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.

NORTHLAKE BEHAVIORAL HEALTH SYSTEM 23515 HIGHWAY 190 MANDEVILLE, LA 70448 March 25, 2014
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on record reviews and interviews, the hospital failed to comply with 489.24 as evidenced by:

1) Failing to ensure a patient was accepted for admission when the hospital had the capacity and capability to provide psychiatric services as evidenced by the hospital refusing to accept a patient with the reason of no beds available on 08/24/13 and 08/25/13 when 5 adolescent male beds were available on 08/24/13 and 08/25/13 for 1 of 1 patient record reviewed for a delay in acceptance from a total of 24 sampled patients (#2) (see findings in tag A2411);

2) Failing to provide documented evidence of the inquiries made from referral sources and their disposition according to hospital policy. The hospital's referral log was incomplete as evidenced by a pattern of having blanks (no writing noted in the blank) in the columns titled "Disposition", "Denial Reason", "Intake/RN" (Registered Nurse), and "MD" (Physician) and was not accurate as evidenced by:

a) Having a patient logged as "accepted" on 08/24/13 with documentation in the medical record from Hospital A of continued attempts to place the patient on 08/25/13 and 08/26/13 and no documentation on the log when the patient was accepted on 08/26/13 for 1 of 1 patient's record reviewed who was accepted, not admitted , and later accepted from a total sample of 24 patients (#2);

b) Having patients who were admitted to the hospital not being logged on the referral log for 3 of 7 patients' records reviewed who were admitted to the hospital from a sample of 24 patients (#1, #3, #23);

c) Having a patient documented on the referral log as "accepted" with no medical record of admission at the hospital for 1 of 1 patient reviewed on the referral log who was accepted with no medical record from a total of 24 sampled patients (#8);

d) Having 4 of 24 patients reviewed on the referral log with no documented evidence of the disposition (whether the patient was accepted or whether the patient was denied with the reason why he/she was denied and the physician who denied the acceptance of the patient) (#4, #5, #7, #10);

e) Having 3 of 24 patients reviewed on the referral log who were denied with no documented evidence of the reason for denial (#6, #11, #12); and

f) Having 8 of 24 patients reviewed on the referral log who were denied with documentation of "medical issues", "doesn't meet criteria", or "medically complex" with no documented evidence of the physician who reviewed the patient information and denied the acceptance of the patient for admission (#13, #14, #15, #16, #17, #20, #21, #22) (see findings in tag A2411); and

3) Failing to develop and implement a policy that addressed exclusionary criteria for admission to the hospital that defined what "medically complex" or "didn't meet criteria" meant as evidenced by documentation of these terms on the hospital's Admissions Department referral log (see findings in tag A2411).
VIOLATION: RECIPIENT HOSPITAL RESPONSIBILITIES Tag No: A2411
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to:

1) Ensure a patient was accepted for admission when the hospital had the capacity and capability to provide psychiatric services as evidenced by the hospital refusing to accept a patient with the reason of no beds available on 08/24/13 and 08/25/13 when 5 adolescent male beds were available on 08/24/13 and 08/25/13 for 1 of 1 patient record reviewed for a delay in acceptance from a total of 24 sampled patients (#2);

2) Provide documented evidence of the inquiries made from referral sources and their disposition according to hospital policy. The hospital's referral log was incomplete as evidenced by a pattern of having blanks (no writing noted in the blank) in the columns titled "Disposition", "Denial Reason", "Intake/RN" (Registered Nurse), and "MD" (Physician) and was not accurate as evidenced by:

a) Having a patient logged as "accepted" on 08/24/13 with documentation in the medical record from Hospital A of continued attempts to place the patient on 08/25/13 and 08/26/13 and no documentation on the log when the patient was accepted on 08/26/13 for 1 of 1 patient's record reviewed who was accepted, not admitted , and later accepted from a total sample of 24 patients (#2);

b) Having patients who were admitted to the hospital not being logged on the referral log for 3 of 7 patients' records reviewed who were admitted to the hospital from a sample of 24 patients (#1, #3, #23);

c) Having a patient documented on the referral log as "accepted" with no medical record of admission at the hospital for 1 of 1 patient reviewed on the referral log who was accepted with no medical record from a total of 24 sampled patients (#8);

d) Having 4 of 24 patients reviewed on the referral log with no documented evidence of the disposition (whether the patient was accepted or whether the patient was denied with the reason why he/she was denied and the physician who denied the acceptance of the patient) (#4, #5, #7, #10);

e) Having 3 of 24 patients reviewed on the referral log who were denied with no documented evidence of the reason for denial (#6, #11, #12); and

f) Having 8 of 24 patients reviewed on the referral log who were denied with documentation of "medical issues", "doesn't meet criteria", or "medically complex" with no documented evidence of the physician who reviewed the patient information and denied the acceptance of the patient for admission (#13, #14, #15, #16, #17, #20, #21, #22); and

