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An unannounced onsite complaint survey was conducted related to allegations regarding the Emergency Medical Treatment & Labor Act (EMTALA) contained within complaint number SC 00052045 at Palmetto Lowcountry Behavioral Health on 05/16/2022 - 05/19/2022. The hospital was determined to be out of compliance with 42 CFR 489.20(l)(r) and 494.24 at the time of the survey.

The findings are:

Refer to A2404 and A2406.

Based on the hospital's log for patient referrals from other healthcare facilities and interview, the hospital failed to ensure documentation was maintained for those patient referrals received from other healthcare facilities requesting a bed for a patient that the referring healthcare facility determined to need admission for a psychiatric emergency medical condition, Patients #14 and #20.

The findings are:

On 05/18/2022 at 9:45 AM, the Assistant Director of Intakes (ADI) submitted a log for the past 6 months that listed the patients for whom a referral for a bed was requested. When the patients' documentation and/or referral forms were requested, the ADI reported that there was no documentation and/or referral forms for these requests since the hospital did not admit the patients. The ADI also explained that although the hospital has 92 licensed psychiatric beds, the hospital closed 64 beds in 2021 due to lack of staffing. Consultation with the State Agency revealed the State Agency had not received any information to the closure of the psychiatric beds in 2021.

On 5/17/2022 at 9:23 AM, review of the hospital's central log revealed "4/06/2022 Patient (#14) is 53, female, arrived by car at 0905 AM." The complaint was documented as "psych." The EMC column has a yes answer on the central log and then the yes answer is crossed through and a no appears in this column. The central log had a departure time as 10:18 AM and the patient's disposition was listed as home. No departure mode was documented on the central log. Staff initials are noted in the last column of the log. When the patient's referral or assessment was requested, the hospital did not submit any documentation for the patient's 4/06/2022 presentation.

In an interview on 5/18/2022 at 11:00 AM, the Assistant Intake Director (AID), stated, "The patient presented on 4/06/2022, and then came back on 4/18/2022. " The AID, when asked if the Patient (#14) was assessed by staff and the physician on 4/06/2022, replied, "There would be a chart. " The hospital did not submit a chart for Patient #14's 4/06/22 presentation.

On 5/17/2022 at 9:18 AM, review of the hospital's central log revealed Patient #20 (37-year-old female) came in on 2/22/2022 (walk-in) by car at 7:35 PM with the complaint of "dual". The central log stated the patient had an emergency medical condition. The log stated the patient departed the hospital at 8:27 PM via ambulance as a referral to another hospital. The central log entries were documented by Intake Coordinator #5. There was no documentation of an intake form or Medical Screening Examination for the log entry dated 2/22/2022 or a Memorandum of Transfer (MOT) form from the psychiatric hospital.

Based on Governing Body bylaws, intake assessment form and interviews, the psychiatric hospital failed to ensure its psychiatrist designated as the on-call physician performed a Medical Screening Examination (MSE) onsite via Telemedicine, or telephone with the patient for those persons presenting to the hospital via the hospital's entrance requesting to be seen. The psychiatric hospital failed to present any specialized training and competencies that qualified its Intake Staff to perform a Medical Screening Examination or Psychiatric Screening Examination to determine if an Emergency Medical Condition existed.

The findings are:

On 5/16/2022 at 1:00 PM, review of the psychiatric hospital's "Bylaws of the Board of Governors" revealed, "Active staff is able to provide continuous and timely care to and supervision of his patients, whether on site or via Telemedicine, .. and perform all on call duties as assigned .....".

On 5/16/22 at 1:50 PM, review of the psychiatric hospital's "Bylaws of the Board of Governors", revealed, " ...The Board will separately adopt a policy designating qualified medical personnel ("QMPs") and qualified mental health professionals ("QMHPs") capable of performing within the Hospital's capabilities, appropriate medical screening examinations or appropriate psychiatric medical screening examinations as required by EMTALA(Emergency Medical Treatment And Labor ACT) . If no policy is in place, then upon completion of the provider's credentialing, the Board hereby designates the following providers as QMPs and QMHPs capable of performing, within the hospital's capabilities, appropriate medical screening examinations or appropriate psychiatric medical screening examinations as required by EMTALA (unless restricted by the provider's applicable scope of practice): (i) Licensed Physicians; (ii) Licensed Psychologists; (iii) Licensed Allied Health Professionals (ARNPs, NPs, Pas) (iv) Licensed Social Workers; (v) Registered Nurses; and (vi) Licensed Professional Counselors." The Governing Body Bylaws was silent as to what specialized education or training was required to perform a Medical Screening Examination and/or Psychiatric Medical Screening Examination was required for above staff . The Governing Body Bylaws was silent related to on call physician responsibilities.

