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Based on interviews, record reviews, and review of the facility's policy, it was determined the facility failed to comply with 42 CFR 489.24(e)(1-2) regarding not transferring a patient with the appropriate paper work as evidenced by lack of documentation that the receiving facility 1) had agreed to accept the transfer for four (4) patients (Patient #1, #7, #8, and #19); and 2) had sent the required documentation to the receiving facility for one (1) patient (Patient #1) of twenty (20) sampled patients, on 01/08/2021.

The findings include:

Refer to findings in Tag A-2409.

Based on interview, record review, and review of facility's policy titled, "EMTALA," (Emergency Medical Treatment and Labor Act) it was determined the facility failed to ensure four (4) of twelve (12) patients selected for review as transfers from the facility via private vehicle (out of a total of twenty (20) patients reviewed) had an appropriate transfer as evidenced by lack of documentation that the receiving facility 1) had agreed to accept the transfer for four (4) patients (Patient #1, #7, #8, and #19); and 2) had sent the required documentation to the receiving facility for one (1) patient (Patient #1).

The findings include:

Review of the facility's policy titled, "EMTALA," last reviewed 02/2020, revealed the facility would provide appropriate screening, stabilization, and transfer of individuals who attempted to gain access to the hospital for emergency care regardless of payor source. The policy revealed, when individuals could not be admitted due to lack of space or capability to treat, a receiving physician and facility, appropriate to meet the individual's needs was secured, with communication documented of the receiving facility, including the date and time of the transfer and the name of the person accepting the transfer on the Memorandum of Transfer Form. The policy stated the receiving facility would be provided with copies of all assessment documents, to include any assessment documents with results of mental status, psychiatric history, and current symptoms.

1. Review of Patient #1's medical record revealed Patient #1 arrived at Facility #1, at 5:30 PM on 01/08/2021, with his/her guardian and a chief complaint of suicidal ideation with no attempt made and homicidal ideation. The Intake Assessment Clinical Summary stated Guardian #1 reported, on the previous two (2) nights, Patient #1 had been chasing the guardian and his/her siblings around the house with kitchen knives and threatening to kill him/herself, with no apparent trigger, and had been referred to the facility by Patient #1's outpatient therapist. Further review revealed the record stated Patient #1 denied any suicidal ideation or homicidal ideation, to Intake Clinician #1, and exhibited no behaviors while present with Guardian #1, during the assessment or while in the waiting room. Continued review of the medical record revealed Physician #1 recommended inpatient treatment for Patient #1, although Patient #1 did not meet criteria for placement at the facility, due to intellectual/developmental delay, and was recommended for inpatient treatment elsewhere. Review of a Level of Care Recommendation form, completed by Intake Clinician #1 and signed by Guardian #1 at 8:45 PM, referred Patient #1 to Facility #2 (according to Internet website https://mapquest.com, Facility #2 was located approximately twelve (12) miles from Facility #1). Recorded on Patient #1's Admitting Call Detail Log Notes, Patient #1 was referred to another treatment center as he/she was developmentally inappropriate for the facility. There was no documentation in Patient #1's medical record of who, at Facility #2, agreed to accept transfer of Patient #1, or the date and time of the communication with Facility #2. There was no Memorandum of Transfer Form or Bed Availability Form in Patient #1's medical record.

Interview with the Intake Director, Facility #1, on 07/14/2021 at 9:11 AM and again at 3:15 PM, revealed the Memorandum of Transfer Form mentioned in the facility's EMTALA policy was the Medical Transfer Form and was completed whenever a patient was transported out of the facility via ambulance, whether an emergent situation or not. She revealed it was not routinely completed when a patient left the premises in any other transportation, such as by family car. She stated the Level of Care Recommendation form was completed in other cases, and she would expect the name, title, date and time of contact with person accepting referral from another facility to be documented on both the Level of Care Recommendation form, and when used, the Bed Availability Form. She stated the Bed Availability Form was used to show contact with multiple facilities in order to find placement for patients. She stated the Bed Availability Form should be completed for any on-site assessment if a bed was not available or the patient was not program appropriate. In addition, she stated she expected staff to document who they spoke with and when, at the receiving facility, to ensure a smooth transition, as there had been times when delays in transfers resulted in confusion at the receiving facility; and, having that information assisted in ensuring patient placement and safety. The Intake Director reported it was important to look at bed availability prior to transferring a patient, as it was potentially a waste of time to send a patient to a facility with no available beds. Per the interview, she stated the goal was to ensure patients were provided appropriate care as soon as possible.

