The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

SOUTHCOAST HOSPITAL GROUP, INC 363 HIGHLAND AVENUE FALL RIVER, MA 02720 Jan. 20, 2017
VIOLATION: QUALIFIED EMERGENCY SERVICES PERSONNEL Tag No: A1112
Based on records reviewed and interviews, the Hospital failed to ensure for 9 of 12 patients(Patients #1, #3, #4, #5, #7, #8, # 10, #11, #12), that qualified personnel in emergency care met the needs of psychiatric patients in the Emergency Department.

Findings included:

The Hospital policy titled Emergency Department Scope of Care, dated 12/2007, indicated that emergency care was delivered by qualified staff.

The Hospital policy titled Emergency Medical Treatment and Active Labor Act (EMTALA), dated 5/5/16, indicated that a qualified medical provider (physician or non-physician practitioner) must perform an appropriate medical screening examination. The EMTALA policy indicated that a licensed independent practitioner (non-physician practitioners, Allied Health Professionals) with clinical privileges in the Emergency Department as designated by Medical Staff bylaws performed the medical screening examination.

Medical Staff bylaws, dated 11/19/14, indicated that Allied Health Professionals were Clinical Psychologists, Advanced Registered Nurse Practitioners, Certified Registered Nurse Anesthetists, Certified Nurse Midwives and Physician Assistants; approved by the Governing Body and the Medical Staff credentialing process were permitted to practice medicine at the Hospital.

Medical Staff bylaws did not indicate that individuals who signed Emergency Psychiatric Evaluations with the initials of LCSW (undefined), LMHC (undefined), MSW (undefined), and MA (undefined) were Allied Health Professionals that were approved by the Governing Body and Medical Staff credentialing process to provide psychiatric evaluations at the Hospital. Medical Staff bylaws did not indicate that Hospital Social Workers were approved by the Governing Body and Medical Staff credentialing process to provide psychiatric evaluations at the Hospital.

Nine of twelve medical records reviewed (Patients #1, #3, #4, #5, #7, #8, # 10, #11, #12), indicated Hospital Social Workers and ESP Contracted Service Clinicians provided Emergency Psychiatric Evaluations.

The Surveyor interviewed the Executive Director of Risk Services and the Associate Chief Nursing Officer, at 10:20 A.M. on 1/13/17. The Executive Director of Risk Services and the Associate Chief Nursing Officer said the Hospital did not credential (grant Medical Staff privileges or appoint to the Medical Staff) ESP Clinicians and Hospital Social Workers who provided Emergency Psychiatric Evaluations in the Emergency Departments.

The Hospital did not provide documentation to indicate Medical Staff credentialing procedures, competency review, nor granting and delineation of clinical privileges based on licensure, training, experience, capacity to perform or evidence of current competency for the ESP Contracted Service Clinicians or Hospital Social Workers, who provided Emergency Psychiatric Evaluations to nine Emergency Department patients (Patients #1, #3, #4, #5, #7, #8, #10, #11 and #12), in accordance with State law and Medical Staff bylaws.

The Hospital did not provide documentation to indicate Medical Staff credentialing procedures or competency review for the Hospital Licencened Independent Clinical Social Workers who performed and authorized Section 12A's (emergency restraint and hospitalization of patients posing risk of serious harm due to psychiatric illness).
VIOLATION: GOVERNING BODY Tag No: A0043
The Condition of Participation for Governing Body was not met.

Findings included:

1.) The Governing Body failed to ensure that Psychiatric Evaluations in the Emergency Departments were completed by staff or contractors who were determined eligible candidates for appointment to the Medical Staff or to be granted Medical Staff privileges, in accordance with State law.

Refer to TAG: A-0045

2.) The Governing Body failed to ensure that the Medical Staff operated under bylaws that were in accordance with hospital Conditions of Participation for providing Emergency Psychiatric Evaluations in the Emergency Department.

Refer to TAG: A-0047

3.) The Governing Body failed to ensure that the Medical Staff was accountable to the Governing Body for the quality of care to psychiatric patients in the Emergency Department and that those psychiatric patients were under the care of a practitioner that met Medical Staff bylaws criteria and were granted Medical Staff privileges in accordance with the criteria established by the Governing Body.

Refer to TAG: A-0049

4.) Although the Hospital appointed a Chief Executive Officer, the Governing Body failed to ensure for 9 of 12 patients (Patients #1, #3, #4, #5, #7, #8, # 10, #11 and #12) the Chief Executive Officer was responsible for and managed the Emergency Services provided to psychiatric patients in the Emergency Departments.

Refer to TAG: A-0057

5.) The Governing Body failed to ensure that Quality Assessment and Performance Improvement (QAPI) activities evaluated 4 Emergency Department contracts whose staff provided emergency psychiatric evaluations as allowed by Medical Staff bylaws.

Refer to TAG: A-0083
VIOLATION: MEDICAL STAFF Tag No: A0045
Based on records reviewed and interviews, the Governing Body failed to ensure for 9 of 12 patients (Patients #1, #3, #4, #5, #7, #8, #10, #11 and #12), that Psychiatric Evaluations in the Emergency Departments were completed by staff or contractors who were determined eligible candidates for appointment to the Medical Staff or to be granted Medical Staff privileges, in accordance with State law.

Findings included:

The Hospital policy titled Emergency Medical Treatment and Active Labor Act (EMTALA), dated 5/5/16, indicated that a qualified medical provider (physician or non-physician practitioner) must perform an appropriate medical screening examination on the patient to determine if an emergency medical condition existed. The EMTALA policy indicated that a licensed independent practitioner (non-physician practitioner, Allied Health Professionals) with clinical privileges in the Emergency Department, as designated by Medical Staff bylaws, may perform a medical screening examination to determine if an emergency medical condition existed.

The Medical Staff bylaws, dated 11/19/14, indicated that Medical Staff policies, procedures and rules and regulations were considered part of the Medical Staff bylaws. Medical Staff bylaws indicated the Hospital appointed to the Medical Staff and gave privileges to practice medicine to physicians, dentists and podiatrists. The Medical Staff bylaws indicated that Allied Health Professionals were Clinical Psychologists, Advanced Registered Nurse Practitioners, Certified Registered Nurse Anesthetists, Certified Nurse Midwives and Physician Assistants. The Medical Staff bylaws indicated Allied Health Professionals approved by the Governing Body and the Medical Staff credentialing process were permitted to practice medicine at the Hospital.

The Medical Staff bylaws did not indicate that individuals who signed Emergency Psychiatric Evaluations with the initials of LCSW (undefined), LMHC (undefined), MSW (undefined), and MA (undefined) were Allied Health Professionals that were approved by the Governing Body and Medical Staff credentialing process to provide psychiatric evaluations at the Hospital. Medical Staff bylaws did not indicate that Hospital Social Workers were approved by the Governing Body and Medical Staff credentialing process to provide psychiatric evaluations at the Hospital.

