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Based on review of facility policies and medical records (MR) and staff interviews (EMP), it was determined that the facility failed to meet the requirements of the Emergency Medical Treatment and Labor Act and failed to adopt policies and procedures to ensure compliance with the requirements of 42 CFR 489.24.

Findings include:

Review of the facility policy "Emergency Department Collection of Co-Pays and Financial Discussions on Emergent Patients " reviewed January 2014, stated " Policy: To assume the appropriate Emergency Medical Treatment and Labor Act Policy guidelines are followed when collecting co-pays/deposits or entering into financial discussions on emergent patients in the Emergency Department. Procedures: * This policy applies to both Medicare and Non-Medicare patient accounts. * Uniontown Hospital will make every attempt to collect the co-pay/deposit patient responsibility amounts in the Emergency Department for medically assessed emergent patients. * No personnel may delay a Medical Screening Examination in order to determine whether an Emergency Medical Condition (EMC) exists to discuss financial information or responsibility. * Once a patient has been medically assessed as emergent, and it has been appropriately documented in the patient's medical record, financial information and co-pays/discount responsibility will be discussed during the registration process. After a discharge disposition has been indicated on the Firstnet Tracking board the patient will be asked to pay their co-pay/deposit amount. The patient's assessment level will be indicated on the Firstnet Tracking board as either EMC (emergent medical condition) or ATN (additional treatment needed to make a further defined assessment). * After the assessment has been completed, financial information and responsibility will be discussed during the registration process. * At the time of discharge disposition or an admission event is set, the patient may be asked to pay the co-pay/deposit amount. * The patient will be asked if they need financial assistance. If they indicate they would like help, a further conversation will occur regarding the options our organization has available to help them meet their financial obligations. * Any previous balances greater than 120 days old and considered bad debt will also be discussed at the time of discharge. Financial Assistance will be discussed and help will be offered them to meet their financial obligations. ... ."

