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.

CRESTWYN BEHAVIORAL HEALTH 9485 CRESTWYN HILLS COVE MEMPHIS, TN June 13, 2018
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on policy review, document review, medical record review and interview, the hospital failed to ensure all patients presenting tot he Psychiatric hospital's Intake Assessment Department (also known as their hospital emergency department area) seeking medical care received an appropriate Medical Screening Exam (MSE) to determine whether an emergency medical condition existed for 20 of 20 (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, # 11, #12,
#13, #14, #15, #16, #17, #18, #19 and #20) sampled patients who presented to the Emergency Department seeking medical attention. The facility failed to post signs at all entrances specifying the rights of patients related to EMTALA and failed to ensure the physician certification was completed for 2 of 3 (Patient #11 and #12) sampled patients transferred to another hospital.

Refer to findings in A 2402, A 2406 and A 2409.
VIOLATION: POSTING OF SIGNS Tag No: A2402
Based on observation and interview, the hospital failed to post conspicuously a notice specifying the rights of individuals in respect to examination and treatment of emergency medical conditions, women in labor or whether they participate in the Medicaid program for 2 of 2 (6/ 11/18 and 6/13/18) days of observation.

The findings included:

On 6/11/18 at 2:30 PM the Risk Manager provided a tour of the facility's entrances for patients. This included the front entrance, outpatient entrance and ambulance entrance. There was no signage posted related to examination and treatment of emergency medical conditions, women in labor or whether the hospital participated in the Medicaid program.

On 6/13/18 at 10:20 AM, the Risk Manager provided a tour to show that there was signage related to EMTALA [Emergency Medical Treatment and Labor Act]. The signage stated, "IT'S THE LAW! If you have a medical emergency or are in labor, you have the right to receive, within the capabilities of this hospital's staff and facilities: An appropriate medical screening examination. Necessary stabilizing treatment (including treatment for an unborn child) and, if necessary, an appropriate transfer to another facility. Even if you cannot pay or do not have medical insurance or you are not entitled to Medicare or Medicaid. This hospital does participate in the Medicaid." There was signage posted in the Admission/Sub-waiting Room (Intake Assessment waiting room) and 3
assessment rooms. The door to the Admission/Sub-waiting Room was secured and could not be open except bt staff. There was no signage posted in the main lobby, the outpatient lobby or by the ambulance entrance.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital document review, policy review, Emergency Medical Treatment and Labor Act (EMTALA) log, health related board statutes, medical record review and interview, the hospital failed to ensure all patients presenting to the Intake Assessment Department of the Psychiatric hospital (also known as their Emergency Department area) seeking medical attention received an appropriate Medical Screening Examination (MSE) to determine if an emergency medical condition (EMC) existed for 20 of 20 (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10,
#11,#12,#13,#14,#15,#16,#17,#18,#19 and #20) sampled Emergency Department patients.

The findings included:

1. Review of the hospital "MEDICAL STAFF BYLAWS" revealed, "..,ALLIED HEALTH PROFESSIONALS or AHP means an individual other than a physician who is permitted by law, the Board, and the Medical Executive committee to provide patient care services within the scope of their license, certificate, or other legal credentials in accordance with individually granted Clinical Privileges...LICENSED INDEPENDENT PRACTITIONER (LIP) means any individual permitted by law and by the Facility, in accordance with the limits established by the Board and the Medical Staff, to provide patient care and services at Facility without direction or supervision, but within the scope of the individual's license and consistent with j individually granted Clinical Privileges...The purposes of the Medical Staff are:...2.1.6 to assure that each Medical Staff Member and Allied Health Professional provides services within the scope of individual Clinical Privileges granted and...3.3.22 unless excused by the Medical Director or CEO [Chief Executive Officer], in his sole discretion, participate in emergency service coverage and consultation panels as may be required by the Bylaws, the Rules and Regulations, and the Facility's Policies and Procedures...Removal or exclusion from the emergency call rotation shall not be considered a change in Medical Staff category or privilege and shall not be grounds for a hearing...The
A2406 Continued From page 6
Prerogatives of an Allied Health Professional shall be to: 5.3.1 exercise granted Privileges within the scope of their license, certificate..."