Cross Reference to A 2406 as it relates to Staff qualifications and competencies.

On 5/17/2022 at 12:52 PM, an interview with the psychiatric hospital's Medical Director via telephone revealed the psychiatric hospital uses exclusivity criteria to determine if a patient who presents to the hospital has an emergency medical condition. The criteria is based on whether the hospital is able to handle the patient's medical concerns. The Medical Director reported that if the patient doesn't meet the psychiatric inpatient criteria for admission, other agencies will be called for placement. The Medical Director reported that if a patient presents with suicidal or homicidal ideation, the patient will be admitted. The Medical Director reported the Intake Coordinator will interview the patient, gather the information, and then telephone the psychiatrist on call and run the data by the psychiatrist on call. The psychiatrist on call does not speak to the patient or examine the patient. The Medical Director reported that after the Intake Coordinator speaks with the physician on call, then the physician on call will talk about the patient's admission or disposition. The Medical Director reported that he/she was not sure where the patient's Medical Screening Examination is documented. The Medical Director reported that if the psychiatric hospital has no beds, the hospital would transfer the patient.

On 5/18/2022 from 9:38 AM until 4:06 PM, interviews were conducted with the ADI(Assistant Director Intake), Intake Coordinator(IC) #1, #2, #4, #5, #6, and #9. During the interviews, the ADI and Intake Coordinator reported the hospital has on call psychiatrists, but the on call psychiatrist is not called until after the Intake Coordinator completes the patient's intake information. The ADI reported the on call psychiatrist does not come to the hospital to see the patient and does not talk with the patient by telephone or Telemedicine. If the patient is admitted, then the psychiatrist will see the patient within 24 hours.

On 5/18/2022 from 10:32 AM to 11:10 AM, an interview with Intake Coordinator (IC) #4 revealed when the patient walks in the door, vital signs are obtained, intake questions are obtained, establish if the patient is medically stable or not, wands the patient for contraband, remove belongings, completes the intake assessment, and calls the on call physician to tell the on call psychiatrist the information gathered from the patient. IC #4 reported the on-call physician does not come to see the patient.

On 5/19/2022 from 9:50 AM to 10:01 AM, Registered Nurse #1 revealed the nursing manager and nursing supervisors cover the intake department at night. RN#1 stated he/she completes the intake assessment form with the patient and calls the on-call physician. Based on the patient's information, the on call physician decides whether to admit the patient or not. RN #1 verified the on-call physician does not come in to assess the patient.

On 5/19/2022 at 10:10 AM, an interview with IC #7 revealed the on- call physician decides if the patient meets the hospital's criteria for admission, and verified the on-call physician does not come in to see the patient and does not talk with the patient.

On 5/19/2022 from 12:25 to 12:41 PM, an interview with IC #8 revealed the on- call physician is called by the Intake Coordinator to review the patient's assessment data. The on- call physician tells the IC what the next step is for the patient. IC #8 reported, "I just do the assessment. The on -call physician determines if there is a medical emergency. IC #8 verified the on-call physician does not talk with the patient or come in to see the patient."

Review of the hospital's form, titled, "Standardized Intake Assessment", V.4 11/21, PLBH 1000, revealed the following sections completed by the patient:
Page 1 - Demographic that includes but is not limited to Legal Status and Referral Source; Patient Search/Portable Metal Detector; that included vital signs, allergies, balance, Oxygen, and pain; Health and Communicable Disease; Fall Risk; Organ Donor; then a signature space for Medical Screen Completed by: Date and Time.
Page 2- Presenting Problem; Suicide Risk last 6 months with Columbia - Suicide Severity Rating Scale.
Page 3- Sexually Aggressive Behavior; Potential for Sexual Victimization; Homicidal/Violence Risk Factors; Elopement Risk Factors; Access to lethal/Self Harm Means. Signature space for Triage Completed by, Date and time.
Page 4: Previous Treatment; Major Life Areas; Behavior Changes; Sleep; Eating/Weight; Child/Adolescent Patients Only;
Page 5: Family History; Legal Issues; History of Trauma; Substance Abuse History; Current Withdrawal Symptoms; Prior Substance Use Treatment.
Page 6: Medications As Reported By Patient/Others; Current Mental Status; and Protective Factors; Risk Factors.
Page 7: Current Mental Status; Protective Factors; and Risk Factors.
Page 8 - Level Of Care Determination.
Page 9- Disposition; Assessment Reviewed with: Via- Phone[ ] In Person[]. Provider: Date: Time: Provisional Primary DSM 5 Diagnosis: Provisional Secondary DSM5 Diagnosis
Assessor Signature Credentials Date Time.