4) Review of the facility policy " Patient Financial Access/Registration Emergency Department Collection of Co-Pays and Financial Discussions on Non-Emergent Patients " reviewed January 2014, stated " Procedures: This policy applies to both Medicare and Non-Medicare patient accounts. Uniontown Hospital will make every attempt to collect the co-pay/deposit patient responsibility amounts in the Emergency medical Condition exists to discuss financial information or responsibility. Once a patient has been medically assessed and an Emergency Medical Condition does not exist, and it has been appropriately documented in the patient ' s medical record as a non-emergent condition, financial information and responsibility will be discussed. The patient's assessment will be indicated on the Firstnet Tracking board as No EMC. On non-emergent patients, continuation of medical treatment will not be continued until the patient has paid the co-pay amount for that visit. If the patient refuses to pay the co-pay or deposit amount, they will be asked to seek further care from an appropriate provider for a non-emergent condition. The patient will be asked if they need financial assistance. If they indicate they would like help, a further conversation will occur regarding the options our organization has available to help them meet their financial obligations. All non-emergent patients will receive information on the types of medical conditions that could be treated outside of an Emergency Department setting. A list of alternate providers will also be given to the patient. Any previous balances greater than 120 days old and considered bad debt will also be discussed before medical treatment continues. Financial Assistance will be discussed and help will be offered to them to meet their financial obligations. A patient ' s treatment for a non-emergent visit will not be stopped for bad debt. Only a discussion will take place. "
Review of MR1's ED History and Physical (H&P) performed by ED Physician EMP26 dated July 22, 2014, at 14:00 stated, " Chief Complaint: Abdominal pain now for several weeks. History of Present Illness: The patient tells me 3-4 weeks and that in the computer 2 weeks. Right side occasional, right lower quadrant, right groin toward umbilicus, worse last night. Nursing assessment noted pain rated at 8/10. No nausea, vomiting, fever, chills. No urinary symptoms. No rectal bleeding. The patient did not seek any medical help for this condition. The patient does have past medical history significant for multiple visits for abdominal pain dating back at least to 2012 with significant imaging done on multiple occasions including CAT scan and ultrasound. The imaging did show fatty infiltration of the liver and ovarian cyst for which the patient received appropriate instructions and request for follow up. Subsequently, sonogram however, did show ovarian cyst at that time. There is also history of C-section, 5 childbirths, hypertension, bilateral tubal ligation. Again, ovarian cyst is seen in July 2013, clearly discharged home with diagnosis of ovarian cyst requested to follow up with OB/GYN... . Current Medications...Hydrochlorothiazide...Lisinopril...Metropolol...Review of Systems...Constitutional...There is no fever of weight loss...Neurological...No syncope, headache...Psychological...No delusions or paranoia...Pulmonary...No cough, no congestion...Gastrointestinal...See HPI...Remainder of systems negative...Physical Examination...Alert and oriented x3...Vital Signs...Abdomen...Somewhat obese, protuberant, but soft. Normoactive bowel sounds. No guarding, no rebound. No severe tenderness on palpation. ... Emergency Room Course: [Patient] previous medical records and [patient] condition probably is related to ovarian cyst. However, the patient clearly advised that she never had ovarian cyst. I pointed out that [patient] has had multiple imaging sonograms, laboratory work. [Patient] did have PCP in the past, but at that this point, the patient told me that [patient] was in between PCPs .... In review of [patient] symptoms lasting for several weeks, more than 2 weeks, more like 3-4 weeks, benign abdominal examination and the fact that the patient would be best served if her care was coordinated by PCP. ... The patient had known ovarian cyst and failed to follow up with OB/GYN, which obviously will not have happened if [patient] had PCP coordinating those treatments. I think to be in best patient's interest would be to find [patient] PCP and consider further testing. The patient's condition complains of several weeks and benign examination are deemed non emergent. ... The patient decided to leave before completion of the tests due to financial reasons I believe. "
During an interview on August 6, 2014, at approximately 1:00 PM, ED Medical Director EMP19 stated, " The Pre Services Payment Initiation started in January. We have had debt with frequent flyers, they sign in under false names, we have medication seeking patients that are clogging the ER for people that need seen. It ' s challenging to keep doctors here because of the pay, and because it ' s not in the city. We also try to steer them toward programs they may qualify for. It is the hospital trying to survive. We still have charity care that is available. We have people that come in for eczema that they've had for 15 years. We screen them and decide if they have an emergency medical condition (EMC). I urge the doctors to err on the side of caution. We do try to tell them also that their copay will be cheaper if they go to med express. A no EMC order is written. It can never be a verbal order. They go back and talk to the patient, after finance discussions, the light turns green and we go back in and finish the process. Yes, it makes people nervous, but if you have any doubts, to toward an emergency condition. If it is kids, go toward emergency. ERMI (emergency room management incorporated) is looking at this process and planning to institute this process if we are successful. .... If that were my patient, I would have done more testing, especially with abdominal pain. He is going through evidence based medicine, the last three times she was here she had a CT that showed ovarian cyst. He felt she should not have an additional CT because of the risks associated with CT scan.
During an interview on August 8, 2014, at 1:30 PM, EMP24 stated, "On January 1, 2014, we did a lot of research. Our CFO felt we needed to be more proactive on copay's before services for walk-ins for non-emergent testing. We had a process in place to determine if it is an urgent test. EMTALA regulations drove the process in the ED. No registration or financial decision occurs before a medical screen. A quick screen happens when they come in, they are triaged, but in a room and after the physician is completed, a registration event is sent and we know that we can enter and finish registration. We have a third category called ATN - Additional Treatment Needed. Emergent or non-emergent treatment. Our associate staff have been trained to give financial information If non emergent, then the EMTALA regs stop because it is no longer an emergent condition. If they owe a co-pay, and can't pay, we tell them we have to stop your treatment now. We give them brochures for alternate less expensive treatment. If self-pay, we work with the Wesley Center for free healthcare and educate them about going to ER or Urgent care. If self-pay we ask for $100.00 copay. If they can ' t pay we offer our charity program. If they sign the charity application, we let them through. If they make a payment on the copay, we let them through as well. We mailed our new policy to the public when they came in to register 4 months before this occurred. If they sign the form, (Emergency Department Non-Emergent Release of Responsibility LWTC due to Financial Reason), we release them of the charge for the visit. If they refuse to sign the form, we charge them for the visit."