3) Develop and implement a policy that addressed exclusionary criteria for admission to the hospital that defined what "medically complex" or "didn't meet criteria" meant as evidenced by documentation of these terms on the hospital's Admissions Department referral log.
Findings:

1) Ensure a patient was accepted for admission when the hospital had the capacity and capability to provide psychiatric services:

Review of the hospital policy titled "Intake and Admission", policy # CC-1300 and presented as a current policy by S1Owner, revealed that the Admission Office is staffed with intake clinicians who are expected to maintain on-going contact with referral sources regarding bed availability, obtain intake information via phone as a preliminary screen of appropriateness, review referral packets from agencies to determine appropriateness for admissions, obtain nurse review when medical problems are identified, review intake information with the physician and obtain approval for admission, and maintain data on inquiries and their disposition. Further review revealed that the intake process performed by the intake clinician for an agency referral included the following: complete contact information; screen for preliminary appropriateness, especially medical; obtain hospital records; refer medical concerns to Nurse Supervisor; obtain Psychiatrist review; and if approved, schedule the admission.

Review of the hospital's "Packet Receipt, Review and Disposition" (referral log) revealed the following information related to Patient #2:
08/24/13 at 7:32 a.m. - Patient #2; [AGE] year old male; referral source Hospital A Pediatric ER (emergency room ); contact phone number of referral source; "doesn't fit criteria" with no documented evidence of what criteria was not met and which physician reviewed and denied acceptance;
08/24/13 at 7:00 p.m. - Patient #2; [AGE] year old male; referral source Hospital A; contact phone number of referral source; disposition as "accepted" with no documented evidence of which physician reviewed Patient #2's packet and accepted him for admission;
08/25/13 at 9:02 a.m. - Patient #2; [AGE] year old male; referral source Hospital A; contact phone number of referral source; disposition "no bed/not med. app." (not medically appropriate); the entire entry had a line drawn through the writing.
Patient #2 was admitted on [DATE], and there was no documented entry on the referral log beyond the entry on 08/24/13 at 7:00 p.m. Patient #2 was accepted for admission (per Hospital A's documentation in Patient #2's Emergency department record) at 1:45 p.m. on 08/26/13, and there was no documented evidence of this entry on the hospital's referral log.

Review of documentation in Patient #2's medical record of the "ED Course" from Hospital A revealed the following:
08/23/13 at 7:53 p.m. - per (first name of male) at Northlake Behavioral Health System, can fax ppwk (paperwork) to be reviewed;
08/24/13 at 9:12 a.m. - spoke to (first name of female - former social worker at Northlake Behavioral Health System, awaiting MD (medical doctor) to review chart for possible bed place;
08/24/13 at 2:56 p.m. - other: notified by S4Admissions MHT (mental health tech) at Northlake Behavioral Health System that they are awaiting discharges, and there are no beds available at this time;
08/24/13 at 7:15 p.m. - ppwk faxed to Northlake Behavioral Health System admissions for review;
08/24/13 at 8:32 p.m. - per Northlake Behavioral Health System admissions, no beds available; check back in the am (morning);
08/25/13 at 8:53 a.m. - faxed paperwork to Northlake Behavioral Health Systems per instructions of (first name of male RN) in admitting;
08/26/13 at 7:13 a.m. - spoke with (S4Admissions MHT) at Northlake Behavioral Health System, states to re-fax packet to (phone number listed); states that she will send to DNP (Developmental Neuropsychiatric Program) program for review for possible transfer;
08/26/13 at 9:20 a.m. - social work contacted Northlake Behavioral Health System, spoke with S4Admissions MHT who reports still awaiting review for possible placement; will call back later to check on status;
08/26/13 at 1:20 p.m. - social work S4Admissions MHT with Northlake Behavioral Health System returned call; request current labs and EKG (electrocardiogram) to be faxed to (phone number listed) for review;
08/26/13 at 1:37 p.m. - social work faxed requested information to Northlake Behavioral Health System (phone number listed); consent was signed and placed on chart;
08/26/13 at 1:45 p.m. - social work S4Admissions MHT with Northlake Behavioral Health System called to report acceptance to S3Psychiatrist.
There was no documented evidence that Hospital A was notified that Patient #2 was accepted for admission on 08/24/13 at 7:00 p.m. as documented on the hospital's referral log.

