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Based on interviews and document review, the facility failed to comply with the Medicare provider agreement as defined in §489.20 and §489.24 related to Emergency Medical Treatment and Active Labor Act (EMTALA) requirements.

FINDINGS

1. The facility failed to meet the following requirements under the EMTALA regulations:

Tag 2402: (q)) Sign Posting. Based on observation, interviews and document review, the facility failed to ensure Emergency Medical Treatment and Labor Act (EMTALA) signage was posted at relevant locations in the facility.

Tag 2405: (r)(3)) Logs. Based on interviews and document review, the facility failed to ensure a central log was maintained of individuals who came to the dedicated emergency department seeking treatment and indicated whether these individuals: refused treatment, were refused treatment, were transferred, admitted and treated, stabilized and transferred, or discharged as required.

Tag 2406: (c)) Appropriate Medical Screening Examination. Based on interviews and record review, the facility failed to ensure an appropriate Medical Screen Exam (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulation was provided by qualified medical personnel (QMP) in 21 of 21 records reviewed for patients who presented to the facility for an emergency evaluation.

Tag 2407: (d)(3)) Stabilizing Treatment. Based on interviews and document review, the facility failed to ensure patients were provided stabilizing treatment when presenting for a psychiatric emergency.

Tag 2409: (e)(1) and (2)) Appropriate Transfer. Based on interviews and document review, the facility failed to provide completed Emergency Medical Treatment and Labor Act (EMTALA) forms for the transfer of a patient to an accepting facility in 1 of 1 records reviewed in which a patient was transferred from the facility (Patient #1).

Based on observation, interviews and document review, the facility failed to ensure Emergency Medical Treatment and Labor Act (EMTALA) signage was posted at relevant locations in the facility.

Findings include:

Facility policy:

The Emergency (EMTALA) and Non-Emergency Patient Transfers Policy read, the facility includes the main hospital building, building D, building E, the driveways and sidewalks outside all buildings (including the driveway and sidewalks outside Building B), the lawn/grounds areas immediately surrounding those buildings and the NW staff parking lot. The hospital will assess and stabilize an individual who comes to the facility (see definition of emergency department below) and requests examination for what may be an emergency medical condition, whether an admitted patient or not.

Signage- the hospital shall post signs in conspicuous locations likely to be noticed by all individuals entering admissions and other areas where patients are screened (including areas such as entrances, admitting areas, waiting rooms, treatment areas). At a minimum the signs must specify the rights of individuals with emergency conditions and women in labor who come to a facility or to other areas of the Medical Center for health care services. It must also indicate whether the facility participates in the Medicaid program. The signs shall be posted in English and Spanish. Signs shall also state the name, address and telephone for the State Department of Health Services. (See Attachment 4 for required language).

1. The facility failed to post signs specifying the rights of individuals seeking examination and treatment for emergency medical conditions and women in labor at entrances and waiting areas used by patients seeking emergency services. Specifically, there was no EMTALA signage at the main entrance to the hospital or the entrance to the walk-in crisis evaluation entrance.

a. On 10/5/22 at 2:49 p.m., an interview was conducted with the chief operating officer (COO) #22. COO #22 stated after research conducted during the survey, she identified the facility met the definition of a dedicated emergency department as outlined in Appendix V of the State Operating Manual (SOM). COO #22 stated the facility leadership, prior to the survey, had not identified the facility met the definition of a dedicated emergency department.

b. On 10/6/22 at 8:29 a.m., observations were conducted of the facility through the main patient entrance and revealed no EMTALA signage posted at the main entrance or the walk-in crisis evaluation entrance. There was, however, a sign posted at both entrances which read, open 24 hours providing inpatient psychiatric health services.

c. Review of facility policy The Emergency (EMTALA) and Non-Emergency Patient Transfers revealed EMTALA signage should have been posted at locations likely to be noticed by all individuals entering admissions and other areas where patients are screened.

Based on interviews and document review, the facility failed to ensure a central log was maintained of individuals who came to the dedicated emergency department seeking treatment and indicated whether these individuals: refused treatment, were refused treatment, were transferred, admitted and treated, stabilized and transferred, or discharged as required.

