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Based on review of the Emergency Department (ED) policies and procedures, medical executive committee meetings, ED minutes, and staff interviews, the Governing Body failed to establish policies and procedures and a Quality Assurance Performance Improvement (QAPI) plan, related to the Emergency Medical Treatment And Labor Act (EMTALA) regulations.

Findings included...

On 01/10/19 at approximately 2:20 PM, the surveyor conducted a review of the ED policies and procedures, medical executive committee meetings from 07/18 to 11/18, ED minutes, and the quality improvement plan. The review lacked evidence of EMTALA policies and procedures, as well as ED and QAPI minutes, specifically related to EMTALA regulations and QAPI monitoring and/or remedial activities, in the emergency department. Additionally, there was no evidence of measures taken to ensure performance improvement, as it relates to EMTALA regulations.

The practice lacked evidence that the Governing Body complied with EMTALA regulations to ensure safe practices and performance improvement.

During a face to face interview on 01/10/19 at approximately 12:51 PM, with Employee #1, ED Medical Director, he directed to check with the quality staff to obtain EMTALA policies and procedures.

During a face to face interview on 01/11/19 at approximately 12:00 PM, with Employee #8, Director of Accreditation and Regulatory Readiness, she acknowledged that there were no written EMTALA policies and procedures or QAPI plan.

Based on review of the Emergency Department (ED) policies and procedures, medical executive committee meetings, ED minutes, and staff interviews, the Governing Body and the Quality Assurance Performance Improvement (QAPI) staff failed to ensure a QAPI plan, related to the Emergency Medical Treatment And Labor Act (EMTALA) regulations.

Findings included...

On 01/10/19 at approximately 2:20 PM, the surveyor conducted a review of the ED policies and procedures, medical executive committee meetings from 07/18 to 11/18, ED minutes, and the quality improvement plan. The review lacked evidence of EMTALA policies and procedures, as well as ED and QAPI minutes, specifically related to EMTALA regulations and QAPI monitoring and/or remedial activities, in the emergency department. Additionally, there was no evidence of measures taken to ensure performance improvement, as it relates to EMTALA regulations.

The practice lacked evidence that the Governing Body and QAPI staff reviewed and monitored ED activities and minutes, and ensured a QAPI plan, specific to the compliance to EMTALA regulations.

During a face to face interview on 01/10/19 at approximately 12:51 PM, with Employee #1, ED Medical Director, he directed to check with the quality staff to obtain EMTALA policies and procedures.

During a face to face interview on 01/11/19 at approximately 12:00 PM, with Employee #8, Director of Accreditation and Regulatory Readiness, she acknowledged that there were no written EMTALA policies and procedures or QAPI plan.

Based on review of the Emergency Department (ED) policies and procedures, medical executive committee meetings, ED minutes, and staff interviews, the medical staff failed to establish policies and procedures, related to the Emergency Medical Treatment And Labor Act (EMTALA) regulations.

Findings included...

On 01/10/19 at approximately 2:20 PM, the surveyor conducted a review of the ED policies and procedures, medical executive committee meetings from 07/18 to 11/18, ED minutes, and the quality improvement plan. The review lacked evidence of EMTALA policies and procedures, as well ED and Quality Assurance Performance Improvement (QAPI) minutes, specifically related to EMTALA regulations and QAPI monitoring and/or remedial activities, in the emergency department. Additionally, there was no evidence of measures taken to ensure performance improvement, as it relates to EMTALA regulations.

The practice lacked evidence that the medical staff ensured the requirements for the provisions for the EMTATA regulations.
During a face to face interview on 01/10/19 at approximately 12:51 PM, with Employee #1, ED Medical Director, he directed to check with the quality staff to obtain EMTALA policies and procedures.

During a face to face interview on 01/11/19 at approximately 12:00 PM, with Employee #8, Director of Accreditation, Regulatory Readiness and Quality, she acknowledged that there were no written EMTALA policies and procedures or QAPI plan.