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Based on a review of medical records, review of policy and procedures, and interviews with staff, it was determined that the facility failed to ensure that an appropriate medical screening examination was conducted on four (P#1, P#4, P#12, and P#15) of 20 sampled records and failed to ensure that stabilizing treatment was conducted on four (P#4, P#14, P#15, and P#16) of 20 sampled records.


Cross-refer to A-2406 as it relates to the facility's failure to ensure that an appropriate medical screening examination was completed on three sampled patients (P#1, P#4, P#12, and P#15).

Cross-refer to A-2407 as it relates to the facility's failure to ensure that four (P#4, P#14, P#15, and P#16) of 20 sampled patients were informed of the risks and benefits of failure to continue treatment and acknowledge by signing a refusal for treatment.

Based on a review of the facility's central log, a review of medical records, a review of the policies and procedures, and interviews with staff, it was determined that the facility failed to maintain a central log of all patients who presented for emergency services when one (Patient #1) of 20 sampled patients presented to the facility but was not recorded into the central log on 10/29/22.

Findings included:

A review of the facility's Log of Individuals Presenting for Emergency Services' failed to reveal an entry for Patient (P) #1 on 10/29/22.

A review of P#1's Intake Assessment Report revealed that he arrived at the facility on 10/29/22 at 10:47 a.m. The presenting problems were substance abuse, auditory/visual hallucinations (hearing and seeing things that were not there), crying, and anger. P#1 denied suicidal or homicidal ideations (thoughts). P#1 denied depression and anxiety except when people 'are trying to kill me.' P#1 denied medical conditions or use of prescription medications. P#1 denied prior treatment and any mental health diagnoses. P#1 denied any other issues except arguing with family at times. A continued review of the report failed to reveal a homicide risk assessment or suicide risk assessment. A Referral Recommendation and Safety Plan were signed by P#1, including two referral recommendations for outpatient treatment.

A review of the facility's titled 'Log of Individuals Presenting for Emergency Services,' policy number CC 002. Last reviewed, 5/22, revealed that it was the policy of the Assessment and Referral Services Department to document all individuals who presented to the facility for assessment services.
1.0 All individuals who presented themselves for an assessment at the facility would be logged on the Log of Individuals Presenting for Emergency Services.
2.0 The following information will be documented on the log:
1. Date
2. Patient Name
3. Patient age
4. Patient gender
5. Arrival time
6. Mode of transportation to the facility
7. Nature of complaint
8. Whether an emergency medical or psychiatric condition existed
9. Departure time
10. Disposition
11. Departure Mode
12. Mode of Transportation
13. Staff initials
3.0 The Assessment Director/designee would review each completed log for accuracy and completeness.
4. The log shall be maintained by the assessment department according to record retention standards.

A review of the facility's titled 'Assessment and Referral Services EMTALA,' policy number ARS 047, issued 2/13, revealed that it was the policy of the facility to assess, stabilize and/or appropriately transfer individuals who came to the facility with an emergency medical condition (EMC). Qualified Mental Health Professionals (QMHP) provided an appropriate medical screening examination (MSE) for any individual that came to the facility and requested an examination to determine if the person had an EMC. An individual determined to have an EMC was stabilized within the fullest capability of the facility or transferred pursuant to the policy and procedures to another facility that could appropriately meet the person's needs.
7. All persons presenting as walk-ins and or transfers:
All persons presenting to the facility admissions department will be entered into the Emergency Medical Treatment and Labor Act (EMTALA) log.

During an interview with the Director of Assessment and Referral Services (Dir) AA on 11/28/22 at 11:00 a.m. in the conference room, he acknowledged that P#1 was not included on the Log of Individuals Presenting for Emergency Services.

Based on a review of medical records, a review of policy and procedures, e-mail, and interviews with staff, it was determined that the facility failed to ensure that an appropriate medical screening examination was provided within the capability of the hospital's emergency department including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition exists for individuals requesting emergency services for four (4) (P#1, p#4, P#12, and P#15) of 20 sampled patients. Specifically, the Intake Assessment Report was not completed in its entirety for four (P#1,P#4, P#12, and P#15) of 20 sampled patients.