Facility Policy:

Emergency (EMTALA) and Non-Emergency Patient Transfers policy, this policy applies to: All staff and all staff working at the facility and all admitted patients and those individuals at the facility who are not admitted. The hospital has an obligation to treat patients fairly, equitably and to the full capability of our hospital and without regard to their ability to pay. Patients may come to the admissions area in the belief we are an emergency room and, in that case, the hospital has an obligation to stabilize, to the best of our ability, and then transfer those patients to a more appropriate facility. The hospital will assess and stabilize an individual who comes to the facility (see definition of emergency department below) and requests examination for what may be an emergency medical condition, whether an admitted patient or not.

The nurse will complete the unit Transfer/EMTALA Central Log Book entry for every patient who is transferred due to a medical emergency. The general requirements read: Centralized Log - Records and Records Retention, read, all WSH locations where a patient might present for emergency services or receive a Medical Screening Examination will maintain EMTALA Central Logs, which identify the patients who have presented for such services. a. Logs will be maintained in the admissions area and in each unit. b. Central Logs must be maintained in a manner that makes them readily available (generally within 30 minutes) to regulators in the event of an EMTALA survey. c. The Central Log will include, at a minimum, the patient's name, outcome, and indicate whether the patient: i. Refused treatment ii. Was refused treatment iii. Was Transferred iv. Was admitted and treated v. Was Stabilized and Transferred vi. Was discharged. The Central Log and Physician on-call lists shall be maintained for at least five (5) years.

1. The facility failed to maintain a central log of patients who presented to the facility seeking emergency medical care.

a. On 10/5/22 at 2:49 p.m., an interview was conducted with the chief operating officer (COO) #22. COO #22 stated after research conducted during the survey, she identified the facility met the definition of a dedicated emergency department as outlined in Appendix V of the State Operating Manual (SOM). COO #22 stated the facility leadership, prior to the survey, had not identified the facility met the definition of a dedicated emergency department.

b. Upon request, the facility was unable to provide a central log which included the criteria set forth in the facility policy above. This was in contrast to facility policy and EMTALA regulations.

Due to the nature of the survey findings, an Immediate Jeopardy (IJ) was declared 11/21/22, after CMS review.

Based on interviews and record review, the facility failed to ensure an appropriate medical screening examination (MSE) as required by the Emergency Medical Treatment and Labor Act (EMTALA) regulation was provided by qualified medical personnel (QMP) in 21 of 21 records reviewed for patients who presented to the facility for an emergency evaluation. (Patients #1 through #21)

Findings include:

Facility policy:

The Emergency (EMTALA) and Non-Emergency Patient Transfers policy revised 7/13/22 read, purpose: To comply with the requirements of the Emergency Medical Treatment and Labor Act (EMTALA) and outline the hospital policies and procedures for handling both emergency transfers and non-emergency transfers to and from the hospital.

This policy applies to: 1. All inpatient staff and all staff working at the hospital facility. 2. All hospital admitted patients and those individuals at the hospital facility who are not admitted. 3. The hospital facility includes the main hospital building, building D, building E, the driveways and sidewalks outside all buildings (including the driveway and sidewalks outside Building B), the lawn/grounds areas immediately surrounding those buildings and the northwest staff parking lot a. The parking lot east of Building B, Building A north parking lot and all of Building A are specifically excluded as part of the hospital facility for EMTALA purposes.

Policy 1. The facility has an obligation to treat patients fairly, equitably and to the full capability of our hospital and without regard to their ability to pay. Patients may come to the admissions area in the belief we are an emergency room and, in that case, the facility has an obligation to stabilize, to the best of our ability, and then transfer those patients to a more appropriate facility. The facility will assess and stabilize an individual who comes to the facility (see definition of emergency department below) and requests examination for what may be an emergency medical condition, whether an admitted patient or not.