1.) The Emergency Department Physician Note, dated 6/2/16 at 12:04 P.M., indicated Patient #1 presented to the Emergency Department at Hospital Campus A for a psychiatric evaluation. The Emergency Department Note indicated that the physician plan of care included a Hospital Social Worker assessment. The Emergency Department Physician Note did not indicate a physician, or Allied Health Professional as permitted by Medical Staff bylaws, completed a comprehensive psychiatric evaluation.

The Social Worker Note, dated 6/3/16 at 1:12 A.M., indicated a comprehensive psychiatric evaluation was completed, which included a medical diagnosis and signed as completed by a Hospital Social Worker without initials to indicate the credentials of the Social Worker who performed the evaluation.

Medical Staff bylaws did not indicate that Hospital Social Workers were approved by the Governing Body and Medical Staff credentialing process to provide psychiatric evaluations at the Hospital.

2.) The Emergency Department Physician Note, dated 1/12/17 at 12:47 A.M., indicated Patient #3 presented to the Emergency Department at Hospital Campus A for a medical screening evaluation and drug or alcohol assessment. The Emergency Department Note indicated the physician plan of care included a psychiatric evaluation by an Emergency Services Program (ESP) Clinician. The Emergency Department Physician Note did not indicate a physician, or Allied Health Professional as permitted by Medical Staff bylaws, completed a comprehensive psychiatric evaluation.

The ESP Adult Comprehensive Assessment, dated 1/12/17 at 11 A.M., indicated a comprehensive psychiatric evaluation was completed, which included a medical diagnosis and was signed as completed by an ESP Clinician with the initials of LCSW performed the evaluation. The ESP Adult Comprehensive Assessment indicated Patient #3's disposition as to be discharged to home.

3.) The Emergency Department Physician Note, dated 1/11/17 at 11:25 A.M., indicated Patient #4 presented to Hospital Campus A for a psychiatric evaluation. The Emergency Department Physician Note did not indicate a physician, or Allied Health Professional as permitted by Medical Staff bylaws, completed a comprehensive psychiatric evaluation.

The Social Worker Note, dated 1/11/17 at 4:09 P.M., indicated a comprehensive psychiatric evaluation was completed, which included a medical diagnosis and signed as completed by a Hospital Social Worker without the credentials of the Social Worker performed the evaluation. The Social Worker Note indicated Patient #4's disposition as to be admitted to an inpatient psychiatric hospital.

4.) The Emergency Department Physician Note, dated 1/11/17 at 9:32 A.M., indicated Patient #5 presented to the Emergency Department at Hospital Campus A for a psychiatric evaluation. The Emergency Department Physician Note did not indicate a physician, or Allied Health Professional as permitted by Medical Staff bylaws, completed a comprehensive psychiatric evaluation.

The ESP Adult Comprehensive Assessment, dated 1/12/17 at 12:15 A.M., indicated a comprehensive psychiatric evaluation was completed, which included a medical diagnosis and signed as completed by an ESP Clinician with the initials of MSW (to indicate the credentials of the ESP Clinician from ESP Contracted Service A) performed the evaluation. The ESP Adult Comprehensive Assessment indicated Patient #5's disposition as to be admitted to an inpatient psychiatric hospital.

5.) The Emergency Department Physician Note, dated 6/8/16 at 7:25 P.M., indicated that Patient #7 presented to the Emergency Department at Hospital Campus A for a psychiatric evaluation. The Emergency Department Physician Note did not indicate a physician, or Allied Health Professional as permitted by Medical Staff bylaws, completed a comprehensive psychiatric evaluation.

The Social Worker Note, dated 6/9/16 at 1:17 A.M., indicated a comprehensive psychiatric evaluation was completed which included a medical diagnosis and signed as completed by a Hospital Social Worker with the initials of LMHC (to indicate the credentials of the Social Worker) performed the evaluation). The Social Worker Note indicated Patient #7's disposition as to be admitted to an inpatient psychiatric hospital.

6.) The Emergency Department Physician Note, dated 10/21/16 at 2:38 P.M., indicated Patient #8 presented to the Emergency Department at Hospital Campus A for a psychiatric, drug and alcohol evaluation. The Emergency Department Physician Note did not indicate a physician, or Allied Health Professional as permitted by Medical Staff bylaws, completed a comprehensive psychiatric evaluation.

The ESP Adult Comprehensive Assessment, dated 10/22/16 at 1:04 P.M., indicated a comprehensive psychiatric evaluation was completed which included a medical diagnosis and signed as completed by an ESP Clinician with the initials of MA (to indicated the credentials of the ESP Clinician from ESP Contracted Service A) performed the evaluation. The ESP Adult Comprehensive Assessment indicated Patient #8's disposition was undetermined.

7.) The Emergency Department Physician Note, dated 12/19/16 at 6:01 A.M., indicated Patient #10 presented to the Emergency Department at Hospital Campus A for a psychiatric evaluation. The Emergency Department Physician Note did not indicate a physician, or Allied Health Professional as permitted by Medical Staff bylaws, completed a comprehensive psychiatric evaluation.

The ESP Adult Comprehensive Assessment, dated 12/19/16 at 4:51 P.M., indicated a comprehensive psychiatric evaluation was completed which included a medical diagnosis and signed as completed by an ESP Clinician with the initials of LMHC (indicate the credentials of the ESP Clinician from ESP Contracted Service A) performed the evaluation. The ESP Adult Comprehensive Assessment indicated Patient #10's disposition as to be admitted to an inpatient psychiatric hospital.

8.) The Emergency Department Physician Note, dated 12/19/16 at 6:01 A.M., indicated Patient #11 presented to the Emergency Department at Hospital Campus B for a psychiatric evaluation. The Emergency Department Physician Note did not indicate a physician, or Allied Health Professional as permitted by Medical Staff bylaws, completed a comprehensive psychiatric evaluation.

The ESP Adult Comprehensive Assessment, dated 1/14/17 at 10:45 P.M., indicated a comprehensive psychiatric evaluation was completed which included a medical diagnosis. The ESP Adult Comprehensive Assessment did not indicate the signature and did not indicate the credentials of the ESP Clinician from ESP Contracted Service A, performed the evaluation. The ESP Adult Comprehensive Assessment indicated Patient #11's disposition as to be admitted to an inpatient psychiatric hospital.

9.) The Emergency Department Physician Note, dated 1/18/17 at 2:01 P.M., indicated Patient #12 presented to the Emergency Department at Hospital Campus C for a psychiatric evaluation. The Emergency Department Physician Note did not indicate a physician, or Allied Health Professional as permitted by Medical Staff bylaws, completed a comprehensive psychiatric evaluation.

The ESP Adult Comprehensive Assessment, dated 1/18/17 at 9:30 P.M., indicated a comprehensive psychiatric evaluation was completed which included a medical diagnosis and signed as completed by an ESP Clinician with the initials of LICSW (indicate the credentials of the ESP Clinician from ESP Contracted Service B) performed the evaluation. The ESP Adult Comprehensive Assessment indicated Patient #12's disposition as to be admitted to an inpatient psychiatric hospital.

