HospitalInspections.org

Based on review of a Department of Human Resource (DHR) letter, Behavioral Health Link's (BHL) online link, PBHS of Atlanta's Intake Call log, EMTALA log, transferring facility's medical record, BHL's fax'd material, Intake Call forms, PBHS of Atlanta's staff interviews, policies and procedures, and total number of psychiatric beds capacity and availability for 08/22/12, it was determined that the facility failed to ensure compliance with 42 CFR 482.24, Special Responsibilities of Medicare Participating Hospitals in Emergency Cases.

Findings were:

Cross refer to A2408 as it relates to the facility delaying the patient's examination or treatment in order to seek additional information regarding an individual's insurance and/or payor source. Cross refer to A2411 as it relates to the facility's refusal to accept an individual when the facility had the specialized capabilities and capacity.

Based on review of a DHR letter, BHL's online link, PBHS of Atlanta's Intake Call log, EMTALA log, transferring facility's medical record, BHL fax'd material to PBHS of Atlanta, Intake Call forms, PBHS of Atlanta's staff interviews, and total number of psychiatric beds capacity and availability for 08/22/12, it was determined that the facility delayed the patient's examination and/or treatment in order to seek additional information regarding the individual's insurance and/or payor source for 1 of 20 (#2) selected patient's Intake Call forms.

Findings were:

A letter sent from DHR to "Fulton County Providers & Emergency Room Personnel" dated 11/08/06 was reviewed. The letter noted that BHL provided a Georgia Crisis & Access Line that was a statewide service. The letter informed readers that the service was available 24/7 for urgent and emergent MHDDAD (mental health, developmental disabilities, and addictive diseases) services through 1-800-715-GCAL (4225) or online at mygcal.com. The letter noted that in Fulton County the service had been contracted by the Region 3 DHR Department of MHDDAD to serve as the single point of entry provided by the service. The letter noted that BHL maintained information with current bed availability for 12 area intensive residential programs including private psychiatric hospitals.

The BHL online link at beharioralhealthlink.com was reviewed and confirmed that the service was available 24/7. The site noted that the services had been credentialed by Georgia's DHR and the Department of MHDDAD services.

Review of the facility's Intake Call and EMTALA logs revealed the transferring facility never called PBHS of Atlanta to request a transfer for patient #2. The Intake Call form revealed the Assessment Counselor (interviewee #4 and personnel file #3) received a fax from BHL (a 24/7 center for mental health, addiction, and behavioral health crisis services, that Georgia's DHR funds) at 8:20 p.m. on 08/22/12. The fax informed the facility that the transferring facility had a patient that required psychiatric inpatient treatment.

Review of the transferring facility's medical record revealed that on 08/22/12 at 8:47 a.m. the patient was taken to the transferring facility's Emergency Department (ED) by the police after making threats to kill his/her family members. The patient was triaged as an "Emergent" patient. Documentation by the ED physician revealed the patient's past medical history included Paranoid Schizophrenia (chronic mental illness in which the person loses touch with reality, the classic features include delusions and hearing things that are not real). The physician noted that the patient had been diagnosed one (1) month ago. Documentation revealed that while the patient's mother was giving the patient's history the patient was laughing, telling the mother that she was wrong, and calling her a liar. The physician noted that the patient had kicked the mother multiple times, told her to stop telling him/her things, and had a bizarre thought process. The physician noted that the medical decision making included: Patient is not mentally stable at this time ... has had homicidal ideations with threats to murder his/her family for two (2) days, and physical threats made with a knife. The physician noted that at the time he/she had witnessed the patient's behavior and did not feel that the patient was stable for discharge. In addition, the physician noted that he/she felt the patient needed inpatient management for the safety of the patient and the family. At 2:00 p.m., the patient was evaluated by the transferring facility's Mental Health Licensed Clinician (MHLC). The MHLC noted that he/she discussed the patient with the ED physician and that the patient was going to be placed on a 1013 (Georgia's legal form that allows a patient to be involuntarily committed to a psychiatric facility when the patient is a threat to self or others). In addition, the MHLC noted that a referral was made to GCAL (Georgia Crisis & Access Line - BHL) for admission to an appropriate adolescent psychiatric facility. The 1013 was signed by the transferring facility's ED physician at 5:00 p.m. At 7:32 p.m., the physician noted that the patient's psychoses had become very apparent and that the patient was yelling, counting tiles on the wall, and acting aggressive in the ED. Documentation revealed the patient was administered Haldol (an anti-psychotic medication) 5 milligrams intravenously.

