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Based on interviews, document review, and during the course of a complaint investigation, it was determined the facility staff failed to comply with §489.24 - Special Responsibilities of Medicare Hospitals in Emergency Cases.

The findings were:

A.) The facility staff denied requests from two transferring hospitals, for admissions to the child and adolescent behavioral health unit on 06/01/19, for two (2) child/adolescent patients (Patient #21 and Patient #22) who required specialized behavioral health care services offered by the facility.

B.) The facility staff failed to provide evidence they lacked capacity and/or capability to accept the two requests for admission (Patient #21 and Patient #22).

C.) The facility staff's Intake documentation on the Daily Logs, specific to the reasons for denial of admission for Patient #21 and Patient #22, was altered after the date of it's initial completion, on or about the time the concern was brought forward of an EMTALA violation related to the denials of Patient #21 and Patient #22.

D.) The facility staff's documentation on the Daily Logs for 2019, revealed a pattern of denials for admission that listed the reason for denial only as Autism, or in part related to Autism and often included "out of area." In addition, there was a pattern of denials for other documented reasons that were not in alignment with the facility's exclusionary criteria.

E.) The facility's leadership staff failed to have Policies and/or Procedures in place providing clear guidance regarding the requirements and expectations for documentation used in the Intake process of handling referrals and requests for admission to the behavioral health units.


Please see tag A-2411 for detailed information.

Based on interviews and document reviews occurring during the course of a complaint investigation, it was determined the facility staff, 1.) denied requests from transferring hospitals for behavioral health unit admissions, for two (2) child/adolescent patients who required specialized behavioral health care services, and 2.) failed to provide evidence they lacked capacity and/or capability to accept the two requests for transfer. The two (2) child/adolescent patients denied admission were (Patient #21 and Patient #22).

The findings were:

The survey team conducted a tour of the Behavioral Health units, including the Child and Adolescent (CA) unit, on 07/02/19 beginning at 3:00 p.m. The Vice President (VP) of Behavioral Health (BH), who was also a Registered Nurse (RN), was present during the tour of the CA unit and stated "we don't tend to take kids on the lower end of the autism spectrum" but they would take kids with "higher functioning."

The surveyor conducted a tour of the Psychiatric Emergency Services (PES) unit on 07/03/19 beginning at 11:25 a.m., accompanied by the Director of Psychiatric Emergency Services. The Director described the functions of the unit did include, among others, to receive and process all referrals for inpatient admission to all BH units in the facility. The Director introduced the Intake Specialist Team Lead(employee #14), and stated he/she (the Intake Specialist Team Lead) would be the best person to explain the PES unit's processes for receiving and determining the outcome of, referrals for inpatient admission to the BH units.

