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.

THE MOSES H CONE MEMORIAL HOSPITAL 1200 N ELM ST GREENSBORO, NC 27401 Sept. 1, 2017
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on current hospital policy and procedure reviews, Medical and Dental Staff bylaws, rules and regulations review, medical record reviews, central log reviews, personnel file reviews, provider schedule reviews, observations during tour, physician and staff interviews; the hospital's Dedicated Emergency Department (DED) physicians failed to ensure that an appropriate Medical Screening Examination (MSE) were provided/conducted by Qualified medical personnel as defined in their Medical and Dental Staff Bylaws, Rules and Regulations to determine whether or not an Emergency Medical Condition (EMC) existed for 3 of 37 sampled DED patients who presented to the hospital's DED for evaluation and treatment (Patients #34, #35, and #33).

Findings revealed:

1. On 08/25/2017 at 1155, Patient #33 a [AGE]-year-old pregnant female presented to Hospital A's Women's Hospital (Campus C) via private transportation for complaints of "Contractions." An MSE was performed by a qualified RN. The patient was discharged at 1307. Record review failed to reveal any documentation a physician, certified nurse-midwife, or other qualified medical person acting within his or her scope of practice as defined in hospital medical staff bylaws and State law, certified that, after a reasonable time of observation, Patient #33 was in false labor. Record review failed to reveal any documented final discharge diagnosis or discharge order authenticated by a physician.


2. On 08/11/2017 at 1255, Patient #34 a [AGE]-year-old male presented to Hospital A's Behavioral Health Hospital (BHH) [Campus D] as a "walk-in" for complaints of "Polysubstance Abuse" and "irritable, drug use, alcohol use." The patient was assessed by a Licensed Professional Counselor and discharged at 1346. The patient was not provided a MSE by a QMP as defined in the hospital's Medical and Dental Staff, Bylaws, Rules and Regulations; to rule out the existence of an EMC.

3. On 08/09/2017 at 1721, Patient #35 a [AGE]-year-old male presented to Hospital A's Behavioral Health Hospital (BHH) [Campus D] as a "walk-in" for complaints of "Major Depressive Disorder, Recurrent Severe." The patient was assessed by a Licensed Professional Counselor and discharged at 1750. The patient was not provided a MSE by a QMP as defined in the hospital's Medical and Dental Staff, Bylaws, Rules and Regulations; to rule out the existence of an EMC.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on current hospital policy and procedure reviews, Medical and Dental Staff bylaws, rules and regulations review, medical record reviews, central log reviews, personnel file reviews, provider schedule reviews, observations during tour, physician and staff interviews; the hospital's Dedicated Emergency Department (DED) physicians failed to ensure that an appropriate Medical Screening Examination (MSE) were provided/conducted by Qualified medical personnel as defined in their Medical and Dental Staff Bylaws, Rules and Regulations to determine whether or not an Emergency Medical Condition (EMC) existed for 3 of 37 sampled DED patients who presented to the hospital's DED for evaluation and treatment (Patients #34, #35, and #33).

Findings included:

