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Based on the manner and degree of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §485.627 ORGANIZATIONAL STRUCTURE was out of compliance.

C-0241 - Standard: Governing Body or Responsible Individual - The governing body failed to ensure the role and responsibility of mental health providers providing consultation and conducting assessments for CAH patients was clearly delineated by contract or through medical staff bylaws. This failure resulted in non-contracted and non-affiliated personnel to access patient's current status and medical history, assess patients while in the care of the facility and coordinate the transfer of patients requiring psychiatric hospitalization or outpatient services, on behalf of the facility. Further, this failure potentially contributed to poor patient outcomes.

Based on interview and document review the governing body failed to ensure the role and responsibility of mental health providers providing consultation and conducting assessments for hospital patients was clearly delineated by contract or through medical staff bylaws.

This failure resulted in non-contracted and non-affiliated personnel to access patient's current status and medical history, assess patients while in the care of the facility and coordinate the transfer of patients requiring psychiatric hospitalization or outpatient services, on behalf of the facility. Further, this failure potentially contributed to poor patient outcomes.

FINDINGS

1. The Governing Body did not ensure medical staff bylaws addressed practitioners providing specialized mental health services at the facility and failed to evaluate the quality of care provided by these practitioners.

a) On 03/28/17 the current Board of Directors Bylaws and Bylaws of the Medical Staff for the facility were reviewed. The role, responsibility, oversight and review of the quality of care provided by the external mental health service provider entity was not addressed in either document.

b) On 03/28/17 a list of contracted services and an index of policies and procedures followed by the facility was provided. There was no contract or other agreement for services provided by the unaffiliated mental health service provider utilized by the facility. There was no policy or procedure listed that addressed how and when to access the mental health provider, the services to be provided and how the services would be evaluated.

c) During an interview, with the Chief Executive Officer (CEO #2) on 03/29/17 at 12:10 p.m., s/he stated there was no contract with the external mental health provider entity. S/he stated once a patient was medically stabilized, the external mental health provider was contacted and asked to come assess the patient and provide recommendations for care and treatment. If psychiatric hospitalization was recommended, the mental health provider was the entity that made the referral to the hospital and coordinated admission and transportation to the psychiatric hospital. If outpatient psychiatric services were recommended, those services would be provided by or coordinated by the external mental health entity. CEO #2 stated the facility did not have a business associate agreement or contract with the mental health entity, did not reimburse the mental health entity for the services provided, and did not have a process for vetting, monitoring or evaluating the services provided by the mental health provider.

d) Record review showed multiple instances where the unaffiliated mental health entity evaluated and decided treatment plans for patients who were currently receiving emergency services at the hospital. As example,

Patient #13 presented to the emergency department on 01/27/17 at 11:51 p.m. for a multiple sclerosis flare up and complaints of severe pain rated 10 of 10 (on a scale of 1-10). The patient was evaluated, medicated and discharged home on 01/28/17 at 12:50 a.m.

Patient #13 returned to the emergency department at 9:22 a.m. on 01/28/17 with complaints of severe pain in his/her back, arms and abdomen. Patient #13 had a history of multiple sclerosis with intractable pain that was worsening and s/he was expressing suicidal ideation due to the severity of the pain. According to the Pain Assessment, conducted on 01/28/17 at 9:26 a.m. by Registered Nurse #5 (RN), Patient #13's pain was rated at a 10 of 10, worst possible pain, in his/her back. The patient's pain was reassessed at 11:50 a.m. and remained a 10 of 10.

Review of Progress Notes showed RN #5 answered the patient's call light to find him/her sitting on the floor with oxygen tubing loosely wrapped around his/her neck twice. The patient was flushed and crying, but difficult to understand with crying. The patient was moved to a room with no cords with direct observation put in place. There was no time documented as to when the event occurred.

Subsequently, the patient was assessed by RN #6. When asked if the patient "wished self dead or to not wake up", the patient responded "yes". The patient answered "yes" when asked if s/he actually thought about killing yourself. The patient stated "just today, because I hurt so bad." Further documentation showed the patient stated s/he had only ever wished to be dead today while in the hospital's care because his/her pain was so great. At 11:50 a.m., RN #6 documented the patient was put on suicide precautions.

The external mental health service provider entity was contacted and requested to come assess the patient due to the suicidal gesture. The Registered Nurse caring for Patient #13 documented the mental health provider was in to evaluate Patient #13 at 3:15 p.m. The patient was discharged and driven home by the mental health provider at 3:35 p.m.

