N.Y. Comp. Codes R. & Regs. tit. 10 § 85.16

Current through Register Vol. 46, No. 50, December 11, 2024

Section 85.16 - Review of adverse finding

(a) A nurse reviewer at the area office of the Office of Health Systems Management shall be assigned to review the information forwarded by the utilization review agent, and determine whether all relevant factors were considered in arriving at the adverse finding.

(b) The nurse reviewer may send the case back to the facility for appropriate corrections if the information on the patient review forms (PRI and SCREEN) is not internally consistent, or if the information on the forms is not legible, or if the forms are not fully completed or signed by authorized individuals, or if the information provided is otherwise unacceptable.

(c) If the patient's or resident's attending physician has not supplied the utilization review agent with information concerning the patient's or resident's current clinical status and the patient's or resident's ability to accept transfer, the nurse reviewer shall contact the attending physician and obtain this information.

(d) If the nurse reviewer finds that all written information is acceptable, the reviewer shall contact the facility administrator to schedule an onsite visit. Upon the onsite visit, the nurse reviewer shall:

(1) compare the patient review forms with the patient's or resident's medical record or chart to ensure that the form is reflective of the patient's or resident's current medical condition;

(2) discuss the appropriateness of the adverse finding, including the patient's or resident's physical and psychological response to transfer with the social worker, attending nurse, attending physician and other facility staff directly involved in providing care to the patient or resident;

(3) observe the patient's or resident's physical and emotional condition; and

(4) request the patient's or resident's attending physician to clinically examine the patient or resident if his medical record is not up to date.

(e) If the nurse reviewer believes the transfer is not medically safe and not in the best interest of the patient or resident, and that the proposed transfer is not suited to the particular needs of the patient or resident, then the nurse reviewer shall refer the case back to the Office of Health Systems Management's area office for physician review and certification, indicating whether continued stay at the current level of care is appropriate. If the Office of Health Systems Management's physician certifies that the current level of care is appropriate, the residential health care facility will be notified of this certification.

(f) If the nurse reviewer agrees with the adverse finding, or the Office of Health Systems Management physician upholds the adverse finding as cited in subdivision (e) of this section, the nurse reviewer shall contact the patient or resident and advise him that a recommendation of transfer has been made, and shall determine whether the patient or resident voluntarily agrees to the transfer. If the patient or resident is unable to consent to the transfer because of confusion or impaired judgment, it will be presumed that the patient or resident has not voluntarily agreed to the transfer.

(1) If the patient or resident voluntarily agrees to the transfer, the decision of the utilization review agent shall stand, and the case shall be referred to the Office of Health Systems Management's area office for physician review and certification that he concurs with the adverse finding.

(2) If the patient or resident does not voluntarily agree to the transfer, except that the patient or resident agrees to be transferred to a specific facility or facilities, the decision of the utilization review agent shall stand upon condition that the patient or resident can only be transferred to the specified facility or facilities.

(3) If the patient or resident does not voluntarily agree to the transfer, and the patient or resident is a resident of a multi-level facility and can be transferred within the facility to a lower level of care in accordance with the utilization review agent decision, the decision of the utilization review agent shall stand upon condition that the patient or resident can only be transferred within the multi-level facility.

(4) If the patient or resident does not voluntarily agree to the transfer, and the patient or resident is not a resident of a multi-level facility, the case shall be referred to the Office of Health Systems Management's area office for physician review and certification that continued stay at that level of care is approved.

(g) If the patient or resident voluntarily agrees to the transfer, a dated, written and signed statement shall be obtained from the patient or resident, describing the specific transfer consented to and reciting that the patient or resident understands that the transfer will not be required without his consent. This statement shall also be signed by the nurse reviewer who shall certify that the patient or resident understood and voluntarily signed the statement, and that the patient or resident is not unable to consent to the transfer because of confusion or impaired judgment.

N.Y. Comp. Codes R. & Regs. Tit. 10 § 85.16