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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 regulation:

Tag A2408 - Delay in Examination or Treatment

Based on interviews and document review, the facility failed to ensure examination and treatment of individuals presenting to the emergency department was not delayed due to the patient registration process. In 6 of 20 medical records reviewed, patients were asked, at the time of registration, to sign a financial agreement prior to being seen by clinical staff in order to receive a medical screening examination. In 1 of 20 medical records reviewed, a patient who entered the facility seeking emergency care was screened for a discounted health care program prior to being registered in the Emergency Department. The patient was bleeding from a hand laceration at the time of the financial screening.

Based on interviews and document review, the facility failed to ensure examination and treatment were not delayed for those patients presenting to the Emergency Department (ED) to receive care, as required by the Emergency Medical Treatment and Active Labor Act (EMTALA). In 6 of 20 medical records reviewed, registration staff presented patients with a financial agreement to sign at the time of registration, prior to receiving a medical screening examination and receiving care. In 1 of 20 medical records reviewed, registration staff investigated discounted health care services for a patient who presented for emergency care, prior to ensuring the patient was registered in the ED and received a medical screening examination. These processes created the potential to not only delay treatment, but to discourage patients entering the ED from staying to receive care.

This failure created the potential for negative patient outcomes and the worsening of patients' conditions as the registration process, used by some staff, required patients to review and sign a financial agreement.

FINDINGS:

POLICY

According to the policy, EMTALA-Medical Screening Examination and Stabilizing Treatment, reasonable registration processes, including insurance information, may be followed as long as individuals are not unduly discouraged from remaining for further evaluation.

The facility may complete its routine registration process, including inquiries about insurance coverage, provided that the inquiry does not delay medical screening or stabilizing treatment.

The facility will train personnel to respond to individual inquiries about their financial liability. Hospital staff will encourage individuals to defer questions about financial liability until after the medical screening examination has been completed.

DOCUMENT

The document titled, Financial Agreement, a 5 paragraph document of approximately 560 words, was used by staff as part of the registration process. The document contained a line for the patient or the patient's authorized representative to sign and a line for a witness to sign and write the date and time the agreement was signed by both parties.

The 1st paragraph of the Financial Agreement stated, in part, patients will pay the account or make financial arrangements satisfactory to the facility "and/or any other providers for payment unless the patient's bill is paid by applicable insurance, governmental programs or other sources. If an account is sent to an attorney for collection, I agree to pay reasonable attorney's fees and collection expenses in addition to the amount due and owing on the bill for health services rendered to the patient. I understand and agree that a delinquent account will be subject to interest at the legal rate."

The agreement stated, in paragraph 2, that insurance would be billed for medical services rendered to the patient, and payment from the insurer would be sought by the facility before the insured would be required to make payments, with the exception of applicable co-payments and deductibles, which, it stated, the patient or the insurance holder must pay. The agreement stated, "I understand and agree that I am responsible for and will pay for medical services rendered to the patient in the event that our insurance does not authorize these services or does not pay for these services." The agreement stated the signing party agrees to normal business communication from the facility, regarding payment, through letter, email, telephone, test, voice message, or any other available technologies used by businesses.

The agreement stated, in part, in paragraph 3, "It is understood and agreed, however, that the patient and I are primarily responsible for payment of the patient's bill and that we are obligated to pay and agree to pay for any portion of the bill not paid for by insurance and other sources."

The agreement stated, in paragraph 5, in the event that the patient and/or the representative have made a payment on an active account, whether through cash, check, credit card or other means, and there remains additional funds available after that account is satisfied (e.g. an overpayment), the facility is authorized to apply the overpayment to any other account owed by the patient that remains unpaid.

According to the job description, Patient Financial Services Representative (PFS), these employees explain and obtain signatures on the facility's legal forms including Financial Agreements. The PFS employees perform all functions according to established policies, procedures, and regulatory requirements. PFS employees use sound judgement to prioritize work and to ensure appropriateness and timeliness of each patient's care.

1. A PFS representative failed to ensure care was not delayed for Patient #2, who presented to the facility seeking emergency treatment for an injury. Patient #2 was bleeding from a hand laceration when s/he entered the facility.

a) Review of the medical record for Patient #2 revealed the patient was registered at the Emergency Department (ED) at 4:19 p.m., with the chief complaint being a laceration on the right palm. The record revealed the laceration was approximately 2 centimeters and had a large amount of "super glue" on the laceration. The patient stated s/he sustained an injury to his/her hand from a door the previous night. The patient was unsure of the date of his/her most recent tetanus shot.

b) Review of the document, MS4 Passport, revealed the patient came to "the front" of the facility and was screened for, and qualified for, discounted health care services. The MS4 document revealed PFS #1 gave the patient booklets regarding the discounted health care services.

