HospitalInspections.org

Based on a review of clinical records and facility documentation, the facility failed to provide an appropriate, medical screening exam for 13 of 21 patients that presented for treatment. These 13 patients received screening exams by individuals whose scopes of practice did not permit them to do so.

Findings were:

* Patient #2 presented to the facility on 3-4-23 at 9:31 am, stating that they had attempted suicide by overdosing on a "handful of pills". The intake assessment was conducted by staff #9 (Licensed Professional Counselor). Staff #9 contacted a facility psychiatrist who did not see the patient in person or virtually, but gave an order to send the patient to the emergency room via EMS. The patient left the facility at 10:33 am via EMS.

* Patient #4 presented to the facility on 3-22-23 at 11:34 am, stating that they had attempted suicide by overdosing on Trazodone and Ritalin. The intake assessment was conducted by staff #15 (Licensed Marriage and Family Therapist). Staff #15 contacted a facility psychiatrist who did not see the patient in person or virtually, but gave an order to send the patient to the emergency room via EMS. The patient left the facility at 3:02 pm via EMS.

* Patient #7 presented to the facility on 3-14-23 at 4:42 pm, stating that they had suicidal ideations. The patient's blood pressure was 185/132 during the intake and the patient vomited in the intake area. The intake assessment was conducted by staff #9 (Licensed Professional Counselor). Staff #9 contacted a facility psychiatrist who did not see the patient in person or virtually, but gave an order to send the patient to the emergency room via EMS. The patient left the facility at 5:17 pm via EMS.

* Patient #8 presented to the facility on 3-28-23 at 1:19 pm, requesting psychiatric help for suicidal ideations. The intake assessment was conducted by staff #8 (Social Worker). The patient's blood pressure and pulse were elevated. Staff #8 contacted a facility psychiatrist who did not see the patient in person or virtually, but gave an order to send the patient to the emergency room via EMS. The patient left the facility at 1:53 pm via EMS.

* Patient #12 presented to the facility on 1-26-23 at 10:23 pm with his mother, seeking help for very erratic behavior. The intake assessment was conducted by staff #7 (Social Worker). Due to the patient's erratic behavior and combativeness, staff #7 contacted a RediAnswer® physician (contracted by the facility). The physician did not see the patient in person or virtually, but gave an order to send the patient to the emergency room via EMS. The patient left the facility at 10:56 pm via EMS with local, law enforcement in attendance.

* Patient #13 presented to the facility on 1-24-23 at 8:47 am and stated that they had attempted suicide by ingesting a bottleful of Trazodone. The intake assessment was conducted by staff #9 (Licensed Professional Counselor). Staff #9 contacted a facility psychiatrist who did not see the patient in person or virtually, but gave an order to send the patient to the emergency room via EMS. The patient left the facility at 9:53 am via EMS.

* Patient #14 presented to the facility on 1-18-23 at 12:39 pm, stating that they had attempted suicide by overdosing on benzodiazepenes, heroin, cocaine and alcohol. The intake assessment was conducted by staff #6 (Social Worker, Licensed Professional Counselor). Staff #6 contacted a facility psychiatrist who did not see the patient in person or virtually, but gave an order to send the patient to the emergency room via EMS. The patient left the facility at 1:20 pm via EMS.

* Patient #15 presented to the facility on 1-17-23 at 4:45 pm, requesting help for alcohol abuse and vomiting blood. The intake assessment was conducted by staff #12 (Social Worker). Staff #12 contacted a RediAnswer® physician, who conducted a "clinical record review" but did not see the patient in person or virtually. The same physician gave an order to send the patient to the emergency room via EMS. The patient left the facility at 7:57 pm via EMS.

* Patient #17 presented to the facility on 1-16-23 at 8:11 pm, stating that they had ingested a quantity of 10 hydrocodone tablets. The intake assessment was conducted by staff #18 (Social Worker). Staff #18 contacted a facility psychiatrist who did not see the patient in person or virtually, but gave an order to send the patient to the emergency room via EMS. The patient left the facility at 10:50 pm via EMS.

* Patient #18 presented to the facility on 1-16-23 at 9:47 pm with confusion and paranoia, who subsequently fainted in the facility lobby. The intake assessment was conducted by staff #15 (Licensed Marriage & Family Therapist). Staff #15 contacted a facility psychiatrist who did not see the patient in person or virtually, but gave an order to send the patient to the emergency room via EMS. The patient left the facility at 10:20 pm via EMS.