The ED Medical Director EMP19 also stated during his August 6, 2014 interview, " We put forth an effort to collect funds to make us viable. "

Based on a review of facility documents and medical records (MR), and staff interviews (EMP), it was determined the facility failed to provide an appropriate medical screening examination within the capability of the hospital's Emergency Department for one of 17 medical records (MR1).

Findings include:

Review of the facility's EMTALA policy, reviewed March, 2014, Policy: Any individual who comes to [facility] requesting emergency services is entitled to and will receive a Medical Screening Exam performed by individuals qualified to perform such exams to determine whether an Emergency Medical Condition exists. ... . Definitions: ... . 12. Medical Screening Examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not Emergency Condition exists or a woman is in labor. Such screenings must be performed within the Capabilities and Qualified Medical Personnel, including On-Call Physicians. The Medical Screening examination is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and continue until the patient is either stabilized of appropriately transferred.

Review of facility policy "Emergency Department Collection of Co-Pays and financial Discussions on Emergent Patients," reviewed January 2014 revealed, "Policy: To assume the appropriate Emergency Medical Treatment and Labor Act Policy guidelines are followed when collecting co-pays/deposits or entering into financial discussions on emergent patients in the Emergency Department. Procedures: * This policy applies to both Medicare and Non-Medicare patient accounts. * Uniontown Hospital will make every attempt to collect the co-pay/deposit patient responsibility amounts in the Emergency Department for medically assessed Emergent patients. * No personnel may delay a Medical Screening Examination in order to determine whether an Emergency Medical Condition exists to discuss financial information or responsibility. * Once a patient has been medically assessed as Emergent, and it has been appropriately documented in the patient's medical record, financial information and co-pays/discount responsibility will be discussed during the registration process. After a discharge disposition has been indicated on the Firstnet Tracking board the patient will be asked to pay their co-pay/deposit amount. The patient's assessment level will be indicated on the Firstnet Tracking board as either EMC (emergent) or ATN (additional treatment needed to make a further defined assessment). * After the assessment has been completed, financial information and responsibility will be discussed during the registration process. * At the time of discharge disposition or an admission event is set, the patient may be asked to pay the co-pay/deposit amount. * The patient will be asked if they need financial assistance. If they indicate they would like help, a further conversation will occur regarding the options our organization has available to help them meet their financial obligations. * Any previous balances greater than 120 days old and considered bad debt will also be discussed at the time of discharge. Financial Assistance will be discussed and help will be offered them to meet their financial obligations. ... ."

Review of facility policy " Patient Financial Access/Registration Emergency Department Collection of Co-Pays and Financial Discussions on Non-Emergent Patients " dated January 6, 2014, revealed " Procedures: This policy applies to both Medicare and Non-Medicare patient accounts. Uniontown Hospital will make every attempt to collect the co-pay/deposit patient responsibility amounts in the Emergency medical Condition exists to discuss financial information or responsibility. Once a patient has been medically assessed and an Emergency Medical Condition does not exist, and it has been appropriately documented in the patient ' s medical record as a non-emergent condition, financial information and responsibility will be discussed. The patient's assessment will be indicated on the Firstnet Tracking board as NoEMC. On non-emergent patients, continuation of medical treatment will not be continued until the patient has paid the co-pay amount for that visit. If the patient refuses to pay the co-pay or deposit amount, they will be asked to seek further care from an appropriate provider for a non-emergent condition. The patient will be asked if they need financial assistance. If they indicate they would like help, a further conversation will occur regarding the options our organization has available to help them meet their financial obligations. All non-emergent patients will receive information on the types of medical conditions that could be treated outside of an Emergency Department setting. A list of alternate providers will also be given to the patient. Any previous balances greater than 120 days old and considered bad debt will also be discussed before medical treatment continues. Financial Assistance will be discussed and help will be offered to them to meet their financial obligations. A patient's treatment for a non-emergent visit will not be stopped for bad debt. Only a discussion will take place.

