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.

ALLEGHENY VALLEY HOSPITAL 1301 CARLISLE ST NATRONA, PA 15065 July 29, 2014
VIOLATION: ON CALL PHYSICIANS Tag No: A2404
Based on a tour of the facility, review of facility documentation, and employee interviews (EMP), it was determined that the facility failed to maintain an appropriate on-call list of physicians available to provide necessary treatment to stabilized individuals with emergency medical conditions.

Findings include:

Review of facility policy "Section 1000, Provision of Care, Treatment and Services, Subject: Emergency Medical Treatment and Active Labor Act (EMTALA)" last revised, 12/20/10, stated, "...E. Emergency Department On-Call Physician Coverage ... Physician group names are not acceptable for identifying the on-call physician. Individual physician names are to be identified on the list with their accurate contact information."

1) Tour of the Emergency Department on July 28, 2014, at 1:00 PM, revealed an On-Call Physician Specialty list located across from the physician documentation room. Further review of the On-Call Physician Specialty list indicated that PCOA group, Tri-County Cardiology, Penn Psycare group, and Allegheny Ear, Nose and Throat group were all on call. No individual physician names were listed for any of the physician groups on call.


2) Interview with EMP19, on July 28, 2014, at approximately 1:30 PM, revealed, "They just call the answering service and the on-call doctor calls them back."
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on a review of facility documentation and staff interviews (EMP), it was determined that the facility failed to maintain a central log for all patients who present to their Emergency Department (ED) for one of 41 medical records reviewed (MR1).

Findings include:

Review of facility policy "Emergency Medical Treatment and Active Labor Act" reviewed 3/31/14, revealed "...Central Log is a log that a Hospital is required to maintain on each individual who comes to its emergency room or any location on the Hospital Property or Premises seeking emergency assistance and the disposition of each individual whether he or she refused treatment or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged . The purpose of the central log is to track the care provided to each individual who comes to the Hospital Property or Premises seeking care for an Emergency Medical Condition. The Hospital has the discretion to maintain the central log in a form that best meets the needs of its patients. All logs must be available in a timely manner for surveyor review. The Central Log shall be maintained in the Emergency Department of the Hospital, and any patients who receive a medical screening exam at a location to which this policy applies other than an Emergency Department shall telephone or e-mail the central log information to the appropriate Emergency Department personnel. This includes tracking patients who seek assistance but then refused to be assisted..."

1) During an interview on July 29, 2014, at approximately 10:29 AM, EMP1 confirmed that MR1 did present to the facility's ED on July 20, 2014, at approximately 8:00 PM. Further interview with EMP1 revealed " ...that was me sitting at the registration desk. I was shift leader. I was covering the registration desk ...I was actually behind the doors of the ED when you first come in ...[MR1] came in and another person ...I asked if I could help ...I usually just say let's get you registered and do not even bring up insurance ...[MR1] wanted to know if we took [MR1's] insurance first ...[MR1] did not want to register if we did not take [MR1's] insurance ...I told [MR1] I am not the one to answer that question about insurance, registration would be to the left ...they both went over to the registration desk and after that I saw them leaving ...when we do register we have the patient type in their social security number ...we type in the chief complaint and their name ...I did not enter [MR1's] name because she did not want to register if we did not take her insurance ... "

2) During an interview on July 28, 2014, at approximately 11:00 AM, EMP3 revealed "...we don'tt have [MR1] in our system or on the log..."
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
Based on review of facility documentation, medical records (MR), and staff interviews (EMP), it was determined the facility failed to ensure that all elements of an appropriate transfer were met for 26 of 26 medical records reviewed (MR2, MR5, MR6, MR8, MR9, MR11, MR12 MR14, MR15, MR16, MR17, MR18, MR19, MR20, MR24, MR25, MR26, MR28, MR31, MR32, MR34, MR36, MR37, MR38, MR39, and MR40).

Findings include:

Review of facility policy "Section 1000, Provision of Care, Treatment and Services, Subject: Emergency Medical Treatment And Active Labor Act (EMTALA)" last revised, 12/20/10, stated, " ... A. Definitions: ... Physician Certification: is a written certification by the treating physician ordering the transfer and prior to the patient's transfer, that based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual and, in the case of a woman in labor, to the unborn child, from effecting the transfer. The certification shall include a summary of the risks and benefits upon which the certification is based and the reason(s) for the transfer ... C. Stabilization: 5... a. For Transfer with Physician Certification ... v. The certification form must contain a complete picture of the benefits to be expected from appropriate care at the receiving facility and the risks associated with the transfer, including the time away from an acute care setting necessary to affect the transfer ... D. Transfer: The requirements of an Appropriate Transfer must be met before a patient can be transferred to a second facility. This includes transfers between different WPAHS hospitals or between WPAHS hospital Campuses. These requirements are as follows ... 7. The Physician at the transferring Hospital has the responsibility to determine appropriate mode of transportation, equipment and attendants necessary to affect a transfer to a receiving or recipient facility... "

1) Review of facility procedure "Transfer of Patient to Other Facility" no date of review documented, stated, "... Transfer To Another Facility Check List: ... 3. Written orders for care during transport .... 7. Mode of transfer and personnel to accompany patient determined .... "

2) During a review of medical records on July 28, 2014 and July 29, 2014, it was discovered that MR2, MR5, MR6, MR8, MR9, MR11, MR12 MR14, MR15, MR16, MR17, MR18, MR19, MR20, MR24, MR25, MR26, MR28, MR31, MR32, MR34, MR36, MR37, MR38, MR39, and MR40 did not include a physician order or documentation signed by the physician for the required mode of transport or personnel needed to accompany the patient to the receiving facility.

3) An interview with EMP1 and EMP2 on July 29, 2014, at approximately 12:00 PM, revealed that the physician verbally informs the nurse of the mode and means of transportation, and that there is no written documentation or written order.


3) During a review of medical records on July 28, 2014 and July 29, 2014, it was discovered that MR2, MR5, MR6, MR8, MR9, MR11, MR12 MR14, MR15, MR16, MR17, MR18, MR19, MR20, MR24, MR25, MR26, MR28, MR31, MR32, MR34, MR36, MR37, MR38, MR39, and MR40 did not include a Physician Certification.

4) An interview with EMP2 on July 29, 2014, at approximately 12:00 PM, confirmed that the medical records listed above did not include a Physician Certification form. EMP2 replied, "No, there is only the consent for transfer, there is no separate form."