* Patient #19 presented to the facility on 1-15-23 at 10:00 pm with a chief complaint of psychosis and psychoactive medication non-compliance. The intake assessment was conducted by "staff" and no staff names were present on any intake documentation for patient #19. Without consulting a physician, the patient left the facility via local law enforcement at 11:26 pm. The intake documentation gave no indication as to why law enforcement was contacted.

* Patient #20 presented to the facility on 1-13-23 at 10:49 am following a suicide attempt by excess methamphetamine ingestion. The intake assessment was conducted by staff #11 (Licensed Professional Counselor-Associate). Staff #11 contacted a facility psychiatrist who did not see the patient in person or virtually, but gave an order to send the patient to the emergency room via EMS. The patient left the facility at 11:27 am via EMS.

* Patient #21 presented to the facility on 1-2-23 at 8:29 am, stating that they were severely depressed. The intake assessment was performed by staff #11 (Licensed Professional Counselor-Associate). Staff #11 contacted a RediAnswer® physician, who conducted a "record review" but did not see the patient in person or virtually. The same physician gave an order to send the patient to the emergency room via EMS. The patient left the facility at 12:24 pm via EMS.

Facility policy 12460670 titled" Emergency Medical Treatment and Active Labor Act (EMTALA)" states, in part:
"Purpose:
To ensure Springstone hospitals comply with the requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA) and associated regulations. All persons presenting to a Springstone Hospital will be provided a medical screening examination to determine if they have an emergency medical condition. This includes persons presenting for an examination or treatment at the request of the mental health authority, sheriff's office, or local police department."

The facility document titled "Medical Staff Rules & Regulations" states, in part:
"21. Emergency Service - Stand-Alone Facilities.
A. The Hospital provides the essential services to evaluate, stabilize (within its capabilities), and transfer when necessary and appropriate, individuals who present to the Hospital with conditions of emergent or urgent nature, in accordance with the following:
B. The Hospital shall comply with federal, state, and regulatory agency requirements regarding emergency services and offer services within its capability. Such services shall include the provision of an appropriate "medical screening examination" by a Physician or other "qualified medical personnel" for individuals who present with an "emergency medical condition" (or are in active labor) and request "examination or treatment" to determine if the individual is experiencing an "emergency medical condition" (as such terms are defined by EMTALA, the Emergency Medical Treatment and Active Labor Act), and shall further include appropriate treatment to stabilize the patient or transfer the patient to another facility if medically necessary, all in conformance with EMT ALA and other applicable federal, state, and regulatory agency requirements, in addition to staff identified in Hospital bylaws.
C. Qualified medical personnel may include any Provider acting within the scope of their licensure and medical staff/AHP privileges."

The above was confirmed in an interview with the CEO and other administrative staff on 6-14-23.

Based on a review of clinical records and facility documentation, the facility failed to provide appropriate, stabilizing treatment for 2 of 21 patients that presented for treatment.

Findings were:

* Patient #10 presented to the facility on 2-6-23 at 9:38 pm, requesting psychiatric help for suicidal ideation. A RediAnswer® physician saw the patient virtually and gave an order to send the patient out for medical clearance and the patient left the facility at 12:05 am on 2-7-23. The patient was suicidal and required an involuntary hold and continuous, safe, close monitoring, neither of which were provided.

* Patient #11 presented to the facility on 2-4-23 at 11:58 pm, requesting chemical dependency help. A RediAnswer® physician saw the patient virtually and gave an order to send the patient out for medical clearance and the patient left the facility at 12:35 am on 2-5-23. As the patient was listed as moderate risk of suicide by the physician, this patient required an involuntary hold and continuous safe, close monitoring, niether of which were provided.

The above was confirmed in an interview with the CEO and other administrative staff on 6-14-23.

Based on a review of clinical records, facility documentation and an interview with staff, the facility failed to secure an appropriate transfer for 21 of 21 patients.

Findings were:

Pt #1 arrived at MS on 3-12-23 at 11:55 am via private vehicle. The patient was initially screened by a licensed, professional counselor. The patient's initial complaint was listed as "agitated, ongoing audio/visual hallucinations". The patient resided in a group home and had a history of schizophrenia.