Interview with Intake Clinician #1, Facility #1, on 07/13/2021 at 3:02 PM, and again, on 07/14/2021 at 11:38 AM, revealed she recalled Patient #1 and Guardian #1, stating Patient #1 had been brought in on a recommendation by his/her therapist as he/she had been exhibiting aggressive behaviors and making suicidal statements at home. Intake Clinician #1 revealed, after discussion with Physician #1, it was determined Patient #1 met criteria for requiring inpatient care; however, the facility did not have programming appropriate, as Patient #1 was developmentally delayed. Intake Clinician #1 stated she called Facility #2, who said to send Patient #1 over, and they would assess him/her, although they did not want referral paperwork sent. Intake Clinician #1 stated Facility #2 was the only place she could think of that would have the programming to meet Patient #1's needs, and that was the only place she contacted. She stated she completed the Level of Care Recommendation form for Facility #2, reviewed with Guardian #1 that Patient #1 did not meet requirements for placement at Facility #1, and Guardian #1 was in agreement to take Patient #1 to Facility #2. Per the interview, she stated non-emergent ambulance transport was a day behind schedule. Since Patient #1 had not shown any signs of being unsafe for family transport, with no aggression toward Guardian #1 during the time the two (2) of them were at the facility, she stated the determination had been made by herself and Physician #1 that it was safe for Guardian #1 to transport Patient #1 to Facility #2. Intake Clinician #1 stated she did not know why she did not document who she had spoken to at Facility #2 or when. Usually, she stated, if the facility did not have any available beds, they used the Bed Availability Form to document contact information, but as Facility #2 was the only possible referral for Patient #1, due to Patient #1 being developmentally delayed, she did not use that form. Intake Clinician #1 revealed it was important to document contact with other facilities to confirm contact had been made. She also stated Facility #2 did not share their bed availability, although she did ask, but she was told to send Patient #1 over for an assessment.

Interview with Physician #1, Facility #1, on 07/14/2021 at 8:33 AM, revealed she reviewed patient information with Intake Clinician #1 over the phone and made a determination of level of care needed based on that information. She stated, for Patient #1, she recommended inpatient hospitalization; but, due to Patient #1 being developmentally delayed, he/she was inappropriate for placement at Facility #1. She stated Facility #2 had staff trained to work with developmentally delayed patients, and Patient #1 would benefit from their program. In addition, she believed Patient #1 could feel out of place in Facility #1 because he/she was not able to follow the program. She stated Intake Clinician #1 arranged placement, which was approved by family, at Facility #2, and based on the report by Intake Clinician #1, Guardian #1 was safe to transport Patient #1 to Facility #2. Further, Physician #1 stated, had she known there were no beds at Facility #2, she would have admitted Patient #1 to ensure the patient's safety, at least until a more appropriate placement could be found. Per the interview, Physician #1 stated, if Guardian #1 had called back and said there were no beds available at Facility #2, she would have instructed the Guardian to come back to Facility #1 and would have admitted Patient #1.

Interview with Guardian #1, on 07/13/2021 at 5:18 PM, revealed she transported Patient #1 to Facility #1 under the recommendation of Patient #1's therapist. She revealed she was informed by the facility that Patient #1 needed to be admitted, but was told shortly after, that Facility #1 would not accept Patient #1 due to his/her Intelligence Quotient (IQ, a measure of a person's ability to reason and solve problems) being below seventy (70), which indicated cognitive impairment. The guardian stated Facility #1 referred Patient #1 to Facility #2 and had her sign paperwork to that effect. Guardian #1 stated she contacted Facility #2 by phone, after leaving Facility #1, and was told they could come to Facility #2; however, there were no beds available. She stated she did not take Patient #1 to Facility #2 and tried in vain to find an alternative placement for Patient #1. She stated, although Patient #1 did not have a negative outcome, and later received the help he/she needed, she expressed concern for other minors who could not be so fortunate.