The Surveyor interviewed the Executive Director of Risk Services and the Associate Chief Nursing Officer at 10:20 A.M. on 1/13/17. The Executive Director of Risk Services and the Associate Chief Nursing Officer said the Hospital did not credential (grant Medical Staff privileges or appoint to the Medical Staff) ESP Clinicians or Hospital Social Workers who provided Emergency Psychiatric Evaluations in the Emergency Departments.

The Surveyor interviewed the Manager of Social Work Services at 11:30 A.M. on 1/13/17. The Manager of Social Work Services said that the patient's health care insurance coverage determined if the ESP Contracted Service or the Hospital Social Worker performed the psychiatric evaluation. The Manager of Social Work Services said that the Hospital Social Workers evaluated the patient's need for inpatient psychiatric hospitalization or outpatient psychiatric treatment. The Manager of Social Work Services said that the Social Workers made psychiatric diagnoses. The Manager of Social Work Services said that the Hospital employed 3 categories of Social Workers; Licensed Mental Health Counselors, Licensed Clinical Social Workers and Licensed Independent Clinical Social Workers.

The document titled Social Work Counselor Job Description, dated 10/2007, and the document titled Clinical Social Worker Job Description, dated 9/2007, both indicated job functions included independently assessing and diagnosing psychiatric and substance abuse illnesses in the Emergency Departments.

The document titled Clinical Social Worker Job Description, dated 10/2010, indicated Licensed Independent Clinical Social Worker job functions included independently assessing, evaluating, consulting and interpreting psychiatric and substance abuse illnesses in the Emergency Department. Job functions included assessment for the risk of harm and initiating emergency hospitalization and the ability to authorize a Section 12A (emergency restraint and hospitalization of patients posing risk of serious harm due to psychiatric illness) and for emergency evaluation of the patient by a psychiatrist.

The Surveyor interviewed an Emergency Department Physician at 2:15 P.M. on 1/13/17. The Emergency Department Physician said that the Hospital Social Workers and the ESP Clinicians provided psychiatric evaluations and consulted with the Emergency Department Physician regarding their recommendation for inpatient psychiatric hospitalization or outpatient psychiatric treatment. The Emergency Department Physician said that the psychiatric evaluation was the same process in the 3 Hospital Emergency Departments.
VIOLATION: MEDICAL STAFF - BYLAWS Tag No: A0047
Based on records reviewed and interviews, the Governing Body failed to ensure for 9 of 12 patients (Patients #1, #3, #4, #5, #7, #8, # 10, #11 and #12), that the Medical Staff operated under bylaws that were in accordance with hospital Conditions of Participation for providing Emergency Psychiatric Evaluations in the Emergency Departments.

Findings included:

The Hospital policy titled Emergency Medical Treatment and Active Labor Act (EMTALA), dated 5/5/16, indicated that a qualified medical provider (physician or non-physician practitioner) must perform an appropriate medical screening examination on the patient to determine that if an emergency medical condition existed. The EMTALA policy indicated that a licensed independent practitioner (non-physician practitioner, Allied Health Professionals) with clinical privileges in the Emergency Department, as designated by Medical Staff bylaws, may perform a medical screening examination to determine if an emergency medical condition existed.

The Medical Staff bylaws, dated 11/19/14, indicated that Medical Staff policies, procedures and rules and regulations were considered part of the Medical Staff bylaws. Medical Staff bylaws indicated the Hospital appointed to the Medical Staff and gave privileges to practice medicine to physicians, dentists and podiatrists. The Medical Staff bylaws indicated that Allied Health Professionals were Clinical Psychologists, Advanced Registered Nurse Practitioners, Certified Registered Nurse Anesthetists, Certified Nurse Midwives and Physician Assistants. The Medical Staff bylaws indicated Allied Health Professionals approved by the Governing Body and the Medical Staff credentialing process were permitted to practice medicine at the Hospital.

The Medical Staff bylaws did not indicate that individuals who signed Emergency Psychiatric Evaluations with the initials of LCSW (undefined), LMHC (undefined), MSW (undefined), and MA (undefined) were Allied Health Professionals that were approved by the Governing Body and Medical Staff credentialing process to provide psychiatric evaluations at the Hospital. Medical Staff bylaws did not indicate that Hospital Social Workers were approved by the Governing Body and Medical Staff credentialing process to provide psychiatric evaluations at the Hospital.

Nine of twelve medical records reviewed (Patients #1, #3, #4, #5, #7, #8, # 10, #11, #12) did not indicate individuals who provided Emergency Psychiatric Evaluations were approved by the Governing Body and Medical Staff credentialing process to provide psychiatric evaluations at the Hospital.

1.) The Social Worker Note, dated 6/3/16 at 1:12 A.M. for Patient #1, indicated a comprehensive psychiatric evaluation was completed which included a medical diagnosis and signed as completed by a Hospital Social Worker without initials to indicate the credentials of the person who performed the evaluation.

Medical Staff bylaws did not indicate that Hospital Social Workers were approved by the Governing Body and Medical Staff credentialing process to provide psychiatric evaluations at the Hospital.

2.) The ESP Adult Comprehensive Assessment, dated 1/12/17 at 11 A.M. for Patient #3, indicated a comprehensive psychiatric evaluation was completed which included a medical diagnosis and signed as completed by an ESP Clinician with the initials of LCSW to indicate the credentials of the ESP Clinician from ESP Contracted Service A, who performed the evaluation.

3.) The Social Worker Note, dated 1/11/17 at 4:09 P.M. for Patient #4, indicated a comprehensive psychiatric evaluation was completed which included a medical diagnosis and signed as completed by a Hospital Social Worker without initials to indicate the credentials of the Social Worker who performed the evaluation.

4.) The ESP Adult Comprehensive Assessment, dated 1/12/17 at 12:15 A.M. for Patient #5, indicated a comprehensive psychiatric evaluation was completed which included a medical diagnosis and signed as completed by an ESP Clinician with the initials of MSW to indicated the credentials of the ESP Clinician from ESP Contracted Service A, who performed the evaluation.

5.) The Social Worker Note, dated 6/9/16 at 1:17 A.M. for Patient #7, indicated a comprehensive psychiatric evaluation was completed which included a medical diagnosis and signed as completed by a Hospital Social Worker with the initials of LMHC to indicate the credentials of the Social Worker who performed the evaluation.

6.) The ESP Adult Comprehensive Assessment, dated 10/22/16 at 1:04 P.M. for Patient #8, indicated a comprehensive psychiatric evaluation was completed which included a medical diagnosis and signed as completed by an ESP Clinician with the initials of MA to indicated the credentials of the ESP Clinician from ESP Contracted Service A, who performed the evaluation.

7.) The ESP Adult Comprehensive Assessment, dated 12/19/16 at 4:51 P.M. for Patient #10, indicated a comprehensive psychiatric evaluation was completed which included a medical diagnosis and signed as completed by an ESP Clinician with the initials of LMHC to indicate the credentials of the ESP Clinician from ESP Contracted Service A, who performed the evaluation.