A RediAnswer® (the facility's telehealth contracted physician service) doctor saw the patient via video call at approximately 3:00 pm and recommended inpatient treatment, but the facility had no inpatient beds available. The assessment progress notes read as follows:
* 3:18 pm - "Recommended IP [inpatient] transfer d/t no available bed. Due to altered mental status (intellectual disability/disorientation) pt is unable to consent to treatment recommendation. Staffed with AOC [administrator on call]. Notified House Sup[ervisor]. Contact PD [police department] for potential assistance for getting patient a mental APP [application for mental health warrant]/placed."
* 3:34 pm - "non emergent FWPD [Fort Worth police department] contacted PD to send assistance."
* 3:46 pm - "patient gave permission to talk to group home regarding next steps."
* 3:54 pm - "Informed [group home manager] at the group home about calling PD to help her to get care."
* 6:43 pm - "Police arrived."
* 6:55 pm - "Police MAP [unknown acronym] pt and took in custody to transport her to JPS."
No memorandum of transfer was found in the intake paperwork and there was no documentation of attempts to contact nearby psychiatric hospitals to secure a bed and effect an appropriate transfer.

A document titled "Medical Stability Attestation" stated the following:
"I have conducted a review of the above patient's presenting clinical data for preadmission evaluation on 3-12-23, 3:18 pm central standard time. A physical exam and labs are not available at this time. Based on the available information, this patient is medically stable and demonstrates a need for admission to an inpatient psychiatric facility."

Pt #1 left the facility at 6:55 pm in the company of law enforcement.

In an interview with staff #1 on 6-12-23, he was asked why other hospitals were not contacted and an appropriate transfer secured. He stated that Tarrant County (the county in which the facility is located) had instructed the facility that they needed to send all patients that might need an emergency detention order (as in the case of pt #1) to John Peter Smith Hospital for treatment. He was asked to provide the surveyor with paperwork to document these instructions and presented the surveyor with a document from the Tarrant County Criminal District Attorney's Office and a letter on facility letterhead explaining the process they had been instructed to follow.

* Pt #2 arrived at the facility on 3-4-23 at 9:31 am following an intentional overdose on "a handful of pills" that included Vyvanse, Adderall, Iron, Gabapentin and Abilify. A staff psychiatrist recommended emergent medical clearance and an ambulance was contacted at 9:56 am. Pt #2 left the facility at 10:33 am via ambulance. No memorandum of transfer was found in the intake paperwork and there was no documentation of attempts to contact nearby hospitals and effect an appropriate transfer.

* Pt #3 arrived at the facility on 5-17-23 at 10:20 am pursuant to a suicide attempt the prior night on "$400 worth of crack". The patient reported current chest pain. The patient was seen electronically by a RediAnswer® physician at 10:58 am and an order was given to transport the patient for medical clearance. EMS and police were contacted and pt #3 left the facility at 11:42 am. Although a memorandum of transfer was found in the intake paperwork, it had not been completed and there was no documentation of attempts to contact nearby hospitals and effect an appropriate transfer. The fields marked "Name of contact person at receiving hospital", "Name of receiving physician", "Name of receiving hospital administration person" and the ambulance detail field had all been marked "9-1-1".

* Pt #4 arrived at the facility on 3-22-23 at 11:34 am due to an overdose on medications. An order was received from a staff psychiatrist to send the patient out for medical clearance. EMS was contacted and the patient left the facility via ambulance at 3:02 pm. Although a memorandum of transfer was found in the intake paperwork, it had not been completed and there was no documentation of attempts to contact nearby hospitals and effect an appropriate transfer. The fields marked "Name of contact person at receiving hospital", "Name of receiving physician", "Name of receiving hospital administration person" and the ambulance detail field had all been marked "9-1-1".

* Pt #5 arrived at the facility on 3-30-23 at 9:47 pm following a suicide attempt by taking a handful of pills of unknown type. The patient was seen electronically by a RediAnswer® physician at 10:40 pm and an order was given to send the patient out for medical clearance. The patient left the facility at 11:15 pm via ambulance. Although a memorandum of transfer was found in the intake paperwork, it had not been completed and there was no documentation of attempts to contact nearby hospitals and effect an appropriate transfer. The fields marked "Name of contact person at receiving hospital", "Name of receiving physician", "Name of receiving hospital administration person" and the ambulance detail field had all been marked "9-1-1".