There is no section on the Standardized Intake Assessment form for documentation of the contents of the conversation that the Intake Coordinator has with the on - call physician to the determination of the disposition of the patient.

Based on review of the hospital's central log, staff interviews, and hospital policy and procedure review, the hospital failed to maintain a central log that included all individuals who presented for treatment through the hospital's entrance, why the patient presented for treatment, and the disposition of the patient for 1 of 1 patient. (Patient #14)

The findings are:

On 5/16/2022 at 12:55 PM, the hospital's central log, titled, "Everyone that comes through the lobby and directly to the unit", and then, "Palmetto Low Country Behavior Health, EMTALA (Emergency Medical Treatment and Labor Act) Log with the date at the top of each sheet. The hospital's central log sheets have 12 columns for name of patient with last and first name, address: age of patient, sex of the patient, arrival time of the patient, and arrival mode (car, police, ambulance etc.), Complaint the patient presents with, Emergency Medical/Psychiatric Condition (EMC), and the choices in parenthesis under the EMC title included either yes or no. The last five columns address: depart time, admit time, disposition, depart mode (car, Police, Ambulance) and Memorandum of transfer (MOT). The last column includes the initials of the staff completing the central log. Documentation for the patient's chief complaint showed Psychiatric, Medical, or Chemical Dependency (CD).

On 5/17/2022 at 9:23 AM, review of the hospital's central log revealed "4/06/2022 Patient (#14) is 53, female, arrived by car at 0905 AM." The complaint is documented as "psych." The EMC column has a yes answer on the central log and then the yes answer is crossed through and a no answer appears in this column. The central log has a departure time as 10:18 AM and disposition listed as home. No departure mode was documented on the central log. Staff initials are noted in the last column of the log. When the patient's chart or assessment was requested, the hospital did not submit any documentation for the patient's 4/06/2022 presentation.

On 5/18/2022 at 11:00 AM, the Assistant Intake Director (AID) stated, "The patient presented on 4/06/2022, and then came back on 4/18/2022. " The AID, when asked if the Patient (#14) was assessed by staff and the physician on 4/06/2022, replied, "There would be a chart. "

No chart for Patient #14's admission was submitted by the hospital for the patient's 4/06/2022 presentation.

Hospital policy, titled,"EMTALA-Assessing an Emergency #AOP-001, revised on 12-29-03 and 3-29-2022,", reads, "An EMTALA log shall be maintained in the intake department documenting all scheduled and emergency assessments including the date, patient's first name and last name, age, sex, time of arrival, arrival mode of transportation, type of complaint, if it was an emergency medical/psychiatric condition, departure time, disposition, departure mode of transportation if Memorandum of Transfer was completed, and staff initials."

Based on medical record reviews, hospital policy and procedure, Medical Staff Bylaws, personnel files, central log, and staff interviews, the hospital failed to ensure that medical screening examinations were provided within the capability of the hospital to include Qualified Medical Personnel routinely available in the hospital to determine whether or not an emergency psychiatric condition existed for 4 of 20 psychiatric patients' documentation reviewed (Patient #14, #16, #12, and #20).

The findings are:

Hospital Governance and Medical Staff By laws
On 5/16/22 at 1:50 PM, review of the psychiatric hospital's Governing Body Bylaws revealed " ...The Board will separately adopt a policy designating qualified medical personnel ("QMPs") and qualified mental health professionals ("QMHPs") capable of performing within the Hospital's capabilities, appropriate medical screening examinations or appropriate psychiatric medical screening examinations as required by EMTALA(Emergency Medical Treatment And Labor ACT). If no policy is in place, then upon completion of the provider's credentialing, the Board hereby designates the following providers as QMPs and QMHPs capable of performing, within the hospital's capabilities, appropriate medical screening examinations or appropriate psychiatric medical screening examinations as required by EMTALA (unless restricted by the provider's applicable scope of practice): (i) Licensed Physicians; (ii) Licensed Psychologists; (iii) Licensed Allied Health Professionals (ARNPs, NPs, Pas) (iv) Licensed Social Workers; (v) Registered Nurses; and (vi) Licensed Professional Counselors."

