Ala. Admin. Code r. 560-X-5-.09

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-5-.09 - Inspection Of Care

(1) The Medicaid Quality Assurance Program will periodically perform an inspection of care and services provided to recipients in accordance with 42 C.F.R. Part 456, Subpart I. The review team must consist of psychiatrist or physician with knowledge and experience in the provision of care in mental institutions and other appropriate mental health and social service personnel. This physician may not inspect the care of a recipient for whom he is the attending physician or for whom he has served as the consulting physician. The Medicaid Agency will determine, based on the quality of care and services provided in the facility and the condition of recipients in the facility, at what intervals inspections will be made. However, the review team must inspect the care and services provided to each recipient in the facility at least annually. The inspection must include:

(a) Personal contact with and observations of each recipient; and/or

(b) Review of each recipient's medical record.

In making determination of adequacy of services, the team may consider items such as, but not limited to:

(a) The medical, social, and psychiatric evaluations and an assessment of the adequacy and completeness of the plan of care;

(b) The plan of care is followed;

(c) All services ordered are provided and properly documented;

(d) The attending physician reviews of prescribed medication regimens are made at the appropriate times and properly documented;

(e) Tests or observations of each recipient indicated by his medication regimen are made at appropriate times and properly documented;

(f) Professional progress notes are made as required and consistent with the observed condition of the recipient;

(g) The recipient receives adequate services based on observation;

(h) The recipient needs continued inpatient care; and

(i) Alternative care is available and appropriate.

(2) Each recipient's chart will be reviewed by the Medicaid review team to assure that the following items are included on the chart:

(a) Certification of need. (PSY-5)

(b) Recertifications. (PSY-6 or acceptable equivalent)

(c) Completed medical, social, and psychiatric evaluations.

(d) Current plan of care.

(3) The review team will also review the chart for:

(a) Physician, nurse, and other professional staff members' progress notes. These notes will be assessed for consistency with the observed condition of the patient.

(b) Services being provided as ordered.

(c) Completeness of the plan of care.

(d) Documentation supporting the need for continued hospitalization.

(e) Documentation of review of medication by a physician every 30 days.

(f) Discharge plan or a plan for alternative care.

(4) The review team must submit a report on each inspection that contains observations, conclusions, and recommendations as specified in 42 C.F.R. 456.611.

(5) At the time of the inspection, the team will also review each recipient's record for compliance with all state and federal regulations. Payments for admissions that are found to be out of compliance may be recouped by Medicaid.

Author:

Ala. Admin. Code r. 560-X-5-.09

New Rule: Filed September 6, 1995; effective October 12, 1995. Amended: Filed October 6, 1997; effective November 10, 1997.

Statutory Authority:42 C.F.R. Part 456, Subpart I; Section 456-600-456.614