Review on 08/30/2017 of Hospital A's policy, "Emergency Medical Treatment and Labor Act (EMTALA) Compliance", PR-ED-2012-63, effective date: 06/16/2017, revealed "PURPOSE: To establish the procedure by which individuals seeking or requiring emergency care are appropriately screened, examined, stabilized, treated, and/or transferred from or to a (Hospital A name) Health facility. To establish guidelines for providing appropriate medical screening examinations and, if the individual is determined to have an emergency medical condition, any necessary stabilizing treatment or an appropriate transfer for the individual as required by the Emergency Medical Treatment and Labor Act (EMTALA), 42 U.S.C. Section 1395dd, and all federal regulations and interpretive guidelines promulgated thereunder. ...DEFINITIONS: ...o Medical screening examination (MSE): The process required to reach, with reasonable clinical confidence, determination of whether or not an emergency medical condition exists or a woman is in labor. Such screening is done within the capability of the hospital and available personnel, including on-call physician. The MSE is an ongoing process that continues until the patient is either stabilized or appropriately transferred. o Qualified medical personnel (QMP): The medical screening exam will be conducted by an individual who is determined qualified by the hospital by-laws or rules and regulations to conduct the examination. At....Health, it will be a physician, physician assistant, nurse practitioner, sexual assault nurse examiner (SANE), and/or a labor and delivery nurse. ...POLICY: It is the policy of....Health to conduct MSEs for all patients who come to the hospital seeking emergency care, provide stabilizing treatments to those individuals found to have an emergency medical condition, and transfer all individuals appropriately without delay in compliance with federal guidelines (EMTALA). PROCEDURE: Medical Screening Examination (MSE): 1. Any individual that presents to a....Health dedicated Emergency Department or hospital property and requests examination or treatment for a medical condition; or has such a request made on his or her behalf; or would appear to a prudent layperson observer to need examination or treatment for a medical condition will be provided a MSE to determine if an emergency medical condition exists. 2. The MSE will be performed within the capability and capacity of the hospital, including ancillary services, resources routinely available, and on-call providers as indicated. 3. Patients presenting to the....Health Behavioral Health Hospital (BHH) for evaluation of a medical condition will have an MSE performed by a QMP. 4. The QMP shall determine if an emergency medical condition exists. ...6. Emergency Department triage is not a medical screening examination. 7. The MSE will be uniform for patients presenting with similar symptoms. ...11. If an individual or legal representative on behalf of the individual refuses to allow an MSE, including the refusal of ancillary services, conducted in the course of the examination or treatment, the following shall occur: o The provider shall attempt to determine the individual's decisional capacity to refuse an MSE. o The provider shall inform the individual (or legal representative) of the hospital's obligation to perform an MSE as well as the benefits of the examination, and the significant known risks of refusing such an examination. o If the individual is determined to be capacitated and thus able to make a decision to refuse the examination, the individual will be asked to sign an informed consent for refusal of examination and treatment. The individual shall be invited to return to....Health at any time. o If the individual is determined to be incapacitated and unable to make a decision to refuse the examination, the hospital shall detain the individual until an MSE has been performed. A description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual shall be documented in the medical record. ..."

Review on 08/30/2017 of Hospital A's 2017 Medical and Dental Staff Bylaws and Rules and Regulations revealed on page 164, "...7. The Medical Screening Examination required under EMTALA shall be conducted by one of the following categories of staff: (a) Physician on the Staff with appropriate Clinical Privileges; or (b) a Class I Advanced Practice Provider (APP) (Physician Assistant/Nurse Practitioner); or (c) a Class II Allied Health Professional (Registered Nurse Level II or higher). ..." Review revealed no documentation a "Counselor" was deemed a QMP for conducting MSE on patients to determine the existence of an EMC.

Review on 09/01/2017 of Hospital A's DED policy, "Triage", effective 04/2015, revealed, "I. Purpose: Determine priority of care based on physical and psychological needs. II. Guideline: 1. Every patient will be medically screened by an Emergency Department Physician, Physician's Assistant, Nurse Practitioner or other staff physician. ..."

