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Based on record review and interview, the hospital failed to ensure compliance with:
A. 489.20 (r)(3) Emergency Room Log;
B. 489.24 (a) and (c) Appropriate Medical Screening Examination; and
C. 489.24 (e)(1) and (2) Appropriate Transfer, in that,

A. The facilities EMTALA Log" did not contain each patient's chief complaint, Physician name or correct disposition.
The facility's "EMTALA Log" reflected Emergency Medical Condition determination by a counselor, not a physician.
B. Telemedicine Physicians were not completing and documenting a medical Screening examination to determine if there was an emergency medical condition for each patient seeking treatment/assistance. Counselors were determining if there was an emergency medical condition. There were no Governing Board/Medical Executive Committee appointed counselors or nurses to complete a Medical Screening Examination to determine Emergency Medical Condition. There was no discharge or referral orders by physicians.
C. There was incomplete MOTs (Memorandum of Transfer) including no hospital/Physician acceptance of the patient transfer, no Physician to Physician report, physician signature/Patient acknowledgement and/or Medical Records sent with the patient to the acute hospital.

Cross Reference to Tag A2405, A2406, A2409
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Based on record review and interview, the facility failed to ensure maintenance of the central log of each individual whether they refused treatment, were refused treatment, transferred, admitted, treated, stabilized and transferred or discharged, in that,

A. 10 of 20 patients (Patient #1, #2, #4, #8, #9, #10, #13, #15, #17, and #19) who presented to the facility for treatment/assistance and were listed on the facility's "EMTALA Log" did not contain each patient's chief complaint, Physician name or correct disposition (Disp); and

B. 10 of 20 patients (Patient #1, #2, #4, #8, #9, #10, #13, #15, #17, and #19) who presented to the facility for treatment/assistance and were listed on the facility's "EMTALA Log" as not having an EMC (emergency medical condition) although they were not provided a Medical Screening Exam.

Findings included

A. The facility's "EMTALA Log" did not include the chief complaint or the Physician name for each patient listed.
The facility's "EMTALA Log" did not depict the correct disposition documented in the medical record for Patient #1, #2, #4, #8, #9, #10, #13, #15, #17, and #19.

Patient #1 was referred to an outpatient clinic.
Patient #2 was Discharged.
Patient #4 was Discharged.
Patient #8 was Discharged.
Patient #9 was Discharged.
Patient #10 was referred to an outpatient clinic.
Patient #13 was referred to an outpatient clinic.
Patient #15 was referred to an outpatient clinic.
Patient #17 was referred to an outpatient clinic.
Patient #19 was Discharged.

B. The facility's "EMTALA Log" reflected a column that designated whether or not there was an emergency medical condition (EMC) for each patient (PT) listed. The log reflected:
(R=Refused) (R/O=Referred Out)
PT Disp EMC
#1 R N (No)
#2 R/O N
#4 R/O N
#8 R/O N
#9 R/O N
#10 R N
#13 R N
#15 R N
#17 R N
#19 R/O N

There was no medical record of a Medical Screening Examination to determine if the patients had an Emergency Medical Condition by a physician for Patient #1, #2, #4, #8, #9, #10, #13, #15, #17, and #19.

During an interview on 6/18/18 at 11:43 AM, Personnel #4 was informed of the above findings. Personnel #4 confirmed the findings and stated, "what if they don't see a doctor." Personnel #4 was asked what do you mean. Personnel #4 stated, "telemedicine (Tele docs) is used to drop an APOW when the patient is referred to a hospital for medical clearance and for admits and orders for admits. Walk-ins that are referred out (R/O) are not seen by Tele docs." Personnel #4 was asked who decides if there is an emergency medical condition. Personnel #4 stated, "The only people in intake are clinician's." Personnel #4 was asked what are clinician's. Personnel #4 stated, "Licensed professional counselors and master's (counselor). They can diagnose psychiatric problems."

The DBH Facility's 9/03/16, last revised "EMTALA Hospital Plan for Emergency Services/Screening and Evaluation of an Emergency" policy required, "Medical Screening Examinations ...to determine whether an individual has an emergency medical condition

Based on observation, record review and interview, the facility failed to perform and document a medical screening exam to determine if there was an emergency medical condition on patients who presented to the facility for treatment/assistance, in that,

A. 5 of 5 patients (Patient #2, #4, #8, #9, and #19) listed on the facility's "EMTALA Log" as referred out (R/O) did not have a MSE (Medical Screening Exam) to determine if there was an emergency medical condition by a physician or orders for discharge and outpatient referral.

B. 5 of 20 (Patient #1, #10, #13, #15, and #17) patients were listed on the facility's "EMTALA Log" as having (SI-suicidal ideation/HI-homicidal ideation/CD-chemical dependency/AV- audio visual disturbances) and listed as "Refused" but were referred to an outpatient treatment center, even though they had no MSE (Medical Screening Exam) to determine if there was an emergency medical condition, and no referral order.