Interview with the Director of the Assessment Referral Center (ARC) from Facility #2, on 07/15/2021 at 9:34 AM, revealed if someone called requesting a transfer, staff would ask them to fax over clinical information, pending bed availability. She stated staff would let a professional referral source (other facility) know if there were no available beds. She stated phone calls were not documented, although referrals received were documented. The Director stated, if individuals or families called, staff worked to ensure they were safe and encouraged them to come in for an evaluation and referral, getting police or other resources involved if they were not safe. Per the interview, she stated anyone presenting would be evaluated for safety, provided a medical screening, and would be admitted, if necessary, or admitted elsewhere if beds were unavailable. Regarding Patient #1, she stated there was no referral received, on 01/08/2021, and Patient #1 had never been admitted to Facility #2. In addition, she reported fifteen (15) staff was working the referral center, on the evening of 01/08/2021, and as records were not maintained of every call, there was no way of knowing who could have spoken with Intake Clinician #1 or with Guardian #1, on the night of 01/08/2021.

Interview with Assessment Clinician #1, from Facility #2, on 07/15/2021 at 11:03 AM, revealed she was one (1) of the fifteen (15) staff working the ARC, on the night of 01/08/2021, and had no specific recollections from that evening. She stated she identified herself and title when she answered the phone, got information, and assisted if she was able. In addition, she stated she would always encourage facilities to send over a fax referral with clinical information, assessment, and a contact to follow up with. Per the interview, she stated, if a facility called and there were no beds available, she would share that information with them, but would encourage them to follow up the next day. Assessment Clinician #1 reported, when a potential patient or their family called, the facility did not provide bed status information but would always encourage the individual to come in for his/her safety and would work on finding an appropriate placement for him/her.

Interview with Assessment Clinician #2, from Facility #2, on 07/15/2021 at 11:36 AM, revealed she was one (1) of the fifteen (15) staff working the ARC, on the night of 01/08/2021, and had no specific recollections from that evening. She stated, if a facility called looking for patient placement, she asked for basic information, checked the appropriate units for bed availability, and would let the calling facility know if there were no available beds. She stated she would encourage the facility to check again, as bed availability status changed frequently. In addition, she stated she would not necessarily ask for a referral if there were no available beds, but if there were available beds, she would ask for a referral to be faxed over. Assessment Clinician #2 stated, if a parent called, the clinicians do not share bed status but would encourage the parent to bring the son/daughter in for an assessment.

2. Review of Patient #7's medical record revealed the patient arrived at Facility #1, on 03/16/2021, and was assessed by Intake Clinician #3 at 4:22 PM. Review of the Intake Assessment Clinical Summary revealed Patient #7 presented with a suicide attempt at school, where the patient attempted to jump off of a bridge but was stopped by school counselors. Continued review of the record revealed Patient #7 was evaluated by Physician #1 to require inpatient care, and the legal guardian was instructed to proceed to the children's Emergency Room of another recommended facility with Patient #7 to receive the inpatient care. Further review revealed a Bed Availability Form in the record, but only one (1) page of the two (2) page form was documented in the record, and it did not indicate who was spoken with at the receiving facility, or the date or time the conversation took place, in which the receiving facility agreed to the transfer of Patient #7.

Interview with Intake Clinician #3, Facility #1, on 07/14/2021 at 10:50 AM, revealed she assessed patients that came in and reviewed assessments with physicians to make a determination regarding level of care for patients. She stated the physician ultimately made the determination regarding level of care. In addition, she stated, if patients required inpatient care and were either not appropriate for the facility or there were no beds available at the facility, she looked for appropriate placements from the closest facility to the furthest. Per the interview, she stated, if a patient was not appropriate for certain facilities, the staff would reach out to appropriate facilities to meet the patient's need. Further, if a bed could not be found at another facility, she stated patients would be admitted until an appropriate facility could be found or a bed became available. She reported not all contacted facilities' staff would share bed status, but this facility always sent assessments anyway for other facilities to review. Intake Clinician #3 stated she documented who she spoke with on the Bed Availability Form, documenting if there were no available beds and documenting when a facility accepted the referral. When asked about Patient #7, Intake Clinician #3 revealed Patient #7 was not age appropriate for the facility's programs and was transferred to another facility that could provide a safe environment for Patient #7. She stated documentation would have been on page two (2) of the Bed Availability Form, that included who she spoke with, along with the time and date the referral was accepted.