Review of a handwritten Safety Plan, dated 01/28/17 with no time noted, was signed by the patient and the unaffiliated mental health provider. There was no documentation to show the facility evaluated and agreed with the safety plan. There was additional documentation in the medical record which showed Patient #13 was evaluated by the mental health service provider; however, there was no documentation as to who the evaluator was and their credentials. Additionally, there was no documentation the facility reviewed and approved of the evaluation and the recommendations.

Later in the evening on 01/28/17, Patient #13 committed suicide at home by a self inflicted gunshot wound to the head.

Of note, the handwritten Safety Plan and evaluation conducted by the unaffiliated mental health provider was faxed to the facility on 02/01/17 at 4:43 p.m., 3 days after the patients emergency department visit and subsequent suicide, for inclusion in the facility's medical record.

Cross Reference Tag 0275

Based on the manner and degree of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §485.635 PROVISION OF SERVICES was out of compliance.

C-0273 - A description of the services the CAH furnishes, including those furnished through agreement or arrangement. The facility failed to establish a contract, agreement or arrangement with the entity providing mental health services at the facility. This failure allowed personnel who were not affiliated nor credentialed by the facility to examine patients and determine treatments which were relied on by the practitioners at the facility and potentially contributed to negative patient outcomes.

C-0275 - Guidelines for the medical management of health problems that include the conditions requiring medical consultation and/or patient referral, the maintenance of health care records, and procedures for the periodic review and evaluation of the services furnished by the CAH. The facility failed to establish guidelines for the management of behavioral and psychiatric conditions which required consultation and referral for behavioral or psychiatric services. Additionally, the facility failed to establish guidelines for the maintenance of health records and failed to review services provided by unaffiliated entities on behalf of the facility. This failure resulted in personnel not affiliated with the CAH, and whose credentials, qualifications, background and experience were unknown to the facility, providing mental health evaluations and determining the course of treatments for patients with behavioral and psychiatric conditions.

C-0276 - Rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storage area that is administered in accordance with accepted professional principles, that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use. The facility failed to ensure outdated medications were removed from stock according to manufacturer's expiration. This failure created the potential for patients to receive compromised or expired medications.

C-0278 - A system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel. The facility failed to maintain appropriate infection control processes in the areas of food storage and dishwashing. Specifically, the facility failed to have a process in place which ensured opened food items were labeled when opened and with a use by date. This failure created the potential for patients to experience illness due to exposure to food borne pathogens if unlabeled food or expired/unsafe food was served to patients and dishes were not cleaned with the proper water temperature.

C-0291 - The CAH maintains a list of all services furnished under arrangements or agreements. The list describes the nature and scope of the services provided. The facility failed to maintain an agreement with the external mental health provider entity conducting mental health assessments and other services on behalf of the facility. This failure resulted in the facility having no control of the nature and scope of services provided by the mental health entity and potentially resulted in negative patient outcomes.

Based on interviews and document review the facility failed to establish a contract, agreement or arrangement with the entity providing mental health services at the facility.

This failure allowed personnel who were not affiliated nor credentialed by the facility to examine patients and determine treatments which were relied on by the practitioners at the facility and potentially contributed to negative patient outcomes.

FINDINGS

1. The facility did not have a contract or policies that described the healthcare service provided by the external mental health service provider entity.

a) On 03/28/17 a list of contracted services and an index of policies and procedures followed by the facility was provided. There was no contract or other agreement for services provided by the mental health service provider entity utilized by the facility. There was no policy or procedure that addressed how and when to access the mental health provider, the services provided and how the services would be evaluated.

b) During an interview, with the Chief Executive Officer (CEO #2) on 03/29/17 at 12:10 p.m., s/he stated there was no contract with the external mental health provider entity. S/he stated once a patient was medically stabilized, the external mental health provider was contacted and asked to come assess the patient and provide recommendations for care and treatment. If psychiatric hospitalization was recommended, the mental health provider was the entity that made the referral to the hospital and coordinated admission and transportation to the psychiatric hospital. If outpatient psychiatric services were recommended, those services would be provided by or coordinated by the external mental health entity. CEO #2 stated the facility did not have a business associate agreement or contract with the mental health entity, did not reimburse the mental health entity for the services provided, and did not have a process for vetting, monitoring or evaluating the services provided by the mental health provider.

c) Seven medical records reviewed indicated the external mental health service provider entity had conducted evaluations of patients at the facility (Patients #11, 12, 13, 14, 15, 16, and 21). Five patient records (Patients # 3, 14, 15, 16, and 21) contained documentation from the mental health service provider entity, such as summary notes, assessments, discharge plans, etc. Two patient records (Patients #11 and 12) contained no documentation from the mental health service provider, even though the facility's practitioner notes indicated the mental health service provider had evaluated the patients. Cross Reference tag 0275.