Findings included

A. During a tour of the "Intake Department" on 6/18/18 at 9:15 AM, Personnel #1 showed the surveyor the patient care areas. There was no physician or nurse present.

Patient #2's, #4's, #8's, #9's, and #19's record did not document a MSE (Medical Screening Exam) by the physician, or orders for discharge or outpatient referral.

Pt #2:
On 04/04/18, a 66 year old male presented to the hospital from a senior living facility with loud yelling, non sensical statements, and not answering questions. He had a previous diagnosis of schizophrenia and was taking Risperdal. The intake coordinator was unable to elicit a history or review of systems and contacted the patient's guardian who indicated this was the patient's baseline. The guardian suggested that the patient be sent to a homeless shelter as assisted living facilities had all declined the patient. The patient was discharged and sent to a homeless shelter. When the patient arrived at the homeless shelter, a staff member called the hospital and told them they would be unable to accept the patient and were transferring him back. The patient was refused admission. He was sent to a second hospital. The patient was not evaluated by a physician or qualified medical provider.


Pt #4:
On 04/06/18, a 67 year old male presented to the hospital with suicidal ideations. Vital signs were obtained by an intake coordinator. A past medical history and allergies were documented by the intake coordinator. No history taken other than a note that the patient lacked homicidal ideations or auditory visual hallucination. It was noted that the patient had an emergency medical condition by the intake coordinator. The patient was discharged for outpatient treatment. The patient was not evaluated by a physician or qualified medical provider.

Pt #8:
On 03/01/18, a 36 year old female presented to the hospital for anxiety/panic attacks, thoughts of anxiety/depression getting worse, killing myself. An intake coordinator spoke with the patient and determined the patient did not have an emergency medical condition. The patient was discharged for outpatient treatment. The patient was not evaluated by a physician or qualified medical provider.

Pt #9:
On 04/01/18, an 18 year old female presented to the hospital for talking to herself, packing and repacking everything for college, and rearranging things all day and night. An intake coordinator spoke with the patient and determined the patient did not have an emergency medical condition. The patient was discharged for outpatient treatment. The patient was not evaluated by a physician or qualified medical provider.

Pt #19:
On 11/22/17, a 36 year old female presented to the hospital for suicidal ideations with a plan. A intake coordinator spoke with the patient and determined the patient did not have an emergency medical condition. The patient was discharged for outpatient treatment. The patient was not evaluated by a physician or qualified medical provider.

During an interview on 6/18/18 at 11:43 AM, Personnel #4 was informed of the above findings. Personnel #4 confirmed the findings and stated, "telemedicine (Tele docs) is used to drop an APOW when the patient is referred to a hospital for medical clearance and for admits and orders for admits. Walk-ins that are referred out (R/O) are not seen by Tele docs." Personnel #4 was asked who decides if there is an emergency medical condition. Personnel #4 stated, "The only people in intake are clinician's." Personnel #4 was asked what are clinician's. Personnel #4 stated, "Licensed professional counselors and master's. They can diagnose psychiatric problems."

During an interview on 6/18/18 at 12:40 PM, Personnel #4 and Personnel #5 stated that they were a psych hospital and not licensed as an ER Hospital and questioned if they had to comply with the EMTALA regulations. Personnel #5 was asked if the community - Police, EMT's, parents, etc understood that the hospital would take in patients, determine if they needed to be admitted, treated, transferred and or referred somewhere else for treatment. Personnel #5 stated, "Yes." Personnel #5 was asked what they call that process. Personnel #5 stated, "Intake."

During a telephone conference call on 6/18/18 with Personnel #21, Corporate Attorney, Personnel #4, #5 and #6 were present. The surveyors were questioned by Personnel #21. Personnel #21 stated, "We (Attorney and surveyors) have a fundamental disagreement on whether or not we (hospital) have to comply with EMTALA regulations. I deal with CMS in Baltimore and before EMTALA regulations can be applied, we have to meet the trigger. Based on other surveys, we are a psych hospital and do not have a dedicated ER. We are not licensed by the state as the ER Hospital. The calculation has not been done to determine one third of the patients. We don't advertise having an emergency room. We have an intake, not an emergency room." Personnel #21 was asked if she believed that DBH does not have to follow the EMTALA regulations. Personnel #21 stated, "Yes." Personnel #21 was informed that the surveyors were merely fact finders for CMS and that CMS would make the determination. Personnel #21 was asked if she had any other questions. Personnel #21 stated, "No."

The facility's 1/10/14 effective, "Discharge of Patients" policy required, "transition to next level of care ...outpatient services ...and to ensure continuity of the treatment modalities selected ...all patients leaving the facility require a formal discharge ...written order from the physician ..."