Review on 09/01/2017 of Hospital A's Behavioral Health Services policy, "Initial Screening Assessment", reviewed 3/16, revealed "PURPOSE: Patients presenting with a psychiatric condition to a....Health System emergency department or the Behavioral Health Hospital [BHH] (Campus D) will be evaluated to determine the appropriate level of care. ...POLICY: In order to evaluate the person presenting for possible care from....Behavioral Health Services, an initial screening of the individual's physical, psychological and social function is conducted to determine the need for treatment. The initial assessment is performed by Behavioral Health Services staff in the emergency department or at....Patients presenting to the....Health Behavioral Health Hospital (BHH) for evaluation of a medical condition will have a Medical Screening Exam (MSE) performed by a qualified medical person (physician, physician assistant, or nurse practitioner) as defined by the....Health Medical Staff Rules and Regulations. If the patient's psychiatric condition does not warrant inpatient hospitalization , the patient will have a MSE completed by a qualified medical person (QMP). If an emergency medical condition is present, then stabilizing treatment and/or appropriate transfer will be provided. PROCEDURE: 1. A member of Behavioral Health Services will assess the patient presenting for psychiatric evaluation. This assessment includes the following: * Relevant personal information * The presenting problem * Psychiatric history * Functional Status * Risk assessment for suicide, homicide, and violence * Substance abuse history * Medical history * Legal history * Abuse history * Suicide risk * Violence risk ...3. If the patient presents to a....Health System emergency department for psychiatric issues, the ED physician will determine appropriate disposition based on the patient's presenting problem. The ED physician may involve a member of Behavioral Health Services to assist with disposition and/or securing appropriate placement. 4. If the intake assessment is completed by a member of the Therapeutic Triage or Intake/Referral Specialist, the findings will be reviewed with the on-call psychiatrist or designee (nurse practitioner or physician assistant). Recommendations from the on-call psychiatrist will be shared with the ED physician. The ED physician makes final decision on disposition. Assessments completed by the psychiatrist, nurse practitioner, or physician assistant will be communicated to the ED physician. ...7. Patient's meeting criteria for outpatient services will have a medical screening exam by a qualified medical person if presenting to the Behavioral Health Hospital as a walk-in assessment. If the patient refuses the medical screening exam, the patient will be given a form to sign stating they are refusing the exam. This form will be sent to medical records and scanned into the patient's chart. ..."

Comparison reviews between Hospital A's DED policy "Triage" and the BHH policy, "Initial Screening Assessment" revealed patients presenting for emergency care with similar psychiatric and/or substance abuse complaints to the hospital's DED(s) on Campus A, B, C, E and F and to the BHH (Campus D) as "Walk-ins" do not receive the same MSE to rule out the existence of an EMC.

Observation on 08/31/2017 at 1540 during tour of Hospital A's Behavioral Health Hospital (Campus D) revealed the following signage posted outside the main entrance to the building, "Patient Emergency Entrance ---> (arrow pointing towards the right)'."

1. Review on 08/30/2017 of Hospital A's "COBRA Log" for the BHH (Campus D) dated 08/11/2017, revealed Patient #34, a [AGE]-year-old male presented via car at 1230 as a "walk-in" for complaints of "Polysubstance Abuse." The patient's disposition was "Outpatient Resources." The patient's departure time was 1346. Further review revealed "MSE Complete, N/A (not applicable)" with "N/A" documented.