Review of Patient #2's medical record revealed he was admitted on [DATE] at 5:25 p.m. Review of the "Initial Care Assessment" completed by a social worker no longer employed at the hospital revealed the accepting physician was S3Psychiatrist.

Review of documentation presented by S7Administrator on 03/25/14 at 2:05 p.m. revealed the adolescent boys' unit in August 2013 was an 8 bed unit. Further review revealed the census on this unit on 08/25/13 was 3 patients with 5 available beds when the referral log was documented as no bed available. Further review revealed there were 5 available beds on 08/23/13 and 08/24/13 (when Hospital was told there were no beds available) when bed placement was sought by Hospital A.

Review of the contract between Company A and Company B, entered into on 01/01/13 and presented by S1Owner as the contract for the Duty Doctors, Residents, S3Psychiatrist, and S13Psychiatrist from Company B, revealed that the purpose of the coverage was to provide an on-site/after-hours physician to evaluate, diagnose, and admit persons referred for in-patient treatment. Further review revealed the physician may provide rounding on "safety net" adolescents and adults in patient units and agreed to provide evaluation of new clients, evaluation for restraints, seclusion, and precautions, and emergency coverage for clients and staff after hours related to "safety net" units.

In an interview on 03/25/14 at 8:30 a.m., S4Admissions MHT (mental health tech) indicated when referral packets are received by fax, she logs them on the "Packet Receipt, Review and Disposition". She further indicated that she tries to document an approximate time, but she doesn't always log it when the referral is received by the hospital. She further indicated that sometimes the time documented on the fax isn't always accurate from the fax machine at the referring facility. S4Admissions MHT indicated that she had reviewed the time that Patient #2's referral was received, and there were beds available. She further indicated that she doesn't know or remember why she said there were no beds. S4Admissions MHT indicated if the unit is full where the referred patient would be admitted , she tells the referral source that there is no bed available and would not refer the phone call to a nurse. She further indicated that when she looked back at that time, she noted that no patients were admitted to that unit over that weekend.

In an interview on 03/25/14 at 9:00 a.m., S3Psychiatrist reviewed the "Initial Care Assessment" and the information in the medical record of Patient #2 from Hospital A seeking bed placement. She indicated that she had an issue with this, because she didn't accept the patient and didn't authorize her name to be placed as the accepting physician. She further indicated that no one called her to review Patient #2's packet or to discuss the patient. She further indicated that she became aware of Patient #2's admission when he was accepted by someone else to her unit. S3Psychiatrist indicated she started Patient #2's psychiatric evaluation with a resident physician who signed the evaluation on 08/27/13 at 8:50 a.m. She further indicated that she wrote orders on 08/26/13 at 5:15 p.m. when she was walking off the unit and saw Patient #2 being admitted on a stretcher. She indicated that she recalled calling the Admissions department to question the hospital's policy of accepting non-verbal autistic children. S3Psychiatrist indicated that she had previously been told the hospital wouldn't accept autistic children and questioned if the hospital had criteria that addressed this issue. She further indicated that she has "questioned over and over and got no answer." She indicated that she was told by S6Medical Director that if a patient is PEC'd (Physician Emergency Certificate) and medically cleared, the hospital can accept the patient. S3Psychiatrist indicated that she didn't have clear criteria for the hospital's DNP (Developmental Neuropsychiatric Program) unit, and she wanted to send Patient #2 there, but the hospital didn't answer her questions about the criteria for admission to the unit.