The facility's 1/10/14, effective "Plan for Provision of Care and Services" policy required, "high quality of comprehensive nursing care to all patients on a twenty-four hours basis ..."


B. There were no medical records for Patient #1, #10, #13, #15, and #17 including a MSE or refusal to include risk of refusal.

During an interview on 6/18/18 at 11:43 AM, Personnel #4 was informed of the above findings. Personnel #4 confirmed the findings and stated, "Walk-ins that are referred out (R/O) are not seen by Tele docs." Personnel #4 continued, "They sign the refusal of treatment." Personnel #4 was informed the page that was signed by the patient for refusal of treatment stated, "Acceptance of referral/Recommentations (sp) for service/Refusal of treatment" with the refusal of treatment underlined or circled. There is a referral source written in for an outpatient provider. The patient signed the form under the statement that reflected, "I have read and understand the above referral information. I also give my consent for the above professional(s) or agencies to be notified of the referral and assessment information." There was no indication the patient refused assessment or treatment. There is no physician order for the referral. Personnel #4 confirmed and stated, "I understand."

The DBH Facility's 9/03/16, last revised "EMTALA Hospital Plan for Emergency Services/Screening and Evaluation of an Emergency" policy required, "The scope of emergency medical treatment is limited to minor problems. First Aid, Basic Life Support may be rendered in preparation for transfer to a licensed, medical/surgical facility ...Medical Screening Examinations: The attending physician and/or on-call physician is responsible for the supervision, evaluation and stabilization ...on-call list of physicians who are responsible to perform medical screening evaluations to determine whether an individual has an emergency medical condition ...In the absence of a physician, a registered nurse with two years' experience may conduct medical screening examinations ...Upon assessment by physician ...life-saving and emergency measures are implemented, when required, in order to support and stabilize patients for transporting to an emergency care facility. Paramedics ...911 ...will be called immediately upon identification of the crisis ...The physician in charge ...will notify the physician on duty at the receiving facility ...The registered nurse, upon physician's order, will contact the receiving facilities emergency room Supervisor to initiate arrangements necessary to assure that appropriate clinical data is exchanged ..."

There were no Governing Board/Medical Executive Committee appointed counselors or nurses to complete a Medical Screening Examination to determine Emergency Medical Condition.

Based on record review and interview, the facility failed to ensure an appropriate transfer, in that,

5 of 20 patients (Patient #5, #11, #12, #16, and #18) listed on the facility's "EMTALA Log" were sent for medical clearance and/or transferred out to an acute hospital. There was incomplete MOTs (Memorandum of Transfer) including no hospital/Physician acceptance of the patient transfer, no Physician to Physician report, physician signature/Patient acknowledgement and/or Medical Records sent with the patient to the acute hospital.

Findings included

Patient #5 had no medical records including vital signs, MSE, or MOT.

Patient #11's record did not document a complete MOT (Memorandum of Transfer) including no Physician acceptance of the patient transfer, no Physician to Physician report, no physician signature/Patient acknowledgement of the benefits and risks and/or no Medical Records sent with the patient to the acute hospital.

Patient #12 record did not document a complete MOT including no Diagnosis, no Physician acceptance of the patient transfer, no Physician to Physician report, physician signature/Patient acknowledgement of the benefits and risks and/or no Medical Records sent with the patient to the acute hospital.

Patient #16's record did not document a complete MOT including no Diagnosis, no Physician acceptance of the patient transfer, no Physician to Physician report, physician signature/Patient acknowledgement of the benefits and risks and no transferring physician name.

Patient #18's record did not document a complete MOT including no Physician acceptance of the patient transfer, no Physician to Physician report, no physician signature/Patient acknowledgement of the benefits and risks and/or no Medical Records sent with the patient to the acute hospital.

During an interview on 6/18/18 at 3:00 PM, Personnel #4 was informed of the above findings. Personnel #4 confirmed the findings.

The DBH Facility's 9/03/16, last revised "EMTALA Hospital Plan for Emergency Services/Screening and Evaluation of an Emergency" policy required, "The scope of emergency medical treatment is limited to minor problems. First Aid, Basic Life Support may be rendered in preparation for transfer to a licensed, medical/surgical facility ...responsible to perform medical screening evaluations to determine whether an individual has an emergency medical condition ...life-saving and emergency measures are implemented, when required, in order to support and stabilize patients for transporting to an emergency care facility. Paramedics ...911 ...will be called immediately upon identification of the crisis ...The physician in charge ...will notify the physician on duty at the receiving facility ...The registered nurse, upon physician's order, will contact the receiving facilities emergency room Supervisor to initiate arrangements necessary to assure that appropriate clinical data is exchanged ..."