The Governing Body Bylaws was silent as to what specialized education or training to perform a Medical screening examination and/or psychiatric medical screening examination was required for above staff . The Governing Body Bylaws was silent related to on call physician responsibilities.

On 5/16/2022 at 1:00 PM, review of the Medical Staff By-Laws revealed, "All qualified Medical Personnel (QMPs) and/or Qualified Mental Health Professionals (QMHPs), as approved by the Board, may perform appropriate medical screening examinations or appropriate psychiatric medical screening examinations, to the extent said examinations are within the Facility's capabilities as required by EMTALA." Also, "Active staff is able to provide continuous and timely care to and supervision of his patients, whether on site or via Telemedicine, .. and perform all on- call duties as assigned ...".

Hospital policy, "EMTALA-Assessing an Emergency, Policy AOP-001 revised 12/29/03, 3/29/2022, reads, "Mental health Code. With respect to individuals presenting with psychiatric disturbances or symptoms of substance abuse, the facility should use the criteria for emergency detention under State Mental Health Code to determine whether such individuals have emergency medical conditions. Reference 1.2.2. The person evidences a substantial risk of serious harm to self or others. Patients meeting criteria for acute inpatient care at (hospital named in complaint)shall be provided stabilizing treatment within the capabilities of the hospital staff, including whether the hospital is able to treat the acuity of the patient and if a vacant bed and sufficient staff are available."

Record Reviews

On 5/17/2022 at 9:23 AM, review of the hospital's central log revealed Patient #14 presented to the hospital's lobby requesting an examination on 4/06/2022. The hospital's central log showed "Patient #14 is 53, female, arrived by car at 0905 AM." The complaint is listed as "psych." The EMC column has a yes answer on the central log, and then the "yes" is crossed through and a "No" appears in this column. The central log has a departure time as 10:18, and the disposition of Patient #14 is listed as home. No departure mode is documented on central log for Patient #14. Staff initials are noted in the last column of the log. No chart could be provided for Patient #14 on 4/06/2022. There was no documentation that the patient received an Medical Screening Examination (MSE) to determine if an Emergency Medical Condition existed on 4/6/2022.

Review of the psychiatric hospital's EMTALA log revealed Patient #16 arrived to hospital by car on 11/29/21 at 12:05 PM. The patient's father reported he was seeking help because "the patient kept running away and not going to school or caring about anything." There was no documentation of an MSE performed. There was documentation that an intake assessment was completed by an Intake Coordinator(IC) on 11/29/2021 at 12:10 PM. The IC documented he/she had discussed the information gathered from the patient with the on - call psychiatrist by telephone on 11/29/21 at 1:31 PM. There was no documentation that the on -call physician saw the patient in person or via Telemedicine. Documentation on the EMTALA log showed the patient was discharged for not meeting the hospital's admission inpatient criteria.

Review of the psychiatric hospital's EMTALA log revealed Patient #12 arrived to the hospital on 4/14/22 at 11:03 AM by car with a chief compliant of depression. Patient #12 reported increased anxiety from an attack by a dog, panic attacks, flashbacks, struggling to function. Review of the intake documentation on 4/14/22 at 12:00 PM by a Registered Nurse revealed the nurse reviewed the intake information with the on - call psychiatrist by telephone on 4/14/22 at 12:15 PM. The on-call psychiatrist did not see the patient in person or via Telemedicine. Review of the documentation on the intake assessment form showed "Reports of Collateral Information/Additional Comments ...Mental Wellness. She/he had passive SI (Suicidal Ideation) only in early adolescence, but she/he states this was because she/he was medically not diagnosed properly. She/he denies SI or HI (Homicidal Ideation) ...". Patient discharged from the intake area on 4/14/2022 at 12:15 PM with an outpatient referral.