The surveyor conducted an interview with the Intake Specialist Team Lead (employee #14) on 07/03/19 beginning at 11:45 a.m. Employee #14 stated he/she was aware of and familiar with the referrals for the two (2) children (Patient #21 and #22), who were denied admission to the CA BH unit on 06/01/19. Employee #14 was asked to describe the process that occurred for referrals received requesting admission to the BH unit. Employee #14 stated the process, which was the responsibility of the assigned Intake Specialist, was as follows:
· They receive all the phone calls or referrals for BH inpatient admission and the caller is asked to provide basic information such as the patient's age and if they are male or female in order to determine whether there is bed availability. The CA unit was described as having no private rooms and therefore male patients would be placed with male patients and female patients with female patients. Employee #14 stated that for patient safety, the Intake Specialist must take into consideration the level of aggressive behaviors patients are exhibiting, since there were no private rooms.
· They ask which hospital or location is making the referral and for "initials only" as far as patient identity.
· They have real time information regarding bed availability for the BH units and if there is an appropriate bed available, they ask for additional information to be faxed such as the medical record for their current encounter, ECO (Emergency Custody Order) or TDO (Temporary Detention Order) if applicable, as well as any Mental Health Evaluation for the current encounter.
· They [Intake Specialists] review the faxed information to "determine if the case is appropriate to our facility."
· If the Intake Specialist determines the case is appropriate to the facility they "present the case to the psychiatrist" for a final decision to admit or not to admit.
· If the Intake Specialist determines the case is not appropriate to the facility, it is not presented to the psychiatrist and the Intake Specialist denies the case for admission and notifies the referral source.
· The Intake Specialists document regarding the referrals, including the outcome which is documented in the section titled "Comments," on a Daily Log document. That document is saved electronically at the conclusion of each calendar day and a new one would be started for the next calendar day.
· Each morning, Employee #14 or the day shift Intake Specialist were responsible for emailing a copy of the Daily Log document for the previous day, to a list of facility personnel which included the BH Unit Managers.
Employee #14 stated the Daily Log was a "Word Document" and therefore it could have been "manipulated by anyone." Employee #14 stated, "I can assure you that all of my Daily Logs that I print [for the unit binder] and save and share with the Unit Directors on a daily basis, are accurate and have not been manipulated." Employee #14 was asked to make the Daily Logs for 2019 available to the surveyor, as well as all faxed information the facility received on 06/01/19 related to the referrals for the two (2) aforementioned children (Patient #21 and #22).
The surveyor asked Employee #14 if "Autism out area" was an acceptable reason for denying admission based on the facility's guidelines. Employee #14 stated that if the surveyors saw "Autism out of area" listed as a reason for denying admission on the Daily Logs, it was "most likely an error in wording...and should have been a denial based on capability or capacity" since the CA unit had no private rooms. Employee #14 stated that on the day of the denials for Patient #21 and #22, the patient census on the CA unit was low and beds were available.
Employee #14 stated he/she received a call from the CA Unit Manager on the morning of 06/02/19 questioning why two children [Patient #21 and #22] had been denied admission for the reason of "Autism-out of the area" on 06/01/19, according to the Daily Log. Employee #14 stated he/she told the CA Unit Manager "that's not how we operate and has never been how we operate" and that the denials would have been related to the patient's level of functioning and would not have been based only upon the "Autism-out of area." Employee #14 stated the CA Unit Manager was upset and wanted the two (2) children admitted to the CA unit, if they had not already been placed in another facility. Employee #14 stated they learned on 06/02/19 that one of the children [Patient #22] had already been placed in another facility's BH unit, and later that day the other child [Patient #21] was accepted for admission by one of the Psychiatrist. Employee #14 stated it was his/her opinion, that the child [Patient #21] was still "exclusionary" related to moderate-to severe developmental delays, and that "but for the Unit Manager intervening" due to a low census on the CA BH unit, the patient "did not meet criteria."

The surveyor reviewed on 07/08/19, the facility's "Medical Screening and Transfer EMTALA" Policy-(CLIN.08.16.31), which was dated as having been last reviewed 05/06/19. The policy included the following at item number 5, on page 10:
"Receiving Transfers from Another Hospital. The Hospital must accept from another hospital within the boundaries of the United States the Appropriate Transfer of an individual with an EMC [Emergency Medical Condition] if:
a. Such Transfer is for treatment in an area in which the Hospital has a specialized capability such as the neonatal intensive care unit,

b. The transferring hospital does not have the specialized capability, and

c. The Hospital has the capability and capacity to treat the individual."

The Director of Accreditation and Licensure provided the survey team with printed documents that were pamphlet type documents and/or screenshots of the facility's website information which was available to the public. The surveyor reviewed those documents and found they provided evidence the facility advertised their provision of specialized care in behavioral health services for adults and children, to include inpatient admissions.

