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Based on observation, interviews and document reviews, the facility failed to comply with the Medicare provider agreement as defined in §489.20 and §489.24 related to Emergency Medical Treatment and Labor Act (EMTALA) requirements.

FINDINGS

1. The facility failed to meet the following requirements under the EMTALA regulations:

Tag 2408: §489.24(d)(4),(5)(4) Delay in Examination or Treatment.(i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual's method of payment or insurance status.(ii) A participating hospital may not seek, or direct an individual to seek, authorization from the individual's insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section.(iii) An emergency physician or non-physician practitioner is not precluded from contacting the individual's physician at any time to seek advice regarding the individual's medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section.(iv) Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. Based on document reviews and interviews, the facility failed to comply with the Emergency Treatment and Labor Act (EMTALA). Specifically, the facility failed to ensure the registration process did not delay examination and treatment in three of four pregnant patients who sought emergency care. (Patient #1, #22, and #23)

Based on document reviews and interviews, the facility failed to comply with the Emergency Treatment and Labor Act (EMTALA). Specifically, the facility failed to ensure the registration process did not delay examination and treatment in three of four pregnant patients who sought emergency care. (Patient #1, #22, and #23)

Findings include:

Facility policy:

The Emergency Medical Treatment and Labor Act (EMTALA) policy read, neither the medical screening exam nor any required stabilizing treatment for an emergent medical condition shall be delayed to inquire about the individual's insurance status. Under no circumstances shall an individual be required to complete a financial responsibility form prior to receiving a medical screening exam and/or necessary stabilizing treatment. Registration could occur so long as it does not delay or otherwise adversely affect the medical screening exam and/or treatment to stabilize an emergent medical condition.

1. The facility failed to ensure the registration process did not delay examination and treatment for pregnant patients who sought emergency care.

a. On 12/12/2024 at 7:24 a.m., the financial responsibility form, referred to in the EMTALA policy, was requested. The Agreement for Assignment of Insurance Benefits consent was provided. Review of the Agreement for Assignment of Insurance Benefits consent revealed section one allowed the facility to bill and receive payment from patients' insurance companies. Section two was a statement of financial responsibility in which patients promised to pay for any service not covered by their insurance company.

b. Medical record review revealed Patient #1, who was 39 weeks and 6 days pregnant, arrived at the facility on 12/2/24 at 6:36 a.m. with a chief complaint of contractions. Patient #1 signed the Agreement for Assignment of Insurance Benefits consent (financial responsibility form) at 6:38 a.m. Nursing documentation revealed Patient #1's vital signs were obtained at 6:45 a.m. and a triage assessment was completed at 6:51 a.m. Provider documentation at 8:11 a.m. revealed Patient #1 was in labor.

c. Medical record review revealed Patient #22, who was 36 weeks pregnant, arrived at the facility on 9/8/24 at 11:40 a.m. with a chief complaint of decreased fetal movement. Patient #22 signed the Agreement for Assignment of Insurance Benefits consent at 11:41 a.m. Nursing documentation at 12:27 p.m. revealed Patient #22 reported they did not feel any fetal movement for two days and there were no fetal heart tones. Provider documentation at 12:30 p.m. revealed Patient #22 had an intrauterine fetal demise (death of a fetus).

d. Medical record review revealed Patient #23, who was 39 weeks and 1 day pregnant, arrived at the facility on 9/15/24 at 7:49 p.m. with a chief complaint of labor. Patient #23 signed the Agreement for Assignment of Insurance Benefits consent at 7:50 p.m. Nursing documentation at 7:52 p.m. revealed Patient #23 was in 10 out of 10 pain. Patient #23's vital signs were obtained at 8:00 p.m. and a triage assessment was completed at 8:39 p.m. Provider documentation at 10:16 p.m. revealed Patient #23 had an intrauterine fetal demise.

These medical record reviews were in contrast to the EMTALA policy which read, under no circumstances shall an individual be required to complete a financial responsibility form prior to receiving a medical screening exam and/or necessary stabilizing treatment.

e. Review of the Admission, Discharge, and Transfer of Emergency Department (ED) Patients policy revealed financial information for ED patients was requested after the medical screening exam had begun. Registration associates could request information from patients to begin the registration process, provided care was not delayed due to inquiry about the patient's insurance status.

f. On 12/12/24 at 8:42 a.m., upon request, the facility was unable to provide a policy or process staff were to follow for how to register pregnant patients who presented to the obstetrics (OB) registration desk for emergency care.

g. On 12/9/24 at 10:25 a.m. through 12/12/24 at 8:32 a.m., interviews were conducted with patient access representative (PAR) #1. PAR #1 stated they registered patients in the ED and at the OB registration desk. PAR #1 stated when patients presented to the ED for emergency care, they were asked for their photo ID, the last four digits of their social security number if they did not have a photo ID, their chief complaint, and were provided an identification wristband. PAR #1 stated PAR staff verified patients' demographic information, collected insurance information, and had patients sign their consents once they had been examined in the ED. PAR #1 stated insurance information was collected after patients had been examined because of EMTALA, and patients were treated whether or not they had insurance.

