(a) Certification. (1) A physician must certify for each applicant or beneficiary that ICF services are or were needed.

(2) The certification must be made at the time of admission or, if an individual applies for assistance while in an ICF, before the Medicaid agency authorizes payment.

(b) Recertification. (1) A physician, or physician assistant or nurse practitioner (as defined in § 491.2 of this chapter) acting within the scope of practice as defined by State law and under the supervision of a physician, must recertify for each applicant or beneficiary that ICF services are needed.

(2) Recertification must be made at least—

(i) Every 12 months after certification in an institution for Individuals with Intellectual Disabilities or persons with related conditions; and

(ii) Every 60 days after certification in an ICF other than an institution for Individuals with Intellectual Disabilities or persons with related conditions.

This subpart prescribes requirements for control of utilization of intermediate care facility (ICF) services including requirements concerning—

(a) Certification of need for care;

(b) Medical evaluation and admission review;

(c) Plan of care; and

(d) Utilization review plans.

As used in this subpart:

Intermediate care facility services means those items and services furnished in an intermediate care facility as defined in §§ 440.140 and 440.150 of this subchapter, but excludes those services if they are provided in religious nonmedical institutions as defined in § 440.170(b) of this chapter.

(a) Before admission to an ICF or before authorization for payment, an interdisciplinary team of health professionals must make a comprehensive medical and social evaluation and, where appropriate, a psychological evaluation of each applicant's or beneficiary's need for care in the ICF.

(b) In an institution for Individuals with Intellectual Disabilities or persons with related conditions, the team must also make a psychological evaluation of need for care. The psychological evaluation must be made before admission or authorization of payment, but not more than three months before admission.

(c) Each evaluation must include—

(1) Diagnoses;

(2) Summary of present medical, social, and where appropriate, developmental findings;

(3) Medical and social family history;

(4) Mental and physical functional capacity;

(5) Prognoses;

(6) Kinds of services needed;

(7) Evaluation by an agency worker of the resources available in the home, family and community; and

(8) A recommendation concerning—

(i) Admission to the ICF; or

(ii) Continued care in the ICF for individuals who apply for Medicaid while in the ICF.

If the comprehensive evaluation recommends ICF services for an applicant or beneficiary whose needs could be met by alternative services that are currently unavailable, the facility must enter this fact in the beneficiary's record and begin to look for alternative services.

Medical and other professional personnel of the Medicaid agency or its designees must evaluate each applicant's or beneficiary's need for admission by reviewing and assessing the evaluations required by § 456.370.

(a) Before admission to an ICF or before authorization for payment, a physician must establish a written plan of care for each applicant or beneficiary.

(b) The plan of care must include—

(1) Diagnoses, symptoms, complaints, and complications indicating the need for admission;

(2) A description of the functional level of the individual;

(3) Objectives;

(4) Any orders for—

(i) Medications;

(ii) Treatments;

(iii) Restorative and rehabilitative services;

(iv) Activities;

(v) Therapies;

(vi) Social services;

(vii) Diet; and

(viii) Special procedures designed to meet the objectives of the plan of care;

(5) Plans for continuing care, including review and modification of the plan of care; and

(6) Plans for discharge.

(c) The team must review each plan of care at least every 90 days.

A written report of each evaluation and plan of care must be entered in the applicant's or beneficiary's record—

(a) At the time of admission; or

(b) If the individual is already in the ICF, immediately upon completion of the evaluation or plan.

Sections 456.401 through 456.438 of this subpart prescribe requirements for a written utilization review (UR) plan for each ICF providing Medicaid services. Sections 456.405 through 456.407 prescribe administrative requirements; §§ 456.411 through 456.413 prescribe informational requirements; and §§ 456.431 through 456.438 prescribe requirements for continued stay review.

(a) The State plan must provide that—

(1) UR is performed for each ICF that furnishes inpatient services under the plan;

(2) Each ICF has on file a written UR plan that provides for review of each beneficiary's need for the services that the ICF furnishes him; and

(3) Each written ICF UR plan meets requirements under §§ 456.401 through 456.438.

(b) The State plan must specify the method used to perform UR, which may be—

(1) Review conducted by the facility;

(2) Direct review in the facility by individuals—

(i) Employed by the medical assistance unit of the Medicaid agency; or

(ii) Under contract to the Medicaid agency; or

(3) Any other method.

The UR plan must include a written description of—

(a) How UR is performed in the ICF; and

(b) When UR is performed.

(a) The UR plan must include a written description of who performs UR in the ICF.

(b) UR must be performed using a method specified under § 456.401(b) by a group of professional personnel that includes—

(1) At least one physician;

(2) In an ICF that cares primarily for mental patients, at least one individual knowledgeable in the treatment of mental diseases; and

(3) In an institution for individuals with intellectual disabilities, a least one individual knowledgeable in the treatment of intellectual disability.

(c) The group performing UR may not include any individual who—

(1) Is directly responsible for the care of the beneficiary whose care is being reviewed;

(2) Is employed by the ICF; or

(3) Has a financial interest in any ICF.

