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Based on the systemic nature of the standard-level deficiency related to determining, implementing and monitoring policies the CAH's governing body failed to substantially comply with this condition.

Based on interviews and record reviews, it was determined that the Governing Body for the CAH failed to assure adherence to the policies and procedures adopted by the CAH with respect to physician responsibilities related to patients who present to the CAH's emergency department, entitled, "Emergency Medical Treatment and Active Labor Act (EMTALA)," which was in effect November 18, 2013.

Findings:

Patient #14 arrived at the CAH Emergency Department under an Emergency Custody Order (ECO) and was triaged by nursing staff at 12:55 p.m. on November 18, 2013. The ED physician evaluated the patient at 2:00 p.m. and ordered various laboratory tests and an X-ray. The ED physician did not make a determination about whether or not Patient #14 had an emergency medical condition. There is no documentation that the CAH's professional healthcare staff performed any further assessment of Patient #14. Instead, the CAH permitted an employee of the Community Service Board (CSB), an unrelated entity, to evaluate Patient #14. The CSB employee was not a physician, nor was the employee designated under the CAH's bylaws as a QMP (Qualified Medical Personnel) to evaluate patients. The CSB employee failed to document the employee's assessment of Patient #14 in the medical record, including the results of the assessment and plans for admitting or transferring the patient.

The CAH's EMTALA Policy and Procedures state, "...[a]n appropriate medical screening to determine whether or not an emergency medical condition exists must be performed by an Emergency Department physician or other qualified medical personnel, as set forth in Hospital's Bylaws. For purposes of providing medical screening examinations, the Hospital's Bylaws designate the following persons as qualified medical personnel: physicians and nurse practitioners." Although physicians and nurse practitioners are generally authorized to perform a medical screening examination under the CAH's EMTALA policy, the policy specifically requires a physician to perform the screening when the situation involves an individual with psychiatric or substance abuse problems. The policy and procedures state, "[r]esponsibility for providing an appropriate screening, stabilizing treatment and making transfer decisions for individuals with psychiatric or substance abuse problems rests with the physician." The CAH's EMTALA policy makes no mention of any involvement by the CSB or its employees, or of any process for designating CSB employees as QMPs.

The CAH Policy entitled, "Psychiatric Care and Substance Abuse Care Provisions," that was in effect November 18, 2013 was also reviewed and does make reference to a CSB role, but this policy is not consistent with the CAH's EMTALA policy. The "Psychiatric Care and Substance Abuse Care Provisions" policy specifies the following among other things:

"c. Emergency Custody Order
i. Community Services Board (CSB) will be notified of an Emergency Custody Order (ECO) and the patient's need for an evaluation.
ii. CSB will work in cooperation with the Sheriff's Office
and/or magistrate to obtain ECO.
iii. CSB will evaluate the patient to determine the need for TDO."

Use of the CSB as called for in the "Psychiatric Care and Substance Abuse Care Provisions" policy put the CAH in the position of not being able to satisfy its obligations under EMTALA, since CSB employees who performed assessments on behalf of the CAH were not designated QMPs whose qualifications were examined by the CAH, nor were they under the supervision of the CAH's medical director, nor were they required by the CAH to document in the patient's clinical record the services they provided or the arrangements they made for discharge or transfer of the patient.

Based on the systemic nature of a standard-level deficiency related to the CAH (Critical Access Hospital) governing body's responsibility to ensure that a contractor of services provides services that enable the CAH to comply with all applicable conditions and standards, the CAH failed to be in substantial compliance with the requirements governing the provision of services.

CAH clinical staff commenced an evaluation of Patient #14 who presented to the CAH Emergency Department under an Emergency Custody Order (ECO) based on psychiatric problems. CAH clinical staff did not finish their assessment of the patient and, instead, permitted an employee of an unrelated entity, the Community Services Board (CSB), to evaluate Patient #14. The CAH failed to provide any oversight regarding the CSB employee's evaluation of Patient #14. The patient's clinical record failed to contain any information entered either by CAH professional healthcare personnel or by the CSB employee related to the assessment the CSB employee had performed. There is no documentation that the CAH had examined the qualifications of and granted privileges to the CSB employee in the same way that it did for other members of its professional healthcare staff. Patient #14's clinical record documents that the CSB employee was trying to locate an inpatient psychiatric bed to which Patient #14 could be transferred. Yet, the CAH failed to monitor the actions of the CSB employee with respect to the assessment of Patient #14 and with respect to the disposition plan for Patient #14, resulting in the expiration of the Emergency Custody Order before the CAH was able to effect the transfer of Patient #14 to an inpatient psychiatric facility that the CSB employee had evidently determined was required.

