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Based on document review, interview, and videotape review, the facility failed to follow its own policy prohibiting prescreening discussion of a patient's ability to pay for services, thereby delaying the conduct of a medical screening examination for 1of 23 sampled patients (Patient #19). The findings are:

A. Review of the facility's policy number LGL.PDS-E. 117, dated 11/08/2006, entitled "EMTALA-Registration Policy" revealed the following statements in the "Procedure" section:
1. Paragraph 2:
"A Medical Screening Examination may not be delayed in order to:
-Inquire about an individual's ability to pay;
-Inform the individual patient that he or she must pay for his/her care if they choose to be treated;
-Perform insurance verification or authorization;
-Inform the patient that his/her care will be free or at a lower cost if they transfer to another facility."
2. Paragraph 4:
"All hospital staff, including admitting personnel and physicians, shall refrain from making any remarks that the patient might interpret to mean services may not be provided based on his or her ability to pay."
3. Paragraph 5:
"The registrar must refrain from requesting co-pays, deductibles, or past due balances from the patient until Medical Screening Examination, and necessary stabilization have occurred."

Based on document review, interview, and video tape review, the facility, by allowing a prescreening discussion of a patient's ability to pay for emergency services, delayed the conduct of a medical screening examination for 1 of 23 sampled patients (Patient #19). The facility, in so doing, failed to follow its own policy prohibiting prescreening discussion of a patient's ability to pay for emergency services, and unduly discouraged 1 of 23 sampled patients (Patient #19) from remaining for further evaluation. The findings are:

A. Review of an e-mail message dated 10/12/10, written by Staff #2, an ED physician, to the ED Medical Director, revealed the physician's concern that ED registration clerks had been asking patients for payments before the patients are triaged. A subsequent e-mail sent to all registration clerks later the same day stated that "You must not ask for patients' co-pay until after they are seen by the triage nurse."
1. Subsequent correspondence in the same e-mail chain revealed an interpretation of EMTALA regulations dated 10/13/10 from the facility's Healthcare Services compliance auditor that it is permissible to incorporate financial matters into a reasonable registration process as long as treatment is not unduly delayed.
2. The final message in the e-mail chain revealed a communication dated 10/15/10 from the hospital Director of QAPI/Compliance to the hospital business manager, ED nurse manager, and ED medical director. The message stated in part, "Note that triage is not the medical screening exam. Any money collected prior to this medical screening exam could be considered to be in violation of EMTALA. This means that the licensed independent practitioner needs to perform the medical screening."
3. On 03/23/11 at 3:46 pm, during interview, the hospital Director of QAPI/Compliance stated that the hospital [leadership] knew of the ED physician's October complaint but had done nothing about it.

B. Review of the facility's policy number LGL.PDS-E. 117, dated 11/08/2006, entitled "EMTALA-Registration Policy" revealed the following statements in the "Procedure" section:
1. Paragraph 2:
"A Medical Screening Examination may not be delayed in order to:
-Inquire about an individual's ability to pay;
-Inform the individual patient that he or she must pay for his/her care if they choose to be treated;
-Perform insurance verification or authorization;
-Inform the patient that his/her care will be free or at a lower cost if they transfer to another facility."
2. Paragraph 4:
"All hospital staff, including admitting personnel and physicians, shall refrain from making any remarks that the patient might interpret to mean services may not be provided based on his or her ability to pay."
3. Paragraph 5:
"The registrar must refrain from requesting co-pays, deductibles, or past due balances from the patient until Medical Screening Examination, and necessary stabilization have occurred."

