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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the §485.627 Condition of Participation Organizational Structure was out of compliance.

C0962: The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing and monitoring policies governing the CAH'S total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment. Based on interviews and record review, the facility failed to ensure contracted mental health providers providing consultation and conducting assessments for patients were qualified and competent to provide the level of care intended and that the expected roles and responsibilities of the mental health providers were clearly delineated by contract or through the medical staff bylaws.

Based on interviews and record review, the facility failed to ensure contracted mental health providers providing consultation and conducting assessments for patients were qualified and competent to provide the level of care intended and that the expected roles and responsibilities of the mental health providers were clearly delineated by contract or through the medical staff bylaws. This failure was identified in six of six patients reviewed who presented with psychiatric and behavioral health emergencies and were not admitted to the facility. (Patients #1, #2, #3, #4, #5, and #6)

Findings include:

Facility policy:

The Contract Review Policy read, all contracts/agreements whose terms exceed one year and/or thirty thousand dollars ($30,000) per fiscal period (with the exception of consumable supplies and maintenance agreements) require the approval of the Finance Committee. Contracts that exceed one year and $30,000 per year also require approval of the Board of Directors. The Chief Executive Officer shall have the authority to execute contracts/agreements below the authority levels set forth above.

References:

The Medical Staff Rules and Regulations read, the Board has designated physicians as qualified medical personnel to perform a medical screening examination. An emergency medical condition is now defined in the regulations as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could be reasonably expected to result in placing the health of the individual in serious jeopardy.

The facility and external mental health provider Services Agreement read, the external mental health provider agrees to hold necessary license(s). Provide assessment, monitoring, evaluation and treatment standards of care by a full-time Master's level therapist. Provide services to the facility's residents and patients on site at the facility. Provide the appropriate level of administrative and clinical supervision necessary for the successful delivery of services.

1. The Governing Body did not ensure medical staff bylaws and review of contracts addressed practitioners providing specialized mental health services at the facility and failed to evaluate the quality of care provided by these practitioners.

A. Record review

i. Medical record review showed Patient #1 presented to the emergency department on 8/16/22 at 2:39 p.m. with extreme paranoia and hallucinations. Patient #1 had a history of schizophrenia. RN #4 documented Patient #1 had denied suicidal ideations, but refused to answer further questions. RN #4 documented the external mental health provider was contacted and provided the psychiatric medical screening exam for Patient #1. RN #4 documented the external mental health provider determined Patient #1 was appropriate for transfer and plans were made to transfer to an external mental health facility. There was no evidence in the medical record showing how the facility's physician determined the patient was appropriate to transfer.

ii. Medical record review showed Patient #2 was brought from school by police to the emergency department on 9/20/22 at 12:21 p.m. with suicidal ideations with a plan to shoot herself with her grandmother's gun. Review of Patient #2's medical record showed the external mental health provider evaluated Patient #2 at her school before she was brought to the facility's emergency department. Review of the medical record showed there was no psychiatric health screening provided by the facility or the external mental health provider while she was in the facility's emergency department. RN #6 documented Patient #2 was accepted by an inpatient psychiatric facility based on the evaluation completed by the external mental health provider at Patient #2's school prior to her admission to the facility emergency department. There was no evidence in the medical record showing how the facility's physician determined the patient was appropriate to transfer.

iii. Medical record review showed Patient #3 was brought from school by police to the emergency department 1/16/23 at 7:09 p.m. for acute psychosis and had attempted to break his mother's arm. Patient #3 was placed on an M1 psychiatric hold (placed when an individual was deemed to be in imminent danger of harming him or herself or someone else or was gravely disabled). The external mental health provider completed the psychiatric medical screening exam and determined Patient #3 was appropriate for transfer to an external mental health facility. RN #7 documented she was unable to assess the patient due to his condition. There was no evidence in the medical record showing how the facility's physician determined the patient was appropriate to transfer.

iv. Medical record review showed Patient #4 presented to the emergency department on 10/1/22 at 11:54 a.m. after a suicide attempt where he drank half a gallon of household bleach. Documentation showed Patient #4 had a attempted suicide a week prior by overdosing on his medications. Physician #8 documented Patient #4 was evaluated by the external mental health provider and was placed on an M1 hold to be transferred to an inpatient psychiatric facility. There was no evidence in the medical record showing how the facility's physician determined the patient was appropriate to transfer.

