CMS SOM App. U, Tag R236

The utilization review plan must contain written procedures for evaluating the

following:

(1) Admissions.

(2) Duration of care.

(3) Continuing care of an extended duration.

(4) Items and services furnished.

Interpretive Guidelines: §403.746(a)

The RNHCI should have procedures that provide for a systematic evaluation of its total

program to ensure appropriate utilization of services and to determine whether the

organization’s policies are followed in providing services to patients through employees

or under arrangements with others. This may include but is not limited to admissions,

duration of care, continuing care and items and services furnished to patients.

Written reports of the results of the evaluation should be maintained, and the RNHCI

should have a performance improvement plan that collects data about the organization’s

performance on an ongoing basis. The evaluation should be conducted by the

professional staff of the organization and outside professionals, where appropriate.

These reports should contain the names of those participating in the evaluation, the

results, and expected action, if indicated.

Survey Procedures:

• Verify that the RNHCI has written procedures which evaluate the elements of this

standard.