c) On 12/16/15 at 8:22 a.m., an interview was conducted with PFS #1 who stated s/he received EMTALA training as a new employee and annually thereafter. PFS #1 stated in meetings with his/her direct supervisor and with other PFS employees, no EMTALA issues or concerns had been discussed since the facility opened. PFS #1 stated patients do enter the main door to the facility, instead of the door to the ED, seeking emergency care. S/he stated recently, a patient entered the main door to the facility with a hand laceration and was bleeding from the wound. PFS #1 stated per his/her training, s/he escorted the patient back to the ED desk for registration and to be seen for his/her injury.

d) On 12/16/15 at 1:59 p.m., an interview was conducted with PFS #1 who stated the patient with the hand laceration was Patient #2. PFS #1 reviewed the MS4 Passport document for this patient and confirmed s/he had seen the patient at the main entrance to the facility on the day the patient entered, bleeding, and seeking emergency care. PFS #1 stated the patient was concerned about the cost of care for the ED visit. In response to this concern, PFS #1 contacted a lead financial staff person by phone for assistance and together they began the process of obtaining discounted heath care for the patient. PFS #1 stated the patient continued to bleed from his/her hand laceration during this time. PFS #1 stated s/he was with the patient for "quite a while" at the front registration desk before walking the patient back to the ED for registration. PFS #1 stated 4:19 p.m. was the time the patient arrived at the ED registration desk and not the time the patient arrived at the main entrance to the facility seeking care. PFS #1 could not state what time the patient entered the main entrance to the facility.

e) On 12/16/15 at 9:05 a.m., an interview was conducted with the PFS Supervisor, PFS #2. The supervisor stated if a patient entered the facility seeking emergency care but did not wish to be registered until knowing the cost of the ED visit, his/her staff had been trained to respond to these patients by encouraging the patients to stay and be seen by the clinical staff so they could "feel better first" before discussing the cost of care. The Supervisor stated PFS staff should not conduct "insurance work-up" for any ED patient until the patient had received a medical screening examination. The Supervisor stated this was part of the PFS staffs' training. The Supervisor stated PFS staff should call for a Registered Nurse to come to the registration area in order to see and speak with any patient who presented to the ED but did not wish to register for any reason, including for financial reasons.

The Supervisor stated the registration process for patients who entered the facility through the main entrance seeking emergency care was the same as for those patients who entered through the ED. The Supervisor stated the PFS staff would escort a patient from the main entrance of the facility to the ED to register at the ED desk. PFS staff could ask the patient's name and phone the ED registration desk to inform staff they were bringing a patient back, or would simply escort the patient back to the ED. The Supervisor stated PFS staff should not delay these patients being registered and seen by clinical staff in order to receive a Medical Screening Examination

2. Registration staff gave patients, who presented to the ED seeking care, a financial agreement to read and sign as part of the registration process, prior to receiving a medical screening examination in 6 of 20 medical record reviewed (Patients #1, #6, #7, #8, #16, and #17). This process was used for patients who presented to the ED with complaints such as chest pain and shortness of breath, abdominal cramping and dizziness, fever and vomiting, and seizure activity. This registration process failed to ensure patients' medical screening examinations and care were not delayed and could have discouraged some patients from staying to receive a medical screening examination and care.

a) Review of the medical records and the MS4 Passport registration documents was conducted for a sample of 20, ED and Obstetrics (OB) patients.

i) Review of the medical record and the MS4 registration documents for Patient #1 revealed the patient came to the ED with complaints of chest pain, shortness of breath, weakness, and feeling "very" disoriented, since experiencing sharp chest pain approximately 1.5 hours prior to entering the ED. The history and physical revealed the patient had no prior history of this type of event. Document review revealed the patient entered the ED, was registered at 6:26 a.m., and the Financial Agreement was signed by the patient's spouse at 6:29 a.m. PFS #1 signed and witnessed the Financial Agreement at this time. The patient received a medical screening examination at 6:31 a.m.

ii) Review of the medical record and the MS4 registration documents for Patient #6 revealed the patient came to the ED with complaints of abdominal cramping, nausea, vomiting, flank pain, head ache, and dizziness. Document review revealed the patient entered the ED, was registered at 5:16 p.m., and signed the Financial Agreement at 5:19 p.m. PFS #1 signed and witnessed the Financial Agreement at this time. The patient received a medical screening examination at 5:35 p.m.

iii) Review of the medical record and the MS4 registration documents for Patient #7 revealed the patient, a child, was brought to the ED by his/her parent with complaints of fever and vomiting x 6. Document review revealed the patient and parent entered the ED and the patient was registered at 2:48 p.m. Review of the Financial Agreement revealed the parent signed the agreement at 4:30 p.m., which was the time of the patient's discharge from the ED. PFS #1 signed and witnessed the Financial Agreement.

The MS4 registration documented contained a statement from PFS #1 that the MS4 system was not able to be accessed and s/he printed a hard copy of the Financial Agreement for the parent to sign. PFS #1 documented the parent did not stop by the desk at the time of discharge (4:30 p.m.) and s/he was unable to update the patient's demographics or obtain insurance information from the parent.