Findings included:

A review of Patient (P) #1's Intake Assessment Report revealed that he arrived at the facility on 10/29/22, and Counselor FF initiated intake at 10:47 a.m. Patient #1's presenting problems were substance abuse, auditory/visual hallucinations, crying, and anger. P#1 denied suicidal or homicidal ideations (thoughts). P#1 denied depression and anxiety except when people 'are trying to kill me.' P#1 denied medical conditions, use of prescription medications, prior treatment, and any mental health diagnoses. P#1 denied any other issues except arguing with family at times. A continued review of the Intake Assessment Report revealed the following documentation was not completed, and or left blank:
'Major Life Areas'
'Behavior Changes'
'Sleep'
'Eating'
'Anxiety'
'Victim of Abuse'
'Potential for Victimization Risk Factors'
'Perpetrator of Abuse'
'Potential for Perpetration Risk Factors'
'Substance' use
'Alcohol Use Screening'
'Medical History'
'Fall Risk'
'Elopement Risk'
'Medications'
'Allergies'
'Previous Treatment'
'Support Systems'
'Relationships'
'Legal History'
'Family History'
'Homicide Risk Assessment'
'Suicide Risk Assessment'
'Brief Mental Status'
'Level of Care Determination'
'Disposition '
'Case staff with MD/Staff'
On site evaluation by MD'
'Assessment Reviewed by' no signature and no date or time entered.
A Referral Recommendation and Safety Plan were signed by P#1, including two referral recommendations for outpatient treatment.
There was no documentation in the medical record indicating that a suicidal or homicidal risk assessment or any discussion with a physician was done. The patient presented to the emergency department (ED) with the following problems: "substance abuse, AVH (audio visual hallucinations-experience of hearing and seeing things that are not there.) crying and angry". However, documentation in the medical record stated in part, "Pt. denies ...AVH (audio/visual hallucinations)." The facility failed to ensure that an appropriate medical screening examination was provided for patient # 1 on 10/29/2022 when he/she presented to ED with psychiatric complaints.

A review of the intake assessment Report for P#4 revealed an intake on 10/05/22 at 12:25 am by a counselor HH. Continued review revealed the 15-year-old patient presented to the emergency department with suicidal ideations (SI). The patient's mother brought the patient in "regarding suicidal notes written to her friends a month ago." Documentation further revealed in part, "Pt (patient) stated that she is not suicidal currently and wrote those notes because she in a depressive state. Pt. Stated that she has since been better and does not currently have a plan, and no attempts. Pt. reported hx (history) of self-harm but has not engages(engaged) in any behaviors recently. Pt stated that she feels safe to go and does not have a plan to harm herself. Pt's mother reported that she can take the pt home and feels comfortable. Provider recommended inpatient treatment, but the patient's Mother refused ."
The section of the note titled "Major Life areas" revealed the patient admits to "bullying at school", and "Loss of energy or interest in activities"; "Behavior Changes: Irritability, Poor Impulse Control; Pt reported she easily gets upset." Review of Columbia Lifetime Suicide Risk Assessment dated 10/05/20220 at 3:10 am. The section of the Columbia Lifetime Suicide Assessment titled "Wish to be dead" Have you wished to be dead or wished you could go to sleep and not wake up? Documentation by the counselor "Pt. reported hx of SI". The section titled "Intensity of Ideation Frequency - How many times have you had these thoughts? Recent: (3) 2-5 times a week; ... Duration: When you have the thoughts how long do they last? Recent: 4-8 hours/most of the day ...Controllability: Could/can you stop thinking about killing yourself or wanting to die if you want to ... Recent Can control thoughts with some difficulty." The patient's suicide risk was listed as low. The intervention was for low risk was listed as "Monitor the patient for any changes in status and complete daily suicide assessment on the daily nursing note." Further review of the medical record revealed patient #4 met the criteria for "Inpatient acute care- Behavior which is life threatening, destructive, or disabling to self or others. Further review revealed the patient needed to be admitted to an Adolescent -Inpatient psychiatric Unit. The review also revealed in part, "Patient's symptoms criteria for emergency medical/psychiatric condition as determined by / Disposition: Appropriate for Admit - Not admitted." Documentation by the counselor indicated the case was staffed MD/Staff: (Physician name). The section of the notes titled "On site evaluation by MD was left blank. The medical screening examination was incomplete as evidenced by there was no documentation of outpatient referrals or attempts for Involuntary Hold/Commitment once it was determined Patient #4 had an identified emergency psychiatric condition.