Based on interview and document review the facility failed to establish guidelines for the management of behavioral and psychiatric conditions which required consultation and referral for behavioral or psychiatric services. Additionally, the facility failed to establish guidelines for the maintenance of health records and failed to review services provided by unaffiliated entities on behalf of the facility.

This failure resulted in personnel not affiliated with the CAH, and whose credentials, qualifications, background and experience were unknown to the facility, providing mental health evaluations and determining the course of treatments for patients with behavioral and psychiatric conditions.

FINDINGS

1. The facility failed to establish a process for providing, documenting and evaluating mental health consultative services provided at the facility.

a) During an interview, with the Chief Executive Officer (CEO #2) on 03/29/17 at 12:10 p.m., s/he stated there was no contract with the external mental health provider entity. S/he stated once a patient was medically stabilized, the external mental health provider was contacted and asked to come assess the patient and provide recommendations for care and treatment. If psychiatric hospitalization was recommended, the mental health provider was the entity that made the referral to the hospital and coordinated admission and transportation to the psychiatric hospital. If outpatient psychiatric services were recommended, those services would be provided by or coordinated by the external mental health entity. CEO #2 stated the facility did not have a business associate agreement or contract with the mental health entity, did not reimburse the mental health entity for the services provided, and did not have a process for vetting, monitoring or evaluating the services provided by the mental health provider.

b) During an interview with the Medical Director of the Emergency Department (MD #3) on 03/29/17 at 3:30 p.m., s/he stated when patients with psychiatric emergencies or behavioral issues presented to the emergency department, s/he would medically stabilize the patient and call the outside mental health provider entity to request a mental health assessment. The facility staff would provide for the safety of the patient while waiting for the mental health provider to arrive and assess the patient. MD #3 stated s/he did not know the credentials of the personnel providing the mental health assessments. When asked if s/he was aware the facility had no contract or other agreement with the mental health service provider, MD #3 stated s/he was "surprised to hear that."

c) On 03/30/17 at 11:00 a.m. an emergency department physician (Physician #4) was interviewed. S/he stated when patients with mental health emergencies presented for care, s/he would conduct an examination and interview the patient to obtain a history of psychiatric conditions or concerns. Once the patient was medically stable, the external mental health provider entity would be contacted and requested to come to the facility to conduct a face to face assessment of the patient. The mental health provider would conduct a thorough psychiatric and behavioral evaluation of the patient and would make recommendations to the physician for placement or referral if needed. Based on the recommendations of the mental health provider, a transfer or discharge plan would be developed and executed.

Physician #4 stated if a patient needed a plan developed for remaining safe at the facility while transfer or discharge arrangements were made, the plan would be developed by the external mental health provider. Physician #4 stated "I don't see the safety plan." Physician #4 was asked if s/he knew the credentials of the individuals from the external mental health provider entity who were relied upon to provide the psychiatric evaluation and s/he stated s/he did not.

d) Patient #13 presented to the emergency department on 01/27/17 at 11:51 p.m. for a multiple sclerosis flare up and complaints of severe pain rated 10 of 10 (on a scale of 1-10). The patient was evaluated, medicated and discharged home on 01/28/17 at 12:50 a.m.

Patient #13 returned to the emergency department at 9:22 a.m. on 01/28/17 with complaints of severe pain in his/her back, arms and abdomen. Patient #13 had a history of multiple sclerosis with intractable pain that was worsening and s/he was expressing suicidal ideation due to the severity of the pain. According to the Pain Assessment, conducted on 01/28/17 at 9:26 a.m. by Registered Nurse #5 (RN), Patient #13's pain was rated at a 10 of 10, worst possible pain, in his/her back. The patient's pain was reassessed at 11:50 a.m. and remained a 10 of 10.

Review of Progress Notes showed RN #5 answered the patient's call light to find him/her sitting on the floor with oxygen tubing loosely wrapped around his/her neck twice. The patient was flushed and crying, but difficult to understand with crying. The patient was moved to a room with no cords with direct observation put in place. There was no time documented as to when the event occurred.