8.) The ESP Adult Comprehensive Assessment, dated 1/14/17 at 10:45 P.M. for Patient #11, indicated a comprehensive psychiatric evaluation was completed which included a medical diagnosis. The ESP Adult Comprehensive Assessment did not indicate a signature and did not indicate the credentials of the ESP Clinician from ESP Contracted Service A, who performed the evaluation.

9.) The ESP Adult Comprehensive Assessment, dated 1/18/17 at 9:30 P.M. for Patient #12, indicated a comprehensive psychiatric evaluation was completed which included a medical diagnosis and signed as completed by an ESP Clinician with the initials of LICSW to indicate the credentials of the ESP Clinician from ESP Contracted Service B, who performed the evaluation.

The Surveyor interviewed the Executive Director of Risk Services and the Associate Chief Nursing Officer, at 10:20 A.M. on 1/13/17. The Executive Director and the Associate Chief Nursing Officer said the Hospital did not credential (grant Medical Staff privileges or appoint to the Medical Staff) ESP Clinicians and Hospital Social Workers who provided Emergency Psychiatric Evaluations in the Emergency Departments.

The Surveyor interviewed the Emergency Department Medical Director of Hospital Campus A and C at 9:35 A.M. on 1/19/17. The Emergency Department Medical Director said he did not know who ESP Contracted Service A Clinicians were that provided Emergency Psychiatric Evaluations and that the Hospital did not credential the ESP Clinicians.

The Hospital did not provide documentation to indicate Medical Staff credentialing procedures, competency review, nor granting and delineation of clinical privileges based on licensure, training, experience, capacity to perform or evidence of current competency for the ESP Contracted Service Clinicians or Hospital Social Workers, who provided Emergency Psychiatric Evaluations to 9 Emergency Department patients (Patients #1, #3, #4, #5, #7, #8, #10, #11, #12), in accordance with State law and Medical Staff bylaws.

The Hospital did not provide documentation to indicate Medical Staff credentialing procedures or competency review for the Hospital Licencened Independent Clinical Social Workers who performed and authorized Section 12A's (emergency restraint and hospitalization of patients posing risk of serious harm due to psychiatric illness).
VIOLATION: CONTRACTED SERVICES Tag No: A0083
Based on records reviewed and interviews, the Governing Body failed to ensure for 9 of 12 patients (Patients #1, #3, #4, #5, #7, #8, # 10, #11 and #12), that Quality Assessment and Performance Improvement (QAPI) activities evaluated 4 Emergency Department contracts whose staff provided Emergency Psychiatric Evaluations in the Emergency Department.

Findings included:

Medical Staff bylaws, dated 11/19/14, indicated that the Medical Staff consulted with Hospital administration on quality-related aspects of contracts for patient care services.

The Surveyor interviewed the Manager of Social Work Services at 11:30 A.M. on 1/13/17. The Manager of Social Work Services said that 2 Emergency Service Program (ESP) Contracted Services provided psychiatric evaluations in the Hospital's three Emergency Departments. ESP Contracted Service A provided services to Hospital Campus A & B Emergency Departments and ESP Contracted Service B provided services to Hospital Campus C.

The document titled Affiliation Agreement, dated 6/1/2015, indicated ESP Contracted Service A's agreement for psychiatric services in the Emergency Departments at Hospital Campus A & B.

The document titled Clinical Affiliation Agreement, dated 12/1/2006, indicated ESP Contracted Service B's agreement for psychiatric services in the Emergency Department at Hospital Campus C.

The Surveyor interviewed the Executive Director of Risk Services at 11:00 A.M. on 1/18/17. The Executive Director of Risk Services said that the Hospital contracted with 2 Emergency Department physician services; Emergency Department Contract A and Emergency Department Contract B.

The document titled Contract for Emergency Services, dated 12/1/16, indicated Emergency Department Contract A's agreement at Hospital Campus A & C. Emergency Department Physician Contract A indicated contracted physicians were responsible for quality patient care of both Emergency Departments, a quality assurance program and monitoring of the program. Emergency Department Physician Contract A indicated the contract was in compliance with Hospital Medical Staff bylaws and the Conditions of Participation. Emergency Department Physician Contract A indicated contracted physicians would recommend criteria to assure quality of Emergency Department services by Allied Health Professionals and non-physician practitioners.

The document titled Contract for ER Services, dated 1/16/13, indicated Emergency Department Physician Contract B's agreement at Hospital Campus B. Emergency Department Physician Contract B indicated the Medical Chief of the Emergency Department was subject to the provisions of the Hospital Medical Staff. Emergency Department Physician Contract B indicated the Medical Chief was responsible to comply with all requirements of the Conditions of Participation.

The Surveyor interviewed the Chief Operating Officer at 2:45 P.M. on 1/18/17. The Chief Operating Officer said that the Hospital did not perform quality monitoring regarding ESP Contracted Service A whose staff provided ESP Services for Hospital Campus A Emergency Department and Hospital Campus B Emergency Department or for ESP Contracted Service B whose staff provided ESP Services at Hospital Campus C Emergency Department.
VIOLATION: INTEGRATION OF EMERGENCY SERVICES Tag No: A1103
Based on records reviewed and interviews, the Emergency Services failed to ensure for 9 of 12 patients (Patients #1, #3, #4, #5, #7, #8, # 10, #11 and #12), to integrate the care of psychiatric patients in the Emergency Department into the Quality Assessment and Performance (QAPI) Program.

Findings included:

The Surveyor interviewed the Chief Operating Officer at 2:45 P.M. on 1/18/17. The Chief Operating Officer said that the Hospital did not perform quality monitoring regarding the Emergency Service Program (ESP) Contracted Services.

The Hospital did not provide documentation to indicate QAPI activities that collected quality improvement psychiatric patient-care data or monitored and tracked performance for quality psychiatric patient care of the two ESP Contracted Services or the 2 Emergency Department Physician Contracts responsible for psychiatric patient care in the Emergency Departments.
VIOLATION: MEDICAL STAFF BYLAWS Tag No: A0353
Based on records reviewed and interviews, the Medical Staff failed to ensure for 9 of 12 patients (Patients #1, #3, #4, #5, #7, #8, # 10, #11 and #12), they enforced their Medical Staff bylaws for Social Workers and Emergency Service Program (ESP) Clinicians who provided Emergency Psychiatric Evaluations in the 3 Hospital Emergency Departments.

Findings included:

Medical Staff bylaws, dated 11/19/14, indicated that Allied Health Professionals (non-physician practitioner) were Clinical Psychologists, Advanced Registered Nurse Practitioners, Certified Registered Nurse Anesthetists, Certified Nurse Midwives and Physician Assistants; approved by the Governing Body and the Medical Staff credentialing process were permitted to practice medicine at the Hospital.