A review of the Intake Assessment Report for P#12 revealed an intake on 10/29/22 at 2:50 p.m. by Counselor FF. A continued review of the report revealed a presenting problem of 'not in my right mind.' Precipitating events revealed that P#12 denied suicidal ideations, homicidal ideations, and audio or visual hallucinations. P#1 reported depression for a few months. P#12 denied a history or treatment of mental health issues. P#12 was referred out. A continued review of the Intake Assessment Report revealed the following documentation was not completed:
'Major Life Areas'
'Behavior Changes'
'Sleep'
'Eating'
'Anxiety'
'Victim of Abuse'
'Potential for Victimization Risk Factors'
'Perpetrator of Abuse'
'Potential for Perpetration Risk Factors'
'Substance' use
'Alcohol Use Screening'
'Medical History'
'Fall Risk'
'Elopement Risk'
'Medications'
'Allergies'
'Previous Treatment'
'Support Systems'
'Relationships'
'Legal History'
'Family History'
'Homicide Risk Assessment'
'Brief Mental Status'
'Level of Care Determination'

A review of an Intake Assessment Report for P#15 revealed that intake was initiated on 10/30/22 at 6:45 p.m. by Counselor FF. The presenting problems were elopement and aggression. A continued review of the report's section titled 'precipitating events' revealed that law enforcement had been called due to P#15 and her (P#15) mother having an altercation in the facility's parking lot. P#15 denied suicidal and homicidal ideations. P#15 reported elopement, alcohol, and THC (marijuana) use. P#15 reported a sexual assault a month ago that had been reported to law enforcement and the Department of Family and Children Services. P#15 reported fighting with family and running away. A history of bipolar disorder (disorder associated with episodes of mood swings) and major depressive disorder was reported by P#15. Inpatient treatment was offered and declined by P#15's mother. The patient's mother reported that she would take P#15 to a residential treatment facility the next day. A continued review of the report revealed that the level of determination was admission to inpatient acute care. Further review revealed that symptoms met the criteria for emergency medical/psychiatric conditions as determined by a qualified medical professional/physician. Disposition was documented as 'Appropriate for Admit-Not Admitted.'
A continued review of the Intake Assessment Report revealed the following sections were not completed:
'Major Life Areas'
'Behavior Changes'
'Sleep'
'Eating'
'Anxiety'
'Victim of Abuse'
'Potential for Victimization Risk Factors'
'Perpetrator of Abuse'
'Potential for Perpetration Risk Factors'
'Child/Adolescent Assessment'
'Substance' use
'Alcohol Use Screening'
'Medical History'
'Fall Risk'
'Elopement Risk'
'Medications'
'Allergies'
'Previous Treatment'
'Support Systems'
'Legal History'
'Family History'
'Homicide Risk Assessment'
'Brief Mental Status'
The medical screening examination for patient #15 was incomplete because the Intake Assessment lacked homicidal and suicidal risk assessments, CCRS form, no vital signs, and no abuse assessments were completed.


A review of the facility's policy titled 'Assessment,' policy number ARS 017, last reviewed 5/22, revealed that it was the policy of the facility to offer a no-cost psychological/additive disease assessment to all persons seeking such service. This service was offered as requested at an individual's earliest convenience, 24 hours a day and seven days a week.