In an interview on 03/25/14 at 10:15 a.m., S2Director of Admissions indicated that she had been employed at Northlake Behavioral Health System since June or July of 2013. She further indicated that the Admissions Department had MHTs, Master's level Counselors, RNs, and herself to staff the department. She indicated that the department either received a referral by telephone call or fax. She further indicated that she and the RN (House Supervisor or Admission RN) reviews the referral packets to determine if the referral is medically stable and an appropriate admission for the hospital. S2Director of Admissions indicated if a referral is medically stable and meets criteria for admission, one of the Admissions staff will call the referring hospital to accept the patient and will tell them the accepting physician is S6Medical Director. She further indicated that the accepting physician is "always" S6Medical Director, unless the nurse takes the packet to a Duty Doctor who will accept the patient. S2Director of Admissions indicated that if "nothing is abnormal, there's no reason to delay the admission." She further indicated that was the reason why the process for accepting referrals was changed, because "the Company B physicians were taking too long." She further indicated that "S6Medical Director is accepting every admission, and there's no reason to wake him at 2:00 a.m." When asked specifically about Patient #2's referral, documentation that no beds were available, and subsequent acceptance, S2Director of Admissions indicated when "doesn't meet criteria" was documented, the reason or explanation of which criteria was not met would not be documented. She further indicated that if the referral material was reviewed, the information about why a referral was not accepted would be documented on it. She further indicated if a referral was not accepted for admission, the hospital does not keep the packet, because "we can't keep every referral packet we get." S2Director of Admissions offered no explanation for Patient #2 not being admitted when beds were available. When informed that the log did not include information on each referral about the disposition of the referral or the reason why the patient didn't meet criteria, what was considered medically complex, or the reason the referral was denied, S2Director of Admissions offered no explanation. When informed that the blanks for the "Intake/RN" and "MD" on the "Packet Receipt, Review and Disposition" were blank, S2Director of Admissions indicated "I need to take it off" the form, because if the nurse reviews it, we don't need the physician" filled in. She further indicated that documentation relative to Patient #2 from Hospital A on 08/26/13 at 7:13 a.m. of information received by S4Admissions MHT was not a decision that S4Admissions MHT could make, and she must have been directed by the former social worker of the Admissions Department. When asked if S4Admissions MHT should have transferred that call to the former social worker, S2Director of Admissions answered, "Yes, but (the former social worker) may have multi-tasked." She further indicated that "apparently S3Psychiatrist accepted the patient." When informed that S3Psychiatrist indicated during an interview that she had never reviewed a referral packet for Patient #2, S2Director of Admissions indicated in August 2013 when Patient #2 was admitted , the Admissions process was to hand-walk the packet to the physician. She further indicated "I don't know what the agenda is, but something is wrong with that answer." After S2Director of Admissions reviewed the "Packet Receipt, Review and Disposition", she was asked if the log was accurate, and she answered "I wouldn't say, it's an inaccurate picture." She indicated that it's not uncommon for the physicians with Company B to go outside the criteria to accept patients, "they have different agendas to what cases they would and would not take." After reviewing Patient #2's documentation from Hospital A, S2Director of Admissions indicated she saw that he was in 4 point restraints for 3 days in the Emergency Department, which meant he was not medically stable. She further indicated if she had screened Patient #2's referral herself, she would have denied the admission and told the hospital to call them back when Patient #2 "was out of restraints for 6-10 hours, because Northlake Behavioral Health System does not use mechanical restraints."

In an interview on 03/25/14 at 12:45 p.m., S6Medical Director, when informed that former interviewees indicated that he was the accepting physician for all patients, he answered, "not all, there's exceptions to that." He indicated that there were 2 ways that patients can be accepted for admission. He further indicated that initially the physician had to review the referral packet and accept the patient before the patient was admitted . He further indicated that there had been a problem with physicians not coming to review packets and not answering the hospital's phone calls. He indicated that the nurse in Admissions would call him, since there could be an EMTALA (Emergency Medical Treatment and Active Labor Act) violation with a delay in acceptance of the patient. S6Medical Director indicated if the Admissions staff looked at the referral packet and noted no medical problems or any other concerns, the Admissions staff could accept the referral. When asked which specific Admissions staff member could accept a patient for referral, he answered, "Whoever's in charge at the time, S2Director of Admissions or the RN." He further indicated that if either of them had a concern about the referral, they were supposed to call a physician to review the packet. When asked to define "concern", S6Medical Director answered, "anything medical that would require a medical subspecialty consult." He indicated if a referral was medically cleared by the transferring hospital, had no concerns, met admission criteria, and a bed was available, the Admissions staff could accept the patient. He further indicated "I'm not the accepting physician for every patient." He further indicated if the referral was an adolescent going to the unit of S3Psychiatrist or S13Psychiatrist, they would be the accepting physician. He further indicated that they (the accepting physician) don't have to be called if there are no concerns noted by the Admissions staff. When asked who is the accepting physician for the units of S3Psychiatrist and S13Psychiatrist if they aren't called, S6Medical Director answered, "it depends on which unit they're (patients) going to, again the accepting physician should be the physician on the unit they're going on, that makes the most sense." S6Medical Director indicated he is familiar with the EMTALA regulations, and that the "confusion is how is this EMTALA if we're accepting and treating the patient." S6Medical Director again indicated that approval for admission is "made by the nurse or whoever's in charge of Admissions at the time", and whoever's the Duty Physician should be documented as the accepting physician for the units staffed by S3Psychiatrist and S13Psychiatrist.