Medical Staff bylaws did not indicate that individuals who signed Emergency Psychiatric Evaluations with the initials of LCSW (undefined), LMHC (undefined), MSW (undefined), and MA (undefined) were Allied Health Professionals that were approved by the Governing Body and Medical Staff credentialing process to provide psychiatric evaluations at the Hospital. Medical Staff bylaws did not indicate that Hospital Social Workers were approved by the Governing Body and Medical Staff credentialing process to provide psychiatric evaluations at the Hospital.

The Hospital did not provide documentation to indicate Medical Staff credentialing procedures or competency review for Hospital Independent Social Workers who performed and authorized Section 12A's (emergency restraint and hospitalization of patients posing risk of serious harm due to psychiatric illness).

Nine of twelve medical records reviewed (Patients #1, #3, #4, #5, #7, #8, # 10, #11, #12), did not indicate individuals who provided Emergency Psychiatric Evaluations were approved by the Governing Body and Medical Staff credentialing process to provide psychiatric evaluations at the Hospital.

Social Worker Notes for Patient #1 dated 6/3/16 at 1:12 A.M., for Patient #4 dated 1/11/17 at 4:09 P.M. and for Patient #7 dated 6/9/16 at 1:17 A.M., indicated a comprehensive psychiatric evaluation completed, that included a medical diagnosis and signed as completed by a Hospital Social Worker who provided the evaluation.

The Emergency Service Program (ESP) Adult Comprehensive Assessments for Patient #3 dated 1/12/17 at 11 A.M., for Patient #5 dated 1/12/17 at 12:15 A.M., for Patient #8 dated 10/22/16 at 1:04 P.M., for Patient #10 dated 12/19/16 at 4:51 P.M., for Patient #11 dated 1/14/17 at 10:45 P.M. and for Patient #12 dated 1/18/17 at 9:30 P.M., indicated comprehensive psychiatric evaluations completed that included a medical diagnosis and were signed as completed by an ESP Clinician with the initials of either or LCSW, MSW, MA, LMHC, LICSW.

The Surveyor interviewed the Executive Director of Risk Services and the Associate Chief Nursing Officer, at 10:20 A.M. on 1/13/17. The Executive Director of Risk Services and the Associate Chief Nursing Officer said the Hospital did not credential (grant Medical Staff privileges or appoint to the Medical Staff) ESP Clinicians and Hospital Social Workers who provided Emergency Psychiatric Evaluations in the Emergency Department.
VIOLATION: MEDICAL STAFF QUALIFICATIONS Tag No: A0357
Based on records reviewed and interviews, the Medical Staff failed to ensure for 9 of 12 patients (Patients #1, #3, #4, #5, #7, #8, # 10, #11 and #12), that they followed the qualifications to be met by a candidate in order for the Medical Staff to recommend Hospital Social Workers and Emergency Service Program (ESP) Clinicians, who provided Emergency Psychiatric Evaluations in the Emergency Department, be appointed by the Governing Body.

Findings included:

Medical Staff bylaws, dated 11/19/14, indicated that Allied Health Professionals (non-physician practitioner) were Clinical Psychologists, Advanced Registered Nurse Practitioners, Certified Registered Nurse Anesthetists, Certified Nurse Midwives and Physician Assistants; approved by the Governing Body and the Medical Staff credentialing process were permitted to practice medicine at the Hospital.

Medical Staff bylaws did not indicate that individuals who signed Emergency Psychiatric Evaluations with the initials of LCSW (undefined), LMHC (undefined), MSW (undefined), and MA (undefined) were Allied Health Professionals that were approved by the Governing Body and Medical Staff credentialing process to provide psychiatric evaluations at the Hospital. Medical Staff bylaws did not indicate that Hospital Social Workers were approved by the Governing Body and Medical Staff credentialing process to provide psychiatric evaluations at the Hospital.

The Hospital did not provide documentation to indicate Medical Staff credentialing procedures or competency review for Hospital Independent Social Workers who performed and authorized Section 12A's (emergency restraint and hospitalization of patients posing risk of serious harm due to psychiatric illness).

Nine of twelve medical records reviewed (Patients #1, #3, #4, #5, #7, #8, # 10, #11, #12) did not indicate individuals who provided Emergency Psychiatric Evaluations were approved by the Governing Body and Medical Staff credentialing process to provide psychiatric evaluations at the Hospital.

The Hospital did not provide documentation to indicate Medical Staff credentialing procedures, competency review, nor granting and delineation of clinical privileges based on licensure, training, experience, capacity to perform or evidence of current competency for the ESP Contracted Service Clinicians or Hospital Social Workers, who provided Emergency Psychiatric Evaluations to nine Emergency Department patients (Patients #1, #3, #4, #5, #7, #8, #10, #11, #12), in accordance with State law and Medical Staff bylaws.
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
Based on records reviewed and interviews, although the Hospital appointed a Chief Executive Officer, the Governing Body failed to ensure for 9 of 12 patients (Patients #1, #3, #4, #5, #7, #8, # 10, #11 and #12) the Chief Executive Officer was responsible for and managed the Emergency Services provided to psychiatric patients in the Emergency Departments.

Findings included:

Nine of twelve medical records reviewed indicated Hospital Social Workers and Emergency Service Program (ESP) Clinicians completed Emergency Psychiatric Evaluations for Patients #1, #3, #4, #5, #7, #8, # 10, #11 and #12.

The Hospital did not provide documentation to indicate that Hospital Social Workers and ESP Clinicians, who provided Emergency Psychiatric Evaluations to 9 of 12 patients (Patients #1, #3, #4, #5, #7, #8, #10, #11 and #12), underwent Medical Staff credentialing procedures that included competency review, granting and delineation of clinical privileges based on licensure, training, experience, capacity to perform or evidence of current competency in accordance with State law and Medical Staff bylaws.

The Hospital did not provide documentation to indicate Medical Staff credentialing procedures or competency review for the Hospital Licencened Independent Clinical Social Workers who performed and authorized emergency restraint and hospitalization of patients posing risk of serious harm due to psychiatric illness (the document, Section 12A).

The Surveyor interviewed the Chief Operating Officer at 2:45 P.M. on 1/18/17. The Chief Operating Officer said that the Hospital did not perform quality monitoring regarding the ESP Contracted Services Clinicians who provided Emergency Psychiatric Evaluations.

Refer to TAG: A-083
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
Based on records reviewed and interviews, the Governing Body failed to ensure for 9 of 12 patients (Patients #1, #3, #4, #5, #7, #8, # 10, #11 and #12), that the Medical Staff was accountable to the Governing Body for the quality of care to psychiatric patients in the Emergency Department and that psychiatric patients were under the care of Social Workers or Emergency Service Program (ESP) Contracted Services Clinicians that met Medical Staff criteria, and who were granted Medical Staff privileges in accordance with the criteria established by the Governing Body and working within the scope of those granted privileges.