C. On 03/22/11 at 2:40 pm, during interview, the hospital's Business Office Manager was asked about her involvement in a reported incident on 03/15/11 in which a hospital employee was alleged to have discussed payment issues with a patient who had not yet received a medical screening examination. This discussion was alleged to have taken place in front of other patients in the ED waiting area. She stated, "An incident came in through MIDAS, the automated patient complaint system. I received it. It was about a financial counselor speaking to a patient after triage in the waiting room. The issue was that the nurse thought it was a HIPAA violation because the nurse thought the financial counselor was speaking to the patient in the waiting room. I reviewed the account and spoke to the counselor. I asked her what was going on. She said that there was no one else around except the patient's girlfriend. She [the financial counselor] told him that we have indigent and state coverage funds available for him and that ER visits are $500 and up. She gave him a list of items he had to provide for coverage. I did not call the patient. She was in error in talking to him at that point. I gave her a verbal counseling because she saw him prior to the MSE. She told him to see her the next day to complete the application. He did see her the next day. There was no allegation that the screening exam was held up because of the discussion. This happened on March 15th."
D. On 03/22/11 at 3:15 pm, during interview, Staff #3, the financial counselor, stated, "I work with self-pay accounts. When the patient comes to the ER, they [the registrars] give us a call and say they have a self-pay. I go to the ER and see them and let them know about different financial types of assistance we have. We talk with them after the doctor has seen them. In this case, I went to see the patient. It was 4:30 pm, my quitting time. I was on my way out but knew about the patient and his past bad debts. I wanted to let him know about the financial assistance available. He was in the ER waiting area. I sat with him and his girlfriend. There was no one else in the room. I let him know about the different types of assistance available. I let him know that the visit would be $500 plus whatever they did to him. He said, 'That's a lot of money.' I said that I'm just here to tell you what your options are. He wasn't upset about me speaking about this issue in a public area. There was no one there but us. I was just about done talking to him when the nurse opened the door. I stood up and he stood up and walked to her and I left. I never talk to a patient until after the exam is completed. This was an exception. I absolutely did not give the patient any indication that he would not be seen if he did not produce payment."
E. On 03/22/11 at 4:10 pm, during interview, Patient #19, stated, "I didn't like the way the lady spoke to me about my personal business in front of everybody. There were a few other people in the waiting room. She said that the visit would cost $500 and wanted to know how we were able to pay for it. I don't know if she said I had to pay $500 to be seen or not. I took off my wrist band and said that I would leave. She started acting different and came up with something that she could get other people to pay for the bill and that's when I said I'd do it. When the nurse came in to get me, the nurse stayed in the waiting room while we were talking. The conversation went on a few minutes. The nurse didn't know what to do. She just stood there while I was talking to the billing person."
F. On 03/22/11, at 4:15 pm, during interview, the girlfriend of Patient #19, stated, "My boyfriend has memory problems. The registration clerk said that she would send someone from the billing office. She said she would put him back to a room and talk to him about financial aid. We went to triage. Our friend [name omitted] was in the waiting room when we came out of triage. She [the financial counselor] was talking to him in front of a bunch of people about financial issues. She told him about his previous bills. She was nasty to him. She told him, 'Do you know how much walk-ins are? It costs $500 to walk-in.' Then he [the friend] went into the doctor. She [the financial counselor] turned around and called [Patient #19]. She sat us down in front of three girls [who were in the waiting room] and said, 'There are hospitals down the road to get seen and walk-ins are $100.' Then the nurse walked out and called for [Patient #19]. He said, 'I'm not going to be seen because it will cost and I'm not going to pay it.' She kept asking if he wanted to be seen and he said, 'If it's $500 I won't do it.' He took off his wrist band and went to throw it away. Her attitude changed and she said, 'We have this coverage, and how to get it.' She then said, 'The visit could be free if you bring in certain information.' Then [Patient #19] decided to get treatment. The nurse heard the discussion. She was present about five minutes -- 10 at the most."
G. On 03/24/11 at 10:35 am, during interview, Staff #4, RN, stated, "With respect to the encounter with [name of Patient #19], "I opened the door to the lobby and went into the lobby to call the patient in. I stood in front of the triage window and called [Patient #19]. He was with [name of financial counselor] from the business office. He yelled back at me, 'Forget it, I'm not being seen, I'm not paying $500 for this visit.' [name of financial counselor] saw me and said [to Patient #19], 'If you bring this paperwork, everything will be taken care of.' I also said, 'Don't worry about that right now, let's see what's going on [medically].' She gave him some paperwork and told him what he needed to bring in. I waited for about 5 minutes. I can't say that if he would have been seen by the physician earlier, but the ER was not busy and it was likely he would have been seen soon after placing him in the room. He was really upset when he was in the room. Specifically, he was upset about personal information being asked in front of everybody. He was really worried about the bill. He said, 'They promised me that if I bring in the paperwork, everything will be taken care of.' There were other patients in the waiting room at the time."
H. On 03/23/11 at 3:31 pm, during interview, Patient #20, a friend of Patient #19 and his girlfriend who had gone to the hospital ED at the same time for treatment of an illness, stated, "While waiting in the waiting room, I spoke with [the hospital financial counselor]. She showed me what I owed the hospital. She explained that it would be $500 just to be seen in the ER."
I. On 03/23/11 at 11:05 am, ED surveillance tapes that were produced from the front waiting area surveillance camera during the period of the alleged encounters between Patients #19 and #20 and the hospital financial counselor on 03/15/11 were reviewed. Tape review revealed the following:
4:17 pm: Person identified as hospital financial counselor enters the ED waiting area and sits down with a male wearing a red "hoodie." [Note: Patient #20 later stated that he wore a red hoodie to the hospital on that date.]
4:21 pm: Financial counselor stands up, then sits down next to person later identified as Patient #19 and a woman (patient #19's girlfriend).
4:23 pm: Patient #19 gets up from chair and throws something into the trash.
4:26 pm: Nurse enters waiting area and calls for someone. She stands there and waits.
4:27 pm: Hospital financial counselor is still talking with Patient #19 and his girlfriend.
4:28 pm: Patient #19 accompanies the nurse into the treatment area.
1. The hospital's security supervisor, who reviewed the surveillance tapes with the surveyors, verified the above events and that there were other people in the ED waiting room at the time of the encounters.