2. Review of the hospital "RULES AND REGULATIONS OF THE MEDICAL STAFF" revealed, "..."Qualified Medical Persons" are those Licensed Independent Practitioners identified on Exhibit A hereto , subject to amendment from time to time by the Governing Board, as evidenced by an updated Exhibit A signed by the Secretary of the Governing Board, who are qualified within the scope of their respective licenses and in compliance with applicable State laws to perform one or more types of medical screening examinations...18.0...AII Med ical Staff Members and AHP Staff Members must abide by EMTALA and by all applicable rules and regulations of CMS [Center for Medicare and Medicaid Services] impending EMTALA, as reflected in Hospital's EMTALA policies and procedures...Exhibit A...The following are recognized as Qualified Medical Persons: Physicians, Nurse Practitioners, Registered Nurses and Physician Assistants ..."

3. Review of the facility "ADMISSION PROCEDURE (Intake)" policy revealed, "...Any person who presents requesting a psychiatric service assessment will be assessed . The assessment will be completed by a Registered Nurse (RN) or Mental Health Professional identified as qualified medical professionals (QMP's)...Upon arrival, individuals to be assessed will be asked for a form of identification and insurance cards...MEDICAL SCREENING...When a patient arrives at the facility and request an examination or treatment of a medical or psychiatric condition, a Medical Screening will be
Icompleted without delay to determine whether an emergency medical condition exist...lf the nurse
determines an emergency medical condition exists, staff will follow the EMTALA [Emergency Medical Treatment and Labor Act] compliance procedures...If the patient has no emergent medical condition then the patient will continue with the QMP to complete the intake assessment. .."

4. Review of the hospital "EMTALA" policy revealed, "...[Named hospital] will provide "emergency services and care" within the capability of its facilities and staff to any individual who requests services, examination or treatment, or for whom services , or examination or treatment is requested ...PROCEDURE Any person who presents to the Hospital will be evaluated to determine whether the person has an emergency medical condition ...The law defines an "emergency medical condition" as an acute medical condition that without immediate medical attention, could reasonably be expected to result in serious jeopardy to the health of an individual...or serious impairment or dysfunction of any bodily organ or part ...Psychiatric Emergency The law requires that persons must be, as a result of a mental disorder, a danger to self, a danger to others, or gravely disabled ...Medical Screening Examinations. The attending physician and/or on-call physician is responsible for the supervision, evaluation and stabilization of his/her
patient when he/she is on the hospital grounds and available . [Named hospital] maintains an on-call list of physicians who are responsible to perform medical screening evaluations to determine whether an individual has an
emergency medical condition. In the absence of a physician, a registered nurse who has demonstrated competency may conduct medical screening examinations ..."

5. Review of the State Health Related Board Statutes for Licensed Psychologists, Licensed Social Workers, Registered Nurses and Licensed Professional Counselors revealed the scope of practices for these disciplines do not allow them to independently practice, treat patients and prescribe medical treatment for patients . Therefore, cannot be considered a Qualified Medical Professional (QMP) or Licensed Independent Practitioner (LIP).

6. Medical record review revealed Patient #1 had an Inquiry Worksheet completed on 4/28/18 at 9:54 PM by Intake Assessor #1 (Masters in Guidance and Counseling) and documented "Alcohol detox [detoxification] 2 pts [pints] daily, I found passed out in [name of local restaurant]...Medical Problems: CHF [congestive heart failure], 3 toes amputated, Hyperglycemia, HTN [hypertension] Diabetes..."

Review of the Level of Care Recommendations completed by Intake Assessor #1 revealed Physician #2 was notified by telephone on 4/28/18 at 9:55 PM and the diagnosis was Alcohol Use, Severe.
The following day, 4/29/18, Patient #1 presented to Hospital #1's Intake Assessment Department at 12:35 AM via ambulance with the presenting problem: "Patient found passed out in [name of local restaurant] and was taken to [name of local hospital] for medical treatment, patient is requesting alcohol detox treatment and was
referred by Mobile Crisis..."
There was no documentation qualified personnel performed a medical screening examination, assessed, examined or diagnosed the patient in Hospital #1's Intake Assessment Department on 4/29/18.
A2406

7. Medical record review revealed Patient #2 had an Inquiry Worksheet completed on 4/20/18 at 7:04 PM by Intake Assessor #3 (Masters in Clinical Mental Health Counseling) and documented "Pt [Patient] Threatened to stab stepmother...Pt wrote a suicide note today..."

Review of the Level of Care Recommendations completed by Intake Assessor #3 revealed Physician #3 was notified by telephone on 4/20/18 at 7:45 PM and the diagnosis was Disruptive Mood Dysregulation Disorder.

The following day, on 04/21/2018, Patient#2, a 15 year old, presented to Hospital #1's Intake Assessment Department at 10:55 AM via police with the presenting problem: "Pt [patient] wrote suicide note@ [at] school...made threats that she wanted to stab her family...Pt wrote a suicide note that she wanted to hang herself by 5:00 PM...she has made suicidal threats in the past..."
There was no documentation qualified personnel performed a medical screening examination, assessed, examined or diagnosed the patient in Hospital #1's Intake Assessment Department on 4/21/18.