The surveyor conducted a review of the medical record of Patient #21 on 07/15/19 at 2:20 p.m. That review included:
· In regards to the initial request for admission to the CA BH unit dated 06/01/19: A review of the faxed information provided to the facility on 06/01/19, by the referring hospital when initially requesting placement in the CA BH unit. That information from the ED (Emergency Department) record of the transferring hospital, documented the patient lived in a homeless shelter with a parent, had a history of ADHD (Attention Deficit Hyperactivity Disorder) and Autism, presented with increasing aggressive behaviors at home, breaking furniture, has broken two laptops in the last week and, had a change in medication one month ago however it was not helping [his/her] behaviors. The record also provided evidence the patient exhibited aggressive behaviors of hitting staff members while in the ED. (Note: The interview described above, as well as the Daily Log review described below, provide evidence this initial request for admission to the CA BH unit was denied).
· In regards to the acceptance of the patient for admission to the CA BH unit after having first been denied: The transferring facility's ED document titled, "Patient Transfer Order and Certificate" provided evidence that a Psychiatrist associated with the CA BH unit accepted the patient for admission on the evening of 06/02/19 at 7:42 p.m. The transferring facility's ED documentation provided evidence that on 06/02/19 at 8:29 p.m., the receiving facility's BH unit nurse was given a report on the patient by the transferring facility's ED nurse. The transferring facility's nursing notes, after the report was given, document ongoing efforts to obtain a TDO and arrange for appropriate transportation, and that the receiving facility's nursing staff were updated. A review of the basic demographic sheet for the admission to the CA BH unit provided evidence the patient was admitted on 06/03/19 at 4:11 a.m. The admitting Psychiatrist documented a "Psychiatric Admission Note" dated 06/03/19 at 3:19 p.m., which listed the admitting diagnosis of ADHD (Attention Deficit Hyperactivity Disorder) and DMDD (Disruptive Mood Dysregulation Disorder).

The surveyor conducted a review of the medical record of Patient #22 on 07/15/19 at 2:50 p.m. That review included:
· A review of the faxed information provided to the facility on 06/01/19, by the referring hospital when requesting placement in the CA BH unit. That information from the ED (Emergency Department) record of the transferring hospital, documented the patient was brought to the ED by the parent and police department with reported increased aggression, attempted to leave school without permission, expelled recently, told the parent [he/she] wanted to kill them, and ran out into traffic that day. The patient had a documented history of ODD (Oppositional Defiant Disorder), ADHD (Attention Deficit Hyperactivity Disorder), Disruptive Mood Regulation Disorder, and Autism Spectrum Disorder. Per the parent, the patient had been on "6 different pills" for the above listed disorders and did not care about his/her own life. The patient was documented as having presented to the ED with reported increasing agitation and violent threats. The ED Physician's Treatment Recommendations were: "Inpatient psychiatric hospitalization is needed for safety and stabilization." (Note: The interview described above, as well as the Daily Log review described below, provide evidence this request for admission to the CA BH unit was denied).

