Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 670031 (X3) Date Survey Completed 01/12/2012
Name of Provider or Supplier St Luke's Patients Medical Center Street Address, City, State 4600 East Sam Houston Parkway South, Pasadena, TX
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
A0654 UTILIZATION REVIEW COMMITTEE
CFR(s): 482.30(b)

A UR committee consisting of two or more practitioners must carry out the UR function. At least two of the members of the committee must be doctors of medicine or osteopathy. The other members may be any of the other types of practitioners specified in ยง482.12(c)(1). (1) Except as specified in paragraphs (b)(2) and (3) of this section, the UR committee must be one of the following: (i) A staff committee of the institution; (ii) A group outside the institution-- (A) Established by the local medical society and some or all of the hospitals in the locality; or (B) Established in a manner approved by CMS. (2) If, because of the small size of the institution, it is impracticable to have a properly functioning staff committee, the UR committee must be established as specified in paragraph (b)(1)(ii) of this section. (3) The committee or group's reviews may not be conducted by any individual who-- (i) Has a direct financial interest (for example, an ownership interest) in that hospital; or (ii) Was professionally involved in the care of the patient whose case is being reviewed.


This STANDARD is not met as evidenced by:
Based on interview and record review, the Hospital failed to ensure the Utilization Review Committee consisted of at least two physician practitioners in 2010 and 2011. Findings include: Record review of the facility's Utilization Review committee meeting minute sign-in sheets revealed only one physician participated in the following meetings: February 25, 2010 April 22, 2010 September 8, 2010 August 25, 2011 October 27, 2011 The Chief Financial Officer stated 1/12/12 at 9:35 a.m. that he was not aware of the requirement by CMS that two physicians are required to participate in the Utilization Review committee process. Record review of a hospital policy titled "Utilization Review Management Plan" dated 11/2011 stated "Composition of the Utilization Review (UR) Committee: A Utilization Review committee consisting of two or more practitioners must carry out the UR function."