In an interview on 03/25/145 at 2:05 p.m. with S1Owner and S7Administrator present, S7Administrator indicated that S2Director of Admissions had no clinical experience, and that's why the hospital has RNs working in Admissions. When informed that S6Medical Director indicated that S2Director of Admissions could make the determination for acceptance of a patient to be admitted , S7Administrator offered no explanation. S7Administrator confirmed there were beds available on 08/23/13, 08/24/13, and 08/25/13 when Hospital A was told the hospital had no available beds to accept Patient #2. S7Administrator confirmed that the Admissions staff had not received training on EMTALA by Northlake Behavioral Health System. He offered no explanation when informed that review of the Admissions staff's personnel files had no documented evidence of an evaluation of competency for performing the duties required in accepting referrals and admitting patients.

2) Provide documented evidence of the inquiries made from referral sources and their disposition according to hospital policy:
Review of the hospital policy titled "Intake and Admission", policy # CC-1300 and presented as a current policy by S1Owner, revealed that the Admission Office is staffed with intake clinicians who are expected to maintain data on inquiries and their disposition.

a) Having a patient logged as "accepted" on 08/24/13 with documentation in the medical record from Hospital A of continued attempts to place the patient on 08/25/13 and 08/26/13 and no documentation on the log when the patient was accepted on 08/26/13:
See findings in #1 above.

In an interview on 03/25/14 at 10:15 a.m., S2Director of Admissions indicated the "log's not perfect", because there's multiple people handling the log.

2b) Having patients who were admitted to the hospital not being logged on the referral log:
Patient #1
Review of Patient #1's medical record revealed he was admitted on [DATE] at 12:10 a.m. Review of his "Initial Care Assessment" completed by S5RSW (Registered Social Worker) revealed the accepting physician was S3Psychiatrist. Review of the "Packet Receipt, Review and Disposition" revealed no documented evidence that Patient #1 was logged as a referral on 08/21/13 or 08/22/13.

Review of documentation in Patient #1's medical record from Hospital B revealed that an admission packet was faxed to Northlake Behavioral Health System for inpatient psychiatric placement on 08/21/13 at 5:55 p.m. Further review revealed that a RN from Hospital B spoke with S2Director of Admissions on 08/21/13 at 7:06 p.m., and she stated that Patient #1 was accepted for inpatient treatment by S8Physician, but "due to staffing constraints may not be able to accept until 7a (7:00 a.m.)."

In an interview on 03/25/14 at 9:00 a.m., S3Psychiatrist indicated that she did not receive a call to accept Patient #1. She further indicated that several meetings were held to address communication between Youth Services and Admissions. She indicated that the physicians requested to be notified of any potential patient to review their packet from the referring hospital, because there had been numerous occasions when the nurse on the unit had received reports from the referring hospital's Emergency Department, and the attending physician had not reviewed the packet and didn't know that the patient had been accepted and was being transported to the hospital. She further indicated that there had been instances that no one knew the patient was accepted and was already at the hospital until the unit nurse received a call from Admissions to tell them the patient was at the hospital. S3Psychiatrist indicated that the physicians from Company B had requested that the referral packet be faxed to the physician to review during the treatment team meeting or that it be e-mailed to the physician who could print a copy to review. She further indicated that she was told by the former Social Worker (no longer employed and unable to interview) that it was "impossible to send packets on every patient she accepted and she (former social worker) was by S6Medical Director that she (former social worker) was authorized to accept patients on his behalf."