Subsequently, the patient was assessed by RN #6. When asked if the patient "wished self dead or to not wake up", the patient responded "yes". The patient answered "yes" when asked if s/he actually thought about killing yourself. The patient stated "just today, because I hurt so bad." Further documentation showed the patient stated s/he had only ever wished to be dead today while in the hospital's care because his/her pain was so great. At 11:50 a.m., RN #6 documented the patient was put on suicide precautions.

The external mental health service provider entity was contacted and requested to come assess the patient due to the suicidal gesture. The Registered Nurse caring for Patient #13 documented the mental health provider was in to evaluate Patient #13 at 3:15 p.m. The patient was discharged and driven home by the mental health provider at 3:35 p.m.

Review of a handwritten Safety Plan, dated 01/28/17 with no time noted, was signed by the patient and the unaffiliated mental health provider. There was no documentation to show the facility evaluated and agreed with the safety plan. There was additional documentation in the medical record which showed Patient #13 was evaluated by the mental health service provider; however, there was no documentation as to who the evaluator was and their credentials. Additionally, there was no documentation the facility reviewed and approved of the evaluation and the recommendations.

Later in the evening on 01/28/17, Patient #13 committed suicide at home by a self inflicted gunshot wound to the head.

Of note, the handwritten Safety Plan and evaluation conducted by the unaffiliated mental health provider was faxed to the facility on 02/01/17 at 4:43 p.m., 3 days after the patients emergency department visit and subsequent suicide, for inclusion in the facility's medical record.

e) Medical record reviewed showed Patient #11 came to the emergency department on 12/26/16 with concerns that s/he had a neuro transmitted in his/her ear. Patient #11 had been diagnosed with a history of schizoaffective disorder and was using methamphetamine on a daily basis. The medical record indicated that a representative from the outside mental health entity had been in to evaluate Patient #11 and had arranged for admission to a behavioral health facility. However, there was no documentation in the medical record from the mental health entity who conducted the mental health assessment and clinical decision making.

f) Patient #12 was brought to the emergency department on 12/13/16 with acute alcohol intoxication and suicide ideation. Patient #12 was assessed by the ED physician to be a danger and was placed on a mental health hold (M-1). The medical record indicated that once Patient #12 was medically stabilized, a representative from the outside mental health entity came to the facility to assess Patient #12. There was no documentation of findings or recommendations from the mental health provider in the medical record. Additionally, there was no documentation the mental health hold had been discontinued prior to the patients discharge. Further, the mental health hold was not in the medical record and the facility was unable to locate a copy during the survey process. Patient #12 was discharged to home from the facility.

g) Patient #21 was brought to the emergency room on 06/14/16 at 12:30 p.m., after a witnessed suicide attempt by overdose. The emergency room physician documented the patient had a "history of depression and previous cutting expressions" and diagnosed the patient with major depressive disorder. The patient was placed on a mental health hold and 1:1 observation in the emergency room which continued once the patient was admitted to the hospital, as the patient continued to express active suicidal thoughts. On 06/15/16, the treating physician documented continue the M-1 hold, awaiting mental health evaluation, medically stable for discharge, not safe for discharge home.

The unaffiliated mental health provider came to the facility on 06/16/16 to assess Patient #21. The mental health provider wrote in his/her summary statement, "this was the first suicide attempt ever in the client's life." This statement contradicted the history taken by the physician who evaluated the patient in the emergency room on 06/14/16.

After the mental health evaluation was completed, the patient was discharged home. In the discharge summary the physician stated, "s/he continues to voice active suicide thoughts, as per [mental health provider entity] s/he is not in immediate danger, they recommend to discharge home and recommend follow up with psychiatrist, I strongly recommend psychiatric re-evaluation or a second opinion as bipolar diagnosis is suspected."

There was no documentation why the patient was discharged home on the recommendation of the unaffiliated mental health provider even though the hospital physician recommended a re-evaluation or a second opinion.

h) The facility's standard practice to rely on unaffiliated mental health provider's evaluations and treatment recommendations for patients presenting to the emergency department resulted in patients being discharged from the facility without complete and comprehensive psychiatric evaluations.

Based on observation and interviews, the facility failed to ensure outdated medications were removed from stock according to manufacturer's expiration.

This failure created the potential for patients to receive compromised or expired medications.