v. Medical record review showed Patient #5 presented to the emergency department on 3/20/23 at 6:45 p.m. for suicidal ideation (having thoughts of ending one's own life). RN #9 documented Patient #5 had active suicidal ideations and a history of bipolar depression. RN #9 documented Patient #5 planned to transport herself to the external mental health provider's regional assessment center for psychiatric care when she left the emergency department. Record review showed Patient #5 was discharged from the facility without a safety plan and no documentation of a psychiatric medical screening exam by either the facility or the external mental health provider. There was no evidence in the medical record showing how the facility's physician determined the patient was safe to discharge.

vi. Medical record review showed Patient #6 presented to the emergency department on 5/8/23 at 7:18 p.m. for suicidal ideation with a plan to overdose on medication. RN #10 documented the external mental health provider evaluated Patient #6 and determined they were appropriate for transfer to an inpatient psychiatric facility. There was no evidence in the medical record showing how the facility's physician determined the patient was appropriate to transfer.

B. Review of the contract between the external mental health provider and the facility revealed the contract was initiated in 2010 and had been auto renewed since that time. There was no evidence the contract was reviewed by the governing board or chief executive officer since its initiation in 2010. The contract read, psychiatric assessment, monitoring, evaluation, and treatment were to be provided by a Master's level therapist. Upon request to verify the individual providing services, CNO #1 stated she reached out to the external mental health provider company and they informed her that the individuals providing psychiatric screening services were unlicensed and the highest level of education was a bachelor's degree in psychology.

i. This was in contrast with the Medical Staff Rules and Regulations which designated physicians as qualified medical personnel to perform medical screening examinations.

C. Interviews

i. An interview was conducted with the chief nursing officer (CNO) #1 on 7/6/23 at 1:58 p.m. CNO #1 stated the facility did not have a process for vetting, monitoring or evaluating the services provided by the external mental health provider. CNO #1 stated the contract for the external mental health provider was given to the director of the emergency department for signatures after it had been approved by the CEO and governing board in 2010. CNO #1 stated the facility was not aware the external mental health provider contract stated evaluators who performed contracted services at the facility would have a minimum of a master's level education. CNO #1 stated she was not aware the evaluators from the external mental health provider were unlicensed and held a bachelor's degree in psychology. CNO #1 stated the risk of the external mental health provider contract not being reviewed by the director of the emergency department was negative clinical implications could be passed on to the patient.

ii. An interview was conducted with the chief executive officer (CEO) #12 on 7/6/23 at 2:25 p.m. CEO #12 stated he reviewed all contracts for approval annually. CEO #12 stated once he approved the contract, it was sent to the finance committee for review and then to the governing board for final approval. CEO #12 stated during the governing board approval, an orthopedic physician was given a summary of the contract for review and could request the full contract if needed.

CEO #12 stated the contract with the external mental health provider was a longstanding contract which was placed on autocracies and did not go through the annual review process. CEO #12 stated once the contract was on auto renewal, it no longer went through the CEO or board approval process and was not reviewed for continued compliance with state and federal regulations. CEO #12 stated the process needed to change and contracts should have been reviewed annually without the option to auto renew. CEO #12 stated he was unaware the external mental health provider contract read evaluators who performed contracted services at the facility would have a minimum of a master's level education. CEO #12 stated he was not aware the evaluators from the external mental health provider were unlicensed and held a bachelor's degree in psychology.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the §485.638 Condition of Participation Clinical Records was out of compliance.

C-1110: For each patient receiving health care services, the CAH maintains a record that includes, as applicable--(i) Identification and social data, evidence of properly executed informed consent forms, pertinent medical history, assessment of the health status and health care needs of the patient, and a brief summary of the episode, disposition, and instructions to the patient. Based on interviews and record review the facility failed to maintain complete medical records for six out of six patients who received care for psychiatric emergencies in the emergency department (Patients #1, #2, #3, #4, #5, and #6). Specifically, the facility failed to have a standard process to ensure services provided by an external mental health provider on behalf of the facility included complete medical records with a medical screening exam.

Based on interviews and record review the facility failed to maintain complete medical records for six out of six patients who received care for psychiatric emergencies in the emergency department (Patients #1, #2, #3, #4, #5, and #6). Specifically, the facility failed to have a standard process to ensure services provided by an external mental health provider on behalf of the facility included complete medical records with a medical screening exam.