For individuals who do not fall under the EMTALA law/regulations, the facility will provide the same level of assessment, stabilization, and transfer services as if the person were covered by EMTALA. For non-emergency medical conditions, facility staff will advise the person of their options and assist in arranging transportation, if so requested. For patients admitted to the facility with an emergency medical condition, staff will assess, treat and stabilize to the limit of our capabilities while arranging transport to a suitable facility with the proper capability to handle the medical emergency. In this case, facility hospital staff will prepare a transfer packet in the same way, with the same contents as if the patient were an EMTALA transfer, to include provider to provider and nurse to nurse communication between facilities.

1. The facility failed to ensure patients who presented to the facility for emergency psychiatric services received a medical screening examination (MSE) to determine if an emergency psychiatric condition existed for the patient.

A. Document review

a. Review of the Governing Body bylaws revealed the facility had not determined which providers and staff were determined to be a Qualified Medical Provider (QMP).

B. Medical Record Review

a. Review of Patient #14's medical record revealed on 8/25/22 at 2:30 a.m., Patient #14 presented as a walk-in patient requesting to receive treatment. Review of the medical record indicated the patient was extremely paranoid, experiencing auditory and visual hallucinations. A note written by operations manager (Manager) #41 at 5:40 a.m., read, the patient left before this writer was able to review the information with the provider.

There was no evidence of an MSE conducted or attempted to determine if the patient was experiencing a psychiatric emergency condition.

i. On 10/11/22 at 1:01 p.m., an interview was conducted with Manager #41 in regards to Patient #14's medical record. Manager #41 stated she remembered completing an initial walk in screening on Patient #14. Manager #41 stated the patient presented to the facility, was brought back to a room in the admissions area and she asked questions regarding why he had presented to the facility. Manager #41 further stated during the patient's encounter, he became aggressive and wanted to leave the facility. Manager #41 stated a security guard came to see the patient, de-escalated the patient and the patient still wanted to leave.

Manager #41 explained the patient was free to leave because he was not on an M-1 hold (involuntary 72 hour hold for evaluation and treatment of mental illness). Manager #41 further explained Patient #14 did not qualify for an M-1 hold because of the patient's past interactions at the facility and the patient seeming to be at baseline. Additionally, Manager #41 stated she was not a licensed provider so she could not place a patient on an M-1 hold. Manager #41 stated it was determined Patient #14 was safe to leave because the security guard had de-escalated the patient. Manager #41 stated the provider was notified of the patient leaving after the patient left the facility.

b. Review of Patient #16's medical record revealed on 9/14/22 at 8:35 a.m., Patient #16 presented for treatment from the facility. Crisis clinician (Clinician) #33's Crisis Contact note read, the patient had a history of depression, alcohol use and a prior suicide attempt. Patient #16 presented to the facility with an unsteady gait, slurred speech and a blood alcohol level (BAL) of 0.241. Clinician #33's note further read, Clinician #33 did not feel comfortable completing the assessment on the patient due to the patient's level of intoxication. Clinician #33 called the administrator on call (AOC). The note further read the AOC on call was the director of clinical information systems (Director) #42. Clinician #33 then referred Patient #16 to outpatient detox to sober up in order for an assessment to be completed.

There was no evidence of an MSE conducted or attempted to determine if the patient was experiencing a psychiatric emergency condition.

C. Video Review

a. Review of video footage for Patient #1 was conducted with quality assurance improvement registered nurse (Quality RN) #17. Video review revealed Patient #1 arrived at the facility on 10/4/22 at 5:11 a.m. and was placed in a crisis room for assessment. At 5:27 a.m., crisis clinician (Clinician) #33 was seen at the patient's doorway for a total of 17 seconds. At 5:35 a.m., Clinician #33 returned and stood in the doorway to observe the patient for 17 seconds. At 8:16 a.m., two hours and 46 minutes later, the patient departed from the facility.

There was no evidence Patient #1 received an MSE in order to determine if she was experiencing a psychiatric emergency.

Similar findings of patients not receiving an MSE from a QMP delineated by the Governing Body were found in the medical record reviews of Patients #2-13, #15, and #17-21.

