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Based on record reviews and interviews, the hospital failed to meet the requirement of §489.24 as evidenced by:

1) Failing to ensure the Medical Staff By-laws or Rules and Regulations designated who was qualified to conduct MSEs as evidenced by failure to define which practitioners were considered to be "other qualified professional" who could conduct MSEs along with licensed independent practitioners (see findings in tag A2406).

2) Failing to develop a policy and procedure for MSEs that addressed the documentation and supervision required for MSEs conducted by Residents and Allied Health Professionals. Patient #5's MSE was conducted by S4Res with no documented evidence of Patient #5 being seen by a physician (see findings in tag A2406).

Based on record reviews and interviews, the hospital failed to ensure:
1) The Medical Staff By-laws or Rules and Regulations designated who was qualified to conduct MSEs as evidenced by failure to define which practitioners were considered to be "other qualified professional" who could conduct MSEs along with licensed independent practitioners.
2) The hospital developed a policy and procedure for MSEs that addressed the documentation and supervision required for MSEs conducted by Residents and Allied Health Professionals. Patient #5's MSE was conducted by S4Res with no documented evidence of Patient #5 being seen by a physician.
Findings:

1) The By-laws or Rules and Regulations didn't define which practitioners were considered to be "other qualified professional" who could conduct MSEs along with licensed independent practitioners:
Review of the "Medical Staff Bylaws And Rules and Regulations", revised April 2013, reviewed December 2015, and presented as the current by-laws by S2DQ, revealed that an appropriate medical screening will be provided by a licensed independent practitioner or other qualified professional with the appropriate clinical privileges to all individuals seeking emergency services to determine the presence or absence of an emergency medical condition. Further review revealed no documented evidence that the by-laws defined which practitioners were considered to be "other qualified professional."

In an interview on 02/16/16 at 8:50 a.m., S2DQ confirmed the hospital's Medical Staff By-laws and Rules and Regulations didn't define which practitioner(s) was meant by "other qualified professional."

In an interview on 02/16/16 at 10:45 a.m., S3EDMD indicated he was the Medical Director of ED. He further indicated the two groups able to perform MSEs are physicians and NPs and PAs. He further indicated it was the intent for licensed physicians and mid-level practitioners to be able to conduct MSEs, but he doesn't have any documentation to present that defines "other qualified professional" as NPs and PAs. S3EDMD indicated he knew that some hospitals allow RNs to perform MSEs, but Leonard J. Chabert Medical Center does not.

2) The hospital failed to develop a policy and procedure for MSEs that addressed the documentation and supervision required for MSEs conducted by Residents and Allied Health Professionals:
Review of the ED policies and procedures presented by S1DED when all ED policies and procedures were requested during the entrance conference on 02/15/16 at 10:10 a.m. revealed no documented evidence of a policy and procedure that addressed the documentation and supervision required for MSEs conducted by Residents and Allied Health Professionals.

Review of Patient #5's ED record revealed she presented to the ED on 11/10/15 at 11:51 a.m. with the arrival complaint of "Face and Hand Numb." Further review revealed her chief complaint was documented as "Chest Pain" for 3 to 4 days with left arm numbness today. Further review revealed Patient #5's MSE was conducted by S4Res on 11/10/15 at 3:24 p.m. and co-signed by S7MD on 11/12/15 at 6:46 a.m. Review of the entire ED record revealed no documented evidence that S7MD examined Patient #5 during her ED visit on 11/10/15.

In an interview on 02/16/16 at 10:45 a.m. with S3EDMD, S1DED, and S2DQ present, S3EDMD indicated he was the ED Medical Director. When he was asked to what does "physician patient contact time" on the patient's ED record refer, he indicated the patients seen by the Resident are seen by the physician. He further indicated that personally less than half the time, he'll see patients with the Resident, and the other times the Resident is sent into the room to gather patient information and come up with a treatment plan. When this occurs the physician will see the patient, and documentation should reflect that the physician has done a face-to-face visit with the patient. S3EDMD indicated for the chart to be completed, there should be an attestation by the physician that states he/she has seen the patient. He further indicated there's one attestation for Residents and another one for the PA and NP. S3EDMD indicated there should be a note by the physician that he/she has made a face-to-face visit and agrees with the assessment and treatment for patients seen by a Resident, and law allows for physicians to co-sign the note documented by the NP or PA. After reviewing the ED record of Patient #5, S3EDMD confirmed that it lacks an attestation by S7MD that he performed a face-to-face evaluation of the patient seen by the Resident. He further indicated to receive Medicare reimbursement, the ED record requires an attestation of the face-to-face evaluation by the physician when the MSE is done by a Resident. He indicated he doesn't think that S4Res saw the patient and discharged the patient without the physician seeing the patient, but it's just that the documentation wasn't done. S3EDMD confirmed he doesn't have any policy to present that explains the MSE protocol (as explained above) related to the process for documentation by and supervision of Residents, PAs, and NPs when performing MSEs in the ED. He further indicated the Resident isn't a licensed independent practitioner, as he/she is working under the license of the attending physician in the ED.

In a telephone interview on 02/16/16 at 4:25 p.m. with S7MD, with S1DED and S2DQ present, S7MD was asked if he remembered Patient #5 and could tell the surveyor anything about her condition at the time of visit. He indicated he would have to look at the chart to know anything about the patient. He further indicated he always sees the patients seen by the Resident, unless the patient leaves before he gets to the patient, such as elopement. He further indicated sometimes EPIC (the hospital's electronic medical record system) doesn't allow him to document in the chart, and he has to do an addendum. S7MD indicated it's a medical record issue. He further indicated if an addendum was done, it would be a second note. During the interview, S7MD indicated again that he couldn't remember anything about the patient without reviewing the medical record.