8. Medical record review revealed Patient #3 had an Inquiry Worksheet completed on 5/28/18 at 5:41 PM by Intake Assessor #8 (Masters in Social Work) and documented, "...walked into police station w/ [with] kitchen knife & [and] stated he wanted to kill himself ...Medical Problems: Seizures..."

Patient #3, a 27 year old, presented to Hospital #1's Intake Assessment Department on 5/28/18 at 10:28 PM via ambulance with the presenting problem : "...Patient states been suicidal and mad/angry with staff at home/group home. Patient states been drinking whiskey and using THC [marijuana] to deal with stress..."

Review of the Level of Care Recommendations completed by Intake Assessor #1 revealed Physician #14 was notified by telephone on 5/28/18 at 8:06 PM and the diagnosis was Bipolar Disorder, Severe. The Intake Assessment form was signed on 5/28/18 at 10:37 PM by Intake Assessor #1.

There was no documentation qualified personnel performed a medical screening examination , assessed , examined or diagnosed the patient in Hospital #1's Intake Assessment Department on 5/28/18.

9. Medical record review revealed Patient #4 had an Inquiry Worksheet completed 6/9/18 at 2:40
PM by Intake Assessor #5 (Masters in Human Services Counseling) and documented, "PRESENTING PROBLEM:
Suicidal...Depressed...SUA [Suicide Attempt] this morning via cut both wrist w/ [with] razor blade, did not require sutures; Broke up w/ boyfriend of 12 years; Loss father January 2018; Mother involved in serious care accident in March 2018; tested positive for THC, last used 4-5 days ago..."

On 6/9/18 at 7:32 PM, Patient #4, a 42 year old, presented to Hospital #1's Intake Assessment via police with the presenting problem: "Patient presents with depression and anxiety. Pt has been depressed since Jan [January) 2018 (death of father); In March 2018, mother was involved in car wreck. Pt broken up w/ boyfriend of 12 years..."

Review of the Level of Care Recommendations completed by Intake Assessor #11 (Masters in
Social Work) revealed Physician #14 was notified by telephone on 6/9/18 at 2:52 PM and there was no diagnosis documented.

There was no documentation qualified personnel performed a medical screening examination, assessed, examined or diagnosed the patient in Hospital #1's Intake Assessment Department on 6/9/18.

During an interview in the Group Therapy Room on 6/12/18 at 9:11 AM, the Director of Intake stated, "Do not know when the physician assessment was done."

10. Medical record review revealed Patient #5 had an Inquiry Worksheet completed on 5/5/18 at 5:41 PM by Intake Assessor #6 (Masters in Marital and Family Counseling) and documented, "...Called 911, Saying she was suicidal, cut self w/scissors; Plan to OD [overdose] on Zoloft, take gun to school; sees ghosts telling her to kill herself...Medical Problems: O..."
Review of the Level of Care Recommendations completed by Intake Assessor #1 revealed Physician #1 was notified by telephone on 5/5/18 at 1:14 PM and the diagnosis was Major Depressive Disorder, Severe.
The following day on 5/6/18 at 11:42 AM, Patient #5, a 13 year old, presented to Hospital #1's Intake Assessment Department via sheriff's department with the presenting problem: "...Patient discharged on [DATE] and got upset on 5/5/18 because her aunt said she didn't want the patient back in her home...Patient got upset and began having thoughts of suicide with plans to overdose or shoot herself..."

There was no documentation qualified personnel performed a medical screening examination, assessed, examined or diagnosed the patient in Hospital #1's Intake Assessment Department on 5/6/18.

11. Medical record review revealed Patient #6 had an Inquiry Worksheet completed on 5/7/18 at 3 :24 PM by Intake Assessor #7 (Registered Nurse [RN]) and documented "Attempted to cut self with a pair of scissors...states he just wants to die...paranoid..."

Patient #6 was an [AGE] year old who presented to Hospital #1's Intake Assessment Department on 5/7/18 at 10:34 PM via ambulance with the presenting problem: "Pt presents after attempting to cut himself with a pair of scissors while at school...Pt is endorsing S/1 (suicidal ideations]..."

Review of the Level of Care Recommendations completed by Intake Assessor #5 revealed Physician #1 was notified by telephone on 5/7/18 at 3:35 PM and the admitting diagnosis was Major Depressive Disorder. The Intake Assessment form was signed on 5/7/18 at 10:59 PM by the Intake Assessor #5.

