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Based on observation and interview, the facility failed to post conspicuously the required signage (per section 1867 of the Social Security Act) specifying the rights of individuals with respect to examination and treatment for emergency medical conditions (EMC) and women in labor and whether or not the hospital participated in the Medicaid program under a State plan (under Title XIX). The hospital failed to:

*Post signage in a manner that was noticeable and visible to individuals waiting for ER examination and treatment (waiting room of ER ).

Findings include:

Record review of facility policy titled "EMTALA Guidelines for Emergency Department Services" dated 2/7/2019, showed the following information:

The hospital shall post a sign in a conspicuous area(s) of the Emergency Department, entrance, admitting area, treatment areas, etc. specifying the rights of the individual with respect to examination and treatment of medical conditions and women in labor.

Record review of Medicare Provider Agreement [Code of Federal Regulations (CFR) 42 CFR 489.20(q) ] "requires a hospital to post conspicuously a sign(s) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor and to indicate whether or not the hospital participates in the Medicaid program. The letters within the signs must be clearly readable at a distance of 20 feet or the expected vantage point of the emergency departments clients...".

Observation on 12/28/2021 at 10:05 AM in the waiting room of the facility ER showed a walk-up registration window.

Observation of the wall to the left of the registration window showed a framed piece of paper stating: "It's the LAW!... If you have a medical emergency...".

This sign was hung fairly high on the wall (approximately above 5 feet); the font size appeared small.

At the time of observation, surveyor was unable to read the printed words on the sign related to "It's the LAW" section ( EMTALA verbiage) without being directly close, in front of the notification.

During an interview with Staff ID-A, CEO, at the time of observation, he was unable to read the words on the sign after being asked to stand roughly twenty (20) feet away from he sign.

Based on observation, interview and record review, the facility failed to:

a. maintain a schedule of on-call physicians to provide further evaluation or stabilizing treatment, after a patient's initial exam;

b. develop written policies that address situations in which a particular specialty is not available or the on-call physician cannot respond due to circumstances beyond the physician's control.

Findings included:

TX00369184

a. Specialty physician on-call list:

Record review of facility "Medical Staff Bylaws" (revised 10-01-2020 ) and "Rules and Regulations"(dated January 2016) showed:

Bylaws: General requirements for medical staff membership included: participation in emergency coverage for the Emergency Department;

Rules & Regulations: Emergency Services: "... schedules , names, and telephone numbers of all Members and others on emergency call duty, including alternate shall be maintained according to state and federal statue (sic)..."..."

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Observation in the facility's ER on 12/28/2021 at 10 A.M. showed a lobby with a walk-up registration window. A separate entrance was located behind the registration window, inside the ER itself. This allowed for - there was a separate entrance to allow patients needing COVID testing to enter and be isolated form the other patients.

During an interview at the time of observation in the ER with Staff F, RN, she was asked which physician specialties were currently on-call to further evaluate and stabilize ER patients, if needed? Staff F showed surveyor a printed form posted on the ER bulletin board titled " East Houston Hospital Physician Specialist." It was not a specific monthly calendar of on-call physicians; it was a listing of specialists' names and phone numbers. Staff F went on to say the House supervisor could provide more information about the specialty on-call schedule.

During an interview on 12/28/2021 at 1: 15 PM with Staff E, house supervisor, she reviewed the specialty physician form with the surveyor.

Review of the form titled "East Houston Hospital Physician Specialists" showed:

-medical/surgical specialties were listed on the left side of the form (i.e. general surgery; ortho; spine, hand, IR, etc..);

-three (3) columns across the top of the form labeled "1rst"; "2nd;" and "3rd";

- a physician name and telephone number was provided in the columns ;

-not all specialties had designated names in all 3 columns; 6 specialities listed had only one physician listed in column # 1- no alternates;

-Under 'Imaging"category: radiology techs were listed-not physicians.

Staff E , house supervisor, said if a certain specialty was needed they would call the physician listed in column 1 first . If this physician was unavailable, they would call staff listed in Column 2. Staff E went on to say there was no monthly on-call schedule to indicate specific physicians on-call by day.

b. Policies that address non-availability of a certain specialty or on-call physician unable to respond:

During an interview on 12/28/2021 at 11 AM with Staff B, ACNO, she was asked to provide policies that addressed the unavailability of a certain specialties and instances if on-call physician was unable to respond.

Record review on 12/28/2021 of all facility policies provided related to EMTALA and emergency services failed to show any written policies and procedures related to the unavailability of certain specialties and non response of on-call physicians to the ER.