HospitalInspections.org

The Condition of Participation of Medical Staff was out of compliance.

Findings included:

1.) The Hospital Medical Staff failed to ensure for one patient (Patient #19) in a sample of twenty-six patients, the qualifications of non-physician practitioners, contracted to provide behavioral health services, were determined to be qualified and eligible for privileges by the Governing Body to provide psychiatric Medical Screening Examinations, in accordance with Hospital's Medical Staff Bylaws and Rules & Regulations.

Refer to TAG: A-0339.

2.) The Medical Staff failed to ensure for one patient (Patient #1) in a sample of twenty-six patients, accountability to the Governing Body quality patient care when Quality Assessment and Performance Improvement (QAPI) activities did not identify the Hospital's Security Officer Staff were not trained or were not effectively trained in the Hospital's Emergency Medical Treatment and Labor Act (EMTALA) obligations following the EMTALA event of Patient #1, as a process for improvement.

Refer to TAG: A-0347.

Based on records reviewed and interviews the Hospital Medical Staff failed to ensure for one patient (Patient #19) in a sample of twenty-six patients, the qualifications of non-physician practitioners, contracted to provide behavioral health services, were determined to be qualified and eligible for privileges by the Governing Body to provide psychiatric Medical Screening Examinations, in accordance with Hospital's Medical Staff Bylaws and Rules & Regulations.

Findings included:

Hospital-A's Medical Staff Rules & Regulations, dated 1/13/2012, indicated practitioners other than physicians may be determined qualified to perform emergency medical screening examinations as follows:

-Nurse Practitioners

-Physician Assistants

-Clinical Psychologists

-Clinical Social Workers with a Master's Degree in Psychology or social work-related field.

The policy titled UMass Memorial Health Care, EMTALA Compliance, Medical Screening, Transfers and Refusal of Care, dated 6/20/2019 and approved by UMMHC, indicated a Medical Screening Examination must be provided by a physician or other qualified individual who was approved by the UMMHC hospital's Board of Trustees to perform such examinations.

The document titled Services Agreement, dated 11/1/17, indicated a contract between Advocates, Inc. and Hospital-A for behavioral health services. The Service Agreement indicated minimum qualifications of contracted staff included:

-Licensed or license-eligible clinical psychologist or clinical social worker with a Master's Degree in psychology or social work-related field,

-Compliance with Hospital-A's Human Services criteria and policies.

The Services Agreement indicated no documentation regarding maintenance and availability of contracted staff personnel file to include documentation of education, training and competency to perform the Emergency Service Program (ESP) Adult Comprehensive Examination for the Psychiatric Emergency Services.

The document titled Adult ESP Comprehensive Assessment, undated, indicated The Adult ESP Comprehensive Assessment provided a standard format to assess mental health, substance use and functional needs of persons served that present for emergency behavioral health services by an Emergency Services Program.

The Surveyor interviewed the Chief of Emergency Medicine at 11:30 A.M. on 9/30/2020. The Chief of Emergency Medicine said ESP Advocates Staff conducted the Psychiatric Medical Screening Examinations. The Chief of Emergency Medicine said that ESP was Psychiatric Emergency Services and a contracted service from Advocates. The Chief of Emergency Medicine said that the ESP Advocates Staff made recommendations to him/her regarding patient discharge and hospitalization.

The Surveyor interviewed the Mental Health Counselor at 11:45 A.M. on 9/30/2020. The Mental Health Counselor said he/she was the Coordinator of the ESP Advocates Staff. The Mental Health Counselor said he/she was a Licensed Mental Health Councilor, with a Master's Degree in Arts and saw (evaluated) patients. The Mental Health Counselor said he/she did not know if the Medical Staff had evaluated his/her qualifications to provide Psychiatric Medical Screening Examinations.

The Surveyor interviewed the Risk Manager at 12:20 P.M. on 9/30/2020. The Risk Manager said that the ESP Advocates Staff were not credentialed (privileged to provide Psychiatric Medical Screening Examinations) at Hospital-A and ESP Advocates Staff were not part of the Medical Staff.

Review of Patient #19's medical record, ESP Adult Comprehensive Examination, dated 9/11/2020 indicated an ESP Advocates Staff with the initials MA (undefined) completed and documented the psychiatric examination.

Hospital-A provided no documentation to indicate Hospital-A's Medical Staff evaluated ESP Advocates Staff and recommended ESP Advocates Staff to the Governing body to grant privileges to provide patients with Psychiatric Medical Screening Examinations, in accordance with Hospital-A's Medical Staff Bylaws or Rules & Regulations.

Based on records reviewed and interviews the Medical Staff failed to ensure for one patient (Patient #1) in a sample of twenty-six patients, accountability to the Governing Body quality patient care when Quality Assessment and Performance Improvement (QAPI) activities did not identify the Hospital's Security Officer Staff were not trained or were not effectively trained in the Hospital's Emergency Medical Treatment and Labor Act (EMTALA) obligations following the EMTALA event of Patient #1, as a process for improvement.

Findings included:

1.) The Surveyor interviewed the Quality Director and Risk Manager at 10:00 A.M. on 9/29/2020. The Quality Director and Risk Manager said Patient #1 arrived at the Hospital Emergency Department (ED at Hospital-A) as directed by Patient #1's physician for a complaint of chest pain. The Quality Director and Risk Manager said ED Technician #1 and ED Registration Clerk #1 could not register Patient #1 (into the ED Log) and Hospital-A was unclear how or who directed Patient #1 to seek care at another hospital (hospital-B). The Quality Director and Risk Manager said Patient #1 arrived at hospital-B one-half hour later; Patient #1 was examined and discharged to home.

The policy titled UMass Memorial Health Care (UMMHC), EMTALA Compliance, Medical Screening, Transfers and Refusal of Care, dated 6/20/2019, provided by Hospital-A and approved by UMMHC, indicated all new UMMHC Workforce Members received education regarding UMMHC's obligations under this policy upon beginning in their role. The policy indicated UMMHC Administrative Workforce Members who work in the Emergency Department and Labor & Delivery, and Workforce members who provided direct clinical care in all departments would also be re-educated regarding their entity's obligations under this policy as part of annual required education.

The document titled Allied Universal, dated 9/15/2019, indicated a contract between Allied Universal and Hospital-A for Security Services.

The Surveyor interviewed Public Safety Officer #1 at 3:30 P.M. on 9/29/2020. Public Safety Officer said that he/she had not heard of what EMTALA was. The Public Safety Officer said that at times on the night shift there was no one to greet a patient seeking care in the Emergency Department.

The Surveyor interviewed the Chief Medical Officer and Interim Lead Executive Chief Operating Officer Chief Nursing Officer at 9:40 A.M. on 9/30/2020. They said that Hospital-A did not have EMTALA training assigned to Public Safety Officers as included in Hospital-A's orientation to Hospital-A (in accordance with UMass Memorial Health Care (UMMHC), EMTALA Compliance, Medical Screening, Transfers and Refusal of Care policy).

The Surveyor interviewed the Quality Director and Risk Manager at 11:15 A.M. on 9/30/2020. The Quality Director and Risk Manager said that all Emergency Department staff was required to complete EMTALA Training yearly.

2.) The Medical Staff failed to ensure that the Emergency Services had its own EMTALA policy, as Hospital-A was its own entity (a Hospital separate and distinct of UMass Memorial Health Care).

The policy titled UMass Memorial Health Care (UMMHC), EMTALA Compliance, Medical Screening, Transfers and Refusal of Care, dated 6/20/2019, provided by Hospital-A and approved by UMMHC, indicated no documentation that Hospital-A approved the policy as its own policy.