Findings include:

Facility Policy:

The Contents of Medical Records Policy read, a complete medical record shall be maintained on every patient from the time of admission through discharge. All patient records shall include: date and time of admission and discharge, adequate identification data-sociological data, admissions diagnosis, final diagnosis, secondary diagnosis, complications, condition on discharge, signature of attending physician, evidence of known advance directives. Additional Information to be included in hospital records: chief complaint and present illness, personal history, reports of consultations by consulting providers, treatment and progress notes signed by the attending physician and a discharge summary.

1. The facility failed to ensure patient medical records were accurate and complete for services provided by an external mental health provider entity at the request of the hospital.

A. Record review

i. Medical record review showed Patient #1 presented to the emergency department on 8/16/22 at 2:39 p.m. with extreme paranoia and hallucinations. Patient #1 had a history of schizophrenia. RN #4 documented the external mental health provider was contacted and provided the psychiatric medical screening exam for Patient #1. RN #4 documented the external mental health provider determined Patient #1 was appropriate for transfer and plans were made to transfer to an external mental health facility. There was no evidence or documentation of a psychiatric medical screening exam in Patient #1's medical record.

ii. Medical record review showed Patient #2 was brought from school by police to the emergency department on 9/20/22 at 12:21 p.m. with suicidal ideations with a plan to shoot herself with her granmother's gun. Review of Patient #2's medical record showed the external mental health provider evaluated Patient #2 at her school before she was brought to the facility's emergency department. Review of the medical record showed there was no psychiatric health screening provided by the facility or the external mental health provider while she was in the facility's emergency department. RN #6 documented Patient #2 was accepted by an inpatient psychiatric facility based on the evaluation completed by the external mental health provider at Patient #2's school prior to her admission to the facility emergency department.

iii. Medical record review showed Patient #3 was brought from school by police to the emergency department 1/16/23 at 7:09 p.m. for acute psychosis and had attempted to break his mother's arm. Patient #3 was placed on an M1 psychiatric hold (placed when an individual was deemed to be in imminent danger of harming him or herself or someone else or was gravely disabled). The external mental health provider completed the psychiatric medical screening exam and determined Patient #3 was appropriate for transfer to an external mental health facility. RN #7 documented she was unable to assess the patient due to his condition. There was no evidence or documentation of a psychiatric medical screening exam in Patient #3's medical record.

iv. Medical record review showed Patient #4 presented to the emergency department on 10/1/22 at 11:54 a.m. after a suicide attempt where he drank half a gallon of household bleach. Documentation showed Patient #4 had a attempted suicide a week prior by overdosing on his medications. Physician #8 documented Patient #4 was evaluated by the external mental health provider and was placed on an M1 hold to be transferred to an inpatient psychiatric facility. There was no evidence or documentation of a psychiatric medical screening exam in Patient #4's medical record.

v. Similar findings of missing MSE for psychiatric emergencies were found in the medical records of Patients #5 and #6.

B. Interviews

i. An interview was conducted with the medical records supervisor (Supervisor) #11 on 7/6/23 at 12:58 p.m. Supervisor #11 stated each medical record was reviewed by the medical records department for completeness before it was sent to be processed by insurance. Supervisor #11 stated medical records of patients who presented to the emergency department (ED) for psychiatric concerns had the same documentation requirements as those who presented for medical concerns. Supervisor #11 stated the emergency department records for patients who were seen by an external mental health provider did not include the patient's psychiatric medical screening exam documentation. Supervisor #11 stated the medical records for patients with psychiatric emergencies were complete from a medical exam standpoint, but were not complete from a psychiatric standpoint. Supervisor #11 stated the providers in the ED were there to treat medical concerns, not psychiatric, therefore she did not expect to see a psychiatric medical screening exam in the medical record. Supervisor #11 stated an incomplete medical record could lead to a breakdown in continuity of care, inability to substantiate billing, and inaccurate reporting of medical records.

ii. This was in contrast to the Contents of Medical Records Policy, which read all patient records should have included reports of consulting providers and treatment and progress notes signed by the attending physician.

iii. An interview with emergency department physician (Physician) #3 was conducted on 7/6/23 at 9:45 a.m. Physician #3 stated he did not complete or document findings of psychiatric medical screening exams for patients who presented with psychiatric emergencies. Physician #3 stated the psychiatric medical screening exams were completed by an external mental health provider and the results of the exams were not shared with him. Physician #3 stated the psychiatric medical screening exams were not included in the patients' medical record.