1. Review of MR1 Emergency Department (ED) physician examinations and assessments revealed the chief complaint of right lower quadrant abdominal pain, for several weeks. The patient reported the pain was worse the previous night. Nursing assessment revealed the pain reported at 8/10. No nausea or vomiting, no fever, chills. Past medical history of visits for abdominal pain and a past diagnosis of ovarian cyst. Also, a history of C-section, five childbirths, hypertension and tubal ligation. The review of systems revealed no fever or weight loss. Neurological, psychological and pulmonary were negative. The patient was alert and oriented times three. Vital signs were within normal limits. Abdomen, somewhat obese, protuberant, but soft. Normoactive bowel sounds, no guarding, no rebound. No severe tenderness on palpation. Further review of MR1 revealed no documentation of orders for diagnostic testing. The ED physician noted in the medical record, " ... In review of her symptoms lasting for several weeks, more than two weeks, more like three to four weeks, benign abdominal examination and the fact that the patient would be best served if her care was coordinated by PCP. The patient had known ovarian cyst and failed to follow up with OB/GYN, which will not have happened if she had a PCP coordinating those treatments. ... . The patient's condition, complaints of several weeks and benign examination are deemed non-emergent. The patient decided to leave before testing completion of the tests due to financial reasons, I believe."

2. Interview with EMP19 on August 7, 2014, revealed, " ... If that were my patient, I would have done more testing, especially with abdominal pain. [Physician] is going through evidence based medicine. The last 3 times [MR1] was here [MR1] had a CT that showed ovarian cyst. [Physician] felt [MR1] should not have an additional CT because of the risks associated with CT scan."
3. Review of the Highlands Hospital Emergency Department medical record [of the patient of MR1] revealed, "July 22, 2014,10:30 PM Chief Complaint: Right lower quadrant abd pain, n/v (nausea/vomiting) onset three days, getting worse. ... . Gastrointestinal: Abdomen soft, bowel sounds active, ... Hyperactive. Pain of right lower quadrant and right mid quadrant. ... to be admitted. ... . Diagnosis/Clinical Impression: right lower abdominal pain, acute appendicitis. ... ." Review of Highlands Hospital, July 23, 2014, History and Physical. Reason For Admission: Abdominal pain. Rule out appendicitis. History of Present Illness: This is a 44 year old [person] who started to have right lower quadrant pain over the past four days. It got worse yesterday. The patient was having nausea and vomiting. ... . The patient presented to the emergency room and was found to have appendicitis on the CT scan and clinical evaluation. ... . Assessment: 1. Acute abdominal pain. Rule out appendicitis. ... . plan: keep patient NPO (nothing by mouth). IV fluids. IV antibiotics and proceed with diagnostic laparoscopy and appendectomy." Highlands Hospital, Report of Operation: Date of surgery: July, 23, 2014. ... . Preoperative Diagnosis: Acute appendicitis. Post operative Diagnosis: Acute appendicitis."