FINDINGS

1. The facility failed to ensure outdated medications were removed and not available for patient use.

a) On 03/28/17 at 8:45 a.m., a tour of the facility revealed several medications that were past the expiration date. As example in the emergency department,

Hurricaine 20% Benzocaine Oral Antiseptic expired 10/2016
2 bags of 5% Dextrose 50 ml expired 02/2016
2 bags of 5% Dextrose 100 ml expired 04/2014

On the inpatient unit expired medications included a 0.9 NaCl 50 ml vial expired 02/2017.

b) During the tour, Registered Nurse #5 (RN) stated the expired medications should have been discarded so they weren't used.

Based on observations, interviews and document review, the facility failed to maintain appropriate infection control processes in the areas of food storage and dishwashing. Specifically, the facility failed to have a process in place which ensured opened food items were labeled when opened and with a use by date.

This failure created the potential for patients to experience illness due to exposure to food borne pathogens if unlabeled food or expired/unsafe food was served to patients and dishes were not cleaned with the proper water temperature.

FINDINGS

POLICY

According to Receiving Food Items and Storage, any items that come into the kitchen, whether from the grocery store or the food supplier, must be labeled with a received date and a use by date. The facility uses the Item Storage Guidelines

REFERENCE

According to the facility guidelines, Item Storage, all items need to be labeled and dated when received, with a use by date, when opened, then again with a use by date.

1. During a tour of the kitchen, on 03/28/17 beginning at 9:55 a.m., the Culinary Supervisor (Supervisor #1) provided Item Storage guidelines utilized by the facility to determine the amount of time food could be safely stored and consumed in the facility. Supervisor #1 stated the facility did not have specific guidelines for storage of fresh fruits and vegetables. S/he stated staff went by how they "looked." If the fruits and vegetables looked "ok" they would use them. If not, they would throw them out. According to Supervisor #1 fruits and vegetables did not have received by or use by dates.

a) While touring with Supervisor #1, multiple instances of unlabeled food were noted. As example, the refrigerator contained the following unlabeled items:

A container with lemons and limes with no received date and no use by date identified.
Asparagus, which was wilted, was received on 03/09 (19 days earlier) with no use by or expiration date.
An open bag of cilantro, with no open date or use by date noted. The cilantro was brown with a brown liquid in the the bottom of the bag.
An open container of cheese with no received date, open date or use by date.

Observation of the freezer revealed additional open and undated items. As example, bags of peas, corn, broccoli, french fries, meatballs, fish, chicken strips and vege burgers were all opened with no date as to when they were opened and when they needed to be discarded.

Additionally, in the kitchen area there were 6 loaves of bread and rolls open with no date of when they were received, when they were opened and when they were required to be discarded. During the tour, Supervisor #1 stated bread needed to be used or discarded within 5 days of opening.

Supervisor #1 stated spices were required to be used within 6 months of the open date. Observation showed containers of garlic, black pepper, oregano, cumin, nutmeg and cinnamon were all opened with no date when they were opened and no date when they expired.

A container of chocolate fudge had an open date of 10/26/16 written on it. The fudge expired on 02/15/17 (more than 30 days prior to the tour).

b) During the kitchen tour, on 03/28/17 beginning at 9:55 a.m., it was noted the rinse temperature gauge on the dishwashing machine was not working. Review of the Temperature for Food Safeness paper, attached to the food storage policy, the "Dish machine final rinse" temperature needed to reach 180 degrees Fahrenheit for tableware and utensil sanitation.

Supervisor #1 stated the gauge had been broken for a "couple of weeks" and s/he had notified maintenance of the problem. However, the facility was not able to provide any documentation showing the gauge had been reported as not working.

All documentation for maintenance on the dishwashing machine was requested. Routine Preventive Maintenance Service Detail Report - Warewashing documents were provided which revealed the last service on the machine had been conducted on 04/18/16 (more then 11 months prior to the survey). There was no documentation to show the facility had identified the rinse temperature gauge was broken and taken action to fix or replace the gauge.

i) Supervisor #1 stated the kitchen staff would check the water temperature on the dishwasher using test strips during the first load washed each day. Supervisor #1 stated if the strip turned black the water temperature was "good." If the test strip was still gray/white the water temperature was not acceptable.

However, even though dishes had already been sent through the dishwasher the day of the kitchen tour, 03/28/17, Supervisor #1 was unable to locate the test strip s/he had utilized that day. Supervisor #1 stated maybe it had been left on the bottom of a pan.

Supervisor #1 stated the test strips were to be stuck on the Dishwasher Temperature Monitoring Sheet each day to show the water temperatures of the dishwashing machine were adequate. Review of the monitoring sheets for February and March 2017 showed multiple dates where the test strip showed water temperatures did not meet the minimum required temperature. As example, on 03/13/17, 03/14/17, 03/16/17 and 03/20/17 the test strips remained gray/white which indicated minimum water temperatures were not acceptable.