D. Interviews

a. On 10/5/22 at 2:49 p.m., an interview was conducted with the chief operating officer (COO) #22. COO #22 stated after research conducted during the survey, she identified the facility met the definition of a dedicated emergency department as outlined in Appendix V of the State Operating Manual (SOM). COO #22 stated the facility leadership, prior to the survey, was unaware and had not identified they met the definition of a dedicated emergency department.

b. On 10/12/22 at 2:00 p.m., an interview with chief executive officer (CEO) #25 was conducted. CEO #25 identified the hospital had EMTALA obligations but was unaware the facility had these obligations until the survey was conducted. CEO #25 stated the facility was not in compliance with EMTALA requirements at the time of the survey. CEO #25 stated patients who walked up to the facility would believe it was an emergency department and seek care.

CEO #25 stated the process of having outpatient mobile crisis staff perform crisis walk-in assessments for the hospital needed to change immediately. CEO #25 stated the AOC should not be making clinical decisions.

A review of the EMTALA policy, revised on 7/13/22, was conducted with CEO #25, at which time he stated he was unsure why the facility had an EMTALA policy since the leadership at the facility was unaware the facility met the required EMTALA obligations until the survey. CEO #25 surmised the previous facility administration may have thought they met EMTALA obligations, but that knowledge was lost somewhere along the way, due to staff and leadership turnover.

Due to the nature of the survey findings, an Immediate Jeopardy (IJ) was declared 11/21/22, after CMS review.

Based on interviews and document review, the facility failed to ensure patients were provided stabilizing treatment when presenting for a psychiatric emergency in six of 21 medical records reviewed (Patients #3, Patient #13, Patient #14, Patient #16, Patient #20 and Patient #21).

Findings include:

Facility policy:

The Emergency (EMTALA) and Non-Emergency Patient Transfers read, the hospital will assess and stabilize an individual who comes to the facility (see definition of emergency department below) and requests examination for what may be an emergency medical condition, whether an admitted patient or not. For individuals who do not fall under the EMTALA law/regulations, the hospital will provide the same level of assessment, stabilization, and transfer services as if the person were covered by EMTALA. For non-emergency medical conditions, hospital staff will advise the person of their options and assist in arranging transportation, if so requested. For patients admitted to the hospital with an emergency medical condition, staff will assess, treat and stabilize to the limit of our capabilities while arranging transport to a suitable facility with the proper capability to handle the medical emergency. In this case, hospital staff will prepare a transfer packet in the same way, with the same contents as if the patient were an EMTALA transfer, to include provider to provider and nurse to nurse communication between facilities.

1. The facility failed to ensure patients were provided safety plans prior to leaving the facility.

A. Review of medical records with Clinic Operations Manager (Manager) #30 revealed patients were discharged home with their parents without a safety plan, even though the patients qualified for in-patient treatment.

a. On 10/4/22, Patient #3 presented to the facility with two adults. According to a Multidisciplinary Note, the patient's mother presented with the patient seeking hospitalization to review the patient's medications after an episode occurred where the patient severely assaulted his brother. The note further read the patient's mother was concerned that she could not keep others safe from the patient and stated the school district stated similar concerns. The note documented referrals for hospitalization were sent and the patient's disposition was pending. There was no further documentation in the medical record stating if the patient was admitted to a hospital, or if the patient received a safety plan and was released from the facility.

i. On 10/6/22 at 9:56 a.m., an interview with the clinical operations manager (Manager) #30 was conducted. Manager #30 stated she had reviewed Patient #3's medical record and was confused with the details of what happened during the patient's visit. Manager #30 explained she was informed that the patient had returned home due to the mother's request. However, Manager #30 confirmed there was no disposition of where Patient #3 went after the visit on 10/4/22 or how it was determined that the patient was safe to return home.

b. On 9/5/22, Patient #20 presented to the facility with his father. The patient's father was requesting inpatient treatment for the patient due to escalating violent behaviors and homicidal ideation. A danger assessment was completed which read Patient #20 was a high risk for harm to others. The disposition note for Patient #20 read, referrals were made to other psychiatric hospitals since patients could not be admitted to the facility due to the patient's young age of five years old.

i. On 10/11/22 at 10:32 a.m., an interview was conducted with Manager #30. Manager #30 stated the medical record was not clear on where the patient was transferred to. Manager #30 explained that typically young children were sent home with their family when there was not an accepting facility to send the patient to. Manager #30 stated if the patient was sent home with family, a safety plan should have been created with the patient and family.

