CMS SOM App. K, Tag I-603

The utilization review committee, consisting of the group of professional personnel

specified in §485.56(c), a committee of this group, or a group of similar composition,

comprised by professional personnel not associated with the facility must carry out the

utilization review plan.

The Utilization Review (UR) Committee must meet at least quarterly. The composition of

this committee should be written into the utilization review plan and should be representative

of the professional personnel that provide services in the CORF. A facility physician or non-

CORF physician must be a member of the UR committee.

____________________________________________________________________

I-604, I-605, I-606, I-607

(Rev. 16, Issued: 01-10-06; Effective/Implementation Date: 11-21-05)

§485.66(b)Standard: Utilization Review Plan

The utilization review plan must contain written procedures for evaluating:

(1) Admissions, continued care, and discharges using, at a minimum, the criteria

established in the patient care policies;

(2) The applicability of the plan of treatment to established goals; and

(3) The adequacy of clinical records with regard to:

(i) Assessing the quality of services provided;

(ii) Determining whether the facility’s policies and clinical practices are

compatible and promote appropriate and efficient utilization of services.

The plan should contain specific procedures and standards necessary to assess the

effectiveness and efficiency of the services provided . The number of cases selected for

review should be representative of the types of patients treated at the CORF and the types of

services provided. The frequency of reviews should be outlined in the plan.

Reports and outcomes of evaluations should be reflected in the minutes of the utilization

review committee. Those minutes should also indicate the extent to which the CORF

program, policies and practices are being followed. Review the minutes of the utilization

review committee to determine if the plan is being followed.

Results of utilization review activities should be made available to all professional personnel.

Identify whether the results of the review prompted recommendations concerning CORF

policies and practices and whether the recommendations were communicated to the

administrator and governing body and the group of professional personnel (if different from

the utilization review committee).

GENERAL COMMENTS:

(Rev. 16, Issued: 01-10-06; Effective/Implementation Date: 11-21-05)

A CORF may be established on the premises of another health entity irrespective of whether

this entity is already certified under Medicare as a provider or supplier of services. For

example, a CORF may be established on the premises of a skilled nursing facility (SNF) and

the SNF's owner(s) may either have legal responsibility for both the SNF and the CORF, or

merely rent space within the SNF to the CORF's owner(s). In either situation, the CORF

must be certified sep arately and be functionally and operationally independent. The

regulatory definition of a CORF precludes the CORF, and another entity from mixing

functions and operations in a common space during concurrent or overlapping hours of

operation.

In the same manner as space may be shared, equipment may also be shared. All common

equipment must be available (on the premises of the CORF) during the CORF's hours of

operation and not, at that time, be utilized by the other entity for any purpose.

The CORFs must be surveyed pursuant to the CORF conditions of participation and all

standards must be surveyed independent of any findings resulting from the completed

survey of the other entity. That is, although there may have been no deficiencies noted

during the survey of the other entity, this fact must not influence any determination with

respect to the survey pursuant to the CORF conditions of participation.

Transmittals Issued for this Appendix

Rev # Issue Date Subject Impl Date CR#

R200SOMA 02/21/2020 Revisions to the State Operations Manual

(SOM) Appendix A -

Hospitals, Appendix AA – Psychiatric

Hospitals, Appendix B – Home Health

Agency, Appendix D - Portable X-Ray,

Appendix G - Rural Health Clinics/Federally

Qualified Health Centers, Appendix H- End

Stage Renal Disease Facilities (ESRD),

Appendix K – Comprehensive Outpatient

Rehabilitation Facility, Appendix L -

Ambulatory Surgical Centers, Appendix M –

Hospice, Appendix U - Religious

Nonmedical Healthcare Institutions,

Appendix W - Critical Access Hospitals

(CAHs), Appendix X-Organ Transplant

Program and Appendix Z - Emergency

Preparedness

02/21/2020 N/A

R016SOMA 01/10/2006 Revisions to Chapter 2, Appendix E and

Appendix K

10/21/2005 N/A

R013SOM 10/21/2005 Revisions to Chapter 2, Appendix E and

Appendix K

10/21/2005 N/A