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Based on record review and interview the hospital failed to be in compliance with 42 CFR ?489.20 (l) of the provider's agreement which requires that hospitals comply with 42 CFR ?489.24, Special responsibilities of Medicare hospitals in emergency cases as evidenced by:


1) Failing to accept appropriate emergency patient transfer requests for which the hospital had the capacity and specialized capability to treat as evidenced by reviewing the patients' payor source prior to accepting patients. (see findings at A2411).

Based on interviews and review of policy and procedures the hospital failed to accept appropriate emergency patient transfer requests for which the hospital had the capacity and specialized capability to treat as evidenced by reviewing patients' payor source prior to accepting patients.
Findings:

Review of the hospital's policy titled: Emergency Room Referrals revealed in part, "It is the policy of the Hospital to act as a resource for psychiatric patients identified in an Emergency Room (ER)...Procedure:
1. When a psychiatric patient is identified by ER staff at a referring facility, the Hospital may be contacted for potential placement.
2. The Hospital staff will complete the Emergency Medical Treatment and Active Labor Act (EMTALA) log as required by the Center for Medicare and Medicaid Services (CMS) referencing 42 C.F.R. 489.24 (e) along with Inquire Log form and notify the Administrator on-call of the patient's presence in an ER.
3. The attending Psychiatrist will be notified of an inquiry.
4. A Pre-Admission Assessment by telephone will be completed by the RN on duty.
5. If the Attending Psychiatrist, determines that the patient is medically stable and admission is indicated, the clinician will;

a. Contact the Director of Nursing or his/her designee;
b. Contact the patient's private physician and/or psychiatrist; if necessary.
c. If the patient is not under the care of a psychiatrist, the psychiatrist on-call will be contacted;
d. Once notified, the psychiatrist will determine appropriateness for admission; and
e. When the patient is ready for admission to the hospital, the referring ER will arrange transport of the patient to the Hospital..."

Review of the hospital's policy and procedure titled, Admission Criteria, revealed in part, "Policy: It is the policy of the Hospital to admit patients, aged 18 years and older, whose mental condition warrants acute, inpatient psychiatric care. Patients appropriate for admission are accepted regardless of third party reimbursement status, ability to pay for services, race, religion, gender, sexual orientation, ethnicity, or disability ...

3. Patients who show evidence of symptoms of acute psychiatric disorder will be accepted for admission if they are medically cleared and who are over 18 years of age. Such conditions include but are not limited to:
-Suicide attempt or risk
-Homicide ideation, intent, or risk of violent/assaultive behavior as a result of a psychiatric disorder.
-Psychiatric symptoms such as hallucinations, delusion, catatonia, mania, depression which are severe enough to cause disordered/bizarre behavior or psychomotor agitation or retardation resulting in functional problems in daily living
-Self-destructive or self-mutilating behavior
-Memory impairment and/or disorientation that might endanger welfare of self or others
-Inability to maintain adequate nutrition, severe enough to threaten life or vital body functions.
-Mental disorder not responding to outpatient therapy or noncompliance with outpatient therapy resulting in severe psychiatric symptoms.
-Patients with chronic, organic mental conditions who are also experiencing severe psychiatric symptoms such as psychosis or disordered/bizarre behavior.
-Patients who are deemed gravely disabled
-Have demonstrated a serious intent to harm, self, others, or property within 72 hours prior to admission.

Contradictions to Admission:
-Patient with a primary diagnosis of alcoholism or substance abuse.
-Uncomplicated brain dysfunction/dementia or Alzheimer's type with no psychiatric symptomatology.
-Patients under the age of 18.
-Is criminally insane.
-Is medically unstable (as determined by a physician).
-Has a primary diagnosis of severe organic brain dysfunction or dementia.
-Has a primary diagnosis of I-II-III-IV-V Codes.
-Have medical devices that would conflict with or prevent therapeutic goals.
-Have a need for ECT (Electroconvulsive Therapy).
-Has an acute/critical medical/surgical status (as determined by a physician).
Patients must be medically stable prior to admission. The attending psychiatrist will evaluate the appropriateness of all potential patients. Patient's medical conditions must allow for the rigorous schedule of the program. Patients are expected to be able to physically and cognitively tolerate the milieu of the program ... "


