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Based on clinical record review, staff and other interviews, facility document review and during the course of a complaint investigation, the facility staff failed to ensure a written certification of transfer was completed and included in the clinical record for five (5) of seven (7) patient's who were transferred from the facility. This included Patient #10, #14, #16, #17, and #20.

At the time of survey, none of the above patients had a written certification of transfer found in the clinical record.

The findings included:

Patient #10 presented to the ED (Emergency Department) on 10/2/23 with a concern for a mental illness under an Emergency Custody Order (ECO- Emergency Custody Order, The Code of Virginia authorizes judicial intervention to order law enforcement personnel to take into custody and transport a person for needed mental health evaluation and care or medical evaluation and care a person who is unwilling or unable to volunteer for such care.) The patient was evaluated and provided a medical screening examination and a mental health evaluation. The patient was cleared medically and was evaluated by the community services board evaluation (CSB) and determined to require inpatient psychiatric treatment. On 10/3/23 a Temporary Detaining Order (TDO-Temporary Detaining Order, if it appears from all evidence readily available, including any recommendation from a physician, clinical psychologist, clinical social worker, or licensed professional counselor treating the person, that the person (i) has a mental illness and that there exists a substantial likelihood that, as a result of mental illness, the person will, in the near future, (a) cause serious physical harm to himself or others as evidenced by recent behavior causing, attempting, or threatening harm and other relevant information, if any, or (b) suffer serious harm due to his lack of capacity to protect himself from harm or to provide for his basic human needs; (ii) is in need of hospitalization or treatment; and (iii) is unwilling to volunteer or incapable of volunteering for hospitalization or treatment.) was issued. Patient #10 was discharged in the custody of law enforcement. Review of the clinical record did not evidence a written certification of transfer upon discharge to the psychiatric facility.

Patient #14 presented to the ED on 10/3/23 with concerns for a mental health issue being unable to manage self-care, becoming aggressive and agitated, having delusional thinking with hallucinations and threatening to kill (family members). The patient was evaluated in the ED on 10/3/23 and medically cleared. The CSB evaluated the patient and a TDO was issued on 10/3/23 to an inpatient psychiatric facility. The patient was discharged in the custody of law enforcement on 10/5/23. The clinical record did not evidence a written certification of transfer upon discharge.

Patient #16 presented to the ED on 10/3/23 with paranoia and agitation. The patient was brought in by EMS/Fire Department. On 10/4/23 a TDO was issued due to patient inability/unwilling to seek voluntary care. The ED performed a MSE (Mental Status Evaluation) and the patient was cleared. The patient was discharged in the custody of law enforcement on 10/4/23. The clinical record did not evidence a written certification of transfer upon discharge.

Patient #17 presented to the ED on 10/3/23 after an ECO was obtained for aggressive behavior. According to ED provider record dated 10/3/23, the patient received a MSE and although a psych consult was completed and inpatient treatment was not recommended, the patient had already been issued a TDO to a psychiatric facility, as the facility the patient came from would not accept (patient) back due to their behaviors. The patient had been medically cleared and left in the company of law enforcement. The clinical record did not contain a written certification of transfer upon discharge.

Patient #20 presented to the ED on 10/3/23 due to suicidal ideations. A TDO was issued due to "high risk of self harm...making multiple suicidal statements and history of several suicide attempts. Client is refusing voluntary hospitalization..." The ED performed a MSE and the patient was cleared. The patient was discharged in the custody of law enforcement. The clinical record did not evidence a written certification of transfer upon discharge.


On 10/24/23 at approximately 1:30 p.m., the surveyor discussed the concerns with SM #1 (Director of Accreditation), SM #2 (Accreditation) #3 (Accreditation) #4 (Accreditation) and #8 (CEO). SM #1 stated the certification of transfer were not found in the records and the facility was investigating whether or not some paperwork for these patients might have been sent to the facility. The facility acknowledged the concerns that the certification for these patients were not present.