The facility was unable to provide evidence of a safety plan for Patient #20.

c. On 8/10/22 Patient #21 presented with his mother for treatment. Patient #21's medical record read, the patient presented physically and verbally aggressive, uncooperative and impulsive. Patient #21 was observed hitting and kicking his mother. The disposition note read, the patient was denied admission to the facility due to the patient's acuity and age. The medical record revealed Patient #21 was five years old. The medical record did not reveal where the patient was transferred to.

i. On 10/11/22 at 10:32 a.m., an interview was conducted with Manager #30. Manager #30 stated Patient #21 was brought in by his mother due to aggressive behavior. Manager #30 stated Patient #21 was screened and review of the screening indicated the patient met inpatient criteria. Manager #30 stated review of Patient #21's record revealed the patient was sent home with family and a safety plan was not documented.

Manager #30 stated it was important to put a safety plan in place to ensure the patient would be safe in the community.

d. An interview with chief executive officer (CEO) #25 was conducted on 10/12/22 at 2:00 p.m. CEO #25 stated patients who presented to the facility may have an emergency medical condition (EMC) and the facility had the responsibility to treat and stabilize the patient within the facility's capacity. CEO #25 stated the facility's current process for the stabilization of patients was not ideal and there was need for improvement to ensure patients were stabilized.

2. The facility failed to ensure patients received treatment and were stabilized prior to discharge.

a. Medical record review for Patient #13 revealed on 8/26/22, Patient #13 presented to the facility seeking treatment. Patient #13's medical record revealed an assessment was completed by intake coordinator (Coordinator) #39. Further review of the medical record revealed Coordinator #39 discussed the patient's presentation with the provider. The Walk-in Initial Screening Note read, the provider determined the patient qualified for inpatient treatment. Coordinator #39 documented there were no beds available at the facility so the patient was provided outpatient services and a safety plan was created.

There was no evidence the facility reached out to other facilities in order to find placement for Patient #13 to receive treatment.

i. On 10/11/22 at 10:32 a.m., an interview was conducted with Manager #30. Manager #30 reviewed Patient #13's record during the interview. Manager #30 stated the patient received an initial screening but did not receive a crisis assessment. Manager #30 stated she would expect to see a note as to why the patient was safety planned and sent home rather than being admitted to an inpatient facility.

b. Review of Patient #14's medical record revealed on 8/25/22 at 2:30 a.m., Patient #14 presented as a walk-in patient requesting to receive treatment. Review of the medical record indicated the patient was extremely paranoid, experiencing auditory and visual hallucinations. A note written by operations manager (Manager) #41 at 5:40 a.m. read, the patient left before she was able to review the information with the provider.

i. On 10/11/22 at 1:01 p.m., an interview was conducted with Manager #41. Manager #41 stated she remembered completing an initial walk in screening on Patient #14. Manager #41 stated the patient presented the facility, was brought back to a room in the admissions area and she asked questions regarding why he had presented to the facility. Manager #41 further stated during the patient's encounter, he began to become aggressive and wanted to leave the facility. Manager #41 stated a security guard came to see the patient, de-escalated the patient and the patient still wanted to leave.

Manager #41 explained the patient was free to leave because he was not on an M-1 hold (involuntary 72 hour hold for evaluation and treatment of mental illness). Manager #41 further explained Patient #14 did not qualify for an M-1 hold because the patient seemed to be behaving at his baseline based on past interactions at the facility. Additionally, Manager #41 stated she was not a licensed provider so she could not place a patient on an M-1 hold. Manager #41 stated it was determined Patient #14 was safe to leave because the security guard had de-escalated the patient. Manager #41 stated the provider was notified after the patient left the facility that he had left.