Hospital A, closed medical record review on 08/30/2017 for Patient #34 revealed a [AGE]-year-old male, who presented as a walk-in to the hospital's Behavioral Health Hospital (Campus D) on 08/11/2017 at 1255 accompanied by his mother for evaluation and treatment for "irritable, drug use, alcohol use." Record review revealed the patient was assessed by a "Counselor." Review revealed the patient had a face-to-face initial assessment at 1353 by Counselor #2. Further review revealed "Medical Screening Exam (BHH Walk-in ONLY) Medical Exam Completed No Reason for MSE not completed Other: Walk-in." Review of BHH Assessment documentation by Counselor #2, dated 08/11/2017 at 1401 revealed, "Assessment Note ...is a 37 y.o. male who presented with mother to BHH as a walk-in. Pt presented voluntarily but grudgingly -- mother insisted he come. Pt and mother provided the following history: Pt moved from NJ to NC three months ago in an attempt to do better in his life. He is currently staying with his sister (sister's name), her husband, and the couple's child. Per mother, Pt is a drug addict. Pt endorsed weekly-to-daily use of alcohol and marijuana. When asked if he wanted to stop use, Pt stated, 'No, I want to keep smoking a lot of weed.' Pt also admitted to crushing and snorting 6-7 tabs of clonazepam last night 'because it felt good.' He said it was his first time using clonazepam. Client was very irritable with mother during assessment, stating that he only came because his sister asked him to leave the family home due to drug use, and mother insisted that he come. Pt stated that he has no interest in seeking substance use treatment at this time. In addition to substance use, Pt endorsed a history of ADHD (Attendtion Deficit Hyperactivity Disorder) for which he was previously treated with Adderall (stimulant). He is currently not taking any psychotropic medication, and he does not have a therapist or psychiatrist. Pt denied that being intoxicated today. Mother expressed concern that Pt poses a danger to his sister and brother-in-law because he openly uses drugs and per her report, left substances around his sister's baby. Pt denied this. Advised mother and Pt about the criteria for inpatient treatment. During assessment, Pt was alert, oriented x4, and very irritable. He had good eye contact. Pt was dressed in street clothes and appeared appropriately groomed. He appeared restless. Demeanor was combative with mother. Pt reported mood as angry. Affect was congruent. Pt denied suicidal ideation, any previous suicide attempts, homicidal ideation, auditory/visual hallucination, and self-injury. He endorsed a life-long history of insomnia and poor appetite, which he attributed to ADHD. Pt endorsed weekly to daily use of marijuana and alcohol -- varied amounts ingested. Pt also endorsed one-time use of snorted clonazepam. He also said that he has used Percocet while in NJ. Pt's speech was loud (angry), but otherwise normal in rate and rhythm. Pt's memory and concentration were intact. Thought processes and thought content were within normal range. Pt's insight, judgment, and impulse control were deemed fair to poor. Consulted with (Nurse Practitioner #1), who determined that Pt does not meet inpatient criteria. Author provided Pt with a list of substance use resources and encouraged mother to contact police if she witnesses Pt driving while intoxicated. Diagnosis: Polysubstance Use Disorder. Past Medical History: No past medical history on file. No past surgical history on file. Family History: No family history on file. Social History: reports that he drinks alcohol. He reports that he uses drugs, including Marijuana and Benzodiazepines, about 7 times per week. His tobacco history is not on file. ...General Assessment Data Location of Assessment: BHH Assessment Services TTS Assessment: In system Is this a Tele or Face-to-Face Assessment?: Face-to-Face Is this an Initial Assessment or a Re-assessment for this encounter?: Initial Assessment Marital status: Single ...Living Arrangements: Other relatives (Sister [name]; brother in law) Can pt return to current living arrangement?: Yes Admission Status: Voluntary Is patient capable of signing voluntary admission?: Yes Referral Source: Self/Family/Friend (Mother [name] xxx-xxx-xxxx) Insurance type: Self-pay Medical Screening Exam (BHH Walk-in ONLY) Medical Exam completed: No Reason for MSE not completed: Other: (Walk-in) Crisis Care Plan Living Arrangements: Other relatives (Sister [name]; brother in law) Name of Psychiatrist: None Name of Therapist: None Education Status Is patient currently in school?: No Risk to self with the past 6 months Suicidal Ideation: No Has patient been a risk to self within the past 6 months prior to admission?: No Suicidal Intent: No Has patient had