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Based upon reviews of hospital policies/procedures, Intake Referral Sheets, Governing Body and Medical Staff Meeting Minutes, and Administrative interviews, the hospital failed to meet the EMTALA requirements as defined in CFR 489.24 for failing to provide inpatient psychiatric treatment for 21 of 29 patients (#s 12-14,16,18,19,21-23, 25-27,32-40) who required hospital admission, when the hospital had the capability and capacity to provide the necessary treatment. The hospital denied patient #s 12, 13, 14, 16, 18, 19, 21-23, 25-27, and #s 32-40 admission based upon their insurance payor sources.

Based upon reviews of medical records, intake sheets, policy/procedures, daily census sheets, nurse staffing schedules and Administrative interviews the hospital failed to admit 21 of 29 patients (#s 12-14,16, 18, 19, 21-23,25-27, and 32-40), based upon the patients' insurance information provided, when the hospital had the capacities and capabilities to provide psychiatric treatment. Findings:

1. The following reflects the review of the April 2010 Referrals:

Review of patient #27's information faxed by Hospital M, 04/05/10, 2:35PM, revealed the patient had been PEC'd (Physicians Emergency Certificate) with a diagnosis of Suicidal Ideation. The information sent failed to contain data relative to patient #27's insurance coverage. Patient #27 was denied admission; however, the hospital failed to document the reason/s for the admission denial.

On April 16, 2010, 6:31AM, Hospital N faxed information on patient #23. Review of the information revealed a PEC for Suicidal Ideation. Review of the Admission Record revealed insurance information was documented as self pay . However, patient #23 was denied admission into the hospital. There lacked documentation as to the reason/s why the admission was denied.

Review of patient #25's information, 04/19/10, 10:42AM, faxed by Hospital A, revealed an Admission Form with the following insurance information: "Insurance #1: Community Care Caid HMO". Continued review revealed patient #25 was PEC'd with a diagnosis of suicide attempt. Patient #25 was denied admission on 04/19/10; however, the hospital failed to list the reason/s for the admission denial.

Review of patient #26's information, 04/19/10, 1:10PM, faxed by Hospital A, revealed an Admission Form with the following insurance information: "Insurance #1: Charity Pending; Insurance #2: Uninsured Discount". Patient #26 was PEC'd for Suicidal Ideation with Plan, 04/19/10. Patient #26 was denied admission; however, the hospital failed to document the reason/s for the admission denial.

On 04/22/10, 4:44PM, Hospital G faxed information on patient #22. Review of the information revealed a PEC for Suicidal Ideation. Review of the Emergency Room Outpatient Admission Record revealed under the section titled "insurance", it was listed as private insurance. Patient #22 was denied admission; however, the hospital failed to document the reason/s for the admission denial.

On 04/27/10, 2:27PM, Hospital J faxed information on patient #21. Review of the information revealed #21 was PEC'd for Psychosis. Review of the Admission Form revealed the patient did not have insurance. Patient #21 was denied admission; however, the hospital did not document the reason/s why the admission was denied.

Review of the daily census revealed: 04/05/10--9 patients, 2 patients were admitted with Medicare coverage at 12:45PM and 3:50PM, while patient #27 was denied admission at 2:37PM, (no insurance information was available on #27); 04/16/10--13 patients, one bed available; 4/19/10--12 patients, with 2 beds available; 04/21/10--10 patients with 4 beds available; 04/23/10--7 patients with 7 beds available; and 04/26/10--7 patients with 7 beds available.

Review of the nursing schedule revealed on 04/05, 04/16, 04/19, 04/21, 04/23, and 04/26/10 there was 1 Registered Nurse (RN) for each of the 8 hour shifts, 1 Licensed Practical Nurse for the 7a-3p and 3p-11p shifts, and 2 Mental Health Technicians (MHTs) on each of the 8 hour shifts, and they were available to provide patient care.

Interview, 10/26/10, with Intake Coordinator/Marketing S3 confirmed patient #s 21-23, 25-27 had psychiatric diagnoses that met the hospital's admission criteria, but they did not have Medicare coverage and that was the reason the admissions were denied.

