HospitalInspections.org

Based on review of documents and staff interview it was determined the facility failed to complete the plan of correction in reference to the completion of medical staff training regarding EMTALA, the development of the new re-appointment/re-privileging application and the re-wording of the Medical Staff Bylaws/ Rules and Regulations and to incorporate the terminology referenced in the Transfer Center Policy and Procedures.

Findings include:

1. All Physicians and Mid Levels are to have completed the EMTALA training by 11/30/11.

2. The hospital is developing a new re-appointment/re-privileging application that will include an EMTALA educational brochure which must be signed and returned with the application. This new process is expected to be completed by 12/1/11.

3. The hospital is also in the process of reviewing and rewriting the Medical Staff Rules and Regulations to be coordinated with the new hospital wide policy on Emergency Department (ED) transfer requests from Referring Emergency Departments. These changes will be finalized during the Medical Staff Executive Committee meeting on 12/8/11.

4. During an interview with the hospital Administrator, the Compliance Officer and The Chief Executive Officer in the morning of 10/25/11 they stated the Plan of Correction would be complete after the Medical Executive Committee meeting scheduled 12/8/11.