Findings:

The CAH Policy entitled, "Psychiatric Care and Substance Abuse Care Provisions," that was in effect November 18, 2013 was reviewed and makes reference to a Community Service board (CSB) role at the CAH. The "Psychiatric Care and Substance Abuse Care Provisions" policy specifies the following among other things:

"c. Emergency Custody Order
i. Community Services Board (CSB) will be notified of an Emergency Custody Order (ECO) and the patient's need for an evaluation.
ii. CSB will work in cooperation with the Sheriff's Office
and/or magistrate to obtain ECO.
iii. CSB will evaluate the patient to determine the need for TDO."

Patient #14 arrived at the CAH Emergency Department under an Emergency Custody Order (ECO) and was evaluated by nursing staff at 12:55 p.m. on November 18, 2013. Patient #14, an adult, had a [history of] of bipolar disorder and the patient's parent reported the patient had not been taking his medications for 6 months. Patient #14's clinical record indicated that his Chief Complaint was "ECO" and further indicated the following "delusions, had escalated yesterday, feels like [parent] assaulting him with words." The CAH's Emergency Room physician evaluated the patient at 2 p.m. Laboratory tests and an X-ray were ordered on behalf of Patient #14. However, the Emergency Room physician did not complete the assessment of the patient's condition. There is no record that the CAH's professional healthcare or nursing staff performed any further assessment of Patient #14 after 2 p.m.

Instead, the CAH permitted an employee of an unrelated entity, the Community Services Board (CSB), to evaluate Patient #14. There is no documentation that the CAH had examined the qualifications of and granted privileges to the CSB employee in the same way that it did for other members of its professional healthcare staff.

The clinical record identifies the following timeline of events upon the arrival of the CSB evaluator:
3:20 p.m. "[CSB employee] here talking to [Patient #14's parent]."
3:20 p.m. "[Patient #14] has remained very cooperative[with] care. Deputy [at] bedside. "
3:26 p.m. "[CSB employee] in [with] [Patient #14] talking to [him/her]."
4:15 p.m. "[CSB employee] calling to find placement for [Patient #14]."
5:00 p.m. "[CSB employee] spoke with [name of hospital] they advised change of shift. Awaiting on call back."
5:45 p.m. "[Three separate facilities] no beds available. Attempting [abbreviation of a facility]."
6:26 p.m. ECO complete. Deputy advised [Patient #14]. [CSB employee] advised [Patient #14]. Deputy left. No bed available. Patient will [follow up] in a.m. [with] [CSB]. [Patient #14] agreed.

The clinical record documents that CAH staff had limited, if, any involvement with Patient #14 once the CSB employee arrived. The clinical record further documents that CAH staff had little, if any, communication with the CSB employee regarding the CSB employee's assessment of Patient #14 and disposition plan for the patient.

Despite the documentation demonstrating the CSB employee had evaluated and searched for an inpatient bed for Patient #14 from approximately 3:10 p.m. to 6:30 p.m. on November 18, 2013, there was no documentation in Patient #14's clinical record regarding the nature of the evaluation the CSB employee had performed of Patient #14 at the CAH. The only documentation written by the CSB employee contained in Patient #14's clinical record was a signed Progress Note the CSB employee had written dated November 18, 2013 at 6:30 p.m., "Clinician assessed client and he presented as decompensating. Client has [history] of bipolar disorder. Client's ECO ran out and [he/she] agrees to follow up with [name of CSB] on 11/19/13 for Crisis Stabilization."