Based on review of facility documents and medical records (MR), and employee interviews (EMP), it was determined that the facility failed to ensure all elements of an appropriate transfer were met for five of seven medical records reviewed (MR20, MR21, MR25, MR26, and MR29).
Findings include:
Review of facility EMTALA policy reviewed 3/2014 revealed, "...14. Physician means: - a doctor of medicine or osteopathy; - a doctor of dental surgery or dental medicine who is legally authorized to practice dentistry by the state and who is acting within the scope of his/her license; - a doctor of podiatric medicine to the extent that he/she is legally authorized to perform state; - a doctor of optometry to the extent that he/she is legally authorized to perform by the state; - a chiropractor who is licensed by the state or authorized to perform by the state but only with respect to treatment by means of manual manipulation of the spine to correct a subluxation demonstrated to exist by x-ray. "...15. Physician Certification refers to written certification by the treating Physician ordering the Transfer and prior to the patient's Transfer that, based on the information available to the Physician at the time of Transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the increased risks and benefits upon which the certification is based and the reason(s) for the Transfer. If the Physician is not physically present at the time of Transfer, qualified medical personnel can sign a certification as long as qualified medical personnel is in consultation with the Physician and the Physician is in agreement with the certification and subsequently countersigns the certification. 16. Qualified Medical Personnel refers to those non-Physician individuals defined by the Hospital's Rules and Regulations/Policies and approved by the Hospital's Board of Directors to perform the Medical Screening Examination for those individuals who come to the Emergency Department and request examination or treatment."
Review of Medical Staff Bylaws Appendix reviewed July, 2014, revealed, "II. ... C. Verbal Orders ...4. Verbal orders for medication or treatment should be issued only under urgent circumstances when it is impractical for the orders to be given in an electronic or written manner by the provider, as defined in the Delinquent Medical Record Policy. For acute inpatients, a provider must sign, date and time verbal orders within 72 hours of issue by the ordering provider by authenticating them through the inbox of the electronic medical record."
Review of facility policy ED Medical Record Documentation, revised 8/13, revealed, "II. Documentation: A. Emergency Department record: reflects physician assessment, interventions, patient response, final diagnosis, final disposition and discharge plan."
1) Review of MR20 revealed the patient presented to the Emergency Department on June 24, 2014, at 19:50 and was transferred to another hospital on June 26, 2014, at 01:57. There was no documentation of a physical assessment by an MD on the record. The authorization and consent for acute care transfer sheet indicating condition on discharge, risk of transfer, and reason for transfer was completed by a registered nurse and signed as verbal order of a physician by a registered nurse on June 25, 2014. There was no documentation of a physician countersignature on the authorization and consent for transfer form.
2) Review of MR21 revealed the patient presented to the Emergency Department on June 24, 2014, at 23:00, and was transferred to another hospital on June 25, 2014, at 16:00. No documentation of a physical assessment by an MD was observed. The authorization and consent for acute care transfer sheet, indicating condition on discharge, risk of transfer, and reason for transfer, was completed by a registered nurse and signed as verbal order of physician by a registered nurse on June 25, 2014. There was no documentation of a physician countersignature on the authorization and consent for transfer form.
3) Review of MR25 revealed the patient presented to the Emergency Department on July 21, 2014, at 13:45, and was transferred to another hospital on July 21, 2014, at 19:20. Documentation of a physical assessment by a physician was dictated on July 24, 2014. The authorization and consent for acute care transfer sheet indicating condition on discharge, risk of transfer, and reason for transfer was signed by the physician on July 21, 2014, at 18:30.
4) Review of MR 26 revealed the patient presented to the Emergency Department on July 15, 2014, at 08:15, and was transferred to another hospital on July 15, 2014, at 12:00. Documentation of a physical assessment by a physician was dictated on July 27, 2014. The authorization and consent for acute care transfer sheet indicating condition on discharge, risk of transfer, and reason for transfer was completed by a registered nurse and signed as verbal order of a physician by a registered nurse on July 15, 2014. A countersignature by a physician was dated July 30, 2014.
5) Review of MR29 revealed the patient presented to the Emergency Department on May 12, 2014, at 22:00, and was transferred to another hospital on May 13, 2014, at 20:38. There was no documentation of a physical assessment by a physician on the record. The authorization and consent for acute care transfer sheet indicating condition on discharge, risk of transfer, and reason for transfer was signed by the physician on May 13, 2014, at 18:30.
6) Review of above completed on August 6, 2014, at approximately 2:30 PM with EMP1, when asked about lack of physician documentation revealed, "I think the doctors were confused about who was covering and who was on call."