PAR #1 also stated patients were sent from the ED registration desk to the OB registration desk if they were greater than 20 weeks pregnant and had an OB related chief complaint. PAR #1 stated if patients had not preregistered, they were asked to verify their name, date of birth, and provide a photo ID or the last four digits of their social security number. PAR #1 stated they were also asked if they had insurance, or insurance information would be verified with them, and their insurance card would be scanned if it was not in the electronic medical record (EMR) system. PAR #1 stated they were additionally asked how many weeks pregnant they were, what clinic they used, if they wanted a religious visit, and if they wanted their primary care physician to be notified of why they had come to the facility. PAR #1 stated patients then signed their consents and were provided an identification wristband. PAR #1 also stated patients were asked to fill out an OB triage notes paper to give to their triage nurse (including the patient's name, last four of their social security number, what clinic they used, allergies, current height and weight, due date, how many times they had been pregnant, how many living children they had, and current medications).

Additionally, PAR #1 stated when patients presented to the OB registration desk with abdominal pain, were in active labor, or screaming in pain, PAR staff only collected their name, date of birth, and what clinic they used to assign the appropriate provider. PAR #1 stated PAR staff then collected consents and verified patients' information once they had been stabilized. PAR #1 stated a pregnant patient who presented for lack of fetal movement took priority over a patient who presented for a lactation appointment, but they were registered the same way. PAR #1 stated they did not know why additional information was collected before OB patients were examined versus the limited information collected before ED patients were examined. PAR #1 stated this was the process they were trained to follow. PAR #1 stated labor was pretty much the only medical emergency patients presented to the OB registration desk with. PAR #1 stated they did not want to delay care for patients who were in labor. PAR #1 stated laboring patients needed to be examined and receive the treatment they required.

This interview was in contrast to the EMTALA policy which read, neither the medical screening exam nor any required stabilizing treatment for an emergent medical condition shall be delayed to inquire about the individual's insurance status. Under no circumstances shall an individual be required to complete a financial responsibility form prior to receiving a medical screening exam and/or necessary stabilizing treatment. Registration could occur so long as it did not delay or otherwise adversely affect the medical screening exam and/or treatment to stabilize an emergent medical condition.

h. On 12/12/24 at 11:10 a.m., an interview was conducted with OB registered nurse (RN) #2. RN #2 stated there were emergent medical conditions (EMC) that could occur in patients who were greater than 20 weeks pregnant, such as vaginal bleeding, high blood pressure, rupture of membranes, fever, labor, and decreased fetal movement. RN #2 stated nurses and providers determined if pregnant patients had an EMC. RN #2 stated all complaints were treated as urgent. RN #2 stated everyone who presented had an EMC until it was determined otherwise and pregnant patients needed to be assessed to determine what had happened so interventions could be provided.

i. On 12/12/24 at 1:13 p.m., an interview was conducted with OB provider (Provider) #3. Provider #3 stated labor, severe preeclampsia (blood pressure condition occurring during pregnancy), abruption (when the placenta pulls away from the uterus), and fetal low heart rate were examples of EMCs patients greater than 20 weeks could experience. Provider #3 stated it was important not to delay the medical screening exam for these patients because staff could not determine these EMCs had occurred unless the patients were talked to and examined by a nurse and/or provider. Provider #3 said patients could be very sick and look well. Provider #3 stated these patients could get sick quickly if the medical screening exam was delayed and their EMC was not addressed immediately.

j. On 12/12/24 at 11:46 a.m., an interview was conducted with patient access manager (Manager) #4. Manager #4 stated when unscheduled OB patients presented to the OB registration desk, they should have only been asked for their name, date of birth, photo ID or last four digits of their social security number, chief complaint, and what clinic the patient used to assign a provider. Manager #4 stated PAR staff should never discuss finances unless patients were scheduled visits.

This was in contrast to the interview with PAR #1 who stated patients who were not preregistered were asked for their insurance information unless they presented with abdominal pain, were in active labor, or screaming in pain.

Manager #4 stated staff completed extensive training to ensure they were fully competent before they were allowed to work the OB registration desk. Manager #4 also stated the facility did not have a policy for PAR staff to follow when unscheduled OB patients were registered. Manager #4 stated if patients appeared to be in distress, had contractions, or were in labor, the Agreement for Assignment of Insurance Benefits consent should have been signed after they had received the medical screening exam. Manager #4 stated they noticed the Agreement for Assignment of Insurance Benefits consents were signed by Patients #1, #22, and #23 when they were registered.

This was in contrast to the EMTALA policy which read, under no circumstances shall an individual be required to complete a financial responsibility form prior to receiving a medical screening exam and/or necessary stabilizing treatment.

Manager #4 also stated contractions, labor, decreased fetal movement, and anything heart related were key words PAR staff listened for that indicated patients were in distress. Manager #4 stated insurance verification happened after the medical screening examination had occurred for patients who came in with decreased fetal movement, contractions, or in labor.

This was in contrast to the interview with PAR #1 who stated insurance information was verified and insurance cards were scanned into the EMR for patients who were not preregistered. This was also in contrast to the interview with RN #2 who stated nurses and providers determined if pregnant patients had an EMC, all complaints were treated as urgent, and everyone who presented had an EMC until it was determined otherwise. Additionally, this was in contrast to the interview with Provider #3 who stated pregnant patients could be very sick and look well, and staff could not determine if pregnant patients experienced an EMC unless the patients were talked to and examined.

Furthermore, this was in contrast to the EMTALA policy which read, neither the medical screening exam nor any required stabilizing treatment for an emergent medical condition shall be delayed to inquire about the individual's insurance status. Registration could occur so long as it did not delay or otherwise adversely affect the medical screening exam and/or treatment to stabilize an emergent medical condition.

Furthermore, Manager #4 stated it was important not to delay care because PAR staff were not clinically trained and the patients' care teams determined their acuity of care.