* Pt #6 arrived at the facility on 3-30-23 at 8:58 pm following an intentional overdose on acetaminophen. The patient was seen electronically by a RediAnswer® physician 10:05 and an order given to send the patient out for medical clearance. The patient left the facility at 10:23 pm via ambulance. Although a memorandum of transfer was found in the intake paperwork, it had not been completed and there was no documentation of attempts to contact nearby hospitals and effect an appropriate transfer. The fields marked "Name of contact person at receiving hospital", "Name of receiving physician", "Name of receiving hospital administration person" and the ambulance detail field had all been marked "9-1-1".

* Patient #7 presented to the facility on 3-14-23 at 4:42 pm, stating that they had suicidal ideations. A facility psychiatrist gave an order to send the patient out for medical clearance and the patient left the facility at 5:17 pm via ambulance. Although a memorandum of transfer was found in the intake paperwork, it had not been completed and there was no documentation of attempts to contact nearby hospitals and effect an appropriate transfer. The fields marked "Name of contact person at receiving hospital", "Name of receiving physician", "Name of receiving hospital administration person" and the ambulance detail field had all been marked "N/A".

* Patient #8 presented to the facility on 3-28-23 at 1:19 pm, requesting psychiatric help for suicidal ideations. A facility psychiatrist gave an order to send the patient out for medical clearance and the patient left the facility at 1:53 pm via ambulance. Although a memorandum of transfer was found in the intake paperwork, it had not been completed and there was no documentation of attempts to contact nearby hospitals and effect an appropriate transfer. The fields marked "Name of contact person at receiving hospital", "Name of receiving physician", "Name of receiving hospital administration person" and the ambulance detail field had all been marked "9-1-1".

* Patient #9 presented to the facility on 3-27-23 at 8:12 pm, requesting psychiatric help for suicidal ideations. A RediAnswer® physician saw the patient virtually and gave an order to send the patient out for medical clearance and the patient left the facility at 9:22 pm via ambulance. Although a memorandum of transfer was found in the intake paperwork, it had not been completed and there was no documentation of attempts to contact nearby hospitals and effect an appropriate transfer. The fields marked "Name of contact person at receiving hospital", "Name of receiving physician", "Name of receiving hospital administration person" and the ambulance detail field had all been marked "9-1-1".

* Patient #10 presented to the facility on 2-6-23 at 9:38 pm, requesting psychiatric help for suicidal ideation. A RediAnswer® physician saw the patient virtually and gave an order to send the patient out for medical clearance and the patient left the facility at 12:05 am on 2-7-23. No memorandum of transfer was found in the intake paperwork and there was no documentation of attempts to contact nearby hospitals and effect an appropriate transfer.

* Patient #11 presented to the facility on 2-4-23 at 11:58 pm, requesting chemical dependency help. A RediAnswer® physician saw the patient virtually and gave an order to send the patient out for medical clearance and the patient left the facility at 12:35 am on 2-5-23. No memorandum of transfer was found in the intake paperwork and there was no documentation of attempts to contact nearby hospitals and effect an appropriate transfer.

* Patient #12 presented to the facility on 1-26-23 at 10:23 pm with his mother, seeking help for very erratic behavior. A RediAnswer® physician saw the patient virtually and gave an order to send the patient out for medical clearance and the patient left the facility at 10:56 pm. No memorandum of transfer was found in the intake paperwork and there was no documentation of attempts to contact nearby hospitals and effect an appropriate transfer.

* Patient #13 presented to the facility on 1-24-23 at 8:47 am, requesting help following a suicide attempt. A staff psychiatrist gave an order to send the patient out for medical clearance and the patient left the facility at 9:53 am. Although a memorandum of transfer was found in the intake paperwork, it had not been completed and there was no documentation of attempts to contact nearby hospitals and effect an appropriate transfer. The fields marked "Name of contact person at receiving hospital", "Name of receiving physician", "Name of receiving hospital administration person" and the ambulance detail field had all been marked "9-1-1".

* Patient #14 presented to the facility on 1-18-23 at 12:39 pm, requesting help following a suicide attempt by overdose. A staff psychiatrist gave an order to send the patient out for medical clearance and the patient left the facility at 1:20 pm. No memorandum of transfer was found in the intake paperwork and there was no documentation of attempts to contact nearby hospitals and effect an appropriate transfer.