In an interview on 03/25/14 at 10:15 a.m., S2Director of Admissions confirmed that the "Packet Receipt, Review and Disposition" log did not have the name of Patient #1 documented. She further indicated the "log's not perfect", because there's multiple people handling the log.

In an interview on 03/25/14 at 12:20 p.m., S5RSW (Registered Social Worker) indicated that does not have any part in determining if a patient meets criteria or accepting a referral for admission. He further indicated that he gives the packet to the RN or S2Director of Admissions, and the last he sees it until the patient arrives to be admitted . He further indicated if he gets a call with a referral and there are beds available, he tells the referral source to fax the paperwork, and someone from the hospital will get back with them. After S5RSW reviewed the "Initial Care Assessment" for Patient #1, he indicated that the diagnosis that he documented came from the packet he received from the transferring hospital. He confirmed that he does not get this diagnosis from the patient's accepting or attending physician. He indicated that he should have documented the accepting physician as S6Medical Director, but he was new and had been putting down the name of the physician on the unit to where the patient was being admitted . He indicated that he couldn't remember if he had spoken with S3Psychiatrist about Patient #1. When asked why he should have put S6Medical Director's name as the accepting physician, S5RSW answered, "S6Medical Director is the accepting physician, when the patient comes at night, they (S2Director of Admissions or the RN) call S6Medical Director." S5RSW indicated when he writes a physician's name on the form, it doesn't mean that he has spoken with the physician. He indicated they do let the physician on the unit know that the patient has arrived, and he confirmed that's after the patient had been accepted for admission. S5RSW indicated he didn't know if the RN or S2Director of Admissions actually called S6Medical Director and was asked if he saw either of them calling S6Medical Director, and he answered, "No."

Patient #3
Review of Patient #3's medical record revealed he was admitted on [DATE] at 9:21 p.m. Review of the "Packet Receipt, Review and Disposition" revealed no documented evidence that Patient #3 was logged as a referral and accepted on 08/26/13.

Review of documentation in Patient #3's medical record from Hospital C revealed that Patient #3 was accepted by Northlake Behavioral Health System by S3Psychiatrist on 08/26/13 at 3:06 p.m.

In an interview on 03/25/14 at 9:00 a.m., S3Psychiatrist indicated that she never reviewed Patient #3's packet to give an opinion of whether she thought Patient #3 met criteria for admission. She further indicated that reviewed it after the patient had been admitted . S3Psychiatrist indicated that she has asked the Admission Department to call the referring hospital's Emergency Department when she didn't feel a patient met criteria (patient was already accepted and being transported at this point) and was told to talk to S6Medical Director or S7Administrator.

In an interview on 03/25/14 at 10:15 a.m., S2Director of Admissions confirmed that the "Packet Receipt, Review and Disposition" log did not have the name of Patient #3 documented. She further indicated the "log's not perfect", because there's multiple people handling the log.

Patient #23
Review of Patient #23's medical record revealed he was admitted on [DATE] at 10:45 p.m. Review of his "Initial Care Assessment" completed by S10RN revealed the accepting doctor was S3Psychiatrist. Review of the "Packet Receipt, Review and Disposition" revealed no documented evidence that Patient #23 was logged as a referral and accepted on 03/12/14.

Review of documentation in Patient #23's medical record from Hospital C revealed that Patient #23 was accepted by Northlake Behavioral Health System by S6Medical Director on 03/12/14 at 6:27 p.m.

In an interview on 03/25/14 at 9:00 a.m., S3Psychiatrist indicated that she never spoke with anyone at the hospital to accept Patient #23.

In an interview on 03/25/14 at 10:15 a.m., S2Director of Admissions confirmed that the "Packet Receipt, Review and Disposition" log did not have the name of Patient #23 documented. She further indicated the "log's not perfect", because there's multiple people handling the log.

2c) Having a patient documented on the referral log as "accepted" with no medical record of admission at the hospital:
Review of the hospital's "Packet Receipt, Review and Disposition" revealed Referral #8 was listed on 08/24/13 at 6:22 p.m. as a [AGE] year old male referred by Hospital D and accepted with no documented evidence of the physician who accepted the patient for admission.