Although the Medical Staff bylaws indicated the Governing Body granted credentials and privileges to practice medicine, to Allied Health Professionals (non-physician practitioners), that included Clinical Psychologists, Advanced Registered Nurse Practitioners, Certified Registered Nurse Anesthetists, Certified Nurse Midwives and Physician Assistants, 9 of 12 medical records reviewed indicated Emergency Psychiatric Evaluations were performed by non-credentialed and privileged Social Workers or ESP Clinicians.

Findings included:

The Medical Staff bylaws, dated 11/19/14, indicated that Allied Health Professionals (non-physician practitioners) were Clinical Psychologists, Advanced Registered Nurse Practitioners, Certified Registered Nurse Anesthetists, Certified Nurse Midwives and Physician Assistants; approved by the Governing Body and the Medical Staff credentialing process were permitted to practice medicine at the Hospital.

For 9 of 12 patients (Patients #1, #3, #4, #5, #7, #8, # 10, #11, #12) the Hospital failed to ensure that practitioners who provided Emergency Psychiatric Evaluations in the Emergency Departments were approved by the Governing Body and Medical Staff credentialing process to provide psychiatric evaluations at the Hospital.

1.) The Social Worker Note, dated 6/3/16 at 1:12 A.M. for Patient #1, indicated a comprehensive psychiatric evaluation was completed and signed by a Hospital Social Worker.

2.) The ESP Adult Comprehensive Assessment, dated 1/12/17 at 11 A.M. for Patient #3, indicated a comprehensive psychiatric evaluation was completed and signed by an ESP Clinician.

3.) The Social Worker Note, dated 1/11/17 at 4:09 P.M. for Patient #4, indicated a comprehensive psychiatric evaluation was completed and signed by a Hospital Social Worker.

4.) The ESP Adult Comprehensive Assessment, dated 1/12/17 at 12:15 A.M. for Patient #5, indicated a comprehensive psychiatric evaluation was completed and signed by an ESP Clinician.

5.) The Social Worker Note, dated 6/9/16 at 1:17 A.M. for Patient #7, indicated comprehensive psychiatric evaluation was completed and signed by a Hospital Social Worker.

6.) The ESP Adult Comprehensive Assessment, dated 10/22/16 at 1:04 P.M. for Patient #8, indicated a comprehensive psychiatric evaluation was completed and signed by an ESP Clinician.

7.) The ESP Adult Comprehensive Assessment, dated 12/19/16 at 4:51 P.M. for Patient #10, indicated a comprehensive psychiatric evaluation was completed and signed by an ESP Clinician.

8.) The ESP Adult Comprehensive Assessment, dated 1/14/17 at 10:45 P.M. for Patient #11, indicated a comprehensive psychiatric evaluation was completed and unsigned by an ESP Clinician.

9.) The ESP Adult Comprehensive Assessment, dated 1/18/17 at 9:30 P.M. for Patient #12, indicated a comprehensive psychiatric evaluation was completed and signed by an ESP Clinician.

There was no indication that a comprehensive psychiatric evaluation was completed for 9 of 12 patients by a credentialed and privileged Allied Health Professional.

The Surveyor interviewed the Emergency Department Medical Director of Hospital Campus A and C at 9:35 A.M. on 1/19/17. The Emergency Department Medical Director said the Hospital did not credential the ESP Clinicians.

The Surveyor interviewed the Executive Director of Risk Services and the Associate Chief Nursing Officer, at 10:20 A.M. on 1/13/17. The Executive Director of Risk Services and the Associate Chief Nursing Officer said the Hospital did not credential (grant Medical Staff privileges or appoint to the Medical Staff) Hospital Social Workers who provided Emergency Psychiatric Evaluations in the Emergency Departments.
VIOLATION: EMERGENCY SERVICES Tag No: A1100
The Condition of Participation for Emergency Services was not met.

Findings included:

The Emergency Services failed to ensure the integration of psychiatric patient care in the Emergency Departments into the Quality Assessment and Performance (QAPI) Program.

Refer to TAG: A-1103

The Emergency Services failed to ensure qualified personnel in emergency care met the needs of psychiatric patients in the Emergency Department.

Refer to TAG: A-1112
VIOLATION: EXECUTIVE RESPONSIBILITIES Tag No: A0309
Based on records reviewed and interviews, the Hospital failed to ensure the Quality Assessment and Performance Improvement (QAPI) Program of 2 Emergency Service Program (ESP) Contracted Services and the 2 Emergency Department Physician Contracts responsible for psychiatric patient care in the Emergency Departments was defined, implemented and maintained.

Findings included:

Medical Staff bylaws, dated 11/19/14, indicated that the Medical Staff consulted with Hospital administration on quality-related aspects of contracts for patient care services.

The documents titled Affiliation Agreement, dated 6/1/2015, and Clinical Affiliation Agreement dated 12/1/2006, did not indicate that the ESP's monitored and tracked performance for quality psychiatric patient care.

The Surveyor interviewed the Chief Operating Officer at 2:45 P.M. on 1/18/17. The Chief Operating Officer said that the Hospital did not perform quality monitoring regarding the ESP Contracted Services.

The documents titled Contract for Emergency Services, dated 12/1/16, and Contract for ER Services dated 1/16/13, indicated the contracted services were responsible for quality patient care of both Emergency Departments, a quality assurance program, compliance with Hospital Medical Staff bylaws and the Conditions of Participation.

The Hospital did not provide documentation to indicate QAPI activities that collected quality improvement psychiatric patient-care data or monitored and tracked performance for quality psychiatric patient care of the 2 ESP Contracted Services or the 2 Emergency Department Physician Contracts responsible for psychiatric patient care in the Emergency Departments.
VIOLATION: QAPI Tag No: A0263
The Condition of Participation for Quality Assurance and Performance Improvement was not met.

Findings included:

The Hospital failed to ensure that Quality Assessment and Performance Improvement (QAPI) activities collected quality improvement psychiatric patient-care data for the 2 Emergency Service Program (ESP) Contracted Services and the 2 Emergency Department Physician Contracts responsible for psychiatric patient care in the Emergency Departments.

Refer to TAG: A-0273

The Hospital failed to ensure that QAPI activities monitored and tracked performance of 2 ESP Contracted Services and the 2 Emergency Department Physician Contracts responsible for psychiatric patient care in the Emergency Departments.

Refer to TAG: A-0283

The Hospital failed to ensure an ongoing QAPI Program of 2 ESP Contracted Services and the 2 Emergency Department Physician Contracts responsible for psychiatric patient care in the Emergency Departments was defined, implemented and maintained.

Refer to TAG: A-0309
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on records reviewed and interviews, the Hospital failed to ensure for 9 of 12 patients (Patients #1, #3, #4, #5, #7, #8, # 10, #11 and #12), that Quality Assessment and Performance Improvement (QAPI) activities collected quality improvement psychiatric patient-care data related to the services provided by the 2 Emergency Service Program (ESP) Contracted Services and the 2 Emergency Department Physician Contracts responsible for psychiatric patient care in the Emergency Departments.

