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Based on record reviews and interviews, the Governing Body failed to ensure a system was in place to verify assessment and consultation services from a crisis agency was furnished by individuals determined to meet minimum qualification determined by the hospital through its Governing Body, Medical Bylaws, or credentialing process. This failure resulted in 14 of 22 sampled patients who presented to the Emergency Department (ED) for evaluation of a psychiatric condition (Patient #1, #2, #4, #5, #6, #8, #10, #12, #13, #15, #18, #20, and #22) potentially receiving services by unqualified individuals.

Findings:

During an EMTALA investigation, issues related to the hospital's compliance related to the Condition of Participation (CoP): Governing Body were identified; therefore, a review of the COP: Governing Body was conducted (complaint 27958). The hospital was issued a CMS 2567, dated 5/22/18, for its failure to ensure a system was in place to verify services from crisis agencies were furnished by qualified individuals for two crisis agencies. The hospital's plan of correction, dated 6/21/18, indicated the following: the hospital did not have a process in place to obtain credentialing information about employees who performed crisis evaluations on patients in the ED; the hospital created a process to ensure all who perform crisis evaluations are qualified; a list of all employees who will perform crisis evaluations on patients at the hospital would be available tin the ED; this list will include information regarding credentials and education for the employees; and when a new crisis employee is hired, the crisis provider will contact the Director of the ED to obtain security clearance and the information regarding the employee would be added to the list at the hospital. The date of correcting the deficiency cited was 6/28/18.

This survey determined the hospital was not in compliance with this regulation as evidenced by the following:

A review of Patient #1's, #2's, #4's, #5's, #6's, #8's, #10's, #12's, #13's, #15's, #18's, #20's, and #22's records was conducted by surveyors. Each of these patients was seen by a representative of Crisis Agency #1 who conducted an assessment that included the following: referral information; service providers; developmental history; health information; substance abuse information; family history; trauma history; educational information; social/other information; risk assessment information; and summary of information. It was noted that the "Summary of Information" included the following: crisis plan/disposition; summary of intervention; disposition; follow up plan, and additional plan information.

On 9/28/18, the Director of the ED/Nursing provided surveyors with a document titled "[Crisis Agency #1's name] Credential File". This document indicated Crisis Agency #1's staff person's name, title, license/certification, education, and verification signature/date. It was noted that this document indicated that the staff's education level and/or license ranged from a high school diploma, AAS (Associate of Applied Science), Bachelors (Bachelors level degree - unknown discipline), LSW (Licensed Social Worker) or Masters (Masters Level Degree - unknown discipline). Staff were noted to have a designation of MHRT/C (Mental Health Rehabilitation Technician/Community Certification) which is a program recognized in the State of Maine only. The MHRT/Community Certification applies to MaineCare (Medicaid) "other qualified mental health professionals" providing services to adults, excluding residential services. This includes providers of community support services, case management services, intensive case management services, assertive community treatment, and day support services as outlined in Chapter II of the MaineCare Benefits Manual, Section 17.

It was noted that four patients (Patient #2, #5, #15, and #22) were seen by Crisis Agency #1 staff who were high school graduates and held a MHRT/C certificate only.

A review of the "Memorandum of Understanding Relative to Crisis Services", signed by the hospital's Interim President on 4/2/18 and the President and CEO from Crisis Agency #1 on 3/20/15, was reviewed. This signed document did not include any language related to the qualifications of individuals provided by Crisis Agency #1.

A review of the Medical Bylaws was completed. These bylaws did not include MHRT/C's in the list of Allied Health Professionals, who could be credentialed to provide services to patients of the hospital, and did not address what qualifications that individuals, specifically Crisis Agency #1 staff, would be required to have in order for those individuals to conduct psychiatric assessments within the hospital.

On 9/27/18 at 1:00 PM, the ED Director/Physician was interviewed. The surveyor asked, "What exactly does a 'psychiatric evaluation' mean to you?" The ED Director/Physician responded by saying "A psychiatric evaluation is one that is done by a [Agency #1] Crisis worker and/or a Psychiatric Nurse Practitioner Provider Consultation." When asked what Agency #1 Crisis workers could do and what were the expectations of Agency #1 staff when they were at the hospital, the ED Director/Physician stated, "risk assessment, psychiatric stability, and inpatient bed search."