2. The following reflects the review of May 2010 Referrals:

Review of patient #18's medical records (that were faxed to the hospital, 05/07/10, 10:13PM by personnel at Hospital E), revealed a form titled "Demographics and Financial Form". Data entered on this form was information relative to patient #18's name, address, and primary insurance. Under the section "primary insurance", the words "uninsured, discount" were type-written. Patient #18 was denied admission into the hospital for psychiatric treatment; however, there failed to be documentation as to the reason/s why the admission was denied.

Review of the daily census, dated 05/07/10, revealed 8 patients were present, leaving 6 beds unoccupied (total of 14 beds for use by patients).

Review of the nursing staffing schedule, dated 05/07/10, revealed: there was 1 Registered Nurse (RN) for each 8 hour shift, 1 Licensed Practical Nurse (LPN) for the 7a-3p and 3p-11p shifts, and 2 Mental Health Technicians (MHTs) for each 8 hour shift and they were available to provide patient care.

Review of patient #12's information, faxed by Hospital L, 05/10/10, 4:35PM, revealed a diagnosis of suicide attempt. Continued review of the information sent revealed a lack of insurance coverage. Patient #12 was denied admission; however, there lacked documentation relative to the reason/s why the admission was denied.

Review of patient #13's information, faxed by Hospital A, 05/10/10, 9:31AM, revealed a psychiatric diagnosis of suicide attempt. Review of the information, that had been faxed, revealed information relative to the patient's name, address, and insurance source. Under the section titled "Insurance Information", Medicaid had been type-written. Patient #13 was denied admission; however, there failed to be documented evidence relative to the reason/s of the denial.

Review of patient #14's information, faxed by Hospital A, 05/10/10, 2:14PM, revealed a form titled "Demographics". Included on the Demographic form was the patient's name, address, and "Payer Information". Under the section titled "Primary Payer: ", and "Secondary Payer:" "Charity"; "Uninsured, Discount" were type-written. Patient #14 was denied admission into the hospital for psychiatric treatment; however, there lacked documented evidence of the reason/s cited for the denial.

Review of patient #16's information, faxed by Hospital C, 05/10/10, 2:29PM, revealed a form that contained information relative to patient #16's name, address, and insurance payment source. Under a section titled "Hospitalization Insurance", the word "Medicaid-I/P" had been type-written. Patient #16 was denied admission for psychiatric treatment; however, there failed to be documented evidence for the reason/s cited for the denial.

Review of patient #17's intake sheets and medical records revealed she was admitted into the hospital for psychiatric treatment on 05/10/2010,with the admission diagnosis of Bipolar, Schizoaffective Disorder. Review of information sent by Hospital F revealed a sheet, dated 05/10/10, 10:04AM, titled "Demographics". Under a section titled "Insurance", the words "Medicare A&B" were type-written. Patient #17 was admitted 05/10/10.

Review of patient #19's information, faxed by Hospital A, 05/10/10, 9:55AM, revealed clinical information was sent along with the faxed copy of a Physician's Emergency Certificate (PEC) for admission. Review of all the information faxed to the hospital by Hospital A revealed there lacked information relative to patient #19's payment source. Patient #19 was denied admission on 05/10/10, 9:55AM; however, as noted above, patient #17 was admitted 05/10/10, 10:04AM.

Review of the census sheet for 05/10/10 revealed a census of 8 and 6 beds available for admissions. There were 6 referrals for admission on 05/10/2010. All 6 referrals had psychiatric diagnoses that met the hospital's admission criteria; however, the only patient accepted for admission was the one (#17) documented as having Medicare.

Review of the nursing staffing schedule, dated 05/10/10, revealed: 1 RN for each 8 hour shift, 1 LPN on the 7a-3p and 3p-11p shifts, and 2 MHTs for each 8 hour shift and they were available to provide patient care.

On 05/13/10, Hospital A again attempted to place patient #13. Continued review of the information sent revealed an "Admission Form" on which patient #13's insurance information was documented as "... Medicaid". Continued review of patient #13's information revealed Hospital D, faxed information dated 05/18/10, 12:44PM, with the attempt to place the patient. Review of data faxed revealed clinical information was sent; however, there failed to be evidence of payment source faxed. Patient #13 was denied admission on 05/18/10; however there failed to be documentation relative to the reason/s why he was denied admission.