Review of the BHL fax' d material that was received by PBHS of Atlanta's Assessment Counselor (interviewee #4 and personnel file #3) revealed a BHL staff member had spoken to the ED physician. The BHL staff member's notes revealed the patient had previously been diagnosed with Paranoid Schizophrenia. The fax noted the patient's current medications, that the patient had been medically cleared, vital signs were within normal limits, and that the patient's blood work was positive for marijuana. In addition, this fax noted the patient's date of birth, address, and that the patient was on Peach State Health Plan / Medicaid.

The Intake Call form revealed the transferring facility fax' d PBHS of Atlanta a copy of the patient's current medical record on 08/22/12 at 8:39 p.m. PBHS of Atlanta's Nursing Intake Medical Assessment form was completed by a Registered Nurse on 08/23/12. The nurse noted that he/she received report from one of the transferring facility's nurses at 1:00 a.m. The nurse had checked the accepted box. In addition, the Eligibility Request form revealed the patient's Medicaid had been verified as being inactive. The Intake Call form noted that the patient was to be placed on unit 6 B. In addition, the Assessment Counselor noted on the Intake Call form that the patient had been sent elsewhere.

During interview #4 on 10/24/12 at 8:30 a.m. in the conference room, the Assessment Counselor (personnel file #3) stated he/she had received a referral from BHL, looked over it, and had given it to the nurse so that the nurse could get a nurse to nurse report. The Counselor stated he/she called BHL and was told that the patient would not receive an APS (American Psychiatric System - works collaborately with Medicaid agencies, state, and local care coordination) number because the patient was on Peach State. The Assessment Counselor stated he/she had then verified that the patient's Peach State was inactive. The Counselor explained he/she later called the facility and informed the nurse that the transferring facility needed to contact BHL so that the patient could be given an APS number. The Counselor stated the transferring facility called back and said the patient was being transferred elsewhere. The Counselor went on to explain that he/she never accepted or declined the patient. The Counselor stated he/she had called the transferring facility in order to get more information because BHL would not allow the facility to accept the patient without an APS number. The counselor stated he/she also needed to know what the patient's APS number was so he/she would know which physician would be accepting the patient.

During a telephone interview #6 on 10/24/12 at 1:30 p.m. in the conference room, the Registered Nurse (received the nurse to nurse report from the transferring facility) stated he/she received report and checked the box signifying that the patient met the criteria for being transferred to the facility. The nurse explained this did not mean that the patient had been accepted for transfer. The nurse stated he/she told the transferring facility's nurse that someone from the Assessment Center would call back to inform the facility whether the patient had been accepted and if accepted to arrange for transportation.

The transferring facility's documentation revealed the patient presented to the facility on 08/22/12 at 8:47 a.m. The transferring facility's nurse noted that he/she gave report to the PBHS of Atlanta's nurse on 08/23/12 at 1:00 a.m. In addition, the nurse noted that he/she was told that the Assessment Counselor would call back to arrange the transportation for the patient. At 3:40 a.m., the transferring facility's nurse noted that he/she received two (2) calls from two (2) different staff members at PBHS of Atlanta, and that the patient had been declined due to insurance issues. The transferring facility's nurse noted that on 08/23/12 at 6:50 a.m., that GCAL called regarding another psychiatric facility. The nurse noted that the patient's mother did not want the patient transferred to the other psychiatric facility and had requested that the patient be transferred to PBHS of Atlanta. On 08/23/12 at 9:30 a.m., the MHLC noted that the patient's insurance started 08/23/12 through Peachcare for Kids. The MHLC noted that he/she collected the information and sent it to PBHS of Atlanta. Documentation revealed MHLC was informed that PBHS of Atlanta only accepted Peachcare coverage through Amerigroup and Peach State. The MHLC noted that the patient's mother contacted Medicaid in order to get the patient accepted by one of the PBHS of Atlanta's acceptable plans. On 08/23/12 at 4:25 p.m., the transferring facility's nurse noted that the patient was still waiting to be transferred to a psychiatric facility. The ED physician noted that the patient was eventually transferred to another psychiatric facility in stable condition

During interview #1 on 10/23/12 at 10:15 a.m. in the conference room, the Director of Nurses stated the facility had received a referral from BHL and that while in the process of reviewing the referral the facility had been notified that the patient had been sent elsewhere.

