Section 410IAC15-1.5-10. Utilization review and discharge planning services

 

                (a) The hospital shall have and implement a written plan, approved by the medical staff and governing body, that describes the utilization review program and governs its operation.

                (b) The utilization review program shall address appropriate utilization of patient care resources.

                (c) Concurrent review shall focus on those diagnoses problems, procedures, or practitioners with identified or suspected utilization-related problems.

                (d) The hospital's utilization review program shall be reviewed and evaluated at least annually and be revised, as appropriate, to reflect the findings of the hospital's utilization review activities.

                (e) To facilitate discharge as soon as an acute level of care is no longer required, the hospital shall have effective, ongoing discharge planning that:

(1) facilitates the provision of follow-up care;

(2) is initiated in a timely manner as established by written hospital policy;

(3) transfers or refers patients, along with necessary medical information and records, to appropriate facilities, agencies, or outpatient services, as needed, for follow-up or ancillary care. The information shall include, but not be limited to, the following:

(A) medical history;

(B) current medications;

(C) activities status;

(D) nutritional needs;

(E) outpatient service needs;

(F) follow-up care needs; and

(4) utilizes available community and hospital resource to provide appropriate referrals or make available social, psychological, and educational services to meet the needs of the patient.

                (f) If required by Medicare, the hospital has a current memorandum of understanding covering binding review that complies with federal peer review rules. (Indiana State Department of Health; 410 IAC 15-1.5-10; filed Dec 21, 1994, 9:40 a.m.: 18 IR 1276; readopted filed Jul 11, 2001, 2:23 p.m.: 24 IR 4234; readopted filed May 22, 2007, 1:44 p.m.: 20070613-IR-410070141RFA; readopted filed Jul 14, 2011, 11:42 a.m.: 20110810-IR-410110253RFA)