The surveyor reviewed Daily Logs which had been provided as attachments by the complainant, when lodging the complaint allegations. Those logs were for multiple dates from February, March, April, May, and June of 2019. The findings related to the review of those logs (specific to referrals for the CA unit) included the following entries:
· 03/03/19, "Denied by [Intake Specialist] due to capability - Exclusionary criteria - Autism"
· 03/05/19, "Denied by [Intake Specialist] due to exclusionary criteria: autism dx [diagnosis], non-verbal"
· 03/12/19, "Denied by [Intake Specialist] due to capability - ID and autism..."
· 03/12/19, "Denied by [Intake Specialist] due to capability moderate autism..."
· 03/18/19, "Denied by [Intake Specialist] - exclusionary criteria - autism; [he/she] is currently in a residential treatment facility [name of treatment facility]"
· 03/26/19, "Denied by [Intake Specialist] due to capability: pt[patient] would likely need a private room, there is suspected autism spectrum disorder, extremely behavioral & would be difficult for millieu [sic] to manage at this time"
· 03/26/19, "Denied by [Intake Specialist] due to exclusionary criteria: Mod-Severe Autism (unit will also be full shortly)"
· 05/11/19, "Denied by [Intake Specialist] - 'Denied multiple times throughout past week // Denied again by [Team Lead Intake Specialist] - at this point pt has been in ER since 5/2 - [he/she] denies all SI/HI/AVH [suicidal thoughts, homicidal thoughts, auditory or visual hallucinations], etc - Pt may or may not have autism diagnosis (Denied throughout the week due to Autism dx - now they stating [sic] [he's/she's] never been formally diagnosed)// pt does have chromosome disorder & developmental delays - pt on multiple antipsychotics (Geodon, Zyprexa, Trileptal, Clonidine) // Pt has denied all symptoms of SI/HI/AVH for past x6 [sic] days & declined at other facilities due to not meeting admission criteria' (05/10/19)" "Called again today: Has been well behaved in the unit. Paperwork says autism but 2 hospitals have said it is not the case. [sic] chromosomal things make [him/her] more at risk for mental illness. However there are no changes to prescreen since yesterday"
· 05/13/19, the Daily Log contained an entry for a patient with the same listed age, gender, Initials, and Location/Referring Agency as the patient described above in the 05/11/19 entry. The entry for 05/13/19 read, "Reviewed by [Intake Specialist] // Admitted by [Psychiatrist]"
· 05/13/19, "Denied by [Intake Specialist] - exclusionary Criteria [sic] - autism"
· 05/19/19, the Daily Log contained an entry with no documentation of who made the decision to deny or who the Intake Specialist was, but listed the reason for denial entirely as "Increasing aggression towards family and peers, fidgety, possible autism dx"
· 05/20/19, "Denied by [Intake Specialist] due to capability Autism"
· 05/20/19, "Denied by [Intake Specialist] - exclusionary criteria - ID (IQ 50) & autism"
· 05/20/19, "Denied by [Intake Specialist] due to capability - Autism spectrum disorder."
· 05/21/19, "Denied by [Intake Specialist] due to exclusionary criteria: Autism Spectrum Disorder (is aggressive)"
· 05/22/19, "Denied by [Intake Specialist] - Exclusionary criteria - dx of autism (Denied yesterday by [another Intake Specialist] for same reason)"
· 06/01/19, (Patient #22) "Denied by [Intake Specialist-Employee #31] due to exclusionary criteria: Autism out of area"
· 06/01/19, (Patient #21) "Denied by [Intake Specialist-Employee #31] due to exclusionary criteria: Autism out of area"
The documented reasons for denial on the Daily Logs, failed to provide sufficient evidence those reasons were in alignment with the facility's Exclusionary Criteria policy (see policy details below).
For the Daily Log entries described above, there was no evidence any of these referrals or the specific cases were presented to a Psychiatrist for a decision regarding whether to admit the patient or not.

The surveyor reviewed the facility's Policy related to Admission Criteria and Exclusionary Criteria for the Acute Psychiatric Inpatient Units throughout the course of the survey. The policy (number CLIN.20.01.04) titled, "Acute Psych Inpatient Units: Admissions: Admission Criteria," was dated as approved on 08/30/2017 and included, in part, the following related to the CA (Child and Adolescent) unit:
· "PURPOSE: To provide clear consistent criteria for admission for our inpatient psychiatric units."
· "Child and Adolescent Psychiatric Program (ages 5 to 17)..."
· "II. Exclusionary Criteria may include:
A. Extensive criminal histories, e.g., arson, assault, sexual assault, detention resulting from other serious crimes
B. History of serious assault against treatment staff, police or other authority figures which may exceed capability to safely care for patient
C. Severe developmental disorders
D. Moderate or severe intellectual disabilities
E. Medical care needs beyond the capability of the unit such as, but not limited to, transfusions, delirium, dialysis, bed-ridden/total care patients
F. Primary substance abuse disorder"

The Intake Specialist Team Lead (Employee #14), provided the facility's copy of the Daily Logs for 2019 on 07/10/19. The survey team reviewed those documents throughout the course of the survey and conducted a comparison of the facility's Daily Logs to the Daily Logs provided by the complainant (described above). Discrepancies between the two sets of Daily Logs were identified for entries dated 06/01/19. The overall findings related to that review were as follows:
· The facility's Daily Logs contained the same documentation as the Daily Logs provided by the complainant and described above, with the exception of the two (2) entries dated 06/01/19. Those entries were different from the complainant's Daily Logs as follows for each.
· 06/01/19, (Patient #22) "Denied by [Intake Specialist-Employee #31] due to capability: autism w/ [with] behavioral issues, assaultive towards treatment staff, received multiple PRNs [unscheduled-as needed medications] in the ER"
· 06/01/19, (Patient #21) "Denied by [Intake Specialist-Employee #31] due to capability: Autism w/ behavioral issues, primary issue is aggression requiring multiple police officers to restrain"

