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Based on review of the Medical Staff Bylaws, Medical Staff Rules and Regulations, policies and procedures, Agreement for Emergency Medical Services and Medical Director Services, staff interviews, and medical records review, it was determined that the facility failed to ensure compliance with 42 CFR 482.24, Special Responsibilities of Medicare Participating Hospitals in Emergency Cases.

Findings were:

Cross refer to A2406 as it relates to the facility's failure to identify in the Medical Staff Bylaws and/or Medical Staff Rules and Regulations those individuals qualified to perform medical screening examinations.

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B. Based on review of the Medical Staff Bylaws, Medical Staff Rules and Regulations, staff interview, policies and procedures, and Agreement for Emergency Medical Services and Medical Director Services, it was determined that the facility lacked effective policies and procedures related to who had been approved to perform a medical screening examination .


Findings were:

Review of the Medical Staff Bylaws, dated 09/05, and the Medical Staff Rules and Regulations, last revised 06/09, revealed that there was no documented evidence of who had been approved to perform medical screening examinations (MSE).

During an interview (#4) at 10:15 a.m. on 03/23/10 in the Conference Room, the Chief Executive Officer (CEO) confirmed that the Medical Staff Bylaws and Medical Staff Rules and Regulations did not address who had been determined qualified to perform a MSE. The CEO explained that the facility had a policy that addressed who could perform a MSE.

Review of facility policy entitled "Medical Screening Examination", no policy number, effective 05/01/09, revealed that the MSE was to be performed by a physician. In addition, the facility had the following policies in place: "Initial Triage/Assessment of ER (Emergency Room) Patients, EMTALA Guidelines, EMTALA, OB (obstetric-pregnant) Patient Presenting for Treatment in the ED (Emergency Department)".

Review of the Agreement for Emergency Medical Services and Medical Director Services, effective 12/18/08, revealed the facility had contracted with physicians and other licensed health care professionals to provide emergency medical services in the facility's ED. This agreement required the physicians to be in compliance with all laws and rules and regulations pertaining to the services to be provided, including EMTALA.