any suicidal intent within the past 6 months prior to admission?: No Is patient at risk for suicide?: No Suicidal Plan?: No Has patient had any suicidal plan within the past 6 months prior to admission?: No Access to Means: No What has been your use of drugs/alcohol within the last 12 months?: Marijuana, Alcohol (Pt reported that he crushed and short [sic] Klonipin [sic] for 1st time) Previous Attempts/Gestures: No Intentional Self Injurious Behavior: None Family Suicide History: No Recent stressful life event(s): Financial Problems (Working two jobs to earn money) Persecutory voices/beliefs?: No Depression: No Depression Symptoms: Feeling angry/irritable Substance abuse history and/or treatment for substance abuse?: Yes Suicide prevention information given to non-admitted patients: Not applicable Risk to Others within the past 6 months Homicidal Ideation: No Does patient have any lifetime risk of violence toward others beyond the six months prior to admission?: No Thoughts of Harm to Others: No Current Homicidal Intent: No Current Homicidal Plan: No Access to Homicidal Means: No History of harm to others?: No Assessment of Violence: None Noted Does patient have access to weapons?: No Criminal Charges Pending?: No Does patient have a court date: No Is patient on probation?: No Psychosis Hallucinations: None noted Delusions: None noted Mental Status Report Appearance/Hygiene: Unremarkable (Street clothes) Eye Contact: Good Motor Activity: Freedom of movement, Restlessness Speech: Logical/coherent, Argumentative Level of Consciousness: Irritable, Alert Mood: Angry Affect: Angry Anxiety Level: None Thought Processes: Relevant, Coherent Judgement: Partial Orientation: Person, Time, Place, Situation Obsessive Compulsive Thoughts/Behaviors: None Cognitive Functioning Concentration: Normal Memory: Recent Intact, Remote Intact IQ: Average Insight: Poor Impulse Control: Poor Appetite: Fair Sleep: Decreased Vegetative Symptoms: None ADL Screening (BHH Assessment Services) Patient's cognitive ability adequate to safely complete daily activities?: Yes Patient able to express need for assistance with ADLs?: Yes Independently performs ADLs?: Yes (appropriate for developmental age) Prior Inpatient Therapy Prior Inpatient Therapy: No Prior Outpatient Therapy Prior Outpatient Therapy: Yes Prior Therapy Dates: About 10 years ago Prior Therapy Facility/Provider(s): Provider in NJ Reason for Treatment: ADHD Does patient have an ACCT team?: No Does patient have Intensive In-House Services?: No Does patient have Monarch services?: No Does patient have P4CC services?: No ADL Screening (condition at time of admission) Patient's cognitive ability adequate to safely complete daily activities?: Yes Is the patient deaf or have difficulty hearing?: No Does the patient have difficulty seeing, even when wearing glasses/contacts?: No Does the patient have difficulty concentrating, remembering, or making decisions?: No Patient able to express need for assistance with ADLs?: Yes Does the patient have difficulty dressing or bathing?: No Independently performs ADLs?: Yes (appropriate for developmental age) Does the patient have difficulty walking or climbing stairs?: No Weakness of Legs: None Weakness of Arms/Hands: None Home Assistive Devices/Equipment Home Assistive Devices/Equipment: None Therapy Consults (therapy consults require a physician order) PT (Physical Therapy) Evaluation Needed: No OT (Occupational Therapy) Evaluation Needed: No SLP (Speech Language Pathology) Evaluation Needed: No Abuse/Neglect Assessment (Assessment to be complete while patient is alone) Physical Abuse: Denies Verbal Abuse: Denies Sexual Abuse: Denies Exploitation of patient/patient's resources: Denies Self-Neglect: Denies Values / Beliefs Cultural Requests During hospitalization : None Spiritual Requests During hospitalization : None Consults Spiritual Care Consult Needed: No Social Work Consult Needed: No Advance Directives (For Healthcare) Does patient have an advance directive?: No Would patient like information on creating an advanced directive?: No - patient declined information Additional Information 1:1 In Past 12 Months?: No CIRT Risk: No Elopement Risk: No Does patient have medical clearance?: No Disposition: Disposition Initial Assessment Completed for this Encounter: Yes Disposition of Patient: Other dispositions Other disposition(s): Information only (Per [NP #1], Pt does not meet inpt criteria- resources) On Site Evaluation by: (LEFT BLANK) Reviewed with Physician: (LEFT BLANK)." The patient was discharged on [DATE] at 2359 (automatic system discharge time). Further record review failed to reveal any available documentation the patient had a MSE performed by a qualified QMP as defined by the hospital's Medical Staff Bylaws, Rules and Regulations.

