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.

LEGACY MOUNT HOOD MEDICAL CENTER 24800 SE STARK STREET GRESHAM, OR 97030 Jan. 19, 2018
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on observation of digital security recordings, interviews, review of medical records documentation for 1 of 21 individuals who presented to the hospital seeking emergency services (Person 18), review of the central log, and review of policies and procedures and training documentation, it was determined the hospital failed to fully develop and enforce its EMTALA and related policies and procedures to ensure all individuals who presented to the hospital seeking emergency services received a MSE.

Findings included:

1. Refer to findings identified under Tag A2406, CFR 489.24(a) and (c) which reflects the hospital's failure to fully develop and enforce its EMTALA, interpreter services, and financial communications policies and procedures related to the provision of MSEs for Person 18.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on observation of digital security recordings, interviews, review of medical records documentation for 1 of 21 individuals who presented to the hospital for emergency services (Person 18), review of the central log, and review of policies and procedures, it was determined the hospital failed to fully develop and enforce its EMTALA and related policies and procedures and training documents to ensure all individuals who presented to the hospital seeking emergency services received a MSE. Person 18 presented to the hospital for emergency services, contrary to hospital policies and procedures financial information was discussed without a qualified interpreter, a MSE was not conducted and Person 18 left to go to another hospital.

Findings include:

1. During interview on 01/18/2018 at 1145 after the survey entrance conference the CEO and CNO reported that they learned from LHS compliance staff that a 6 year old child, Person 18, was brought in by parents to LMHMC ED on 01/05/2018 and was told they would have to call Kaiser before they could be seen in the ED. The parents left the LMHMC ED and proceeded to KSMC where they reported having gone to LMHMC first.

2. Timed digital security footage from 01/05/2018 beginning at 2000 and ending at 2400, without audio, of the hospital's ED entrance and ED registration desk, was reviewed on 01/18/2018 at approximately 1300. Present in the room onsite at the hospital during the review was the: CEO, CNO, Accreditation & Compliance Specialist; and LHS Senior Compliance Consultant. During interview at that time staff in the room confirmed that for security purposes the only public entrance into the hospital after 2100 every night is the ED entrance, all other entrances are locked.

The digital footage revealed a group of two adults and one other person, who appeared to be an adolescent or young adult, enter the ED from the outside of the hospital and approach the ED desk. A small child was being carried by one of the older adults and was observed to have a blanket covering his/her entire head and body with the exception of the child's left lower leg and foot dangling outside of the blanket. The other adult who was not carrying the child and the adolescent/young adult had a verbal interaction with the PAR stationed behind that desk. The group then turned away from the desk and walked out of the hospital. Those digital images were timed beginning at 10:38:24 when the group entered the hospital, and ended at 10:40:20 when the group exited the hospital. The time in the hospital lasting just under two minutes.

The security footage also showed a staff person, identified by staff viewing the footage as the Triage RN, who was sitting within a few feet behind the PAR during the encounter. During the encounter the Triage RN was seated and positioned to be facing the registration desk and looking down, focused on something in his/her hands. The Triage RN did not interact or intervene during the PAR's interaction with the group nor as the group turned away from the desk and exited the hospital.

3. During interview on 01/18/2018 at 1335 an interview was conducted with the PAR who interacted with Person 18's family on 01/05/2018. He/she was provided opportunity to view the security footage and confirmed that the persons identified in the footage were Person 18, his/her parents, and an "older child." He/she indicated that he/she remembered the encounter very well because the family left which caused the PAR to approach the Triage RN to discuss the situation.

The PAR described the interaction with the family as follows:
* The family spoke Spanish and the "older [child] translated" for the parents.
* The "older [child]" told the PAR "the little [child] had a stomach ache."
* "I was about to check them in when [the older child] asked if we take Kaiser."
* "I told [the older child] that Kaiser might not choose to cover...there's no way for me to know...they would have to call Kaiser...we would still see [the little child] and could maybe help out with bills afterward if still a problem...I asked [the older child] do you still want to get checked in?"
* The older child had a discussion with the parents in Spanish and then said "We'll go to Kaiser."
* "After they left I asked the Triage nurse 'Did it sound like I denied care?'" The PAR stated that the Triage RN said "no."
* There were "language challenges" having the older child as a translator.
* "I didn't ask anymore questions."
* "I might have confused them."
* "I also could have told them we see lots of Kaiser patients."
* The PAR stated they have the phone number for interpreter services but "we don't use interpreters at the front desk."