During interview #2 on 10/23/12 at 10:45 a.m. in the conference room, the Director of the Assessment and Referral Services stated the facility had received a referral from BHL which was the state's contracted agency that handled the placement of psychiatric patients. The Director explained that BHL was mostly for unfunded patients. The Director confirmed that the transferring facility had not contacted the Assessment Center directly. The Director stated "we did not refuse to accept the patient, BHL informed us that the patient was being sent elsewhere." The Director explained that BHL had been in place for five (5) to six (6) years and that a psychiatric patient could not be accepted into a state or county psychiatric hospital without going through BHL. The Director stated most EDs called the facility directly to request a transfer. The Director explained that BHL first attempted to transfer patients to state or county psychiatric facilities and that if they couldn't within six (6) hours they would contact private psychiatric facilities. The Director stated BHL used the APS insurance company to review patients' psychiatric treatment and that the state of Georgia was then responsible for the patient's bill. The Director added that whether the patient had Peach State or was given an APS number the state of Georgia would have been responsible for the patient's bill. The Director stated BHL required the APS number to be issued before they would assign a patient to a facility for admittance. The Director stated the facility needed to know the payor source in order to assign a physician who accepted the patient's payment source so that the patient would not have to pay the physician directly. In addition, the Director stated the payment source could also interfere with which medications and treatments could be ordered for the patient. The Director stated the reason EDs in the state had to hold their psychiatric patients for days was because BHL was the gatekeeper for admissions to state hospitals.

During interview #3 on 10/23/12 at 1:45 p.m. in the conference room, the Chief Executive Officer (CEO confirmed that BHL was the contracted state funded single point of entry for psychiatric patients.

During an interview #6 on 10/24/12 at 2:00 p.m. in the conference room, the Assistant Administrator stated the facility performed Medical Screening Examinations as a community service to determine whether patients met the criteria for admission or could be handled on an outpatient basis.

Review of the Peachford BHS of Atlanta's bed availability for 08/22/12 revealed that at 12:01 a.m. the facility's census (total number of psychiatric inpatients) was 210 and at 11:59 a.m. the census was 216. The facility's total number of inpatient beds capacity was 232.

On 08/22/12 PBHS of Atlanta failed to accept patient #2 who required further medical examination and treatment for his/her identified psychiatric emergency medical condition (EMC), based on the patient's insurance status. This resulted in a delay of the patient's further examination and treatment.

Based on review of the Intake Call log, EMTALA log, transferring facility's medical record, BHL fax'd material, Intake Call forms, PBHS of Atlanta's staff interviews, policies and procedures, and total number of psychiatric beds capacity and availability. it was determined that the facility refused to accept an individual when the facility had the specialized capabilities and capacity for 1 of 20 (#2) selected patient's Intake Call forms.

Findings were:

Review of the facility's Intake Call and EMTALA logs revealed the transferring facility never called PBHS of Atlanta to request a transfer for patient #2. The Intake Call form revealed the Assessment Counselor (interviewee #4 and personnel file #3) received a fax from BHL (a 24/7 center for mental health, addiction, and behavioral health crisis services, that Georgia's DHR funds) at 8:20 p.m. on 08/22/12. The fax informed the facility that the transferring facility had a patient that required psychiatric inpatient treatment.