Review on 09/01/2017 of Hospital A's personnel file for Counselor #2 revealed he was hired on 01/16/2017. Review revealed documentation of a job description for a "Triage Specialist BHH" (created 08/01/2014). Review of the job description revealed, "JOB SUMMARY: Provide assessment services (including evaluation, consultation and/or referral) for patients presenting with a psychiatric or substance abuse issue in the emergency department or Behavioral Health. This position serves the adult, geriatric, child and adolescent population. ...LICENSURE/CERTIFICATION/REGISTRY/LISTING-REQUIRED ...N.C. provisional license in one of the following: LPC (Licensed Professional Counselor), LMFT (Licensed Marriage Family Therapist), LCSW (Licensed Clinical Social Worker), LCAS (Licensed Clinical Addiction Specialist) or licensed psychologist. Must obtain full licensure in one of the above categories within 3 years from start date as Triage Specialist. ...MAJOR WORK ACTIVITIES ...Makes a timely assessment of patients who present with behavioral health needs either in the ED (report from BHH within 30 mins) or at BHH. Conduct a behavioral health assessment, determining the level of care that is in the best interest of the patient. ...Consulting with physicians in the evaluation of psychiatric and/or substance abuse patients, contacting collateral's as necessary, making dispositions that are in the best interest of the patient..." Review of the job description revealed no documentation Triage Specialist BHH were authorized to conduct medical/physical examinations or medical screening examinations. Further review of Counselor #2's personnel file revealed he was a LPC and there was no documentation he was trained as a physician, physician's assistant, nurse practitioner, or qualified registered nurse (as required per the Medical Staff Bylaws, Rules and Regulations to perform a medical screening examination).