The clinical record documents that the CSB employee was trying to locate an inpatient psychiatric bed, presumably to admit Patient #14 under a Temporary Detention Order. Facility staff failed to oversee the CSB employee's assessment of Patient #14's need for hospitalization or treatment. Moreover, Hospital staff failed to monitor the actions of the CSB employee, resulting in the expiration of the Emergency Custody Order before the facility was able to complete an appropriate Medical Screening Exam and before an appropriate disposition plan could be made for Patient #14.

In a "late entry" after Patient #14 had already been discharged from the hospital, the nurse documented that previously at 4:07 p.m., the CSB employee had obtained a two hour extension of the Emergency Custody Order in the course of Patient #14's stay at the CAH. Under state law, an Emergency Custody Order may be extended only one time for an additional period not to exceed two hours. There was no contemporaneous documentation, in the nursing notes, of the fact that an extension of the Emergency Custody Order had been obtained by the CSB employee. Nor was there any contemporaneous documentation demonstrating that CAH staff were aware the CSB employee had obtained an extension of the ECO. When interviewed by the survey team on February 6, 2014, the Emergency Department physician stated that he "wasn't keeping track of [Emergency Custody Order] time."

The clinical record documents that, up until the expiration of the Emergency Custody Order, the plan for Patient #14 was to locate an inpatient psychiatric placement so that the patient could be transferred. After the Emergency Custody Order expired, the disposition plan for Patient #14 changed. The plan then became that Patient #14 would be discharged and follow up in the morning with the CSB, "[name of hospital] may have bed available in a.m." The progress note of the CSB employee identifies that the disposition plan for Patient #14 changed only because the Patient's Emergency Custody Order ran out. "Clinician assessed client and [he/she] presented as decompensating. Client has history of bipolar disorder. Client's [Emergency Custody Order] ran out and [he/she] agrees to follow up with [the CSB] on 11/19/13 for Crisis Stabilization."

The facility's Emergency Department physician's notes also indicate that the disposition plan for Patient #14 changed only because the patient's Emergency Custody Order ran out. The physician documented, "The patient has been diagnosed with bipolar disorder and is not taking prescribed medications. An inpatient bed was found, but we were told that the supervisor at that facility had gone home and [patient] could not be admitted tonight, but the bed would be available in the morning. The [Emergency Custody Order] expired. The patient went home with his [parent]. [The CSB] recommended driving to [name of town] in the morning for possible admission. [Parent] expressed concern that [he/she] would not be able to persuade [the adult patient] to go in for treatment, and that another [Emergency Custody Order] could not be obtained for 24 hours." The physician noted that Patient #14's parent stated, "The system has failed." Once the Emergency Custody Order expired, Patient #14 was free to go. In an interview with the facility nurse and Emergency Room Supervisor on February 5, 2014 at 2:48, she indicated that "[with] this [patient], it was all involuntary. [Patient #14] did not think [he/she] had a problem."

Facility staff failed to oversee the CSB employee's assessment of Patient #14's need for hospitalization or treatment. There is no documentation that the CAH's Emergency Department physician made a determination whether an Emergency Medical Condition existed or certified the individual's non-emergency status. Yet, the CSB employee was trying to locate an inpatient psychiatric bed where the patient could be transferred. The physician's Emergency Room Notes document that the patient was discharged home only because the Emergency Custody Order expired before the CSB employee could execute the plan to transfer Patient #14 to an inpatient psychiatric facility, not because CAH clinical staff determined that it was appropriate to discharge Patient #14 home based on an appropriate medical screening examination.

Based on the systemic nature of the standard-level deficiency related to the requirements for the CAH's (Critical Access Hospital) clinical records system to be complete and accurate, the CAH failed to comply with this condition.

Based on interviews and record reviews, it was determined that the CAH failed to maintain a complete, accurately documented, and readily accessible record for 1 of 20 sampled patients (Patient #14) and this failure was as a result of a systematic policy of not requiring evaluation services that were being provided in the CAH by the CSB (Community Service Board) to be documented in patients' clinical records.

Findings:

Patient #14 presented to the CAH Emergency Department on November 18, 2013 at 12:55 under an Emergency Custody Order (ECO). As a result of the ECO, the Community Services Board was notified and responded by assigning a CSB employee to travel to the CAH to evaluate Patient #14 for purposes of the ECO.