In regards to policies, processes, and training the PAR indicated:
* During training they are taught "to accept everybody."
* They don't provide any insurance co-pay or coverage information and tell patients they "must call their own insurance for details."
* They offer financial counselors who are available during regular business hours.
* They are not to ask for insurance information at the ED front desk.
* All financial and insurance discussion is to happen after the MSE "in the back" (referring to inside the ED department).

4. On 01/18/2018 at 1510 an interview was conducted with the Triage RN who was on duty at the triage desk on 01/05/2018 when Person 18 presented. The RN stated one of the family members was carrying a child "under a blanket" and "I couldn't see the child really" and "whoever was holding the child was speaking." The RN stated that he/she could hear the interaction the PAR had with the family. The RN stated that the PAR "said I can't tell you whether insurance is going to pay or not." The RN said that the PAR "said [he/she] would check them in." The RN stated that as the family was walking out the door "someone said we'll call and we'll be back." The RN stated "they didn't come back." The RN stated the interaction he/she heard between the PAR and family "sounded like a conversation." He/she indicated the child was silent, and stated he/she did not hear the child crying or anything that might indicate the child was in distress. The RN stated "I don't get into any discussions about insurance with patients. I tell them I'll have registration talk to you." The RN further reported that later during that night shift the ED CN approached the Triage RN and told him/her that "Kaiser" had called him/her about a patient who presented to KSMC and reported having been to LMHMC before coming to KSMC. The Triage RN stated that he/she told the CN about the interaction between the PAR and the family and heard nothing further after that.

5. Review of the ED Central Log revealed that Person 18 was not identified on the log as having been registered in the ED on 01/05/2018.

6. Review of ED medical records revealed no medical record for Person 18 on 01/05/2018.

7. On 01/18/2018 at 1215 an interview with the PAR Manager and PAR Supervisor was conducted. They described the "quick registration" process that all ED PAR staff are required to perform when patients present to the ED desk. The "quick registration" involved getting the patients name, date of birth, and reason for coming to the ED. They stated that only after the patient is seen by a physician "in the back" (referring to inside the ED department) are PAR staff to complete registration and address finances and insurance.

8. On 01/19/2018 at 0930 during interview with the Accreditation & Compliance Specialist he/she stated that he/she had confirmed that interpretive services are used in the ED and the phone number to initiate those services is at the ED registration desk. He/she stated they use it primarily in triage and "in the back."

9. On 01/19/2018 at 1030 during interview with the PAR Manager he/she stated that the hospital has "robust interpretive services." He/she stated that they have access to interpreter services via phone and via video; they have certified translator employees at the hospital; they have contracts with vendors in numerous languages and American sign language. He/she stated that PAR staff are trained in orientation as to how to access those services. He/she also stated that generally they don't initiate interpreter services at the registration desk when patients present who come in with family members who can translate.

10. The Legacy Health policy and procedure titled "Emergency Medical Treatment and Labor Act (EMTALA) Compliance for Legacy Health Emergency, Labor and Delivery, Psychiatric Emergency Services and Provider Based Urgent Care Departments; On-Call Licensed Independent Practitioners & Reporting Requirements for Non-Compliance," dated as last revised "01/17," reflected that "If an individual comes to one of Legacy's Dedicated Emergency Departments, Legacy will provide an appropriate Medical Screening Examination within the capability of the department, including ancillary services routinely available, to determine whether or not an Emergency Medical Condition exists...Legacy will not base the provision of emergency services and care upon an individual's race, ethnicity...national origin...language...insurance status...Legacy may not delay the provision of an appropriate MSE...in order to inquire about the individual's method of payment or insurance status." The policy and procedure defined "Dedicated Emergency Department" as the ED itself; "Hospital Property;" and "...any Legacy department or facility, regardless of whether it is located on or off a main hospital campus..."

In relation to triage the policy and procedure reflected "'Triage' is a sorting priority by a qualified registered nurse. Triage does not constitute a MSE and does not determine the presence or absence of an EMC...As soon as practical after arrival, individuals who come to the [ED] should be triaged..."

The policy and procedure also included a section titled "Reporting Violations" that stipulated "Any Legacy medical staff member or employee who believes...that Legacy violated EMTALA, must report the incident to the Compliance Officer or Compliance Hotline, as soon as possible for investigation."