The surveyor met with the Director of Privacy on 07/22/19 at 4:20 p.m., also present was the Accreditation and Licensure Specialist II. The surveyor requested copies of the 06/01/19 Daily Logs that were sent as attachments on 06/02/19 and received by the CA BH Unit Manager, Employee #14 and 2 additional recipients on the email list. The Director of Privacy was informed that the email would have been sent by Employee #14 or the day shift Intake Specialist. The surveyor requested the attached document be printed and provided to the surveyor, as it appeared when opened in each of the four (4) recipient's email, without asking those employees to access it or print it. The Director of Privacy stated it would take some time to search for them, but it could be done as requested and without the employee's involvement.

On the afternoon of 07/24/19, the Accreditation and Licensure Specialist II provided the surveyor with the above requested copies of the 06/01/19 Daily Logs that were sent as email attachments to the CA BH Unit Manager, Employee #14, and two other employees on the mailing list for that email. The documents provided with that information included the actual email, the Daily Log attachment, and screen shots of the search criteria used with the name of the employee searched. For each of the four employees searched, the Daily Log document dated 06/01/19 that they received on 06/02/19 was identical to the Daily Log provided by the complainant. The entry for 06/01/19 related to (Patient #22) was, "Denied by [Intake Specialist-Employee #31] due to exclusionary criteria: Autism out of area" and the entry for 06/01/19 related to (Patient #21) "Denied by [Intake Specialist-Employee #31] due to exclusionary criteria: Autism out of area" The Accreditation and Licensure Specialist II was asked to inquire if the Director of Privacy could track the facility's Daily Log document dated 06/01/19, to determine when/how the document was altered.

The surveyor met with the Accreditation and Licensure Specialist II on 07/25/19 at 2:30 p.m. He/she stated they were able to identify when the actual changes were made to the aforementioned entries of the Daily Log dated 06/01/19, and who made the changes. The Accreditation and Licensure Specialist II stated they identified that the document had been "saved" 3 times. The first time it was saved was on 06/01/19, and it was still the same (no changes) as when it was emailed out on 06/02/19. The second time it was saved was on 06/02/19, and there had been changes made to the document but there were no changes made to the entries of concern (related to Patient #21 and #22). The third time it was saved was on 06/05/19, and the entries of concern related to Patient #21 and #22 had been changed by Employee #14. There was no record of the document being saved again after that. The Accreditation and Licensure Specialist II provided evidence of the above findings in the form of screen shots of the changes, as well as screen shots of the search criteria.

The surveyor interviewed Employee #19 (Intake Specialist) on 07/17/19 at 10:35 a.m. Employee #19 was shown a copy of the Admission Criteria policy and was asked to look at the section addressing exclusionary criteria. Employee #19 was asked what the exclusionary criteria language of "serious assault" and "staffing capabilities" meant to him/her and how that would be interpreted in determining whether a case was admitted or not. Employee #19 stated, "depends on what they [referral source] tell me about the patient." Employee #19 stated that sometimes the decisions of "exclusionary" were decided by the Intake Specialist alone, and sometimes the psychiatrist were consulted. Employee #19 stated that when he/she is unclear about the decision of exclusionary, "sometimes" he/she calls the psychiatrist. Employee #19 acknowledged he/she does not always call the psychiatrist. He/she acknowledged the Policy and Procedure does not provide the specificity he/she would like to have "but there are people to ask-resources."

The surveyor interviewed the VP (Vice President) of BH (Behavioral Health) on 07/18/19 at 9:30 a.m., also present was the Director of Critical Care Quality Programs. The VP of BH acknowledged being aware of the denials for admission to the CA BH unit dated 06/01/19, for which the reason listed for denial was "Autism out of area." The VP of BH stated he/she first learned of this on the morning of 06/02/19 when the former CA BH Unit Manager texted him/her with the story and concerns regarding an EMTALA violation. The VP of BH stated the aforementioned concerns of the former CA BH Unit Manager, were reviewed and presented to the EMTALA Committee on 06/19/19. The VP of BH acknowledged the Exclusionary Criteria and the Intake Process "needs work."