The clinical record identifies the following timeline of events upon the arrival of the CSB evaluator:
3:20 p.m. "[CSB employee] here talking to [Patient #14's parent]."
3:20 p.m. "[Patient #14] has remained very cooperative [with] care. Deputy [at] bedside."
3:26 p.m. "[CSB employee] in [with] [Patient #14] talking to [him/her]."
4:15 p.m. "[CSB employee] calling to find placement for [Patient #14]."
5:00 p.m. "[CSB employee] spoke with [name of hospital] they advised change of shift. Awaiting on call back."
5:45 p.m. "[Three separate facilities] no beds available. Attempting [abbreviation for a hospital]."
6:26 p.m. ECO complete. Deputy advised [Patient #14]. [CSB employee] advised [Patient #14]. Deputy left. No bed available. Patient will [follow up] in a.m. [with] [CSB]. [Patient #14] agreed.

Despite the documentation demonstrating the CSB employee had evaluated Patient #14 and was looking for an inpatient bed for Patient #14 from approximately 3:10 p.m. to 6:30 p.m. on November 18, 2013, there was no documentation in Patient #14's clinical record regarding the nature of the evaluation the CSB employee had performed of Patient #14 at the CAH. The only documentation written by the CSB employee contained in Patient #14's clinical record was a signed Progress Note the CSB employee had written dated November 18, 2013 at 6:30 p.m., "Clinician assessed client and he presented as decompensating. Client has [history] of bipolar disorder. Client's ECO ran out and [he/she] agrees to follow up with [the local Community Service Board] on 11/19/13 for Crisis Stabilization."

Patient #14's ED clinical record failed to include evidence of documentation concerning the evaluation performed by the CSB employee. Neither the physician's documentation nor the nurse's documentation included details of the evaluation performed by the CSB employee. The CSB employee's documentation was not complete as it failed to provide any details of the evaluation and search for an inpatient bed the CSB employee had performed between 3:10 p.m. to 6:30 p.m. on November 18, 2013. Additionally, the CSB employee's documentation did not include details of his/her assessment to indicate what type of screening exam the patient received.

On February 5, 2014 at 1:47 p.m., an interview was conducted with the Supervisor for the CSB employee who evaluated Patient #14 on November 18, 2013, the CSB Clinical Director, and the CSB Executive Director. During this interview, these CSB representatives explained the normal process when a CSB employee is called to respond to a CAH in the event of an ECO. The CSB representatives specifically explained the CSB employee acts as a "pre-screener." The CSB representatives further explained that during the evaluation process the "pre-screener" is "constantly talking [with the] doctor." Patient #14's ED clinical record failed to include evidence of documentation concerning communications between the CSB employee and the physician.

During this same interview on February 5, 2014 at 1:47 p.m., the Supervisor for the CSB employee who evaluated Patient #14 on November 18, 2013 described the process of how the CSB evaluator must fill out a "Pre-Screener Form." It was determined that no such "Pre-Screener Form" was contained in the clinical record for Patient #14. Nor was there any documentation describing the evaluation by the CSB employee other than the short entry at 6:30 p.m. identified above. Thus, it was determined that documentation of the CSB evaluation and search for an inpatient bed performed between approximately 3:10 p.m. to 6:30 p.m. on November 18, 2013 existed but, was not contained in the clinical record for Patient #14. Interview with the CAH's Vice President of Nursing and Vice President of Quality at 2:30 p.m. on February 5, 2014 revealed that hospital staff had asked CSB for additional documentation concerning the evaluation that the CSB employee had performed on Patient #14 in the CAH but CSB refused to provide the documentation and further stated that the CSB attorney would not allow CSB to provide such documentation to the CAH.

Cross refer to 42 C.F.R. § 485.635(c)(4)(ii) Services provided through agreements or arrangements. Based on interviews and record reviews, it was determined that CAH failed to properly oversee the evaluation services that were being provided by the Community Service Board in its CAH to Patient #14 and such lack of oversight resulted in a failure to maintain complete, accurately documented, and readily accessible records.