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Based upon record review and interview, the facility failed to ensure the Utilization Review (UR) Committee consisted of at least two members who were doctors of medicine or osteopathy for two of two UR committee meetings reviewed in 2024.

Review of the facility policy Utilization Review Plan (SOP/LDR/001 issued 02/2015) it stated "Membership shall consist of sufficient members to afford, insofar as feasible representation from the major services. No less than two members of the Utilization Management Committee shall be doctors of medicine osteopathy...physicians may not participate in the review of any cases in which he/she has been or anticipates being professionally involved."

Review of the Utilization Meeting in June 2024 and August 2024 meeting revealed only one doctor in attendance.

An interview with Staff # on 09/17/2024 at 11:10 AM in the conference room confirmed the above findings.

Based on review of the facility policy, Utilization Review (UR) Meeting Minutes and confirmed in interview, the facility failed to implement their UR plan that provided review for medical necessity for three of three patient charts reviewed.

Findings included:

Review of the facility policy Continued Stay Criteria (SOP/ADN-012) it stated "after the initial assessment of each Medicare funded patient, the case manager will initiate the continued stay criteria and discharge screen. This screen will be performed very 72 hours; the screen is a tool to ensure that all Medicare patients meet the guidelines for the LTACH (Long term Acute Care) level of service; and once patients do not meet criteria, discharge planning will be completed using the discharge criteria."

Review of the facility policy Utilization Review Plan (SOP/LDR/001) it stated "The Utilization Review Plan shall strive for appropriate allocation of the hospital's resources by provision of quality patient care in the most cost effective manner. It shall provide for timely review of the medical necessity for admissions, continued stays and services rendered. The Utilization Management Plan shall address overutilization, underutilization, inefficient scheduling of resources and denials of service from external agencies.
The Utilization Review Plan shall include a review of services furnished by the hospital and the medical staff to patients entitled to benefits under the Medicare and Medicaid programs. The Utilization Review Plan shall apply to all patients regardless of payment source. The Program shall not address or include utilization review conducted by members of the medical staff under contract with, or via other means of delegation by, a third party payer."

Random review of patient charts from August and September 2024 revealed the following three patients with a continued stay with no documentation of the medical necessity for their continued stay and/or professional services furnished.

Patient #A admitted 08/16/2024
Patient #E admitted 08/16/2024
Patient #F admitted 08/16/2024

Review of the Utilization Review (UR) Meeting Minutes revealed the last UR meeting were on 6/4/2024 and 8/6/2024. Review of the meeting minutes did not include any charts reviewed for medical necessity.

An interview with Staff #2 on 09/17/2024 at 11:35 AM confirmed the above findings. She stated that the facility was actively working on metrics to identify patients for UR review.