3. Review of Patient #8's medical record revealed the patient arrived at Facility #1, on 03/12/2021, and was assessed by Intake Clinician #4 at 2:05 PM. Review of the Intake Assessment Clinical Summary revealed Patient #8 presented with suicidal ideation. Continued review of the record revealed Patient #8 was evaluated by Physician #1 to require inpatient care, and the legal guardian was instructed to transport Patient #8 to another facility recommended by the physician to receive inpatient care. Although a Bed Availability Form was partially completed, the facility Patient #8 was transferred to was not indicated on the Bed Availability Form, nor was information on the contact (name, title, date time) at the receiving facility.

Interview with Intake Clinician #4, Facility #1, on 07/14/2021 at 2:24 PM, revealed when someone presented to the facility, he/she was physically assessed and checked to ensure he/she was not carrying contraband. She stated, if there was nothing concerning in the vitals, staff assessed the patient and then spoke with a physician regarding disposition, usually sending the patient to another facility or continuing with the assessment. She stated, once the physician made the determination of level of care, it was reviewed with the patient and/or guardian. She stated, if the patient did not meet the requirements for placement at the facility, or if there were no beds available, staff attempted to find an alternate placement to meet his/her needs. She stated, if no placement was available, the patient would be admitted while attempts continued to find an appropriate placement. Intake Clinician #4 stated, if a bed was available, information was faxed to facilities, who would review it and determine if the receiving facility would accept the referral. Intake Clinician #4 stated documentation regarding who was contacted, along with the date and time, and whether or not the facility had any available beds, was documented on the Bed Availability Form. She stated the one (1) option for non-emergent ambulance service could take several hours, if it was available at all, and often if the physician determined it was acceptable, patients could be transported with guardians to receiving facilities. Regarding Patient #8, she stated she did not recall who she spoke with at the receiving facility, and she should have documented that information on the Bed Availability Form and the Level of Care Recommendation form as well. Further, she stated it was important for that information to be documented just in case something happened on the way to the receiving facility or if there were any questions regarding the transferred patient being accepted at the receiving facility.

4. Review of Patient #19's medical record revealed the patient arrived at Facility #1, on 01/22/2021, and was assessed by Intake Clinician #5 at 7:31 PM. Review of the Intake Assessment Clinical Summary revealed Patient #19 presented with suicidal ideation and a history of self-harming behaviors. Patient #19 was evaluated by Physician #2 to require inpatient care, and the legal guardian was instructed to transport Patient #19 to another recommended facility to receive inpatient care, as Facility #1 had no available beds. Continued review of Patient #19's medical record revealed no Level of Care Recommendation form or Bed Availability Form, with no documentation in the record of who was contacted or when, at the receiving facility.

Interview with Intake Clinician #2, Facility #1, on 07/13/2021 at 8:10 AM, revealed when a patient came to the facility, he/she was assessed, and if the determination was made that he/she needed to be transferred, staff would go down the list on the Bed Availability Form, assessing their bed status and faxing patient information to receiving or potentially receiving facilities. He stated, if all resources were exhausted, the reviewing physician was contacted to make him/her aware of the situation. Per the interview, if appropriate placement was found, he stated, it was discussed with the patient or guardian, and transportation was arranged. Intake Clinician #2 stated, if the patient was a child or adolescent, and the guardian felt comfortable transporting the patient, the guardian could do so if the physician was in agreement.

Interview with the Chief Nursing Officer (CNO), Facility #1, on 07/14/2021 at 2:59 PM, revealed the Medical Transfer Form was used if someone was sent out via ambulance or, in some cases, when someone was sent out to the hospital through other means, if an ambulance was not available. He stated it was the same form as the Memorandum of Transfer form mentioned in the "EMTALA" policy. The CNO stated the Level of Care Recommendation form was completed when someone was assessed, and the physician made a recommendation for level of care. Also, the CNO stated the recommendation could be for inpatient care at the facility, in which case the patient would be admitted to the facility. Further, he stated he was uncertain where contact information should be documented, although he expected this information to be documented. The CNO stated, anytime a patient was transferred, the contact information should include who was spoken to at other facilities, as well as the time, and that the receiving facility was in agreement to a transfer.

Interview with the Medical Director of Facility #1, on 07/15/2021 at 8:34 AM, revealed he expected staff to follow EMTALA regulations, contact the receiving facility to ensure it was aware of and had accepted the transfer, and document who was the accepting party at the receiving facility. The Medical Director expressed awareness of problems with non-emergent medical transport.