Interview during Patient #34's EMR review with Physician R for the patient's 08/11/2017 visit, revealed she was able to review the documentation of the BHH assessment (psychiatric screening) performed by Counselor #2, who documented consulting NP #1. Interview revealed she was unable to find any available documentation of a consult or MSE performed by NP #1 on 08/11/2017. Interview revealed she would have expected to see documentation by NP #1 of her MSE. She stated, "it does not look like the patient received a complete MSE." Based on the documentation, Physician R stated she could not determine if an EMC existed on 08/11/2017, because there was no medical component documented in the record. Interview revealed all patients were staffed by a licensed counselor, PA/NP, and the case was discussed with the on-call Psychiatrist, even for tele-psychiatry. Further interview revealed she was unable to find any available documentation of an attestation statement signed by the attending Psychiatrist. When asked if Patient #34 had an appropriate MSE, she stated "Nope." Interview revealed, there was a separate documentation template in EPIC (electronic medical record program) for the MSE to be documented by the QMP. The hospital recently had a computer upgrade in July/August and she hoped this was not a "glitch." Interview confirmed the EMR review findings. Further interview revealed all staff were provided ongoing EMTALA education and training.

Interview on 08/31/2017 at 0930 with Physician R revealed she was Hospital A's Chief of Psychiatry and the Medical Director for the Behavioral Health Hospital (Campus D). The BHH was an 80 bed(s) hospital, part of the (Hospital A's Name) Health System and under the same Medicare Certification Number as Campuses A, B, C, E, and F. Interview revealed "walk-ins" were accepted at the BHH campus 24 hours per day/7 days per week along with patients brought in by EMS (emergency medical services) and Law Enforcement personnel. The patient's initial assessment was performed by TTS (Therapeutic Triage Service) licensed counselors. The counselors can be either a Licensed Professional Counselor (LPC), Licensed Clinical Social Worker (LCSW), or Licensed Clinical Addiction Specialist (LCAS). The counselor performs the psychiatric screening and the medical screening examination (MSE) is performed by a Nurse Practitioner (NP), Physicians' Assistant (PA). Both assessment components (Psychiatric Screening and Medical Screening) must be completed on each patient to have an appropriate MSE performed. When the patient refuses to have the medical screening performed by the NP or PA, it is documented as a refusal and the patient signs and AMA (against medical advice) form. EMTALA applies to all patients who present to the BHH except transfers/direct admits. The MSE must be performed by a QMP which includes, NP, PA, Certified Psychiatric NP, and Physicians. The licensed counselors are not considered qualified for conducting an MSE. The NP, PA, or Physician determines if an EMC exists. Further interview during Patient #34's EMR (electronic medical record) review with Physician R for the patient's 08/09/2017 visit, revealed she was able to review the documentation of the BHH assessment (psychiatric screening) performed by Counselor #3, who documented consulting NP #2. NP #2 was currently out of the country after getting married. Interview revealed she was unable to find any available documentation of a consult or MSE performed by NP #2 on 08/09/2017. Interview revealed she would have expected to see documentation by NP #2 of his MSE. She stated, "It does not look like the patient received a complete MSE." Based on the documentation, Physician R stated she could not determine if an EMC existed on 08/09/2017, because there was no medical component documented in the record. Interview revealed all patient's cases were staffed by a licensed counselor, PA/NP, and the case was discussed with the on-call Psychiatrist, even for tele-psychiatry. Further interview revealed she was unable to find any available documentation of an attestation statement signed by the attending Psychiatrist. When asked if Patient #34 had an appropriate MSE, she stated "Nope." Interview revealed, there was a separate documentation template in EPIC (electronic medical record program) for the MSE to be documented by the QMP. The hospital recently had a computer upgrade in July/August and she hoped this was not a "glitch." Interview confirmed the EMR review findings. Further interview revealed all staff were provided ongoing EMTALA education and training.

Concurrent interviews on 08/31/2017 at 1105 with Hospital A's Director #1 and Counselor #4, revealed the Director was the BHH's Interim Director of the Therapeutic Triage Services (TTS) and the Counselor was the Lead Therapist/Counselor. Interview revealed staff maintained a daily log of all walk-ins (patients) who presented to the BHH (Campus D) seeking evaluation and treatment. The number of walk-ins varied daily. The lobby is open and unsecured during the hours of operation. Individuals can walk-in to the hospital lobby and request to be evaluated. The assessment rooms are located adjacent to the lobby. Patients tell the receptionist their complaint and the receptionist notifies the clinical staff member. If the patient has a medical issue the house supervisor (a RN) triages the person and they are sent to the emergency department at Campus B by ambulance. If there were no medical problems the patient's personal possessions are locked up and the patient is screened by security and given a sticker and waits in the lobby. The therapist (counselor) is made aware the patient is ready to be seen. Counselors may be Licensed Professional Counselors (LPC), Licensed Clinical Social Workers (LCSW), or Licensed Clinical Addiction Specialist. The counselor takes the patient to the assessment area and conducts an initial psycho-social assessment. The patient is "offered" a medical screening by a NP or PA and if they refuse, an AMA form is signed. If the patient is admitted the patient will be evaluated by a NP or PA. If the patient is not admitted , the patient may or may not be seen by a NP or PA. Interview revealed the Counselor performs a psycho-social assessment only and does not perform the medical examination. Counselors are not considered QMP. The NP or PA has final say over the MSE and consults the Psychiatrist as needed. If a MSE is performed there should be documentation of the psychiatric assessment and the medical assessment in the record.

Interview on 09/01/2017 at 1023 with CMO #1, revealed he was Hospital A's and the Health System's Chief Medical Officer. Current medical staff bylaws, rules and regulations did not define Behavioral Health Hospital Counselors as Qualified Medical Personnel (QMP) to perform Medical Screening Examinations (MSE). Interview revealed he believed, "the best intentions by the BHH staff was that they were doing the right thing by the patient." Interview revealed "People who walk into the BHH are walking into the ED." Interview revealed the Counselors cannot perform MSE. They can perform psycho-social assessments.