On 12/16/15 at 1:48 p.m., an interview was conducted with PFS #1 who reviewed the registration documents for Patient #7 and stated the Financial Agreement was signed by the patient's parent at the time of registration (2:48 p.m.) and not at the time of discharge from the ED at 4:30 p.m., as documented. PFS #1 confirmed s/he wrote in the time of 4:30 p.m. as the time both s/he and the parent signed the Financial Agreement. PFS #1 stated the time of 4:30 p.m. did not represent the time the document was actually signed.

iv) Review of the medical record and the MS4 registration documents for Patient #8 revealed the patient came to the ED with complaints of flank pain and a history of kidney stones.
Document review revealed the patient entered the ED, was registered at 3:26 p.m., and signed the Financial Agreement at 3:30 p.m. PFS #1 signed and witnessed the Financial Agreement at this time. The patient received a medical screening examination at 3:42 p.m.

v) Review of the medical record and the MS4 registration documents for Patient #16 revealed the patient came to the ED with complaints of heroin use, the desire to begin a detox program, and a diagnosis of bipolar disorder and non-compliance with medications prescribed for bipolar disorder. Document review revealed the patient entered the ED, was registered at 5:28 p.m., and signed the Financial Agreement at 5:00 p.m., 28 minutes prior to being registered in the ED. PFS #1 signed and witnessed the Financial Agreement at 5:00 p.m.. The patient received a medical screening examination at 5:38 p.m. At 9:10 p.m., the ED record revealed the patient eloped from the ED by walking out of the examination room. The patient was documented as "stable" at the time of elopement. No reason was documented in the medical record or in the MS4 system stating why the patient left the ED.

vi) Review of the medical record and the MS4 registration documents for Patient #17 revealed the patient came to the ED by ambulance with complaints of seizure activity. Document review revealed the patient entered the ED, was registered at 10:45 p.m., and gave documented "verbal" agreement to the Financial Agreement at 11:00 p.m., which was witness and signed by 2 staff members. PFS #2 was 1 of 2 staff who signed and witnessed the Financial Agreement.

RN #4 conducted a neurological assessment of the patient at 10:52 p.m., at which time s/he documented the patient was slow to answer questions, was drowsy, and had slurred speech. The RN documented the patient was confused, disoriented, and had tremors. The patient received a medical screening examination at 11:08 p.m. The physician documented at this time the patient presented with alcohol withdrawal, was shaky, and confused.

b) On 12/16/15 at 9:39 a.m., an interview was conducted with the PFS Supervisor, PFS #2. The Supervisor stated the Financial Agreement for patients who entered the ED seeking care should not be signed at the time of initial registration if patients were experiencing issues such as chest pain or symptoms of stroke, for example. The Supervisor stated for patients not stating issues of this nature, but less serious issues, the registration process did not prohibit PFS staff from obtaining the patient's signature on the Financial Agreement. The Supervisor stated PFS staff did not have clinical background or training to enable them to make judgements at the registration desk regarding patients' presenting symptoms. The Supervisor stated s/he observed PFS staffs' work and processes approximately once each month, for each staff person, and had not noted issues with the registration process being carried out as PFS staff had been trained.

c) On 12/16/15 at 1:48 p.m., an interview was conducted with PFS #1 who stated s/he was trained and instructed by his/her supervisor to obtain signed Financial Agreements from patients at the time of discharge or at the patient's bedside in the ED once patients had received a medical screening examination. PFS #1 stated s/he had patients sign the Financial Agreement document at the same time patients signed the consent to treatment document, at initial registration, because it was an easier process to carry out. PFS #1 confirmed his/her signature as the witness on the Financial Agreements for 5 of the 6 patients reviewed (Patients #1, #6, #7, #8, and #16).

d) On 12/16/15 at 2:06 p.m., an interview was conducted with the Chief Operating Officer (COO), Employee #3, who stated s/he had been assured by staff the registration process in the ED was one that met all EMTALA requirements. The COO stated s/he had ultimate responsibility for the processes used in the facility and the care provided to patients in the facility.

The COO stated obtaining financial information from patients and discussion of the financial piece of the ED visit should be conducted at the time of discharge from the ED. The COO stated this included obtaining patients' signatures on the Financial Agreement, as having this document signed at the time of initial registration could delay the medical screening examination and patient care. The COO stated PFS staff were not clinical and therefore could not make a judgement of which patients could sign this document at the time of registration and which should not sign due to the nature of their symptoms and chief complaint. The COO stated presenting the Financial Agreement to patients at the time of registration could deter some patients from staying to receive care, due to the nature of the document.

The COO stated s/he had no knowledge that Patient #2 was screened for discounted health care prior to being registered and seen in the ED. The COO stated Patient #2 should have been escorted to the ED to be registered to receive care and PFS staff should not have spent time investigating discounted health care before the patient was registered and received care.

The COO stated s/he was unaware of the practice by some PFS staff of presenting the Financial Agreement document for patient review and for signatures at the time of initial registration. The COO stated the process for registering patients in the ED was to obtain the patients' name, date of birth, and the name of the primary care physician, if the patient had one. The COO referred to this process as "quick registration" and stated this was the process the PFS staff should be using at all times.