions are necessary because of therapeutic or practical reasons, such as expense, these reasons shall be documented, explained to the patient and family and re-evaluated at least monthly.(d)Behavior Management. Behavior management techniques shall be fair and consistent and must be applied based on the individual's needs and treatment plan, and following established and approved behavior management techniques in accordance with the Rule 111-8-68-.08.(e)Restraint and Seclusion. Each patient has the right to be free from restraint or seclusion, in any form, used as a means of coercion, discipline, convenience, or retaliation.(f)Clothing. Individual patients shall have their own appropriate amounts and types of clothing for the particular activities, climate, etc. There shall be an appropriate storage place for their clothing.(g)Grievances. The patients shall have the opportunity to present opinions, recommendations and grievances to appropriate staff members. The facility shall have written policies and carry out appropriate procedures for receiving and responding to such patient communications in a way that will preserve and foster the therapeutic aspects of conflict-resolution and problem solving; e.g., patient-staff government meetings.(12)Records. The form and detail of the clinical records may vary in accordance with these rules. (a)Content. All clinical records shall contain all pertinent clinical information and each record shall contain at least: 1. Identification data, consent forms, acknowledgment of patient, parent(s), and/or legal guardian's receipt and explanation of facility's emergency safety intervention procedures and a copy of patients' rights; when these are not obtainable, reason shall be noted;3. Reason for referral, e.g. chief complaint, presenting problem;4. Record of the complete assessment;5. Initial formulation and diagnosis based upon the assessment;6. Written treatment plan;7. Medication history and record of all medications prescribed;8. Record of all medication administered by facility staff, including type of medication, dosages, frequency of administration, and persons who administered each dose;9. Documentation of course of treatment and all evaluations and examinations, including those from other facilities, example, emergency room or general hospital;10. Documentation of the use and monitoring of emergency safety interventions;11. Documentation of the use of patient safety observations/interventions;12. Periodic progress report;13. All consultation reports;14. All other appropriate information contained from outside sources pertaining to the patient;15. Discharge or termination summary report; and16. Plans for follow-up and documentation of its implementation.17. Identification data and consent form shall include the patient's name, address, home telephone number, date of birth, sex, next of kin, school name, grade, date of initial contact and/or admission to the service, legal status and legal document, and other identifying data as indicated.18.Progress Notes. Progress notes shall include regular notations at least weekly by staff members, consultation reports and signed entries by authorized identified staff. Progress notes by the clinical staff shall: (a) Document a chronological picture of the patient's clinical course;(b) Document all treatment rendered to the patient;(c) Document the implementation of the treatment plan;(d) Describe each change in each of the patient's conditions;(e) Describe responses to and outcome of treatment including the use of any emergency safety interventions and medications; and(f) Describe the responses of the patient and the family or significant others to significant events.19.Discharge Summary. The discharge summary shall include the initial formulation and diagnosis, clinical resume, final formulation, and final primary and secondary diagnoses, the psychiatric and physical categories. The final formulation shall reflect the general observations and understanding of the patient's condition initially, during appraisal of the fundamental needs of the patients. All relevant discharge diagnoses should be recorded and coded in the standard nomenclature of the current "Diagnostic and Statistical Manual of Mental Disorders," published by the American Psychiatric Association, and the latest edition of the "International Classification of Diseases," regardless of the use of other additional classification systems. Records of discharged patients shall be completed following discharge within a reasonable length of time, and not to exceed fifteen (15) days. In the event of death, a summation statement shall be added to the record either as a final progress note or as a separate resume. This final note shall take the form of a discharge summary and shall include circumstances leading to death. All discharge summaries must be signed by a physician.20.Recording. Entries in the clinical records shall be made by all staff having pertinent information regarding the patient, consistent with the facility policies, and authors shall fully sign and date each entry. When mental health trainees are involved in, patient care, documented evidence shall be in the clinical records to substantiate the active participation of supervisory clinical staff. Symbols and abbreviations shall be used only when they have been approved by the clinical staff and when there is an explanatory legend. Final diagnosis, both psychiatric and physical, shall be recorded in full, and without the use of either symbols or abbreviations.