The UR plan must describe—

(a) The UR support responsibilities of the ICF's administrative staff; and

(b) Procedures used by the staff for taking needed corrective action.

The UR plan must provide that each beneficiary's record include information needed to perform UR required under this subpart. This information must include, at least, the following:

(a) Identification of the beneficiary.

(b) The name of the beneficiary's physician.

(c) The name of the qualified Intellectual Disability professional (as defined under § 442.401 of this subchapter), if applicable.

(d) Date of admission, and dates of application for and authorization of Medicaid benefits if application is made after admission.

(e) The plan of care required under § 456.372;

(f) Initial and subsequent continued stay review dates described under §§ 456.433 and 456.434.

(g) Reasons and plan for continued stay, if the attending physician or qualified Intellectual Disability professional believes continued stay is necessary.

(h) Other supporting material that the UR group believes appropriate to be included in the record.

The UR plan must describe—

(a) The types of records that are kept by the group performing UR; and

(b) The type and frequency of reports made by the UR group, and arrangements for distribution of the reports to appropriate individuals.

The UR plan must provide that the identities of individual beneficiaries in all UR records and reports are kept confidential.

(a) The UR plan must provide for a review of each beneficiaries continued stay in the ICF at least every 6 months to decide whether it is needed.

(b) The UR plan requirement for continued stay review may be met by—

(1) Reviews that are performed in accordance with the requirements of §§ 456.432 through 456.437; or

(2) Reviews that meet on-site inspection requirements under subpart I if—

(i) The composition of the independent professional review team under subpart I meets the requirements of § 456.406; and

(ii) Reviews are conducted as frequently as required under §§ 456.433 and 456.434.

The UR plan must provide that—

(a) The group performing UR develops written criteria to assess the need for continued stay.

(b) The group develops more extensive written criteria for cases that its experience shows are—

(1) Associated with high costs;

(2) Associated with the frequent furnishing of excessive services; or

(3) Attended by physicians whose patterns of care are frequently found to be questionable.

The UR plan must provide that—

(a) When a beneficiary is admitted to the ICF under admission review requirements of this subpart, the group performing UR assigns a specified date by which the need for his continued stay will be reviewed;

(b) The group performing UR bases its assignment of the initial continued stay review date on the methods and criteria required to be described under § 456.435(a);

(c) The initial continued stay review date is—

(1) Not later than 6 months after admission; or

(2) Earlier than 6 months after admission, if indicated at the time of admission; and

(d) The group performing UR insures that the initial continued stay review date is recorded in the beneficiary's record.

The UR plan must provide that—

(a) The group performing UR assigns subsequent continued stay review dates in accordance with § 456.435.

(b) The group assigns a subsequent continued stay review date each time it decides under § 456.436 that the continued stay is needed—

(1) At least every 6 months; or

(2) More frequently than every six months if indicated at the time of continued stay review; and

(c) The group insures that each continued stay review date it assigns is recorded in the beneficiary's record.

The UR plan must describe the methods and criteria that the group performing UR uses to assign initial and subsequent continued stay review dates under §§ 456.433 and 456.434.

The UR plan must provide that—

(a) Review of continued stay cases is conducted by—

(1) The group performing UR; or

(2) A designee of the UR group;

(b) The group or its designee reviews a beneficiary's continued stay on or before the expiration of each assigned continued stay review date.

(c) For each continued stay of a beneficiary in the ICF, the group or its designee reviews and evaluates the documentation described under § 456.411 against the criteria developed under § 456.432 and applies close professional scrutiny to cases described under § 456.432(b);

(d) If the group or its designee finds that a beneficiary's continued stay in the ICF is needed, the group assigns a new continued stay review date in accordance with § 456.434;

(e) If the group or its designee finds that a continued stay case does not meet the criteria, the group or a subgroup that includes at least one physician reviews the case to decide the need for continued stay;

(f) If the group or subgroup making the review under paragraph (e) of this section finds that a continued stay is not needed, it notifies the beneficiary's attending physician or, in institutions for individuals with intellectual disabilities, the beneficiary's qualified Intellectual Disability professional, within 1 working day of its decision, and gives him 2 working days from the notification date to present his views before it makes a final decision on the need for the continued stay;

(g) If the attending physician or qualified Intellectual Disability professional does not present additional information or clarification of the need for the continued stay, the decision of the UR group is final;

(h) If the attending physician or qualified Intellectual Disability professional presents additional information or clarification, the need for continued stay is reviewed by—

(1) The physician member(s) of the UR group, in cases involving a medical determination; or

(2) The UR group, in cases not involving a medical determination; and

(i) If the individuals performing the review under paragraph (h) of this section find that the beneficiary no longer needs ICF services, their decision is final.

The UR plan must provide that written notice of any adverse final decision on the need for continued stay under § 456.436 (g) through (i) is sent to—

(a) The ICF administrator;

(b) The attending physician;

(c) The qualified Intellectual Disability professional, if applicable;

(d) The Medicaid agency;

(e) The beneficiary; and

(f) If possible, the next of kin or sponsor.

The UR plan must provide that the group gives notice under § 456.437 of an adverse decision not later than 2 days after the date of the final decision.