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Based on a review of facility documentation and interviews with staff, the facility failed to comply with §489.24.

Per the Centers for Medicare and Medicaid Services ("CMS"):
"Under the provisions of §489.24, hospitals with an emergency department that participate in Medicare are required under EMTALA to do the following:

o Provide an appropriate MSE to any individual who comes to the emergency department;

o Obtain or attempt to obtain written and informed refusal of examination, treatment or an appropriate transfer in the case of an individual who refuses examination, treatment or transfer; and

Further, any participating Medicare hospital is required to accept appropriate transfers of individuals with emergency medical conditions if the hospital has the specialized capabilities not available at the transferring hospital, and has the capacity to treat those individuals.

Hospitals are required to adopt and enforce a policy to ensure compliance with the requirements of §489.24."

Findings were:

A review of the Facility Department Policy & Procedure Manual revealed no policies related to EMTALA or the completion of MOTs.

Facility policy PC.028 titled "Emergency Medical Care" stated, in part:
"Policy:
It is the policy of Aspire Hospital to provide basic emergency care to the patient in accordance with hospital policy. As directed by the attending physician or hospital nursing supervisor, the patient will be transferred to a hospital medical-surgical unit or the Emergency Department for further evaluation and treatment."

In an interview with staff #9 on 9-4-18, staff #9 stated that the policy pertained only to patients that had already been admitted to the facility (inpatient status).

The above was confirmed in an interview with the DON and other administrative staff the evening of 9-4-18.

Based on a review of facility documentation and an interview with staff, the facility failed to:
§489.20(r)(2)
Maintain a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition.

Findings were:

A review of the physician schedule for March 2018 through August 2018 revealed on-call provider coverage (by either physicians or a mid-level provider) for 24-hour blocks of time.

In an interview with staff #9 on 9-4-18, staff #9 stated that the providers listed on the schedule were on-call only for medical and psychiatric issues pertaining to individuals that had already been admitted to the facility (inpatient status).

The above was confirmed in an interview with the DON and other administrative staff the evening of 9-4-18.

Based on a review of documentation, the hospital failed to provide an appropriate medical screening exam for 5 of 5 patients in order to determine whether or not an emergency medical condition existed. None of the individuals providing screening exams had been deemed qualified to do so by hospital bylaws (or rules and regulations).

Findings were:

* Patient #1 presented to the facility on 5-1-18 after being referred to the facility by her primary care physician. A copy of her driver's license was attached. Her chief complaint was listed as "panic attacks". The section titled "Precipitating Event: (events of past 24-72 hours that resulted in request for assessment)" stated "Panic Attacks, anxiety, depression, SI [suicidal ideation] on Sunday [2 days prior to assessment], hitting self". Also stated was the fact that patient #1 had cut her wrists 2 days prior and that her boyfriend had taken the knife away from her. The patient's disposition stated "Pt [patient] denies current SI or HI - pt able to contract for safety - pt refusing tx at this time - referrals given". The screening was performed by staff #8 (social worker).
* Patient #2 presented to the facility on 6-13-18. No information other than the patient demographics, a copy of the patient's insurance card and a copy of the patient's identification card was present. A statement at the bottom of the page read "Pt refused assessment and left abruptly". The screening was performed by staff #8 (social worker).
* Patient #3 presented to the facility on 6-13-18. Copies of his driver's license and insurance card were attached. His chief complaint was listed as "manic". The section titled "Precipitating Event: (events of past 24-72 hours that resulted in request for assessment)" stated "b/c [because] wife & son think I'm too happy; client is rambling on abt [about] family problems; appears delusional". The disposition area of the screening was blank but a note at the bottom of the front page read "no criteria". The screening was performed by staff #5 (an unlicensed, mental health technician).
* Patient #4 presented to the facility on 7-12-18. A copy of her insurance card was attached. Her chief complaint was listed as "homicidal". The section titled "Precipitating Event: (events of past 24-72 hours that resulted in request for assessment)" stated "thoughts of hurting others x [for] 2 months; increased depression, increased anxiety". The patient's disposition stated "Pt able to contract for safety; obsessive thoughts but no intent, no previous assaultive behavior, referred to outpt [outpatient] psychiatrist, referrals x 3 given". The screening was performed by staff #8 (social worker).
* Patient #5 presented to the facility on 8-29-18. Copies of his driver's license and insurance card were attached. His chief complaint was listed as "meth[amphetamine] use". The section titled "Precipitating Event: (events of past 24-72 hours that resulted in request for assessment)" stated "used crystal meth last Friday; lost time [un]til 3pm Sat[urday], feeling antsy, remorse, depression, poor sleep, restless.". The patient's disposition stated "Refer to PCP [primary care physician] for anxiety". The screening was performed by staff #8 (social worker).

A review of the facility Bylaws, Rules & Regulations for the Medical Staff revealed no reference to or mention of EMTALA or MSEs. No staff members were designated individuals that were qualified to perform medical screening exams.

In an interview with staff #14, staff #14 confirmed that the facility Bylaws, Rules & Regulations for the Medical Staff revealed no reference to or mention of EMTALA or MSEs and that no staff members were designated individuals that were qualified to perform medical screening exams.

A review of personnel files for staff #5, #6, #8, #9, #10, #11, #12 and #13 (all of whom worked as admissions intake personnel) revealed no documentation that the individuals had been designated as qualified to perform medical screening exams by the Medical Staff. Staff #5 held no degree in a medically-related field. Staff #5's education consisted of an Associate's Degree in Computer Science and the staff member's employment experience consisted of a computer-related job and direct, unlicensed, patient care in 2 other healthcare facilities.

A review of the staffing schedule for the intake/admissions department (for January 2018 through the date of the survey) revealed that the full-time intake staff consisted of a social worker and three unlicensed, direct-care personnel.

The above was confirmed in an interview with the DON and other administrative staff the evening of 9-4-18.