11. The EMTALA training Power-Point curriculum, dated 06/05/2017, included the following language: "Registration - Legacy may not delay the provision of an appropriate MSE or any necessary stabilizing medical examination and treatment in order to inquire about the individual's method of payment or insurance status - A request for payment may not be made at the time of registration before the MSE is done." The training also required that "Any Legacy medical staff member or employee who believes...that Legacy violated EMTALA, must report the incident to the Compliance Officer, through ICARE, or the Compliance Hotline as soon as possible for investigation."

12. The Legacy Health policy and procedure titled "Interpreters for Deaf, Hard of Hearing, and Limited English-Speaking Individuals," dated as last reviewed "05/17," reflected it was to "ensure effective communication meets the oral and written communication needs of patients and qualified individuals...to provide equal access to health care services in accordance with federal and state law as well as regulatory organizations...This policy applies to all employees, medical staff, and volunteers of any Legacy organization...." The policy stipulated the following points:
* "Interpretation and translation services will be provided to patients and qualified individuals free of charge."
* "Legacy Health will provide interpreting services 24 hours per day, seven days a week."
* "On-site, telephone, or video with any of Legacy's contracted agencies or in-house staff interpreters."
* "In order to provide interpretation services at Legacy Health, spoken-language interpreters must have obtained at least one of the following...In Oregon...Oregon Certified Health Care Interpreter; Oregon Qualified Health Care Interpreter; or 60 hours of interpreter training by an Oregon Health Authority approved Health Care Interpreter training program."
* "Ad hoc interpreters and untrained bilingual individuals, family members, friend, and children should not be used to interpret during medical encounters except in rare or life-threatening circumstances, or at patient's request with provider agreement."
* "The services of a qualified interpreter shall be used for the following situations...Obtaining the patient's consent or refusal of treatment or waiver of rights...During emergency treatment...Patient reduction to patient and/or qualified individual...Informing the patient about patient rights, advance directives, financial obligations and arrangements..."
* "Legacy Health will honor a patient's request to decline interpreter services..."

13. The Legacy Health policy and procedure titled "Patient Financial Communications, dated as effective 03/01/2016, stipulated the following:
* "Quick Registration: A minimum of three (3) data requirements are required to complete the ER quick registration: Name, Date of Birth (DOB), and symptoms. No Insurance information will be asked a the time of quick registration."
* "Interpretive services are available and offered free of charge when needed or requested."
* "All practices must comply with EMTALA and all other Federal, State and Local regulations affecting the Emergency Department. Team members are to adhere to and comply with State and Federal EMTALA Regulations when securing co-payments and/or past balances. Collection activity can happen only after the medical screening is completed and patient has been stabilized. In no event will a patient be denied treatment in the emergency department because of financial issues."
* "In and out of network...Many plans cover only a portion of emergency care, even for the out of network providers. In those cases, once patient is stabilized they are more likely moved to an in network provider for follow up. It is important to note this applies only to true emergencies. For questions about what constitutes and emergency, or which emergency costs are covered, patient is referred to their insurance carrier."
* "Emergency Department - NOTE: All practices must comply with EMTALA and all other Federal, State and Local regulations affecting the Emergency Department...Team members will secure co-payments and/or past balance collection after the medical screening exam is completed and patient has been stabilized. In no event will a patient be denied treatment in the emergency department because of financial issues...Collection from qualifying patients should take place only after the MSE (medical screening exam) is complete (after patient has seen a Physician, Nurse Practitioner or Physician Assistant - RN triage is not considered MSE)."
* "Non-elective services - defined a emergent or direct admission service - All practices must comply with EMTALA and all other Federal, State and Local regulations affecting the Emergency Department. Staff is to adhere to and comply with State and Federal EMTALA Regulations when securing co-payments and/or past balances. Collection activity can happen only after the medical screening is completed and patient has been stabilized. In no event will a patient be denied treatment in the emergency department because of financial issues."

14. The "Patient Financial Communication" training Power-Point curriculum, dated 03/01/2016, included the following language:
* "Registration Process - Emergency Department - Local, State and Federal EMTALA laws are observed and financial communication occurs after the medical screening exam is completed and patient is stabilized."
* "Patient Share discussions - Emergency Department - Patients are educated about financial responsibility - what is co-payment, coinsurance, etc. Collections efforts from qualifying patients are taking place only after the MSE is completed."
* "Self pay and Financial Assistance discussions - Emergency Department - Local, State and Federal EMTALA laws are observed and financial communication occurs after the medical screening exam is completed and patient is stabilized."
* "In and Out of Network discussions...Emergency Department - To help our patients, team members can advise patients to consult their insurance benefit booklet or call the insurance for detailed benefit information. Legacy's representatives will provide education and support to patients to help reach out to their insurance, if needed."
* "Providing Estimates - Emergency Department - When patient requests and estimate, team members inform that actual costs may vary from estimates depending on actual services performed. Patient is referred to the customer service for a cost estimate."
* "Discussion to help resolve Current and Prior Balances - Emergency Department...Past balances are reviewed with the patient. Resolution options are discussed and if needed patient is referred to the proper resource...for further help, like setting up payment plan etc."