The surveyor requested a copy of the meeting minutes from the EMTALA Committee Meeting dated 06/19/19. That copy was provided, but was still a "DRAFT - UNAPPROVED" version of the document. That document provided evidence that the VP of BH, the Director of Psychiatric Emergency Services, and the Team Lead-Intake Specialist (Employee #14) were present for the meeting. The document provided evidence that the VP of BH presented the review of the cases that were denied admission to the CA BH unit on 06/01/19 [Patient #21 and #22]. That evidence included, in part, the following:
· "In this particular case, the unit manager reviewed the intake log and noticed two cases that had been declined for for autism. [He/she] reviewed the cases and thought they might be an EMTALA violation because beds were available. This was escalated to [VP of BH] and they reached out to the two initial callers for additional details. [The VP of BH] shared that we ended up taking one of the children and the other was sent to [another facility]."
· "[The VP of BH] shared that with these two cases we heard the word autism and assumed primary autism which is not a viable admission criterion and the patients were declined. [She/he] noted that we should have obtained the entire patient history and ensured that there was not another diagnosis like major depression, and they just so happened to have Asperger's, which is something that we can treat."

The surveyor interviewed the VP (Vice President) of BH (Behavioral Health) again on 07/25/19 at 2:50 p.m., also present was the Accreditation and Licensure Specialist I. The VP of BH acknowledged there were "opportunities" to improve the exclusionary criteria and a need for more training, possibly to include EMTALA training for all of the BH staff and that option could be explored as they move forward.

The survey team met with the Director of Accreditation and Licensure on 07/16/19 at 3:45 p.m., also present was the Accreditation and Licensure Specialist I. The survey team informed the Director of Accreditation and Licensure and the Accreditation and Licensure Specialist I, of concerns that areas of the Exclusionary Criteria policy for the BH units were open to the interpretation or judgement call of the Intake Specialists. The Director of Accreditation and Licensure reviewed the Exclusionary Criteria policy and agreed the policy lacked specificity, was open to interpretation, and could result in patients being declined inappropriately.

The surveyor interviewed the Medical Director of Psychiatric Services (Psychiatrist) on 07/17/19 at 2:50 p.m. The survey team asked the Medical Director to look at the Admission Criteria policy, specifically the section addressing Exclusionary Criteria, and informed him/her of surveyor concerns that the policy lacks specificity to guide the Intake Specialist when processing referrals for admission. The Medical Director stated that because he/she gets calls from the Intake Specialists at times when they are unsure of the exclusionary criteria, he/she just assumed they always called. The Medical Director stated he/she was not aware that psychiatrists were not always called and included in the decision process when Intake was unsure of exclusionary criteria-but stated they "should be." The Medical Director acknowledged the exclusionary criteria in the Admission Criteria policy was open to some interpretation, which could have lead to a patient not being admitted that should have been.

The surveyor interviewed on 07/25/19 at 11:20 a.m., a Psychiatrist (Employee #27). The Psychiatrist stated he/she provided psychiatric physician services, including being on-call, for the facility's BH units on a regular basis. The Psychiatrist stated he/she, as well as the other Psychiatrists, had a role in the development of the Admission Criteria policy and the Exclusionary Criteria. He/she stated that role to be attending meetings-discussing drafts- providing input. The Psychiatrist stated he/she was not aware that a psychiatrist was not being called anytime the Intake Specialist was unsure or had a question regarding exclusionary criteria. The Psychiatrist stated, "I'd rather get the call, even in the middle of the night, than to have a person other than a psychiatrist making the decision." After reviewing the Admission Criteria policy, specifically the section addressing Exclusionary Criteria, he/she agreed it did place Intake Specialists in a position to make a judgement call.