Procedure:
1.0 On arrival of the individual to the facility for evaluation, the receptionist/designee would greet the individual/family. The individual/family was asked to complete the registration forms and medical screening questionnaire. If necessary, the receptionist/designee notified the assessment counselor/designee of any behavior/condition warranting immediate attention/intervention.
2.0 Upon completion of the registration forms and medical screening questionnaire, an Assessment Counselor was notified that the individual was ready for an assessment.
3.0 The Assessment and Referral Services Counselor or trained designee reviewed the Intake Call Sheet, as well as the registration forms and medical screening questionnaire, and release of information prior to beginning the assessment.
4.0 The Assessment and Referral Services Counselor or trained designee directed the individual and family to an assessment room.
5.0 A consultation with the next physician on rotation or as indicated by the payor source would take place, and a final disposition would be made. The evaluating counselor presented the recommendation to the individual/family.
6.0 If outpatient services were indicated, the recommendation would be made to the individual/family. If appropriate, the individual would be given three referrals unless driven by a Managed Care Company or referral request. The referrals would contain all the necessary demographic information to obtain an appointment.
7.0 The recommendation for services would always be based entirely on the clinical necessity of the individual. In the event the individual is admitted to a program offered at the facility, the Intake Assessment would be part of a continuous assessment tool.

A review of the facility's policy titled 'Admission/Exclusionary/Continued Stay/Discharge Criteria,' policy number CC 00-4, last reviewed 4/22, revealed that it was the policy of the facility to accept patients into a particular service or setting based on the outcomes of its assessment procedures. Set criteria define the patient information necessary to determine the appropriate care setting or services.

A review of the facility's policy titled 'Assessment and Referral Services EMTALA,' policy number ARS 047, issued 2/13, revealed that it was the policy of the facility to assess, stabilize and/or appropriately transfer individuals who came to the facility with an emergency medical condition (EMC). Qualified Mental Health Professionals (QMHP) provided an appropriate medical screening exam (MSE) for any individual that came to the facility and requested an examination to determine if the person had an EMC. An individual determined to have an EMC was stabilized within the fullest capability of the facility or transferred pursuant to the policy and procedures to another facility that could appropriately meet the person's needs.

Procedure
1. Definitions
For purposes of this policy, the following definitions applied:
1.3 "Qualified Mental Health Professional" means master's Prepared Counselors, Licensed Psychologist, Social Workers, Registered Nurses or Licensed Professional Counselors.
2. Screening Examination
An appropriate screening examination was provided to the individual by a QMHP for determination as to whether an EMC existed. The screening examination was not delayed inquiring whether or the not the individual had sufficient financial resources to pay for treatment, including the availability of insurance.
2.1 If an individual did not have an EMC: If, after screening examination, the QMHP believed that the individual did not have an EMC (as defined in this policy), referrals for treatment were provided to the individual as deemed clinically appropriate and in compliance with the facility policy and procedures.
2.2 EMC: If, after screening, the QMP believed that an individual had an EMC, the QMP contacted the on-call physician and provided a full report of the patient's clinical condition. The physician should:
2.2.1 Make a final determination as to
2.2.1.1 Whether an emergency medical existed
2.2.1.2 Whether the patient met the admission criteria for treatment; and
2.2.1.3. Make the appropriate recommendation for treatment based on the patient's clinical condition.

During an interview with the Director of Assessment and Referral (Dir) AA on 11/28/22 at 11:00 a.m., he acknowledged that P#1 was not included on the Intake Log. Dir AA explained that intake counselors assessed patients presenting to the facility for evaluation. He stated that the counselors were qualified personnel to screen patients; all were either licensed or had a master's degree in social work. Dir AA said that a physician reviewed all assessments via phone call with the counselor to determine a recommendation or disposition. Dir AA explained that the counselor (Counselor FF) that assessed P#1 was no longer employed at the facility. Dir AA stated that there had been performance issues and Counselor FF had been reminded on 9/22/22 to complete the CSSRS (suicide risk assessment screening tool) in its entirety.

An interview with intake counselor (Counselor) CC occurred on 11/28/22 at 1:15 p.m. in the conference room. Counselor CC explained that she had been employed at the facility for a little over a year and had a master's degree in social work. Counselor CC explained that walk-in patients that requested treatment presented to the lobby. An intake staff member escorted the patient back to intake for an assessment. Counselor CC explained that after the assessment, the psychiatrist on call was notified, and the assessment was reviewed for disposition. The communication was documented on the intake assessment. Counselor CC explained that a suicide screening and homicide screening was included in the assessment. In addition, vital signs were taken for patients admitted to an inpatient program. She further explained that if a patient refused treatment, the patient signed a refusal form. Counselor CC recalled that Emergency Medical Treatment and Labor Act (EMTALA) training was done during new employee orientation and annually after that.