15. The "Patient Financial Communications (emergency room )" one page tool for PARs, dated 02/23/2016, included the heading "Helping emergency patients expect multiple bills and understand the possibility of out-of-network benefits." The first row under that heading stipulated "Allow the physician to complete medical screening."

16. The undated, web-based self-learning module titled "Patient Financial Communications - An Introduction to Best Practices - Legacy Health" included the following language:
* "The best practices specify that, in the ED setting, no patient financial discussions should occur before a patient is screened and stabilized, in accordance with the Emergency Medical Treatment and Active Labor Act and other federal, state, and local regulations governing the ED."
* "If the medical screening determines that a patient has an emergency medical condition, the financial discussion should occur during the discharge process. For patients who do not have an emergency medical condition, following the medical screening, discussion may occur during either the registration or discharge process."
* "It is worth restating: In the ED, no patient financial discussions should occur before a patient is screened and stabilized. Once a patient is stabilized, basic registration information, including demographics and insurance coverage, may be gathered, and the potential need for financial assistance may be determined."
* "The practices state that ED patients should be informed that their ability to pay will not interfere with treatment of any emergency medical conditions."

17. During the entrance conference on 01/18/2018 at 0945 with the CEO and CNO they denied knowledge of any allegations of EMTALA violations at the hospital. They were unaware of any reported concerns about persons being turned away due to insurance or any other concerns that may have EMTALA implications. Therefore, they confirmed they had no documentation of alleged incidents and internal investigations to provide.

However, during an interview on 01/18/2018 at 1235 with the LHS Senior Compliance Consultant he/she stated that on 01/10/2018 having received a telephone call from a KPNW compliance staff who reported that on 01/05/2018 during the late evening Person 18 had presented to the LMHMC ED and the parents were told that they would have to call Kaiser before they could be seen. The LHS Compliance Consultant stated in response to that report he/she had checked the hospital's EMR system, EPIC, to see if there was an encounter and found the last encounter for Person 18 was in 2016. He/she confirmed that was the only action taken up to the date of the SA investigation.

In addition, during an interview on on 01/19/2018 at 1300 with the ED CN who was on duty during the night shift of 01/05/2018 he/she stated that during the shift he/she received an "unusual call." The KSMC ED CN called to report that a patient presented to KSMC and that the family "came in to be seen at LMHMC but were told it would be better to go to Kaiser." The CN stated that he/she went to talk to PAR staff who said he/she told the family "we'd be glad to see [the child] but couldn't guarantee coverage...the [parent] decided to take the [child] to Kaiser." The CN confirmed that he/she had not reported the call to anyone else and stated "we were busy and I forgot about it."

18. Person 18 and his/her non-English speaking parents presented to the hospital for emergency services, however the hospital's written policies and procedures related to EMTALA, interpreter services, and financial communication were unclear and not followed, and Person 18 left the hospital without being registered and triaged, and did not receive a MSE. The hospital's interpreter services policies and procedures required the family member interpreters should not be used except in rare or life-threatening circumstances nor during discussions about financial obligations and arrangements. The hospital's financial communications policies and procedures included that interpreter services are available when needed and training documents stipulated that financial communication was to occur only after an MSE was completed and the patient stabilized.

The financial communication policies and procedures and training documents included unclear and contradictory language. For example: References to discussions with patients about "In and out of network" coverage and "Patient Share" did not specify when those conversations could and could not occur; and the "best practices" document reflected that financial discussion "should" occur after an MSE, and "may occur during...registration..." and did not clearly prohibit those discussions to occur only after the MSE as in the other documents. "Best practices" are generally considered recommendations and not requirements.

Further, the ED Triage RN who was present during the encounter failed to intervene to ensure policies and procedures were followed, failed to clarify the hospital's EMTALA obligation for the family, and failed to make an attempt to look under the blanket to assess the child's condition.