Further review of Patient #14's medical record revealed there was no indication the patient was aggressive or that the security guards were involved in de-escalating the patient. Manager #41 stated the event was not documented in the record because it was not part of the Walk In Initial form and there was nowhere in the medical record to document it.

c. Review of Patient #16's medical record revealed on 9/14/22 at 8:35 a.m., Patient #16 presented for treatment from the facility. The Crisis Contact note read, the patient had a history of depression, alcohol use and a prior suicide attempt. Patient #16 presented to the facility with an unsteady gait, slurred speech and a Blood Alcohol Level (BAL) of .241. Crisis clinician (Clinician) #33's note further read, Clinician #33 did not feel comfortable completing the assessment on the patient due to the patient's level of intoxication. Clinician #33 called the administrator on call (AOC) who agreed it would be best for the patient to go to the outpatient detox unit for the night and have an assessment done when the patient was sober. The note further read the AOC on call was the director of clinical information systems (Director) #42. Clinician #33 then referred the patient to outpatient detox to sober up in order for an assessment to be completed.

d. On 10/12/22 at 2:00 p.m. an interview was conducted with CEO #25. CEO #25 stated the AOC should not be making clinical decisions. CEO #25 further explained the crisis team was responsible for deciding whether or not to admit a patient. The interview with CEO #25 was in contrast to the medical record review for Patient #16.

The facility failed to provide evidence Patient #13, Patient #14, and Patient #16 received stabilizing treatment prior to being transferred to another facility or sent home which was in contrast to the facility's policy which read, the facility will provide stabilization.

Based on interviews and document review, the facility failed to provide completed Emergency Medical Treatment and Labor Act (EMTALA) forms for the transfer of a patient to an accepting facility in one of one records reviewed in which a patient was transferred from the facility to a medical hospital (Patient #1).

Findings include:

Facility policy:

The Emergency (EMTALA) and Non-Emergency Patient Transfers policy read, purpose:
To comply with the requirements of the Emergency Medical Treatment and Labor Act ("EMTALA) and outline the hospital policies and procedures for handling both emergency transfers and non-emergency transfers to and from the hospital. This policy applies to:
1. All hospital staff and all staff working at the hospital.
2. All hospital admitted patients and those individuals at the hospital who are not admitted.
3. The hospital includes the main hospital building, building D, building E, the driveways and sidewalks outside all buildings (including the driveway and sidewalks outside Building B), the lawn/grounds areas immediately surrounding those buildings and the northwest staff parking lot
a. The parking lot east of Building B, Building A north parking lot and all of Building A are specifically excluded as part of the hospital for EMTALA purposes.

1. The facility failed to ensure patients were accepted by an outside facility and provided appropriate documentation when a patient was transferred. Specifically, there was not a signed patient consent to transfer explaining the risks and benefits of the transfer, documentation of accepting facility and physician, as well as the physician certification pertaining to the reason for transfer.

a. Review of video footage regarding Patient #1 was conducted with the quality assurance improvement registered nurse (Quality RN) #17. Video review revealed Patient #29 arrived at the facility on 10/4/22 at 5:11 a.m. and was placed in a crisis room for assessment. At 8:16 a.m., two hours and 46 minutes later, the patient departed from the facility with Emergency Medical Service (EMS) personnel.

i. Review of Patient #1's medical record revealed there was no evidence of an accepting facility nor physician certification stating the needed reason for transfer.

c. On 10/6/22 at 9:56 a.m., an interview was conducted with clinical operations manager (Manager) #30. Manager #30 explained there was no specific paperwork used when a patient was sent to another facility from the admissions area. Manager #30 stated the crisis clinicians who assessed patients that presented to the facility for treatment were outpatient employees so they did not have to adhere to EMTALA requirements and therefore, transfer paperwork was not required.

d. On 10/12/22 at 2:00 p.m., an interview was conducted with chief executive officer (CEO) #25. CEO #25 stated if a patient needed to be transferred out from the admissions area, the facility would call 911 for transportation. CEO #25 stated he believed there were forms that were expected to be completed when a patient was sent out to another facility.