Review of the transferring facility's medical record revealed that on 08/22/12 at 8:47 a.m. the patient was taken to the transferring facility's Emergency Department (ED) by the police after making threats to kill his/her family members. The patient was triaged as an "Emergent" patient. Documentation by the ED physician revealed the patient's past medical history included Paranoid Schizophrenia (chronic mental illness in which the person loses touch with reality, the classic features include delusions and hearing things that are not real). The physician noted that the patient had been diagnosed one (1) month ago. Documentation revealed that while the patient's mother was giving the patient's history the patient was laughing, telling the mother that she was wrong, and calling her a liar. The physician noted that the patient had kicked the mother multiple times, told her to stop telling him/her things, and had a bizarre thought process. The physician noted that the medical decision making included: Patient is not mentally stable at this time ... has had homicidal ideations with threats to murder his/her family for two (2) days, and physical threats made with a knife. The physician noted that at the time he/she had witnessed the patient's behavior and did not feel that the patient was stable for discharge. In addition, the physician noted that he/she felt the patient needed inpatient management for the safety of the patient and the family. At 2:00 p.m., the patient was evaluated by the transferring facility's Mental Health Licensed Clinician (MHLC). The MHLC noted that he/she discussed the patient with the ED physician and that the patient was going to be placed on a 1013 (Georgia's legal form that allows a patient to be involuntarily committed to a psychiatric facility when the patient is a threat to self or others). In addition, the MHLC noted that a referral was made to GCAL (Georgia Crisis & Access Line - BHL) for admission to an appropriate adolescent psychiatric facility. The 1013 was signed by the transferring facility's ED physician at 5:00 p.m. At 7:32 p.m., the physician noted that the patient's psychoses had become very apparent and that the patient was yelling, counting tiles on the wall, and acting aggressive in the ED. Documentation revealed the patient was administered Haldol (an anti-psychotic medication) 5 milligrams intravenously.

Review of the BHL fax' d material that was received by PBHS of Atlanta's Assessment Counselor (interviewee #4 and personnel file #3) revealed a BHL staff member had spoken to the ED physician. The BHL staff member's notes revealed the patient had previously been diagnosed with Paranoid Schizophrenia. The fax noted the patient's current medications, that the patient had been medically cleared, vital signs were within normal limits, and that the patient's blood work was positive for marijuana. In addition, this fax noted the patient's date of birth, address, and that the patient was on Peach State Health Plan / Medicaid.

The Intake Call form revealed the transferring facility fax' d PBHS of Atlanta a copy of the patient's current medical record on 08/22/12 at 8:39 p.m. PBHS of Atlanta's Nursing Intake Medical Assessment form was completed by a Registered Nurse on 08/23/12. The nurse noted that he/she received report from one of the transferring facility's nurses at 1:00 a.m. The nurse had checked the accepted box. In addition, the Eligibility Request form revealed the patient's Medicaid had been verified as being inactive. The Intake Call form noted that the patient was to be placed on unit 6 B. In addition, the Assessment Counselor noted on the Intake Call form that the patient had been sent elsewhere because the patient had never been accepted by PBHS of Atlanta.

During interview #4 on 10/24/12 at 8:30 a.m. in the conference room, the Assessment Counselor (personnel file #3) stated he/she had received a referral from BHL, looked over it, and had given it to the nurse so that the nurse could get a nurse to nurse report. The Counselor stated he/she called BHL and was told that the patient would not receive an APS (American Psychiatric System - works collaborately with Medicaid agencies, state, and local care coordination) number because the patient was on Peach State. The Assessment Counselor stated he/she had then verified that the patient's Peach State was inactive. The Counselor explained he/she later called the facility and informed the nurse that the transferring facility needed to contact BHL so that the patient could be given an APS number. The Counselor stated the transferring facility called back and said the patient was being transferred elsewhere. The Counselor went on to explain that he/she never accepted or declined the patient. The Counselor stated he/she had called the transferring facility in order to get more information because BHL would not allow the facility to accept the patient without an APS number. The counselor stated he/she also needed to know what the patient's APS number was so he/she would know which physician would be accepting the patient.

During a telephone interview #6 on 10/24/12 at 1:30 p.m. in the conference room, the Registered Nurse (received the nurse to nurse report from the transferring facility) stated he/she received report and checked the box signifying that the patient met the criteria for being transferred to the facility. The nurse explained this did not mean that the patient had been accepted for transfer. The nurse stated he/she told the transferring facility's nurse that someone from the Assessment Center would call back to inform the facility whether the patient had been accepted and if accepted to arrange for transportation.

