Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 6 - INPATIENT PSYCHIATRIC AND SUBSTANCE USE DISORDER SERVICES › Section 317:30-5-95.42 - Service quality review (SQR) of psychiatric facilities and residential substance use disorder (SUD) facilities

Current through Vol. 41, No. 20, July 1, 2024
(a) The SQR
				  conducted by the OHCA or its designated agent meets the utilization control
				  requirements as set forth in 42 C.F.R. Part 456 .
(b) There will be an SQR of each in-state
				  psychiatric facility and residential SUD facility that provides services to
				  SoonerCare members which will be performed by the OHCA or its designated agent.
				  Out-of-state facilities that provide services to SoonerCare members will be
				  reviewed according to the procedures outlined in the Medical Necessity Manual.
				  Ad hoc reviews may be conducted at the discretion of the agency.
(c) The OHCA will designate the members of
				  the SQR team. The SQR team will consist of one (1) to three (3) team members
				  and will be comprised of LBHPs or registered nurses (RNs).
(d) The SQR will include, but not be limited
				  to, review of facility and clinical record documentation and may include
				  observation and contact with members. The clinical record review will consist
				  of records of members currently at the facility as well as records of members
				  for which claims have been filed with OHCA for acute, PRTF, or residential SUD
				  levels of care. The SQR includes validation of compliance with policy, which
				  must be met for the services to be compensable.
(e) Following the SQR, the SQR team will
				  report its findings in writing to the facility. A copy of the final report will
				  be sent to the facility's accrediting agency, as well as the State Survey
				  Agency, if applicable, and any licensing agencies.
(f) Deficiencies identified during the SQR
				  may result in full or partial recoupment of paid claims. The determination of
				  whether to assess full or partial recoupment shall be at the discretion of the
				  OHCA based on the severity of the deficiencies.
(g) Any days during which the facility is
				  determined to be out of compliance with Federal Conditions of Participation,
				  excluding residential SUD facilities, or in which a member does not meet
				  medical necessity criteria may result in full recoupment. Full recoupment may
				  also result from a facility's failure to provide requested documentation within
				  the time frames indicated on requests for such documents or if the SQR team is
				  denied timely admittance to a facility and/or access to facility records during
				  any on-site portion of the SQR.
(h)
				  Items which may result in full or partial recoupment of paid claims shall
				  include, but not be limited to:
(1)
Assessments and evaluations.
Assessments and evaluations must be
				  completed, with dated signature(s), by qualified staff within the timeframes
				  outlined in Oklahoma Administrative Code (OAC)
				  317:30-5-95.6,
				  317:30-5-95.37, and
				  317:30-5-95.47(1).
(2)
Plan of care.
Plans of care
				  must be completed, with all required dated signatures within the timeframes
				  described in OAC
				  317:30-5-95.4,
				  317:30-5-96.33, and
				  317:30-5-95.47(2).
(3)
Certification of need (CON).
CONs for psychiatric facilities must be completed by the appropriate team and
				  in the chart within the timeframes outlined in
				  42 C.F.R. §§
												441.152,
				  456.160, and
				  456.481.
(4)
Active treatment.
Treatment
				  must be documented in the chart at the required frequency by appropriately
				  qualified staff as described in OAC
				  317:30-5-95.5,
				  317:30-5-95.7,
				  317:30-5-95.8,
				  317:30-5-95.9,
				  317:30-5-95.10,
				  317:30-5-95.34, and
				  317:30-5-95.46(b).
(5)
Documentation of services.
Services must be documented in accordance with OAC
				  317:30-5-95.4,
				  317:30-5-95.5,
				  317:30-5-95.8,
				  317:30-5-95.10,
				  317:30-5-95.41,
				  317:30-5-95.52 and
				  317:30-5-95.47 and
				  42 C.F.R. §§
												412.27(c)(4) and
				  482.61. Documentation with missing
				  elements or documentation that does not clearly demonstrate the therapeutic
				  appropriateness and benefit of the service may result in recoupment.
(6)
Staffing.
Staffing must meet
				  the ratios described in OAC
				  317:30-5-95.24(b)
				  -(d) & (h) and OAC
				  317:30-5-95.38 per unit/per
				  shift; and credentialing requirements as outlined in OAC
				  317:30-5-95.8,
				  317:30-5-95.9,
				  317:30-5-95.35,
				  317:30-5-95.36,
				  317:30-5-95.46(b)
				  and 42 C.F.R. §§
												412.27(d),
				  441.153,
				  441.156, and
				  482.62.
(7)
Restraint/seclusion.
Orders
				  for restraint and seclusion must be completely and thoroughly documented with
				  all required elements as described in OAC
				  317:30-5-95.39 and
				  42 C.F.R. §
												482.13(e) & (f) and 42
				  C.F.R. Part 483 . Documentation must support the appropriateness and necessity
				  for the use of restraint/seclusion. For PRTFs, documentation must include
				  evidence that staff and resident debriefings occurred as required by OAC
				  317:30-5-95.39 and 42 C.F.R. Part
				  483. For residential SUD facilities, restraint may only be used when less
				  restrictive interventions, according to facility policy, have been attempted or
				  when an immediate intervention is required to protect the resident, a staff
				  member, or others. A written incident report must be completed within
				  twenty-four (24) hours following each use of physical
				  restraint.