There was no documentation qualified personnel performed a medical screening examination, assessed, examined or diagnosed the patient in Hospital #1's Intake Assessment Department on 5/7/18.

12. Medical record review revealed Patient #7 had an Inquiry Worksheet completed on 2/2/18 at 9:44 AM by Intake Assessor #12 (Masters in Community Counseling) and documented, "detox from heroin."

Review of the Level of Care Recommendations completed by Intake Assessor #12 revealed Physician #2 was notified by telephone on 2/2/18 at 9:50 AM and the diagnosis was opioid dependence, uncomplicated.

On 2/2/18 at 10:41 AM, Patient #7, a 32 year old, presented to Hospital #1's Intake Assessment Department via car with the presenting problem: "Pt reports partaking in opioid abuse a long time. Pt reports that he uses heroin to be able to maintain on a daily basis . Pt states, "F...ing tired of it and I don't want to be dependent on heroin anymore."

There was no documentation qualified personnel performed a medical screening examination, assessed, examined or diagnosed the patient in Hospital #1's Intake Assessment Department on 2/2/18.

13. Medical record review revealed Patient #8 had an Inquiry Worksheet completed on 3/21/18 at 12:45 PM by Intake Assessor #6 (Masters in Marital and Family Counseling) and documented, "...Passive SI; Dep [depression] ; ETOH [alcohol] Binges...Medical Problems: Epilepsy, Migraines..."

On 3/21/18 at 2:06 PM Patient #8, a 42 year old, presented to Hospital #1's Intake Assessment Department via car with the presenting problem: "...Pt presents extremely tearful reporting feelings of hopelessness and helplessness. Pt denies SI currently but recently expressed wishing she was dead. Pt is not able to contract for safety. Pt spouse is fearful of what Pt may due (do) to herself due to pt explosive anger and uncontrolled behavior..."

Review of the Level of Care Recommendations completed by Intake Assessor #5 revealed Physician #3 was notified by telephone on 3/21/18 at 2:47 PM and the diagnosis was Major Depressive Disorder, Severe W/O Psychosis. The Intake Assessment form was signed on I3/21/18 at 2:40 PM by Intake Assessor #5.
There was no documentation qualified personnel performed a medical screening examination, assessed, examined or diagnosed the patient in Hospital #1's Intake Assessment Department on 3/21/18.

14. Medical record review revealed Patient #9 had an Inquiry Worksheet completed on 4/27/18 at 12:10 PM by Intake Assessor #6 (Masters and Marital and Family Counseling) and documented "Delusional , hyper religious, believes she is God...non-compliant with meds past two weeks..."

On 4/27/18 at 3:23 PM Patient #9, a 46 year old, presented to Hospital #1's Intake Assessment Department via police with the presenting problem: "Patient is psychotic and delusional; patient is 46 and claims to be 17. She says she is God's wife and is supposed to save the world..."

Review of the Level of Care Recommendations completed by Intake Assessor #1 revealed Physician #2 was notified on 4/27/18 at 12:21 PM and the admitting diagnosis was Schizophrenia .

There was no documentation qualified personnel performed a medical screening examination, assessed, examined or diagnosed the patient in Hospital #1's Intake Assessment Department on 4/27/18.

15. Medical record review revealed Patient #10 had an Inquiry Worksheet completed on 3/12/18 at 12:15 PM by Intake Assessor #6 (Masters in Marital and Family Counseling) and documented "Sitting in closet w/ gun : contemplating suicide 'for a while', Depression, work stressors, can't have any children"

On 3/12/18 at 1:30 PM Patient#10, a 35 year old, presented to Hospital #1's Intake Assessment Department via police with the presenting problem: "SI [suicidal ideation] + [plus] Depression has been on meds for past 3-4 months..."
The patient denied SI at the time of his MSE by Assessor #6. Assessor #6 contacted Physician
#4 via telephone at 2:15 PM. Physician #4 recommended outpatient referral and required a safety contract be developed with the patient and his wife. Patient #1O was discharged at 3:03 PM.

There was no documentation qualified personnel performed a medical screening examination, assessed, examined or diagnosed the patient in Hospital #1's Intake Assessment Department on 3/12/18.

16. Review of the EMTALA log dated 6/1/18 revealed Patient #11 presented to Hospital #1's Intake Assessment via ambulance at 2:00 PM.