09/01/2017 - NP #2 was unavailable for interview prior to survey exit.

2. Review on 08/30/2017 of Hospital A's "COBRA Log" for the BHH (Campus D) dated 08/09/2017, revealed Patient #35, a [AGE]-year-old male presented via car at 1721 as a "walk-in" for complaints of "MDD R/S (Major Depressive Disorder, Recurrent Severe." The patient's disposition was "D/C (discharge) c (with) F/U (follow-up)." The patient's departure time was 1750. Further review revealed "MSE Complete, N/A (not applicable)" with "N/A" documented.

Hospital A, closed medical record review on 08/30/2017 for Patient #35 revealed a [AGE]-year-old male, who presented as a walk-in to the hospital's Behavioral Health Hospital (Campus D) on 08/09/2017 at 1732 unaccompanied for evaluation and treatment for "Anxiety, Guilt, Tearful, Religious Experience." Record review revealed the patient was assessed by a "Counselor." Review revealed the patient had a tele face-to-face initial assessment at 1827 by Counselor #3. Review of BHH Assessment documentation by Counselor #3, dated 08/09/2017 at 1835 revealed, "Tele Assessment Note ....is an [sic] 35 y.o. male, Pt reports ongoing religious confusion and frustration. Pt denies SI/HI (suicidal/homicidal ideation). Pt denies AVH (audio-visual hallucinations). Pt states in 6/2017 he felt that he meant [sic] God and as a result cut his wrists. Pt was hospitalized at BHH and released a week later. Pt denies current outpatient treatment. Pt states he is currently prescribed Vyvanse (Stimulant) and Lexapro (Selective Serotonin Reuptake Inhibitor). Pt states he has many religious dreams and he does not know how to process them. Pt reports occasional Hydrocodone use. Pt reports a past Hydrocodone addiction. Pt denies abuse. Writer consulted with (NP #2 name). Per (NP #2 name) Pt does not meet inpatient criteria. Pt provided with outpatient resources. Diagnosis: F33.1 MDD, recurrent, moderate ...Past Medical History: ...o Anxiety o Headache o Multiple sclerosis... o Vision abnormalities No past surgical history on file. ...General Assessment Data Location of Assessment: BHH Assessment Services TTS Assessment: In system Is this a Tele or Face-to-Face Assessment?: Face-to-Face Is this an Initial Assessment or a Re-assessment for this encounter?: Initial Assessment Marital status: Single ...Living Arrangements: Alone Can pt return to current living arrangement?: Yes Admission Status: Voluntary Is patient capable of signing voluntary admission?: Yes Referral Source: Self/Family/Friend Insurance type: BCBS Crisis Care Plan Living Arrangements: Alone Legal Guardian: Other: (self) Name of Psychiatrist: NA Name of Therapist: NA Education Status Is patient currently in school?: No Current Grade: NA Highest grade of school patient has completed: 12 Name of school: NA Contact person: NA Risk to self with the past 6 months Suicidal Ideation: No Has patient been a risk to self within the past 6 months prior to admission? : No Suicidal Intent: No Has patient had any suicidal intent within the past 6 months prior to admission? : No Is patient at risk for suicide?: No Suicidal Plan?: No Has patient had any suicidal plan within the past 6 months prior to admission?: No Access to Means: No What has been your use of drugs/alcohol within the last 12 months?: Hydrocone [sic] Previous Attempts/Gestures: Yes How many times?: 1 Other Self Harm Risks: NA Triggers for Past Attempts: None known Intentional Self Injurious Behavior: None Family Suicide History: No Recent stressful life event(s): Other (Comment) (religious confusion) Persecutory voices/beliefs?: No Depression: Yes Depression Symptoms: Tearfulness, Feeling worthless/self pity Substance abuse history and/or treatment for substance abuse?: No Suicide prevention information given to non-admitted patients: Not applicable Risk to Others within the past 6 months Homicidal Ideation: No Does patient have any lifetime risk of violence toward