The surveyor interviewed the CMO (Chief Medical Officer) on 07/25/19 at 1:00 p.m. The CMO stated he/she had been an ED physician for 20 years and was familiar with EMTALA requirements. The surveyor informed the CMO of the above described findings related to the denial of admission to the CA BH unit, for the two (2) children (Patient #21 and #22) on 06/01/19, in which the reason was documented as "Autism out of area" and, that multiple Daily Logs listed reasons for denials that were not in alignment with the Exclusionary Criteria. The CMO was provided the Admission Criteria policy to allow time for him/her to review the Exclusionary Criteria. The CMO was also informed of the concern that the Daily Log entries for the aforementioned two (2) children had been altered, as there was additional information on the facility's Daily Logs, when compared to what was on the Daily Logs that were emailed as attachments to the BH Unit Managers. The CMO acknowledged there were inconsistencies in how the Exclusionary Criteria was being interpreted and applied.

The surveyor met with the facility's leadership team for an end of day discussion on 07/10/19 at 4:50 p.m. The surveyor provided the names of specific staff members the surveyor would potentially need to interview. That list included the name of Employee #31, the Intake Specialist who processed the referrals and documented the outcomes for the two (2) children denied admission on 06/01/19. On the morning of 07/11/19 the surveyor was informed that Intake Specialist (Employee #31) was recently terminated.

The surveyor interviewed the Director of Psychiatric Emergency Services on 07/11/19 at 11:30 a.m., also present was the Director of Accreditation and Licensure. The Director of Psychiatric Emergency Services stated his/her role included responsibility for the care provided by the PES (Psychiatric Emergency Services) department, which included the Intake Specialists as well as the Mental Health Professionals. He/she described the Intake Specialists each held at least a Bachelor's degree in a mental health related field, and they were responsible for receiving and processing all referrals for inpatient admission to the BH units of the facility. The Director of Psychiatric Emergency Services described the Mental Health Professionals role as one of performing mental health evaluations and some counseling, but was not the same role as the Intake Specialist and that each group had a different work area. The Director of Psychiatric Emergency Services was asked about the termination of Employee #31, and he/she stated the employee was terminated for inappropriately placing pictures of him/her self on social media while at work and within patient care units. He/she stated the pictures did not include any patients but they showed the employee's badge which would identify the facility. The Director of Psychiatric Emergency Services stated that pictures cannot be taken on the psychiatric units. He/she described that Employee #31 had been "written up" about 3 to 4 months previously for: not working well with referral sources, delaying responses for bed requests, telling a CSB [Community Services Board] worker/referral source "I'll get to it when I get to it." The Director of Psychiatric Emergency Services stated he/she [Employee #31] "showed a pattern of defiance - just didn't care." When asked about the Daily Logs and the documentation by the Intake Specialists related to the processing and outcomes of the referrals, the Director of Psychiatric Emergency Services stated the "Call Log" was paper only - for long term, - but is completed on the computer- thinks it is done as a Word document - but wasn't sure. He/she stated that Employee #14 saves the document daily, but whoever works the weakened would save it on those days, then it is emailed as an attachment to a list of recipients including him/her self as well as the BH Unit Managers. When asked if there were policies in place regarding the documentation expectations for the Intake Unit specific to the Daily Logs, the Director of Psychiatric Emergency Services stated he/she did not think so. The surveyor requested that if those policies did exist, they be made available to the surveyor for review. At the time of the exit on 07/25/19, no such policies had been provided.

The surveyor interviewed the Director of Psychiatric Emergency Services for a second time on 07/25/19 at 9:30 a.m., also present was the Director of Accreditation and Licensure. The Director of Psychiatric Emergency Services stated it was his/her expectation that the Daily Logs would not be altered after they are sent out by email. When asked if he/she ever reviews the Daily Logs, the Director of Psychiatric Emergency Services stated, "from time to time." When asked if he/she had any concerns that the 06/01/19 cases of the two children (Patient #21 and #22) were not presented to a psychiatrist, the Director of Psychiatric Emergency Services stated having concerns about the documentation. He/she stated those concerns were that the documentation was too brief, needs to match the exclusionary criteria, and will in the future. The Director of Psychiatric Emergency Services stated "clearly we need to do more education" and "we clearly need to update the exclusionary criteria." He/she stated that in a meeting dated 07/01/19, he/she "urged" more specificity in the exclusionary criteria. The Director of Psychiatric Emergency Services stated his/her staff ha