Medical record review revealed Patient# 11 had an Inquiry Worksheet completed on 6/1/18 at 1:55 PM by Intake Assessor #6 (Masters in Marital and Family Counseling) and documented, "PRESENTING PROBLEM: Suicidal...SUA [suicide attempt] OD on 50 Seroquel [an antipsychotic medication to treat schizophrenia, bipolar disorder and depression], recent breakup w/ GF [girlfriend] who conned him out $3,000.00 - denies attempt says it was accidental..."

The patient was transferred to Hospital #2 on 6/1/18 at 8:43 PM.

There was no intake assessment, Level of Care Recommendations or Physician Certification forTransfer documented. There was no documentation qualified personnel performed a medical screening examination, assessed, examined or diagnosed the patient in Hospital #1's Intake Assessment Department on 6/1/18.

17. Medical record review revealed Patient #12 had an Inquiry Worksheet completed on 4/12/18 at 9:59 AM by Intake Assessor #13 (Masters in Education) and documented, "...Drug abuse (cocaine & marijuana) - Depression & Anxiety..Medical Problems: None..."

The following day on 4/13/18 at 3:00 PM Patient #1 #12, a 22 year old, presented to Hospital #1's Intake Assessment Department on via ambulance with the presenting problem: "...Pt presents following intentional ingestion of Tylenol. Pt reportedly took a handful of pills after reporting no desire to live on 4/12/18. Pt endorses experiencing depression for the past month that worsened the past two days. Pt. reports feeling worthless and not in control of his life ..."

Review of the Level of Care Recommendations completed by Intake Assessor #5 revealed Physician #3 was notified by telephone on 4/13/18 at 12:05 PM and the diagnosis was Major Depressive Disorder, Recurrent Severe.

There was no documentation qualified personnel performed a medical screening examination, assessed, examined or diagnosed the patient in Hospital #1's Intake Assessment Department on 4/13/18.

18. Medical record review revealed Patient #13 had an Inquiry Worksheet completed on 2/8/18 at 9:35 AM by Intake Assessor #2 (Masters in Social Work) and documented "admitted to [named Hospital #3] on 2/6/18 for Stroke...Depression & Anxiety..."

On 2/8/18 at 9:00 PM Patient #13, a 54 year old, presented to Hospital #1's Intake Assessment Department via ambulance with the presenting problem: "Patient was having suicidal ideations on 1/30/18 with plans to shoot herself. Patient denies current suicidal thoughts...she doesn't feel she needs to be readmitted for treatment said
she told [staff at Hospital #3] she felt stable to go home"

Review of the Level of Care Recommendations completed by Intake Assessor #1 revealed Physician #3 was notified by telephone on 2/8/18 at 9:35 PM. Assessor #1 documented, "patient [Patient #13] was being planned for discharge when she had to go out medical so he is ok with her not being admitted if she feels stable." Patient
# 13 was discharged at 9:38 PM.

There was no documentation qualified personnel performed a medical screening examination, assessed, examined or diagnosed the patient in Hospital #1's Intake Assessment Department on 2/8/18.

19. Medical record review revealed Patient #14 had an Inquiry Worksheet completed 1/3/18 at 3:10 PM by Intake Assessor #5 (Masters in Human Services) and documented, "PRESENTING PROBLEM: Suicidal...Homicidal. ..Psychotic...Exhibiting symptoms of psychosis erratic behavior, flight of ideas, racing thoughts, visual hallucinations:
seeing deceased mother. S/1: wants to die every day have thoughts of "blowing head off: H/1 [Homicidal ldeations] towards husband and wants to kill him with a "black jack". Depressed due to verbal and physical abuse from husband. SUA by OD 2 wks [weeks] after discharge from [name of another psychiatric hospital] Non-compliant with medications since November."

Review of the Level of Care Recommendations completed by Intake Assessor #1 revealed Physician #2 was notified by telephone on 1/3/18 at 3:26 PM and diagnoses were Schizophrenia,Opioid Use, Severe.

Patient #14, a 46 year old, did not arrive to the hospital unitl 1/3/18 at 9:07 PM via ambulance from a rural hospital for an involuntary admission with presenting problem: "Patient reports suicidal and homicidal ideations towards her husband in response to auditory commands hallucinations for both. Patient reports plans to shoot herself, and wants to beat her husband to death with a black jack. She reports being upset about him physically and mentally abusing her, she says he starting using "ICE" [ICE: street name for Methamphetamine] last January and became abusive in February..."

There was no documentation qualified personnel performed a medical screening examination, assessed, examined or diagnosed the patient in Hospital #1's Intake Assessment Department on 1/3/18.