Findings included:

Medical Staff bylaws, dated 11/19/14, indicated that the Medical Staff consulted with Hospital administration on quality-related aspects of contracts for patient care services.

The document titled Affiliation Agreement, dated 6/1/2015, indicated ESP Contracted Service A's agreement for psychiatric services in the Emergency Departments at Hospital Campuses A & B. The Affiliation Agreement did not indicate that the ESP collected quality improvement psychiatric patient-care data that evaluated psychiatric patient-care services provided.

The document titled Clinical Affiliation Agreement, dated 12/1/2006, indicated ESP Contracted Service B's agreement for psychiatric services in the Emergency Department at Hospital Campus C. The Clinical Affiliation Agreement did not indicate that the ESP collected quality improvement psychiatric patient-care data that evaluated psychiatric patient-care services provided.

The document titled Contract for Emergency Services, dated 12/1/16, indicated Emergency Department Contract A's agreement at Hospital Campus A & C. Emergency Department Physician Contract A indicated contracted physicians were responsible for quality patient care of both Emergency Departments, a quality assurance program and monitoring of the program and compliance with Hospital Medical Staff bylaws and the Conditions of Participation.

The document titled Contract for ER Services, dated 1/16/13, indicated Emergency Department Physician Contract B's agreement at Hospital Campus B. Emergency Department Physician Contract B indicated the Medical Chief of the Emergency Department was subject to the provisions of the Hospital Medical Staff. Emergency Department Physician Contract B indicated the Medical Chief was responsible to comply with all requirements of the Conditions of Participation.

The Hospital did not provide documentation to indicate QAPI activities that collected quality improvement psychiatric patient-care data of the 2 ESP Contracted Services or the 2 Emergency Department Physician Contracts responsible for psychiatric patient care in the Emergency Departments.

The Surveyor interviewed the Executive Director of Risk Services at 11:00 A.M. on 1/18/17. The Executive Director of Risk Services said that the Hospital contracted with 2 Emergency Department physician services.

The Surveyor interviewed the Chief Operating Officer at 2:45 P.M. on 1/18/17. The Chief Operating Officer said that the Hospital did not perform quality monitoring regarding ESP Contracted Services in al 3 Emergency Departments.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on records reviewed and interviews, the Hospital failed to ensure that Quality Assessment and Performance Improvement (QAPI) activities monitored and tracked performance of 2 Emergency Service Program (ESP) Contracted Services and the 2 Emergency Department Physician Contracts responsible for psychiatric patient care in the Emergency Departments.

Findings included:

Medical Staff bylaws, dated 11/19/14, indicated that the Medical Staff consulted with Hospital administration on quality-related aspects of contracts for patient care services.

The Hospital did not provide documentation to indicate QAPI activities that collected quality improvement psychiatric patient-care data of the 2 ESP Contracted Services or the 2 Emergency Department Physician Contracts responsible for psychiatric patient care in the Emergency Departments.

The documents titled Affiliation Agreement, dated 6/1/2015, indicated ESP Contracted Service A's agreement for psychiatric services in the Emergency Departments at Hospital Campus A & B and Clinical Affiliation Agreement, dated 12/1/2006, indicated ESP Contracted Service B's agreement for psychiatric services in the Emergency Department at Hospital Campus C did not indicate that the ESP's monitored and tracked performance for quality psychiatric patient care.

The Surveyor interviewed the Chief Operating Officer at 2:45 P.M. on 1/18/17. The Chief Operating Officer said that the Hospital did not perform quality monitoring regarding the ESP Contracted Services.

The document titled Contract for Emergency Services, dated 12/1/16, indicated Emergency Department Contract A's agreement at Hospital Campuses A & C. Emergency Department Physician Contract A indicated contracted physicians were responsible for quality patient care of both Emergency Departments, a quality assurance program and monitoring of the program and compliance with Hospital Medical Staff bylaws and the Conditions of Participation.

The document titled Contract for ER Services, dated 1/16/13, indicated Emergency Department Physician Contract B's agreement at Hospital Campus B. Emergency Department Physician Contract B indicated the Medical Chief of the Emergency Department was subject to the provisions of the Hospital Medical Staff. Emergency Department Physician Contract B indicated the Medical Chief was responsible to comply with all requirements of the Conditions of Participation.

The Hospital did not provide documentation to indicate QAPI activities that monitored and tracked performance for quality psychiatric patient care of the 2 ESP Contracted Services or the 2 Emergency Department Physician Contracts responsible for psychiatric patient care in the Emergency Departments.

The Surveyor interviewed the Executive Director of Risk Services at 11:00 A.M. on 1/18/17. The Executive Director of Risk Services said that the Hospital contracted with 2 Emergency Department physician services.

The Surveyor interviewed the Chief Operating Officer at 2:45 P.M. on 1/18/17. The Chief Operating Officer said that the Hospital did not perform quality monitoring regarding ESP Contracted Services at the 3 Emergency Departments.
VIOLATION: MEDICAL STAFF Tag No: A0338
The Condition of Participation of Medical Staff was not met.

Findings included:

The Hospital failed to ensure it operated under Medical Staff bylaws when they allowed different levels of Hospital Social Workers and Emergency Service Program (ESP) Clinicians to provide Emergency Psychiatric Evaluations for 9 of 12 patients (Patients #1, #3, #4, #5, #7, #8, # 10, #11 and #12) in the Emergency Departments. The Hospital failed to ensure that the Hospital Social Workers and the ESP Clinicians performance was reviewed for competency under the Hospital's Medical Staff privileging procedures, determined to be eligible for appointment by the Governing Body to be privileged to provide psychiatric care to Emergency Department patients.

Refer to TAG: A-0339

The Medical Staff failed to ensure that Psychiatric Evaluations were performed by Allied Health Professionals after they examined the credentials of Hospital Social Workers and Emergency Service Program (ESP) Clinicians who provided Emergency Psychiatric Evaluations in the Emergency Departments, for Medical Staff membership and made recommendations to the Governing Body on the appointment of those candidates in accordance with State law, including scope-of-practice laws and the Medical Staff bylaws, Rules, and Regulations.

Refer to TAG: A-0341

The Medical Staff failed to ensure that they enforced their Medical Staff bylaws for Social Workers and Emergency Service Program (ESP) Clinicians who provided Emergency Psychiatric Evaluations in the three Hospital Emergency Departments.

Refer to TAG: A-0353

The Medical Staff failed to ensure that they followed the qualifications of a candidate in order for the Medical Staff to recommend Hospital Social Workers and Emergency Service Program (ESP) Clinicians, who provided Emergency Psychiatric Evaluations in the Emergency Department, be appointed by the Governing Body.