Review of the census reports for 05/13/10 and 05/18/10 revealed census of 6 and 7, respectively; which left 8 beds available for an admission on 05/13/10 and 7 beds available for an admission on 05/18/10.

Review of the nursing staffing schedule, dated 05/13/10 and 05/18/10, revealed 1 RN for each 8 hour shift, 1 LPN on the 7a-3p and 3p-11p shifts, and 2 MHTs on each 8 hour shift and were available to provide patient care.

Interview, 10/26/10, with Intake Coordinator/Marketing S3 confirmed patient #s 12-14, 16, 18 and 19 had psychiatric diagnoses that met the hospital's admission criteria but they did not have Medicare coverage and that was the reason the admissions were denied.

3. The following reflects the June 2010 referrals:

Review of patient #40's information that Hospital G faxed, on 06/01/10, 2:07PM, revealed a PEC and other clinical information relative to patient #40's psychiatric condition, attempted suicide. There was also a demographic form faxed, 06/01/10, 2:07PM, which contained information relative to patient's address, date of birth, and insurance information. The insurance information had not been completed. Patient #40 was denied admission on 06/01/10; there lacked documented evidence as to why patient #40 was denied admission.

Review of the hospital's census, 06/01/10, revealed a total of 7 patients were in the hospital, with one admission, (a patient with Medicare coverage was admitted), which made the census 8. Patient #40 was denied admission even though the admission criteria was met, and there were beds and staff available.

Interview, 10/26/10, with Intake Coordinator/Marketing S3 confirmed patient #40 had a psychiatric diagnosis that met the hospital's admission criteria but they did not have Medicare coverage and that was the reason #40 was denied admission.

4. The following reflects October 2010 referrals:

Review of patient #33's information faxed by Hospital H, 10/16/10, 7:41PM, revealed a form titled "Registration Record" Hospital H. Under the section titled "Insurance", the word "Medicaid" had been type-written. Patient #33's diagnosis was listed as Homicidal Ideation and Schizophrenia and had a PEC form signed by Hospital H emergency room physician S9.
Patient #33 was denied admission into the hospital on 10/16/10; however, there lacked documented evidence for the reason/s for denial.

Review of patient #34's information faxed by Hospital I, 10/16/10, 12:36PM, revealed a diagnosis of suicide attempt and depression. Patient #34 was denied admission; however, there lacked documentation as to the reason/s why the admission was denied.

Review of patient #39's information faxed by Hospital J, 10/16/10, 1:43AM, revealed a form titled "Potential Patient Referral". On this form and under a section titled "Referral Summary", there was a "Payer Source" area and the words "Medicaid-Louisiana" were typed. Continued review of the faxed information revealed patient #39 had received a PEC for delusional behavior. Patient #39 was denied admission; however, there failed to be documentation as to the reason/s why the admission was denied.

Review of patient #32's information faxed by Hospital D, 10/17/10, 3:21AM, revealed a form titled "Patient Demographics". On this form, patient #32's insurance information was documented as "total patient responsibility". Patient #32 had received a PEC for suicide attempt and depression. Patient #32 was denied admission; however, the hospital personnel failed to document the reason/s for the denial.

Review of patient #38's information faxed by Hospital K, 10/23/10, 5:30PM, revealed the patient had been PEC'd for suicidal ideation/attempt. Continued review of the faxed information revealed data that included patient #38's address, birthdate, along with insurance information. Under the section titled "Insurance Info", "Medicaid Com Care" was type-written. Patient #38 was denied admission; however, the hospital failed to document the reason/s for the denial.

Review of patient #37's information faxed by Hospital K, 10/24/10, 5:27PM, revealed the patient was PEC'd with a diagnosis of "Delusional parasitosis induced by amphetamines". Continued review of the cover letter, faxed by Hospital K, revealed an attached note that read "o (no) insurance". Patient #37 was denied admission; however, the hospital failed to document the reason/s why the admission was denied.