Additionally, on 02/27/17, 02/28/17, 03/17/17, 03/18/17, 03/19/17, 03/21/17, 03/22/17 03/24/17 and 03/28/17 there was no evidence tests were conducted to ensure water temperatures met acceptable ranges.

ii) During an interview, on 03/30/17 at 3:25 p.m., the Infection Preventionist (Employee #7) stated the last time s/he had toured the kitchen was "about a month ago." Employee #7 stated s/he did not know the dishwasher's rinse temperature gauge was broken. Employee #7 stated s/he had seen the water temperature logs a couple of times but it was not something s/he routinely monitored. S/he "assumed" the logs were being completed. Employee #7 stated s/he had not noticed there were no dates on produce indicating when it had been received.

Based on interview and document review the facility failed to maintain an agreement with the external mental health provider entity conducting mental health assessments and other services on behalf of the facility.

This failure resulted in the facility having no control of the nature and scope of services provided by the mental health entity and potentially resulted in negative patient outcomes.

FINDINGS

1. The facility did not maintain an agreement with the unaffiliated mental health service provider entity that identified the services to be offered, the individuals providing the services or a process for evaluating the quality of services provided.

a) During an interview, with the Chief Executive Officer (CEO #2) on 03/29/17 at 12:10 p.m., s/he stated there was no contract with the external mental health provider entity. S/he stated once a patient was medically stabilized, the external mental health provider was contacted and asked to come assess the patient and provide recommendations for care and treatment. If psychiatric hospitalization was recommended, the mental health provider was the entity that made the referral to the hospital and coordinated admission and transportation to the psychiatric hospital. If outpatient psychiatric services were recommended, those services would be provided by or coordinated by the external mental health entity. CEO #2 stated the facility did not have a business associate agreement or contract with the mental health entity, did not reimburse the mental health entity for the services provided, and did not have a process for vetting, monitoring or evaluating the services provided by the mental health provider.

Cross Reference Tag 0275.

Based on interviews and record review the facility failed to maintain complete medical records for patients who received care. Specifically, the facility failed to have a standard process to ensure services provided by an unaffiliated mental health provider entity on behalf of the CAH were complete and received in a timely manner.

This failure resulted in incomplete patient medical information available for continuity of care.

FINDINGS

1. The facility failed to ensure patient medical records were accurate and complete for services provided by an unaffiliated mental health provider entity at the request of the hospital.

a) During an interview with the Medical Director of the Emergency Department (MD #3) on 03/29/17 at 3:30 p.m., s/he stated when patients with psychiatric emergencies or behavioral issues presented to the emergency department, s/he would medically stabilize the patient and call the outside mental health provider entity to request a mental health assessment. MD #3 stated s/he did not know the credentials of the personnel providing the mental health assessments.

b) On 03/30/17 at 11:00 a.m. an emergency department physician (Physician #4) was interviewed. S/he stated when patients with mental health emergencies presented for care, s/he would conduct an examination and interview the patient to obtain a history of psychiatric conditions or concerns. Once the patient was medically stable, the external mental health provider entity would be contacted and requested to come to the facility to conduct a face to face assessment of the patient. The mental health provider would conduct a thorough psychiatric and behavioral evaluation of the patient and would make recommendations to the physician for placement or referral if needed. Based on the recommendations of the mental health provider, a transfer or discharge plan would be developed and executed.

c) During an interview, with the Chief Executive Officer (CEO #2) on 03/29/17 at 12:10 p.m., s/he stated there was no contract with the external mental health provider entity. S/he stated once a patient was medically stabilized, the external mental health provider was contacted and asked to come assess the patient and provide recommendations for care and treatment. If psychiatric hospitalization was recommended, the mental health provider was the entity that made the referral to the hospital and coordinated admission and transportation to the psychiatric hospital. If outpatient psychiatric services were recommended, those services would be provided by or coordinated by the external mental health entity. CEO #2 stated the facility did not have a business associate agreement or contract with the mental health entity, did not reimburse the mental health entity for the services provided, and did not have a process for vetting, monitoring or evaluating the services provided by the mental health provider.

d) Seven medical records reviewed indicated the external mental health service provider entity had conducted evaluations of patients at the facility. Two patient records (Patients #11 and 12) contained no documentation from the mental health service provider, even though the facility's practitioner notes indicated the mental health service provider had evaluated the patients.