The transferring facility's documentation revealed the patient presented to the facility on 08/22/12 at 8:47 a.m. The transferring facility's nurse noted that he/she gave report to the PBHS of Atlanta's nurse on 08/23/12 at 1:00 a.m. In addition, the nurse noted that he/she was told that the Assessment Counselor would call back to arrange the transportation for the patient. At 3:40 a.m., the transferring facility's nurse noted that he/she received two (2) calls from two (2) different staff members at PBHS of Atlanta, and that the patient had been declined due to insurance issues. The transferring facility's nurse noted that on 08/23/12 at 6:50 a.m., that GCAL called regarding another psychiatric facility. The nurse noted that the patient's mother did not want the patient transferred to the other psychiatric facility and had requested that the patient be transferred to PBHS of Atlanta. On 08/23/12 at 9:30 a.m., the MHLC noted that the patient's insurance started 08/23/12 through Peachcare for Kids. The MHLC noted that he/she collected the information and sent it to PBHS of Atlanta. Documentation revealed MHLC was informed that PBHS of Atlanta only accepted Peachcare coverage through Amerigroup and Peach State. The MHLC noted that the patient's mother contacted Medicaid in order to get the patient accepted by one of the PBHS of Atlanta's acceptable plans. On 08/23/12 at 4:25 p.m., the transferring facility's nurse noted that the patient was still waiting to be transferred to a psychiatric facility. The ED physician noted that the patient was eventually transferred to another psychiatric facility in stable condition.

Review of PBHS of Atlanta's policy and procedure entitled "Patient Transfer From Another Facility", policy number CC.005, last revised 07/12, revealed it was the policy of the hospital to provide for an appropriate transfer of patients from another facility for admission. The policy noted that patients "may be accepted for transfer under the following circumstances;
1. The emergent condition had been stabilized to the extent possible by the transferring facility.
2. The approved criteria for admission at the level of care for which admission was requested had been met.
3. The transferring facility did not provide the structured behavioral health care treatment for the psychiatric condition, or the treatment was not authorized by the managed care provider or other third party payor and the patient requested or consented to transfer.
4. The admitting physician (i.e. nurse) or designee had directly communicated with the transferring physician or designee to establish the need for transfer and had agreed to accept responsibility for the patient's continuing treatment.
5. Admission was approved by the Chief Executive Officer or his/her authorized administrative representative, including emergencies." This policy also required the Charge Nurse to receive a nurse to nurse report from the transferring facility.

During interview #1 on 10/23/12 at 10:15 a.m. in the conference room, the Director of Nurses stated the facility had received a referral from BHL and that while in the process of reviewing the referral the facility had been notified that the patient had been sent elsewhere.

During interview #2 on 10/23/12 at 10:45 a.m. in the conference room, the Director of the Assessment and Referral Services stated the facility had received a referral from BHL which was the state's contracted agency that handled the placement of psychiatric patients. The Director explained that BHL was mostly for unfunded patients. The Director confirmed that the transferring facility had not contacted the Assessment Center directly. The Director stated "we did not refuse to accept the patient, BHL informed us that the patient was being sent elsewhere." The Director explained that BHL had been in place for five (5) to six (6) years and that a psychiatric patient could not be accepted into a state or county psychiatric hospital without going through BHL. The Director stated most EDs called the facility directly to request a transfer. The Director explained that BHL first attempted to transfer patients to state or county psychiatric facilities and that if they couldn't within six (6) hours they would contact private psychiatric facilities.

During interview #3 on 10/23/12 at 1:45 p.m. in the conference room, the Chief Executive Officer (CEO confirmed that BHL was the contracted state funded single point of entry for psychiatric patients. The CEO stated the facility had tried to challenge the BHL system at the recent Georgia Hospital Association meeting.

Review of the Peachford BHS of Atlanta's bed availability for 08/22/12 revealed that at 12:01 a.m. the facility's census (total number of psychiatric inpatients) was 210 and at 11:59 a.m. the census was 216. The facility's total number of inpatient beds capacity was 232.

On 08/22/12 PBHS of Atlanta failed to accept patient #2 as an appropriate transfer from a referring hospital, an individual who required the facility's specialized psychiatric capabilities.