* Patient #15 presented to the facility on 1-17-23 at 4:45 pm, requesting help for alcohol abuse and vomiting blood. A RediAnswer® physician conducted a "clinical record review" and gave an order to send the patient out for medical clearance and the patient left the facility at 7:57 pm. No memorandum of transfer was found in the intake paperwork and there was no documentation of attempts to contact nearby hospitals and effect an appropriate transfer.

* Patient #16 presented to the facility on 1-17-23 at 6:43 pm, request a mental evaluation and appeared disoriented. A RediAnswer® physician gave an order to send the patient out for medical clearance and the patient left the facility at 8:22 pm. No memorandum of transfer was found in the intake paperwork and there was no documentation of attempts to contact nearby hospitals and effect an appropriate transfer.

* Patient #17 presented to the facility on 1-16-23 at 8:11 pm, stating that they had ingested a quantity of 10 hydrocodone tablets. A staff psychiatrist gave an order to send the patient out for medical clearance and the patient left the facility at 10:50 pm via ambulance. No memorandum of transfer was found in the intake paperwork and there was no documentation of attempts to contact nearby hospitals and effect an appropriate transfer.

* Patient #18 presented to the facility on 1-16-23 at 9:47 pm with confusion and paranoia and subsequently fainted in the facility lobby. A staff psychiatrist gave an order to send the patient out for medical clearance and the patient left the facility at 10:20 pm via EMS. No memorandum of transfer was found in the intake paperwork and there was no documentation of attempts to contact nearby hospitals and effect an appropriate transfer.

* Patient #19 presented to the facility on 1-15-23 at 10:00 pm with a chief complaint of psychosis and psychoactive medication non-compliance. The intake assessment was conducted by "staff" and no staff names were present on any intake documentation for patient #19. Without consulting a physician, the patient left the facility via local law enforcement at 11:26 pm. The intake documentation gave no indication as to why law enforcement was contacted. No memorandum of transfer was found in the intake paperwork and there was no documentation of attempts to contact nearby hospitals and effect an appropriate transfer.

* Patient #20 presented to the facility on 1-13-23 at 10:49 am following a suicide attempt by excess methamphetamine ingestion. A staff psychiatrist gave an order to send the patient to the emergency room via EMS and the patient left the facility at 11:27 am via ambulance. Although a memorandum of transfer was found in the intake paperwork, it had not been completed and there was no documentation of attempts to contact nearby hospitals and effect an appropriate transfer. The fields marked "Name of contact person at receiving hospital", "Name of receiving hospital administration person" and the ambulance detail field had all been marked "9-1-1". The field marked "Name of receiving physician" contained the name of the transferring physician.

* Patient #21 presented to the facility on 1-2-23 at 8:29 am, stating that they were severely depressed. A RediAnswer® physician conducted a "record review" but did not see the patient in person or virtually. The same physician gave an order to send the patient to the emergency room via EMS and the patient left the facility at 12:24 pm via ambulance. Although a memorandum of transfer was found in the intake paperwork, it had not been completed and there was no documentation of attempts to contact nearby hospitals and effect an appropriate transfer. The fields marked "Name of contact person at receiving hospital" and the ambulance detail field were marked "tbd". The fields marked "Name of Receiving Physician" and "Name of receiving hospital administration person" were both marked "N/A".

Facility policy 12460670 titled" Emergency Medical Treatment and Active Labor Act (EMTALA)" states, in part:
"Purpose:
To ensure Springstone hospitals comply with the requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA) and associated regulations. All persons presenting to a Springstone Hospital will be provided a medical screening examination to determine if they have an emergency medical condition. This includes persons presenting for an examination or treatment at the request of the mental health authority, sheriff's office, or local police department.
...
Transfers:
A. When a patient is being transferred from a Springstone Hospital to another medical facility because it does not have the capacity or capability to treat the patient's EMC, the following procedure will be followed:
1. Contact the on-call physician to initiate the Consent to Transfer EMTALA Form;
2. Call an Emergency Department able to provide appropriate care to the patient and obtain a verbal acceptance of transfer, including the name of an accepting physician;
3. Discuss transfer and risks with the patient;
4. If the patient consents for transfer call EMS for transfer;
5. Complete and send a copy of the Consent to Transfer EMTALA Form and assessment to the receiving hospital; and
6. If the patient refuses to be transferred and is not at imminent medical risk, complete a copy of the Consent to Transfer EMTALA form noting the patient's refusal, and complete assessment process."