An interview with Intake Counselor (Counselor) DD occurred on 11/28/22 at 1:45 p.m. in the conference room. Counselor DD explained that she had been employed at the facility since May of this year in the Assessment and Referral Department. Counselor DD had a master's degree in social work. Counselor DD explained that individuals seeking care check in at the desk in the main waiting room. When the individual is called back into the Assessment and Referral Department, they are 'wanded' before being taken to a room. An Intake Counselor completed a mental health assessment. A homicide and suicide screening were included as part of the assessment. After the assessment, the patient's psychiatrist or the psychiatrist on call was called to determine disposition. She explained that the name of the physician called was documented on the intake form using the term 'staffed with.' She stated that the physician completed the document if involuntary commitment was warranted. Counselor DD explained that if a recommendation was made for inpatient hospitalization and the patient refused, a refusal of treatment form was completed unless a 1013 (involuntary hold) was signed. Referrals for outpatient services were also provided. Counselor DD recalled receiving EMTALA training.

An interview with psychiatrist (MD) GG took place on 11/29/22 at 9:45 a.m. in the conference room. MD GG stated that documentation of the homicide and suicide risk assessments was expected. In addition, MD GG said that a physician was called for every patient that presented to the intake department.

A review of four personnel files (Dir AA, Counselor CC, Counselor DD, and Counselor FF) revealed all files contained current state licensure as applicable, background checks, and facility-required orientation and competency testing. Additionally, all files contained evidence of EMTALA training. A review of Counselor FF's personnel file revealed that his last day of employment at the facility was 11/11/22.

A review of email communication from Assessment and Referral Services leadership to Counselor FF with a copy to Dir AA dated 9/9/22 revealed that Counselor FF was reminded to answer all questions on the CSSRS (suicide risk assessment screening tool).

Based on a review of the medical records, interviews with staff, and a review of policy and procedures, it was determined the facility failed to ensure that the medical record contained a signed informed refusal, including a description of recommended treatment, the risks and benefits of treatment, the reasons for refusal, and a description of the refusal for patients that refused recommended treatment for four (P#4, P#14, P#15, and P#16) of 20 sampled patients.

Findings:

P#4 presented with suicidal ideation on 10/5/22 at 12:25 a.m. After an intake assessment, P#4 was determined to be appropriate for admission and the recommendation was for inpatient admission. P#4's mother refused inpatient treatment.

P#14 presented with suicidal ideations on 10/30/22 at 3:26 p.m. After an intake assessment, P#14 was determined to be appropriate for admission and the recommendation was for partial hospitalization. P#14's mother refused partial hospitalization.

P#15 presented with aggression and elopements on 10/30/22 at 6:45 p.m. After the intake assessment, P#15 was determined to be appropriate for inpatient admission. P#15's mother refused inpatient treatment.

P#16 presented with suicidal ideations with a plan on 11/2/22 at 3:21 p.m. After the intake assessment and collateral received from P#16's private therapist, it was determined that the patient was appropriate for inpatient admission. P#16 refused treatment and was released with referrals.

A review of the facility's policy, titled 'Assessment and Referral Services EMTALA,' policy number ARS 047, issued 2/13, revealed that it was the policy of the facility to assess, stabilize and/or appropriately transfer individuals who came to the facility with an emergency medical condition (EMC). Qualified Mental Health Professionals (QMHP) provided an appropriate medical screening examination (MSE) for any individual that came to the facility and requested an examination to determine if the person had an EMC. An individual determined to have an EMC was stabilized within the fullest capability of the facility or transferred pursuant to the policy and procedures to another facility that could appropriately meet the person's needs.

