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HEALTHALLIANCE HOSPITALS, INC 60 HOSPITAL ROAD LEOMINSTER, MA 01453 May 8, 2014
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on interviews, a review of Emergency Department (ED) and Maternal Child Health (MCH) policies and procedures and a review of Medical Staff Bylaws, Rules and Regulations, it was determined the Medical Staff Bylaws, Rules and Regulations did not specify the individuals qualified to conduct Medical Screening Examinations (MSEs) at the Hospital.

Findings include:

The Hospital's Medical Staff Bylaws, Rules and Regulations did not specify the individuals qualified to conducts MSEs.

Emergency Services Policy/Procedure HA-43-25, titled "Initiation of Emergency Department Visit", as revised in 11/13, indicated ED patients will receive a MSE by an ED physician or extender.

MCH Policies/Procedures did not indicate who was qualified to conduct MSEs when obstetric patients present directly to the Obstetric Department for evaluation of labor.

The surveyor interviewed the Director of Quality and Compliance throughout the EMTALA Survey. The Director of Quality and Compliance said Obstetricians and some Labor and Delivery Registered Nurses perform MSEs related to labor.