Facility policy 12635772 titled "Transfer to Another Facility (Texas Only)" states, in part:
"Procedures:
Patient Evaluation
A. Each patient who arrives at the Hospital shall be:
1. evaluated by a Physician who is present in the Hospital at the time the patient presents or is presented or
2. evaluated by a physician on-call who is (a) physically able to reach the patient within 30 minutes after being informed that a patient is present at the Hospital who requires immediate medical attention; or (b) accessible by direct, telephone, or radio communication within 30 minutes with a registered nurse, physician assistant or other qualified medical personnel as established by the governing body at the Hospital under orders to assess and report the patient's condition to the physician; and
3. personally examined and evaluated by the physician before an attempt to transfer is made; however
a. after receiving a report on the patient's condition from the Hospital's registered nurse, Physician Assistant or other qualified medical personnel as established by the governing body by telephone, radio or audiovisual communication, if the Physician on call determines that an immediate transfer of the patient is medically appropriate and that the time required to conduct a personal examination and evaluation of the patient will unnecessarily delay the transfer to the detriment of the patient, the Physician on call may order the transfer by telephone, radio or audiovisual communication; and
b. if the on-call physician issues orders for the transfer of a patient by telephone, radio, or audiovisual communication, those orders shall be reduced to writing in the patient's medical record, signed by the registered nurse, Physician Assistant or other qualified medical personnel as established by the governing body receiving the order, and countersigned by the Physician authorizing the transfer as soon as possible.
...
Physician Duties
A. The transferring Physician shall determine and order life support measures which are medically appropriate to stabilize the patient prior to transfer and to sustain the patient during transfer.
B. The transferring Physician shall determine and order the utilization of appropriate personnel and equipment for the transfer.
C. In determining the use of medically appropriate life support measures, personnel, and equipment, the transferring physician shall exercise that degree of care which a reasonable and prudent Physician exercising ordinary care in the same or similar locality would use for the transfer.
D. Except as allowed under paragraph (A)(3) of Patient Evaluation section supra, prior to each patient transfer, the Physician who authorizes the transfer shall personally examine and evaluate the patient to determine the patient's medical needs and to ensure that the proper transfer procedures are used.
E. Prior to transfer, the transferring Physician shall ensure that a receiving hospital and a receiving Physician that are appropriate to the medical needs of the patient have accepted responsibility for the patient's medical treatment and hospital care.
...
Memorandum of Transfer
A. The Hospital shall provide that a memorandum of transfer (MOT) be completed for every patient who is transferred.
B. The receipt of the MOT shall be acknowledged in writing by the receiving hospital administration and receiving physician.
C. A copy of the MOT must accompany the patient being transferred as well as a copy of the medical record information mentioned above. The original shall stay with the Hospital.
D. A copy of the MOT shall be retained by the transferring and receiving hospitals. The MOT shall be filed separately from the patient's medical record and in a manner which will facilitate its inspection by the department.
E. All MOT forms filed separately shall be retained for a period of five years from the date of transfer.
F. A copy of the MOT may also be filed with the patient's medical record.
G. The memorandum shall contain the following information:
the patient's full name, if known;
the patient's race, religion, national origin, age, sex, physical handicap, if known;
the patient's address and next of kin, address, and phone number if known; the names, telephone numbers and addresses of the transferring and receiving physicians;
the names, addresses, and telephone numbers of the transferring and receiving hospitals;
the time and date on which the patient first presented or was presented to the transferring physician and transferring hospital;
the time and date on which the transferring physician secured a receiving physician; the name, date, and time hospital administration was contacted in the receiving hospital;
signature, time, and title of the transferring hospital administration who contacted the receiving hospital
the time and date on which the receiving physician assumed responsibility for the patient;
the time and date on which the patient arrived at the receiving hospital;
signature and date of receiving hospital administration;
type of vehicle and company used;
type of equipment and personnel needed in transfers;
name and city of hospital to which patient was transported;
diagnosis by transferring physician; and
attachments by transferring hospital."

The above was confirmed in an interview with the CEO and other administrative staff on 6-14-23.