Refer to TAG: A-0357
VIOLATION: COMPOSITION OF THE MEDICAL STAFF Tag No: A0339
Based on records reviewed and interviews, the Medical Staff failed to ensure for 9 of 12 patients (Patients #1, #3, #4, #5, #7, #8, # 10, #11 and #12), it operated under Medical Staff bylaws when they allowed different levels of Hospital Social Workers and Emergency Service Program (ESP) Clinicians to provide Emergency Psychiatric Evaluations in the Emergency Departments. The Hospital failed to ensure that the Hospital Social Workers and the ESP Clinicians performance was reviewed for competency under the Hospital's Medical Staff privileging procedures, determined to be eligible for appointment by the Governing Body to be privileged to provide psychiatric care to Emergency Department patients.

Findings included:

Medical Staff bylaws, dated 11/19/14, indicated that Allied Health Professionals (non-physician practitioners) were Clinical Psychologists, Advanced Registered Nurse Practitioners, Certified Registered Nurse Anesthetists, Certified Nurse Midwives and Physician Assistants; approved by the Governing Body and the Medical Staff credentialing process were permitted to practice medicine at the Hospital.

Medical Staff bylaws did not indicate that individuals who signed Emergency Psychiatric Evaluations with the initials of LCSW (undefined), LMHC (undefined), MSW (undefined), and MA (undefined) were Allied Health Professionals that were approved by the Governing Body and Medical Staff credentialing process to provide psychiatric evaluations at the Hospital. Medical Staff bylaws did not indicate that Hospital Social Workers were approved by the Governing Body and Medical Staff credentialing process to provide psychiatric evaluations at the Hospital.

Nine of twelve medical records reviewed (Patients #1, #3, #4, #5, #7, #8, # 10, #11, #12), did not indicate individuals who provided Emergency Psychiatric Evaluations were approved by the Governing Body and Medical Staff credentialing process to provide Emergency Psychiatric Evaluations at the Hospital.

Social Worker Notes for Patient #1 dated 6/3/16 at 1:12 A.M., for Patient #4 dated 1/11/17 at 4:09 P.M. and for Patient #7 dated 6/9/16 at 1:17 A.M., indicated a comprehensive psychiatric evaluation completed that included a medical diagnosis and signed as provided by a Hospital Social Worker.

Emergency Service Program (ESP) Adult Comprehensive Assessments for Patient #3 dated 1/12/17 at 11 A.M., for Patient #5 dated 1/12/17 at 12:15 A.M., for Patient #8 dated 10/22/16 at 1:04 P.M., for Patient #10 dated 12/19/16 at 4:51 P.M., for Patient #11 dated 1/14/17 at 10:45 P.M. and for Patient #12 dated 1/18/17 at 9:30 P.M., indicated comprehensive psychiatric evaluations completed, that included a medical diagnosis and signed as provided by either an ESP Clinician with the initials of LCSW, MSW, MA, LMHC, or LICSW.

The Surveyor interviewed the Executive Director of Risk Services and the Associate Chief Nursing Officer, at 10:20 A.M. on 1/13/17. The Executive Director of Risk Services and the Associate Chief Nursing Officer said the Hospital did not credential (grant Medical Staff privileges or appoint to the Medical Staff) ESP Clinicians and Hospital Social Workers who provided Emergency Psychiatric Evaluations in the Emergency Departments.
VIOLATION: MEDICAL STAFF CREDENTIALING Tag No: A0341
Based on records reviewed and interviews, the Medical Staff failed to ensure for 9 of 12 patients (Patients #1, #3, #4, #5, #7, #8, # 10, #11 and #12), Psychiatric Evaluations were performed by Allied Health Professionals only after the Medical Staff examined the credentials of Hospital Social Workers and Emergency Service Program (ESP) Clinicians who provided Emergency Psychiatric Evaluations in the Emergency Department. The Medical Staff failed to examine credentials, for Medical Staff membership and made recommendations to the Governing Body on the appointment of those candidates in accordance with State law, including scope-of-practice laws and the Medical Staff bylaws, Rules, and Regulations.

Findings included:

Medical Staff bylaws, dated 11/19/14, indicated that Allied Health Professionals (non-physician practitioners) were Clinical Psychologists, Advanced Registered Nurse Practitioners, Certified Registered Nurse Anesthetists, Certified Nurse Midwives and Physician Assistants; approved by the Governing Body and the Medical Staff credentialing process were permitted to practice medicine at the Hospital.

Medical Staff bylaws did not indicate that individuals who signed Emergency Psychiatric Evaluations with the initials of LCSW (undefined), LMHC (undefined), MSW (undefined), and MA (undefined) were Allied Health Professionals that were approved by the Governing Body and Medical Staff credentialing process to provide psychiatric evaluations at the Hospital. Medical Staff bylaws did not indicate that Hospital Social Workers were approved by the Governing Body and Medical Staff credentialing process to provide psychiatric evaluations at the Hospital.

Nine of twelve medical records reviewed (Patients #1, #3, #4, #5, #7, #8, # 10, #11, #12), did not indicate individuals who provided Emergency Psychiatric Evaluations were approved by the Governing Body and Medical Staff credentialing process to provide Emergency Psychiatric Evaluations at the Hospital.

Social Worker Notes for Patient #1 dated 6/3/16 at 1:12 A.M., for Patient #4 dated 1/11/17 at 4:09 P.M. and for Patient #7 dated 6/9/16 at 1:17 A.M., indicated a comprehensive psychiatric evaluations completed that included a medical diagnosis and signed as completed by a Hospital Social Worker who provided the evaluation.

The Emergency Service Program (ESP) Adult Comprehensive Assessments for Patient #3 dated 1/12/17 at 11 A.M., for Patient #5 dated 1/12/17 at 12:15 A.M., for Patient #8 dated 10/22/16 at 1:04 P.M., for Patient #10 dated 12/19/16 at 4:51 P.M., for Patient #11 dated 1/14/17 at 10:45 P.M. and for Patient #12 dated 1/18/17 at 9:30 P.M., indicated comprehensive psychiatric evaluations completed that included a medical diagnosis and signed as completed by either or an ESP Clinician with the initials of LCSW, MSW, MA, LMHC, LICSW.

The Surveyor interviewed the Executive Director of Risk Services and the Associate Chief Nursing Officer at 10:20 A.M. on 1/13/17. The Executive Director of Risk Services and the Associate Chief Nursing Officer said the Hospital did not credential (grant Medical Staff privileges or appoint to the Medical Staff) ESP Clinicians and Hospital Social Workers who provided Emergency Psychiatric Evaluations in the Emergency Department.

The Hospital did not provide documentation to indicate Medical Staff credentialing procedures, competency review, nor granting and delineation of clinical privileges based on licensure, training, experience, capacity to perform or evidence of current competency for the ESP Contracted Service Clinicians or Hospital Social Workers who provided Emergency Psychiatric Evaluations to 9 Emergency Department patients (Patients #1, #3, #4, #5, #7, #8, #10, #11, #12), in accordance with State law and Medical Staff bylaws.

The Hospital did not provide documentation to indicate Medical Staff credentialing procedures or competency review for the Hospital Licencened Independent Clinical Social Workers who performed and authorized Section 12A's (emergency restraint and hospitalization of patients posing risk of serious harm due to psychiatric illness).