Procedure
1. Definitions
For purposes of this policy, the following definitions apply:
1.3 "Qualified Mental Health Professional" means master's Prepared Counselors, Licensed Psychologist, Social Workers, Registered Nurses, or Licensed Professional Counselors.
2. Screening Examination
An appropriate screening examination was provided to the individual by a QMHP for a determination as to whether an EMC existed. The screening examination was not delayed inquiring whether or not the individual had sufficient financial resources to pay for treatment, including the availability of insurance.
2.1 If an individual did not have an EMC: If, after screening examination, the QMHP believed that the individual did not have an (EMC) (as defined in this policy), referrals for treatment were provided to the individual as deemed clinically appropriate and in compliance with the facility policy and procedures.
2.2 EMC: If, after screening, the QMP believed that an individual had an EMC, the QMP contacted the on- call physician and provided a full report of the patient's clinical condition. The physician should:
2.2.1 Make a final determination as to
2.2.1.1 Whether an emergency medical existed
2.2.1.2 Whether the patient met the admission criteria for treatment; and
2.2.1.3. Make the appropriate recommendation for treatment based on the patient's clinical condition.
3. EMC-Psychiatric Condition
3.1 Individual with EMC refuses further assessment or treatment:
If the individual refuses to receive further assessment and/or treatment by a physician or QMHP, and the QMHP providing the assessment believes the individual met the criteria for an involuntary commitment, the QMHP may seek involuntary commitment as provided by state law after consultation with the physician.
3.1.1 Patient Rights: The QMHP or clinician clearly explained to the individual in factual, not coercive, manner his or her legal rights with respect to potential involuntary commitment.
3.1.2 The clinician followed state law in determining the steps taken to effect an involuntary commitment.
3.2 Individual with an EMC agreed to further assessment and treatment: If the individual consented to further assessment and/or treatment by a physician, the physician makes a recommendation for the appropriate level of care. If the physician was not immediately available, the clinical contacted the on-call physician or other physician and provided a full report of the patient's clinical condition. The physician should:
3.2.1. Make the final determination as to:
3.2.1.1. Whether an EMC existed
3.2.1.2. Whether the patient met admission criteria for treatment; and
3.2.1.3. Make the appropriate recommendation for treatment based on the patient's clinical condition.
3.3. Recommendation for inpatient treatment made/accepted: If the person agreed with the recommendation for inpatient services, an appropriate voluntary admission was facilitated.
3.4 Recommendation for Inpatient Treatment Made/Rejected:
3.4.1 No Emergency Medical Condition: If the individual did not meet the criteria for involuntary commitment and did not have an EMC, the individual was asked to sign the refusal of treatment form. The form should include a full description by the clinician describing the recommendation of inpatient services and the individual's declination of the offer for services. The findings of the assessments, recommendations, and patient response were documented by the clinician on the assessment form.
3.4.2. EMC: If the individual disagreed with the recommendation for inpatient services and the individual met involuntary commitment criteria, then an involuntary commitment should be sought for the protection of the patient.


An interview with Intake Counselor (Counselor) DD occurred on 11/28/22 at 1:45 p.m. in the conference room. Counselor DD explained that she had been employed at the facility since May of this year in the Assessment and Referral Department. Counselor DD had a master's degree in Social Work. Counselor DD explained that individuals seeking care check in at the desk in the main waiting room. When the individual is called back into the Assessment and Referral Department, they are 'wanded' before being taken to a room. An Intake Counselor completed a mental health assessment. A homicide and suicide screening were included as part of the assessment. After the assessment, the patient's psychiatrist or the psychiatrist on call was called to determine disposition. She explained that the name of the physician called was documented on the intake form using the term 'staffed with.' She stated that the physician completed the document if involuntary commitment was warranted. Counselor DD explained that if a recommendation was made for inpatient hospitalization and the patient refused, a refusal of treatment form was completed unless a 1013 (involuntary hold) was signed. Referrals for outpatient services were also provided. Counselor DD recalled receiving EMTALA training.


During the exit conference on 11/29/22 at 1:30 p.m. in the conference room, Dir AA, COO BB, the Assistant Administrator, and Chief Nursing Officer acknowledged that the records did not include refusal to treatment forms.