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Based on document review and interview, it was determined that the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to define in Hospital Bylaws or Rules and Regulations who are qualified medical professionals. See A 2406.

Based on document review and interview, it was determined that the facility failed to define in hospital bylaws or rules and regulations, who it considers Qualified Medical Personnel (QMP). Findings include:

On 08/15/2013 at 1030, a review of the "Mercy Health Partners, Medical Staff Bylaws" revised May 2012, approved June 28, 2012, was conducted. The bylaws failed to define who the facility considers QMP for conducting medical screening examinations of patients in regards to determining if an emergency medical condition exists.

On 08/15/2013 at 1130, review of Mercy Hackley-Health Muskegon's policy titled "Emergency Medical Treatment and Labor Act (EMTALA) Compliance Policy-Risk Management", dated 8/2010 reads "7. Medical Screening Examination: An examination within the capability of Hospital's emergency department, including ancillary services routinely available to the emergency department, conducted by a qualified medical person, in a non discriminatory manner, to determine, with reasonable clinical confidence, whether the individual is in an emergency medical condition." The policy also states, "10. Qualified Medical Person: Non-physician individuals qualified and approved by the Hospital's Board to conduct medical screening examination, as documented in the Hospital's Medical Staff Bylaws or Rules and Regulations."

On 08/15/2013 at 1400, during an interview with staff L (Medical Staff Coordinator), she confirmed that the Medical Staff bylaws and the Medical staff Rules and regulations lacked documentation as to who the Hospital considers a QMP. Staff L also stated "the wording was in the old bylaws before the Hospital merger and somehow it got dropped out of the bylaws." When asked if the documentation could be found in the Hospital Board Bylaws, staff L stated "I have never seen anything like that in there."