20. Medical record review revealed Patient #15 had an Inquiry Worksheet completed on 12/14/17 at 12:00 AM by Intake Assessor #1 (Masters in Guidance Counseling) and documented "PRESENTING PROBLEM: Suicidal, Depressed, Alcohol, Cannabis...Los tjob no plan..."

Review of the Level of Care Recommendations completed by Intake Assessor #1 revealed Physician #4 was notified by telephone on 12/14/17 at 12:07 AM and diagnoses were Severe Recurrent Major Depressive Disorder with Alcohol and Cannabis Use.

Patient #15, a 24 year old, did not arrive at the hospital until 12/14/17 at 1:24 PM via ambulance
from an acute care hospital with presentingproblems: "Patient reports suicidal ideations with
plans to hang himself, patient reports severe depression after losing his job a month ago because of his use of Ecstasy [Methylenedioxy-methamphetamine-synthetic
drug which alters mood and perception]. Patient also reports abusing alcohol and cannabis..."

There was no documentation qualified personnel performed a medical screening examination, assessed , examined or diagnosed the patient in Hospital #1's Intake Assessment Department on 12/14/17,

21. Medical record review revealed Patient #16 had an Inquiry Worksheet completed on 3/5/18 at 4:16 PM by Intake Assessor #5 (Masters in Human Services and Counseling) and documented, "...Depression anxiety - feels overwhelmed taking care of husband...Medical Problems: HBP [high blood pressure]..."

Patient #16 was a [AGE] year old who presented to Hospital #1's Intake Assessment Department on 3/5/18 at 4:45 PM via car with the presenting problem: "...Pt presents endorsing suicidal thoughts yesterday. Pt reports when she saw a pair of scissors yesterday she thought about stabbing herself. Pt reports not feeling suicidal today. Pt denies H/I and psychosis. Pt can contract for safety..."

Review of the Level of Care Recommendations completed by Intake Assessor #5 revealed Physician #2 was notified by telephone on 3/5/18 at 5:29 PM. There was no diagnosis documented.

There was no documentation qualified personnel performed a medicalscreening examination, assessed, examined or diagnosed the patient in Hospital #1's Intake Assessment Department on 3/5/18.

22. Medical record review revealed Patient #17 had an Inquiry Worksheet completed on 12/11/17 at 2:06 PM by Intake Assessor #12 (Masters in Community Counseling) and documented, "...threw a fit w/ mother got out of moving vehicle due to not being able to see certain doctor/walking on highway...she was suicidal w/ plan to hang, cut, or jump off something...Medical Problems: Hx [history of] migraines and nose bleeds..."

Review of the Level of Care Recommendations completed by Intake Assessor #12 revealed Physician #16 was notified by telephone on 12/11/17 at 2:45 PM and the diagnoses were Major Depressive Disorder, Recurrent Severe without Psychosis.

Patient #17, a 14 year old, did not arrive to the hospital until 12/11/17 at 5:40 PM via police with the presenting problem: "...Pt reports...ongoing depression. Pt states 'my depression has been ongoing for a while'...pt was involved in a verbal altercation w/ mother over wanting to see a particular doctor. The pt reported back pain.
Due to not being able to see a particular physician, the pt removed herself from a moving vehicle. Pt was noticed by a sheriff. Pt told the sheriff that she is suicidal w/ plan to hang herself, cut, or jump off of something. Pt has a hx of cutting..."

There was no documentation qualified personnel performed a medical screening examination,
assessed, examined or diagnosed the patient in Hospital #1's Intake Assessment Department on 12/11/17.

23. Medical record review revealed Patient #18 had an Inquiry Worksheet completed on 1/14/18 at 2:26 PM by Intake Assessor #3 (Masters in Mental Clinical Health Counseling) and documented, "...Pt seeking IOP [intensive outpatient] to deal with depression & intrusive thoughts...Medical Problems: Vertigo..."

The following day 1/15/18 Patient #18, a 32 year old, presented to Hospital #1's Intake Assessment Department at 9:52 AM via car with the presenting problem: "...Unwanted SI thoughts, Anxiety..."

Review of the Level of Care Recommendations completed by Intake Assessor #12 revealed Physician #16 was notified by telephone on 1/15/18 at 2:45 PM and the diagnosis was Anxiety.

There was no documentation qualified personnel performed a medical screening examination, assessed, examined or diagnosed the patient in Hospital #1's Intake Assessment Department on 1/15/18.

24. Medical record review revealed Patient #19 had an Inquiry Worksheet completed on 12/27/17 at 6:50 PM by Intake Assessor #1 (Masters in Guidance Counseling) and documented, "...Suicidal, Psychotic, Family Problems,
Drugs/Alcohol..." There were no medical problems documented.