(b)Clinical Records Policies and Procedures. The facility shall have written policies and procedures regarding clinical records which are enforced and provide that: 1. Clinical records shall be confidential, current and accurate;2. The facility shall protect the confidentiality of clinical information and communication between staff members and patients;3. All staff shall have training, as part of new staff orientation and with periodic updates, regarding the effective maintenance of confidentiality of clinical records. It shall be emphasized that confidentiality also refers to discussions regarding patients inside and outside the facility. Verbal confidentiality shall be discussed as part of all employee training.4. Clinical records are the property of the facility and shall be maintained for the benefit of the patient, the staff and the facility;5. The facility is responsible for safeguarding the information in the clinical record against loss, defacement, tampering or use by unauthorized persons;6. Except as required by law, the written consent of the patient, or if the patient is a minor, the parent(s), and/or legal guardian, is required for the release of clinical record information;7. Records may be removed from the facility's jurisdiction and safekeeping only according to the policies of the facility or as required by law; and(c)Maintenance of Records. Each facility shall provide for a master filing system which shall include a comprehensive record of each patient's involvement in every program aspect. 1. Appropriate records shall be kept on the unit where the patient is being treated or be directly and readily accessible to the clinical staff caring for the patient;2. The facility shall maintain a system of identification and filing to facilitate the prompt location of the patient's clinical records;3. The facility shall retain patients' records at least until the fifth anniversary of the patients' discharge. If the patient is a minor, the records must be retained for at least five (5) years past the age of majority. Records may be preserved in the facility's format of choice, including but not limited to paper or electronic format, so long as the records are readable, capable of being reproduced in paper format upon request, and stored and disposed of in a manner that protects the confidentiality of the record;4. The clinical record services required by the facility shall be directed, staffed and equipped to facilitate the accurate processing, checking, indexing, filing, retrieval and review of all clinical records. The clinical records service shall be the responsibility of an individual who has demonstrated competence and training or experience in clinical record administrative work. Other personnel shall be employed as needed, in order to effect the functions assigned to the clinical record services; and5. There shall be adequate space, equipment and supplies, compatible with the needs of the clinical record service, to enable the personnel to function effectively and to maintain clinical records so that they are readily accessible.(13)Program and Patient Evaluation. The staff shall work towards enhancing the quality of patient care through specified, documented, implemented and ongoing processes of clinical care evaluation studies and utilization review mechanisms. (a)Individual Case Review.1. There shall be regular staff meetings and/or unit meetings to review and monitor the progress of the individual child or adolescent patient. Each patient's case shall be reviewed within a month after admission and at least monthly during residential treatment. Review of the use of emergency safety interventions shall be in accordance with Rule 111-8-68-.08(2)(l). The reviews shall be documented and the meeting may also be used for review and revision of treatment plans.2. The facility shall provide for a follow-up review on each discharged patient to determine effectiveness of treatment and disposition.(b)Program Evaluation.1.Clinical Care Evaluation Studies. There shall be evidence of ongoing studies to define standards of care consistent with the goals of the facility, effectiveness of the program, the facility's progress in reducing the use of emergency safety interventions, and to identify gaps and inefficiencies in service. Evaluation shall include, but is not limited to, follow-up studies. Studies shall consist of the following elements: (i) Selection of an appropriate design;(ii) Specification of information to be included;(iii) Collection of data;(iv) Analysis of data with conclusions and recommendations;(v) Transmissions of findings; and(vi) Follow-up on recommendations.2.Utilization Review. Each facility shall have a plan for and carry out utilization review. The review shall cover the appropriateness of admission to services, the provision of certain patterns of services, and duration of services. There shall be documentation of utilization review meetings either in minutes or in individual clinical records.Ga. Comp. R. & Regs. R. 111-8-68-.07
O.C.G.A. Sec. 31-7-2.1.
Original Rule entitled "Services" adopted. F. July 14, 2010; eff. August 3, 2010.