On 5/17/2022 at 9:18 AM, review of the hospital's central log revealed Patient #20 (37-year-old female) came in on 2/22/2022 (walk-in) by car at 7:35 PM with the complaint of "dual". The central log stated the patient had an emergency medical condition. The log stated the patient departed at 8:27 PM via ambulance as a referral to another hospital. The central log entries were documented by Intake Coordinator #5. There was no documentation of an intake form or Medical Screening Examination for the log entry dated 2/22/2022, or a Memorandum of Transfer (MOT) form from the hospital.

On 5/16/2022 at 1:50 PM, review of the hospital's "Comprehensive Assessment" policy and procedure, stated, "The Intake Department conducts the initial screening and assessment for all patients seeking care at the facility. The assessment information is then formulated into a recommendation for services. The Intake Counselor/Nurse documents the initial assessment information on the Standardized Intake Assessment. The initial intake assessment will include, but is not limited to, current symptomology and complaints related to: Suicide, substance abuse, assault/homicide, sexual aggression, sexual victimization, medical compromised, falls and elopement. Upon completion of the initial assessment, the Intake Counselor/Nurse will recommend a level of care appropriate for the patient. Intake Counselor/Nurse consults an appropriately credentialed physician or LIP for determination about admission, including the location that will best serve the patent's immediate safety need and be an appropriate setting for treatment of the individual. "

On 5/17/2022 at 11:00 AM, review of the Intake Clinician Department Orientation and Competency Checklist has the following competencies: 1) demonstrates how to complete a Call Inquiry Form when referrals are received either via fax, telephone, or walk-ins 2) Understands how to enter a Call Inquiry Form and retrieve information from the MS4 software system 3) Knowledge of hospital and visitation policies, EMTALA regulations, demonstrate how to print from the MS4 system 4) demonstrates understanding of all forms used .

The Department's Annual Competency Checklist has the following competencies: 1) demonstrates knowledge of EMTALA regulations, Memorandum of Transplant form 2) demonstrates the ability to accurately complete the level of care assessments for all direct admission and walk-in patients 3) reviews all assessments with the on-call physician for patients who do not meet admission criteria prior to allowing the patient to leave the facility.

The Annual Competency Checklist had no competencies for performing a medical screening examination.

On 5/17/2022 at 3:49 PM, review of random personnel files for those staff who perform Medical Screening Examinations revealed those staff have not received any specialized education and training related to performing a Medical Screening Examination:
1. Assistant Intake Director: job description for assistant director of admissions with a date of hire of 3/19/2018. Master of Rehabilitation counseling. No license and no training documented for a MSE.
2. Intake Coordinator #1: job description for Intake Counselor with a date of hire 6/7/2021. Master of Counseling degree. No training documented for a MSE.
3. Intake Coordinator #8: job description for Intake Counselor with a date of hire 2/21/2022. Master of Arts in forensic psychology. No license. No training documented for a MSE.
4. Intake Coordinator #4: job description for Intake Registered Nurse with a date of hire 6/12/2006. There was a nursing license. No documented training for a MSE.
5. Intake Coordinator #7: job description as Intake Counselor with a date of hire of 4/13/2015. Master of Arts Special Education. No license. No training documented for a MSE.
6. Intake Coordinator #2: Date of Hire 2/21/22. Masters of Science in Clinical Psychology and Bachelor of Science in Psychology. No documentation of training in performing an MSE.
7. Intake Coordinator #7: Mental Health Technician. No license documented. No documentation of training in performing an MSE.
8. Intake Coordinator #6: Date of Hire of 8/2/21. Clinical Therapist. Master of Arts in Clinical Psychology and Bachelor of Arts in Psychology. No licensure or training in the performance of an MSE.

On 5/18/2022 from 9:28 AM to 10:13 AM, an interview with Assistant Director Intake revealed the process for a walk-in seeking treatment is as follows: The patient is separated from belongings, scanned, vital signs, medical screening, full assessment, and call the physician. A medical emergency would be anything we see that would be concerning. We call the (on-call) physician to discuss. We just call the physician, the "physician does not see the patient in the intake area, typically, but will see the patient the next morning after the patient is admitted. If the criterion for admission is not met, we offer community resources. We do not have coverage for the intake department from 11:30 PM to 4:00 AM. The nursing supervisor and nurse manager covers the intake department during this time frame. We have a total of 64 beds (32 adult and 32 Adolescent). Sixteen of the adults are for detox. Review of the psychiatric hospital's state license showed 92 Psychiatric Beds and 16 Substance Abuse Beds.




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