Patient #19 was a [AGE] year old who presented to Hospital #1's Intake Assessment Department on
12/27/17 at :10:50 AM via car with the presenting problem: "...patient requests assistance with heroin abuse, and Percocet abuse, Patient later reported suicidal ideations with plans to walk in traffic or overdose..."

Review of the Level of Care Recommendations completed by Intake Assessor #1 revealed Physician #3 was notified on 12/27/17 at 11:21 PM and the diagnosis was Major Depressive Disorder-Severe Recurrence , Opioid Abuse Severe, Cannabis use Severe. The Psychosocial Assessment form was signed on 12/27/17 at 11:21 PM by lntake Assessor #1.

There was no documentation qualified personnel performed a medical screening examination, assessed, examined or diagnosed the patient in Hospital #1's Intake Assessment Department on 12/27/17.

25. Medical record review revealed Patient #20 had an Inquiry Worksheet completed on 5/19/18
1 at 9:15 PM by Intake Assessor #1 (Masters in Guidance Counseling) and documented "PRESENTING PROBLEM: Homicidal, Family Problems, Drugs/Alcohol ...Threatened to cut his mother's M.F. [profanity] head off mother wasn't give him money for drugs. Uses cocaine and marijuana and Xanax. Hx of violent threats towards police..."

Review of the Level of Care Recommendations completed by Intake Assessor #2 revealed Physician #14 was notified by telephone on 5/19/18 at 9:22 PM and diagnoses were Schizophrenia, Paranoid Type, Cannabis Use, Stimulant Use.

The following day on 5/20/18 at 2:37 AM Patient #20, a 26 year old, presented to Hospital #1's Intake Assessment Department on 5/20/18 at 2:37 AM via ambulance with presenting problems: "I got mad at my mom because she
would not buy me a Xanax." Per MCT [mobile crisis team], pt expressed homicidal ideations
towards mom with a plan to cut her head off..."

There was no documentation qualified personnel performed a me. dical screening examination, assessed, examined or diagnosed the patient in Hospital #1's Intake Assessment Department on 5/20/18.

26. During an interview in the Group Therapy Room on 6/11/18 at 1:00 PM, the Director of Intake stated the on call physician was contacted by Intake Assessors at the time of referral to determine if a patient would be admitted based on criteria provided by the referral source. She verified at times, the patients arrived hours or even the day following referral. She stated once the patient presented to intake, Assessors completed a 9 page Intake Assessment. She stated the physician was not always called a second time (when the patient actually presented for treatment), if they accepted the patient at referral. She verified the physicians were not present in the Intake Unit to perform the assessments .

During an interview in the Admission/Sub-Waiting Room on 6/11/18 at 2:48 PM, Intake Assessor #1 stated, "When a client walks in they are given paper work to fill out. They will get "wanded" (portable metal detector) and get vital signs. Their background information is on the paperwork and registration is done. We have a Master's
Level Assessor or RN complete the assessment for information on the patient, then we review with the doctor if the patient needs inpatient, outpatient services or have no acuity and refer out. We call the doctor per our call list unless the patient has been here before, then we contact the Iprevious doctor. The doctor is not normally in the Intake Department, rarely does the doctor come; unless doctor is in the building, may come up and see the patient onsite..."

During an interview in the Group Therapy Room on 6/12/18 at 9:00 AM, the Director of Intake stated staff did not call the physician when the patient arrived on campus, if they had already called the physician when they received the referral. She verified the only time the physician was called at the time of presentation, was when a patient walked up for services with no prior referral. She again verified the physician was not present and did not perform an MSE on patients in the Intake Department(also known as the hospital's emergency department area). The Director of Intake was asked how the Intake Assessors were qualified to perform MSE. She stated, "..Masters in a Social Service field...License is preferred..." She verified the on call physician determined whether the patient was admitted to the hospital or required another course of treatment. She again verified the physician was contacted via telephone to make the determination.

During an interview in the Group Therapy Room on 6/12/18 at 10:35 AM, the Intake Nurse (RN) stated at times, if the Intake Unit was busy, she conducted the 9 page Intake Assessment for patients who presented for treatment. She verified she called the on call physician who would then determine whether to admit the patient to the hospital. She verified the on call physicians did not come to the Intake Department to see patients, consults were done via telephone

During an interview in the Group Therapy Room on 6/12/18 at 12:08 PM the Risk Manager was asked if the hospital was following their EMTALA policy regarding MSE. She stated, "If you're reading this [referred to the policy], No." When asked whether the Intake Assessors were qualified to perform MSEs, she stated, "I don't know."