Review of patient #35's information faxed by Hospital D, 10/25/10, 9:41PM, revealed the patient was PEC'd and CEC'd with a diagnosis of "Suicidal, Delusional". Review a form titled "Patient Demographics" (faxed by Hospital D) revealed under the section titled "Insurance", it was identified as "Free Care" and under the section "Primary Care Provider" it was listed as "Medicaid". Patient #35's admission was denied; however, the hospital failed to document the reason/s why the admission was denied.

Review of patient #36's information faxed by Hospital D, 10/25/10, 9:44PM, revealed the patient was PEC'd and CEC'd with a diagnosis of "Suicidal Ideation". The information faxed also contained a form titled "Patient Demographics" that had insurance data. Review of the insurance information revealed patient #36 was coded as "Free Care"/"Medicaid". Patient #36 was denied admission; however, there lacked documentation relative to the reason/s the admission was denied.

Interview, 10/26/10, with Intake Coordinator/Marketing S3 confirmed patient #s 32-39 had psychiatric diagnoses that met the hospital's admission criteria but they did not have Medicare coverage and that was the reason the admissions were denied.

Review of the daily census reports revealed: 10/16/10--7 patients in the hospital, leaving 7 beds available for an admission; 10/17/10--8 patients, leaving 6 beds available; 10/23/10--8 patients, leaving 6 beds available; 10/24/10--10 patients, leaving 4 beds available; and 10/25/10--11 patients, leaving 3 beds available.

Review of the nursing schedule revealed on 10/16/10, 10/17/10, 10/23/10, 10/24/10 and 10/25/10, there was 1 RN on each of the 8 hour shifts, 1 LPN on the 7a-3p and 3p-11p shifts, and 2 MHTs on each of the 8 hour shifts and were available to provide patient care.

Review of hospital policy #PE.003, titled "Admission Criteria: Inpatient" revealed the following: "Policy The adult psychiatry program is designed for the treatment of adult patients, ages 18 and over, with primary psychiatric or substance abuse diagnosis which meets the criteria for medically supervised in-patient treatment..."

Review of a hospital policy, #PE.007, titled "Patient Transfer From Another Facility" revealed: "Policy It is the policy of this hospital to provide for appropriate transfer of patients from another facility for admission to this hospital. Procedure 1. ...1.2 The patient meets approved criteria for admission to the level of care for which admission is requested...1.4 Admission is approved by the CEO (Chief Executive Officer) or his/her authorized administrative representative except for emergencies..."

Interview, 10/25/10, 1:40PM, with Confidential Interviewee S10, revealed information that the hospital's practice of admitting patients was determined by the patients' insurance coverage. S10 stated the only patients admitted into the hospital were patients who had Medicare coverage. S10 further stated patients who had private insurance or Medicaid coverage were consistently denied admission. Confidential Interviewee S10 was questioned as to why patients who had private insurance were denied, S10 stated "the hospital was not in the insurance network".

Interview,10/26/10, 9:45AM, with Intake Coordinator/Marketing S3 confirmed when questioned as to why the above patients were denied admission when their psychiatric diagnoses met the hospital's admission criteria, he stated "we only admit patients who have Medicare coverage". Intake Coordinator S3 was questioned as to who had instructed him to only admit patients with Medicare coverage; he stated (name of the owner of the hospital) had told them. Continued interview with S3 revealed he stated that he had told the owner of the hospital that the hospital needed to admit patients even if they did not have coverage as the practice of only admitting Medicare patients was a violation of EMTALA (Emergency Medical Treatment and Labor Act) regulations. The hospital continued to only admit patients who have Medicare coverage.

After reviews of: 1) the information (that had been faxed by various hospitals) that determined the patients (patient #s 12-14,16,18,19, 21-27, 32-40) met the hospital's admission criteria; 2) the hospital's policy/procedures relative to patient transfers; 3) the daily census reports; 4) nurse staffing schedules; and 5) administrative interviews, that indicated the hospital had the capability and capacity to admit patients; the hospital failed to admit 21 of 29 patients based upon their insurance coverage.