Review of the hospital's "Admission Log" revealed no documented evidence that Referral #8 was admitted on [DATE].

In an interview on 03/24/14 at 1:50 p.m., S1Owner indicated the hospital did not have a medical record for Referral #8. She further indicated that sometimes a referral may be accepted by the hospital, and when the staff calls the referral source back, the patient may have been accepted by another facility. S1Owner indicated that the hospital does not keep referral packets received by the Admission Department.

In an interview on 03/24/14 at 3:30 p.m., S1Owner presented a hand-written list of patients/referrals received with the same information documented on the "Packet Receipt, Review and Disposition". Review of the information presented revealed no documented evidence that Referral #8's name was listed on the sheet.

2d) Having no documented evidence of the disposition of the referral (whether the patient was accepted or whether the patient was denied with the reason why he/she was denied and the physician who denied the acceptance of the patient):
Patient #4
Review of the hospital's "Packet Receipt, Review and Disposition" revealed an entry on 09/14/13 at 11:20 a.m. that a referral was received from Hospital C for Patient #4, a [AGE] year old male, with no documented evidence of the disposition, denial reason, intake/RN name, or physician name.

Patient #4 was admitted on [DATE] at 5:15 p.m. Review of his medical record revealed documentation from Hospital C on 09/14/13 at 1:22 p.m. that Patient #4 was accepted for admission at Northlake Behavioral Health System by S9Physician.

In an interview on 03/25/14 at 10:15 a.m., S2Director of Admissions confirmed that the "Packet Receipt, Review and Disposition" log did not have the disposition of Patient #4's referral documented.

Referral #5
Review of the hospital's "Packet Receipt, Review and Disposition" revealed an entry on 08/12/13 at 11:53 p.m. that a referral was received for Referral #5, a [AGE] year old male, from Hospital C with no documented evidence of the disposition, denial reason, intake/RN name, or physician name.

Review of the hospital's "Admission Log" revealed no documented evidence that Referral #5 was admitted on [DATE].

Referral #7
Review of the hospital's "Packet Receipt, Review and Disposition" revealed an entry on 08/19/13 at 5:31 p.m. that a referral was received from Hospital C for Referral #7, a [AGE] year old male, with no documented evidence of the disposition, denial reason, intake/RN name, or physician name.

Review of the hospital's "Admission Log" revealed no documented evidence that Referral #7 was admitted on [DATE].

Referral #10
Review of the hospital's "Packet Receipt, Review and Disposition" revealed an entry on 08/27/13 at 11:18 p.m. that a referral was received from Hospital E for Referral #10, a [AGE] year old male, with no documented evidence of the disposition, denial reason, intake/RN name, or physician name.

Review of the hospital's "Admission Log" revealed no documented evidence that Referral #10 was admitted on [DATE] or 08/28/13.

In an interview on 03/25/14 at 10:15 a.m., S2Director of Admissions indicated the "log's not perfect", because there's multiple people handling the log. She further indicated that blanks on the log is probably due to the referral information being put on the log when it's received, and someone else doesn't go back to update, because the staff is trying to move as fast they can to gets referrals processed. She confirmed that she did not have any additional information to provide regarding the disposition of the above-mentioned referrals other than what's on the log, because she doesn't keep referral packets.

2e) Having patients on the referral log who were denied with no documented evidence of the reason for denial:
Patient #6
Review of the hospital's "Packet Receipt, Review and Disposition" revealed an entry on 08/29/13 at 8:55 a.m. that a referral was received from Hospital C for Patient #6, a [AGE] year old male. Further review revealed the column for disposition had "accept" written, the column for denial reason had "reject" written, the column for intake/RN had "S11Physician's" name written, and the column for MD had "MD" written. There was no documentation that explained whether Patient #6 was accepted or denied, and if denied, the reason for the denial.

Review of the "Admission Log" revealed Patient #6 was admitted on [DATE].

Patient #11
Review of the hospital's "Packet Receipt, Review and Disposition" revealed an entry on 09/02/13 at 9:06 a.m. that a referral was received from Hospital B for Patient #11, a [AGE] year old female. Further review revealed the disposition documented was "denied by S12Physician" with no documented evidence of the reason for denial.

Review of the hospital's "Admission Log"