During a telephone interview in the Group Therapy Room on 6/12/18 at 1:10 PM, the hospital's Medical Director verified Intake Assessors completed the Intake Assessment (MSE) and contacted on call physician's to discuss the information gathered in the intake. She stated that the standard process was for the physician to review the case over the telephone and make a recommendation . She verified the Physicians do not conduct the MSE in person.

During a te
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review, and interview the facility failed to provide a Physician Certification For Transfer for 2 of 3 (Patient #11 and #12) sampled patients transferred from Hospital #1's Intake Assessment Department (also known as their emergency department area).

The findings included:

1. Review of the hospital ''EMTALA" (Emergency Management Treatment and Labor Act) policy revealed, "... A physician will sign a certification that based upon the information available at the time of transfer; the medical benefits reasonably expected from the provision of emergency medical treatment at another facility outweigh the increased risks to the individual... When a transfer is made pursuant to a physician's certification, the form "Physician Certification" should be completed and signed by the physician. If a physician is not physically present in the facility at the time an individual is transferred, a qualified medical person may sign the certification after the physician, in consultation with the qualified medical person, has made the determination...and subsequently countersigns the certification...In the event a patient who is referred to [named hospital] is screened, evaluated and determined to be medically unstable by the registered nurse on duty and requiring a level of care not provided by this facility, the following procedures will be initiated: The attending physician and/or the on-call physician will be notified. The physician and/or the registered nurse will notify the physician at the receiving facility of the impending transfer and arrange for the patient's transfer to a contractual hospital...Patient is transported with documentation of information available regarding the following: Condition upon arrival at [named hospital]... Medical record information which might have accompanied the patient to this facility...Documentation of any interventions/treatments the patient received from the staff of [named hospital]... Any other pertinent data available and requested by the receiving hospital...Transfer Summary. A signed copy of the Transfer Summary shall be kept by the transferring and receiving hospital..."

2. Review of the EMTALA log dated 6/1/18 revealed Patient #11 presented to Hospital #1's Intake Assessment via ambulance at 2:00 PM.

Medical record review revealed Patient #11 had an Inquiry Worksheet completed on 6/1/18 at 1:55 PM by Intake Assessor #6 (Masters in Marital and Family Therapy) and documented, "PRESENTING PROBLEM: Suicidal...SUA [suicide attempt] OD [overdose] on 50 Seroquel [an antipsychotic medication to treat schizophrenia, bipolar disorder and depression], recent breakup w/ [with] GF [girlfriend] who conned him out $3,000.00 - denies attempt says it was accidental..."

On 6/1/18 at 8:43 PM, Patient #11 was transferred to Hospital #2.

There was no Level of Care Recommendations, transfer form or Physician Certification for Transfer documented prior to transfer.

During an interview in the Group Therapy Room on 6/12/18 at 9:13 AM, the Director of Intake stated, "He [referring to Patient #11] was accepted as direct referral and completed the intake forms. Did not complete full assessment. Paper work reflected he was medically complicated outside our scope of care. The nurse on the unit, consulted with Internal Medicine. Then called [Hospital #2] and talked to nurse on the inpatient unit. [Named Intake Assessor #1] spoke to the ED [emergency department] nurse and got OK [okay] to send back to [Hospital #2]. Apparently did not fill out a transfer form because it's to be signed by a nurse and [Intake Assessor #1] is not a nurse. Had there been a nurse in Intake, it would have been done."

3. Medical record review revealed Patient #12 had an Inquiry Worksheet completed on 4/12/18 at 9:59 AM by Intake Assessor #13 (Masters in Education) and documented, "...Drug abuse (cocaine & marijuana) - Depression & Anxiety...Medical Problems: ADHD [Attention Deficit Hyperactivity Disorder] Depression & Anxiety..."

Patient #12 was a [AGE] year old who presented to Hospital #1's Intake Assessment Department on 4/12/18 at 11:58 AM via car with the presenting problem: "...Pt [patient] stated 'Drugs, cocaine & weed, and I experienced heroine.' Pt stated 'I didn't shoot up a needle but I went on a heroine trip and it didn't go well'. Pt stated 'I took a lot of Tylenol this morning around 2 am [AM] and I feel it working right now' I informed pt & Dad that pt has to go to ER [emergency room ]..."

There was no Level of Care Recommendations, transfer form or Physician Certification for Transfer documented.

During an interview in the Group Therapy Room on 6/12/18 at 9:45 AM, the Director of Intake verified staff failed to complete the required transfer paperwork.