On 10/1/18 at 2:00 PM, the Chief Medical Officer and ED Director/Physician were interviewed. The following information was obtained during this interview:

- Psychiatric services are provided by one Psychiatric Nurse Practitioner (PNP) from 7:00 AM to 1:00 PM; two PNPs from 1:00 PM to 7:00 PM; a PNP is available, via Telemedicine, from 3:00 PM to 3:00 AM; a Psychiatrist is available 24 hours per day every day; and Crisis Agency #1 staff are available 24 hours per day every day.

- Crisis Agency #1 does the credentials for their own staff.

- The hospital knows what the qualifications are based upon the information from the Crisis Agency

- When asked as a hospital if they determine what the minimal qualifications of the Crisis Agency Staff are, they indicated they do not.

- When specifically asked if they felt that an individual with a high school diploma and a MHRT/C certificate was qualified to conduct a psychiatric assessment, they indicated that they think of them as team members who provide information and input into the patient's care

- They do not consider the Crisis Agency staff as consultants. They can complete the evaluation by obtaining additional information from family and they sometimes know the patient from the community or have had contact with them.

- When asked if the ED Physicians knew that some of the Crisis Agency staff only had a high school diploma, the response was that they know that the Crisis Agency staff are not Nurse Practitioners or Physicians.

- They indicated that they think of the Crisis Agency workers more like a behavioral technician than a consultant.

On 10/3/18 at 9:20 AM, a representative from Crisis Agency #1 was interviewed. When asked what her role was when she goes to this hospital she stated, "I'm considered a consultant with St. Mary's, I guess. I assess suicidality, choose the least restricted environment for a plan, make recommendations, offer them groups, and referrals to different places."

Based on observation, records review, and interviews, the Condition Participation for Patient Rights was not met as evidenced by the hospital's failure to ensure that patients received care in a safe environment in 1 of 2 areas within the ED (area known as the behavioral ED - BED). The hospital had identified unsafe issues within the environment; yet, had not taken action to mitigate the risk of a ligature issue with a door handle that had been identified, and had no documented mitigation plan and estimated completion date to eliminate the other risks identified.

Finding:

1. Standard: §482.13(c)(1) Patient Rights: Care in a Safe Setting also known as A114 - Based on observations, record reviews, and interviews, the hospital failed to ensure that patients received care in a safe environment in 1 of 2 areas within the ED (area known as the behavioral ED - BED). The hospital had identified unsafe issues within the environment; yet, had not taken action to mitigate the risk of a ligature issue with a door handle that had been identified, and had no documented mitigation plan and estimated completion date to eliminate the other risks identified. A-0114 had been cited at the full standard survey (7/23/18 to 7/26/18); therefore, this is a repeat deficiency. Please see A-0114 for details.

The cumulative effect of the deficient practices resulted in noncompliance with this Condition of Participation.

Based on review of medical records and interviews, the hospital failed to ensure that all entries in the medical record were timed by the person responsible for providing services to the patients for 12 of 27 sampled patients (Patient #1, #2, #4, #5, #6, #8, #10, #12, #13, #15, #18, #20, and #22).

Finding:

Throughout the survey, surveyors reviewed the records of Patient #1, #2, #4, #5, #6, #8, #10, #12, #13, #15, #18, #20, and #22 who were all seen by Crisis Agency #1 staff. It was noted the that reports, completed by Crisis Agency #1, did not contain the time that the entries were made.

On 9/27/18 at 1:00 PM, when asked if there was any way surveyors could see what time Crisis Agency #1 staff evaluated Patient #18, the ED Director/Physician indicated "I can only see what time the report was faxed to us."

On 9/28/18 at 9:00 AM, the Supervisor for Crisis Agency #1 was interviewed and confirmed that the time that a Crisis Agency #1 staff member evaluates a patient is not printed on the documentation.