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Based on record review and interview Staff at this facility failed to report a suspected Emergency Medical Treatment and Labor Act (EMTALA) violation withing the required 72 hours for 1 of 1 EMTALA complaint filed.

Findings include:

Facility staff failed to report a suspected EMTALA violation within 72 hours of occurance. See tag A2401.

Based on record review and interview, staff at this facility failed to report a suspected Emergency Medical Treatment and Labor Act (EMTALA) violation within the required 72 hours of the occurrence for 1 of 1 EMTALA complaint filed.

Findings include:

The facility policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA) Policy" last revised on 10/2017, was reviewed on 2/5/19 at 10:00 AM. The policy revealed in part on page 5 under item #10 "Reporting EMTALA violations: e. If a report is required to CMS (Centers for Medicare Systems), it is done within seventy-two (72) hours of the completion of the investigation."

Per review of a complaint filed by facility Legal Department Representative A on 1/28/19, the complaint alleges an inappropriate transfer occurred on 1/20/19 for Patient #1.

Per review of emergency department log for January 20, 2019 revealed Patient #1 was a direct admit to the Obstetrics/Labor and Delivery floor after coming from an alternate acute care facility.

An interview was conducted with Manager of Accreditation B on 2/4/19 at 3:00 PM who was reading facility EMTALA policy and stated "Our policy says we have 72 hours after our investigation is complete to contact state or CMS." EMTALA regulation tag A 2401 was reviewed with Manager of Accreditation B and Accreditation/Regulatory Specialist I that the CMS or state contact is to be done within 72 hours of the suspected occurrence. Manager of Accreditation B replied "Yep, that's the problem. Our policy is wrong and we will change it."