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Based on review of medical records and the facility's Inquiry Call Form, and family and staff interviews, the hospital failed to comply with the provider agreement for recipient hospitals as defined in 489.24 (f) for expediting the transfer of 3 of 24 sample patients (#7, #11, #17) who had an emergency condition that required specialized psychiatric care. Specifically, the hospital unreasonably delayed the transfer and subsequent treatment based on the patients' ability to pay. Refer to A2411.

Based on review of medical records and the facility's Inquiry Call Form, and family and staff interviews, the hospital failed to comply with the requirements for appropriate transfer for 3 of 24 sample patients (#7, #11, #17) who required this hospital's special capabilities. The findings were:

1. Review of the referring hospital emergency department (ED) medical record for patient #7 showed s/he arrived at the ED on 6/15/13 at 9:51 AM and was examined by the ED physician at 9:54 AM. Review of the ED physician's documentation showed the patient had altered mental status and disorganized mentation. Further review of the documentation showed the ED physician recommended the patient be admitted as an inpatient for treatment for disorganized thoughts and behaviors that had a significant negative impact on the patient's life and for medication stabilization. Review of the medical record showed a psychiatric consult was completed and the consultant agreed with the ED physician's recommendations. This review also showed social worker #1 was consulted to find placement at a hospital with specialized psychiatric capabilities because the referring hospital did not have an available bed on the psychiatric unit. The following concerns were identified:
a. Review of the social worker's documentation showed she made a referral to Wyoming Behavioral Institute (WBI) on 6/15/13 at 6:31 PM. Review of the documentation also showed the WBI staff assigned to implement the admission process (intake staff) told the social worker the patient would be required to pay five thousand dollars at the time of admission; otherwise the hospital would not accept the transfer. During an interview on 7/12/13 at 3 PM, social worker #1 confirmed the 6/15/13 communication was as documented.
b. On 7/26/13 at 10 AM, intake staff #1 who talked with the patient on 6/15/13 was interviewed. During the interview, she stated she told the patient "we ask that they [patients] put forth five thousand dollar, but it is not a requirement." Intake staff #1 stated she called the WBI chief financial officer after she talked with the patient because the patient did not have a certified check and the chief financial officer's approval was needed to accept a personal check. Intake staff #1 also stated patient #7's family "had to go home to get a check" and return to the ED before the patient was transferred.
c. Review of the WBI admission assessment form, dated 6/15/13, showed the chief financial officer was contacted at her home to obtain approval to accept a personal check. This review showed the communication with the chief financial officer was conducted prior to the patient's transfer from the ED.
d. Interview on 8/22/13 at 12:35 PM with a family member who was present with patient #7 at the ED on 6/15/13 revealed the WBI staff communicated by telephone with the patient while s/he was at the ED. The family member stated the patient was told s/he would not be accepted for admission unless s/he paid five thousand dollars at the time of admission. The family member stated it took time to "work out" issues regarding a personal check, but after these issues were resolved the patient was transferred to WBI by ambulance. The family member also stated WBI was paid the required amount at the time of admission.
e. Review of the ED report showed patient #7 was transferred from the ED to WBI on 6/15/13 at 11:59 PM.
f. Review of WBI financial records showed patient #7 paid five thousand dollars on 6/16/13 on the day of admission.

2. Review of the 3/5/13 referring hospital ED medical record for patient #11 showed s/he was admitted to the ED and received medical treatment for suicide attempt, aggression, acute delirium, psychotic break, drug withdrawal, and homicidal ideation. Review of the 3/6/13 physician documentation showed the patient needed specialized inpatient psychiatric treatment following medical stabilization. This review also showed the patient was placed on an observation unit until social worker #1 could find appropriate placement. The following concerns were identified:
a. Review of the social worker's 3/6/13 documentation showed WBI had an available bed, but the transfer could not be done because the patient/family did not have five thousand dollars which was due at the time of admission.
b. Review of the social worker's 3/7/13 documentation showed WBI accepted the admission on 3/7/13 after it was determined the patient qualified for Medicaid assistance.
c. A family member who was present with patient #11 on 3/6/13 at the ED was interviewed on 8/23/13 at 12:30 PM. During the interview the family member stated s/he had a telephone conversation with WBI intake staff on 3/6/13 and was told the patient and family had to pay five thousand dollars at the time of admission. The family member stated the family was unable to pay that amount, the social worker then assisted with inquiries into funding sources, and the patient was accepted for admission to WBI on 3/7/13.
d. On 7/25/13 at 5 PM intake staff #2 was interviewed. During the interview he stated he remembered patient #11 and "waiting for the family to get back to us regarding resources." Intake staff #2 stated patient #11 "was pretty sick".

3. Review of the referring hospital ED medical record for patient #17 showed an ambulance transported the patient to the ED on 2/6/13 and the diagnosis was bipolar disorder manic. According to social worker #2's 2/6/13 documentation, the physician examined the patient and ordered a social worker consult to find specialized inpatient psychiatric placement for the patient. The following concerns were identified:
a. Review of the 2/6/13 social worker's documentation revealed a telephone conference call between the patient's family and WBI intake/admissions staff was conducted on 2/6/13 at 9:45 AM. This review showed after the telephone call, the family member told the social worker they could not afford the payment that WBI required at the time of admission.
b. Interview on 8/22/13 at 12:50 PM with the patient's family member who was present with the patient at the ED confirmed the patient and family were told by WBI staff that the admission would not be accepted unless WBI received payment at the time of admission. The family member stated the transfer was delayed while the social worker contacted other facilities to find one that had an available bed because the patient's family did not have the required payment.
c. According to the ED medical record, the social worker continued to contact other facilities, found an appropriate placement on 2/6/13 at 3 PM, and the ambulance departed from the ED at 3:49 PM.

4. In an interview on 7/25/13 at 3:40 PM the director of admissions gave the following information: The referring hospital was responsible for ensuring patients were medically stable prior to transfer to WBI. The patients were mentally unstable when admitted. The admission process for a referral to WBI started with the intake staff who completed a screening and assessment for clinical appropriateness. The screening information was documented on the Inquiry Call Form, and the decision to accept a transfer was made by a team of professionals including the physician. The business office was responsible for addressing all financial issues.

5. In an interview on 7/25/13 at 5 PM, intake staff #2 stated during the admission process he asked questions regarding finances or sometimes the referring hospital had the information; it didn't matter whether the patient was in the ED or not.

6. Interviews with the business office manager on 7/25/13 at 4:30 PM, the chief executive officer on 7/26/13 at 10:20 AM, and intake staff #3 on 7/26/13 at 11:15 AM, revealed they were not aware of any time when patients were refused admission due to inability to pay. All stated the business office was responsible for addressing all financial issues. However, review of the Inquiry Call Form showed the intake staff "must" ask questions regarding finances during the intake/admission process. Further review revealed the form did not differentiate between an emergency referral and other types of referrals.