Review of a Fax Referral Disposition Form revealed blanks for the following information:

Date, Referral Fax Arrived at(time):, final disposition time, information reviewed by, referral source, patient name, DOB (date of birth), age, sex, and presenting problem. Below the presenting problem information were the following words typed: Harm to Self, Harm to Others, Gravely Disabled, Depressed, Psychotic, Agitated, Violent, Changes in: Eating, Sleeping, Social Life, Paranoid, Delusional, Hallucinating Visual, and Hallucinating Audio. A space to list current medical problems followed and the following words were typed under that area: Diabetic, HTN, Seizure D/O (disorder), Wound, Heart Problem, Surgery, Dialysis, Ambulatory, Wheelchair/Walker, Bed Rest, Self- Care, Incontinent, and Fall Risk.
Under these conditions were noted blanks and information as follows: Contacted Administration on Call and time, Contacted Psychiatrist on Call, Admission Approved: yes/no, If no, why?, If no, admission denial reason code, and under the statement, " ...reviewed the referral packet and discussed the information with the Clinical and Administrative team collectively made the above decision " . A signature line with date and time was noted.

Further review revealed a key to the Admission Denial Reason code as follows: 1)Patient/Family refused; 2)-Already Placed; 3)-No bed available: 4)-Medical; 5)-Gender; 6)-Isolation; 7)-Admission Criteria; 8)-Level of care; 9)-Administrative; 10)Substance Abuse Primary; and 11)-No capacity to handle the patient at the present time.

Review of the personnel file of S3URCoordinator (Utilization Review Coordinator) revealed an UR/Intake/QAPI checklist dated 1/14=1/25 that included Intake Coordination. The skills listed on the checklist were as follows:
-Familiar with Intake process and various methods referrals are obtained
-Appropriately locates and verifies potential admissions financial status as part of the intake process
-Appropriately defers to clinical staff for determination as to whether patient is appropriate for services and that their needs can be met.
Further review revealed that S3URCoordinator checked "never done" under self-assessment, and documentation of method of instruction for all skills listed was protocol/procedure review, education, clinical practice, and demonstration with an evaluation method of observation noted.

In an interview 8/20/13 at 2:00 p.m. S4RN (Registered Nurse) reported that she worked as a staff RN and had been employed for not quite 2 weeks at the hospital. When asked to explain the Referral and Intake Screening process she reported that the nurse received a faxed request for admission from an ER. She stated that the fax is received via a fax machine located in the nurses' station. The nurse will call the (referring) facility and request more information on a potential patient if there is not enough information sent to evaluate the patient for admission. She stated that she looks at the patient's medical conditions, makes sure they are not very violent, and reviews lab results. She further stated that she would ask the ER to fax additional information such as a PEC form (Physician's Emergency Certificate), labs, face sheet for age and sex, and medications the patient was taking. S4RN reported that the screening is done between the nurses and S3URCoordinator. She further reported that S3URCoordinator did more with insurance verification. S4RN reported that sometimes the URCoordinator would get the referral before the nurses would get it. She stated that S3URCoordinator handled insurance verification criteria; if the insurance is good and the patient meets the (admission) criteria then the patient would be accepted. The nurses would then call referring ER/hospital to notify them that the hospital would accept the patient. S4RN provided a cardboard box, with papers in it, from the nurses' station. She explained that the referral and intake screening forms filled out by the nurses, along with any paperwork faxed by the referring hospital, are put in that box. At the end of each month, S10Marketing Director takes them and keeps them for another month, then the papers are shredded. The RN also provided a binder, which held a log of information regarding referral requests received, and reported the log was filled in by the nurses.


An interview was conducted on 8/20/13 at 3:30 p.m. with S3URCoordinator. She reported her job duties related to patient intake was verifying insurance coverage for patients, obtaining authorization from insurance companies, and running eligibility information. She also reported she reviewed patient satisfaction logs and performed some quality assurance duties. When questioned about what insurance the facility accepts, she reported they take all commercial insurance, Medicaid, Medicare, and self-pay. When questioned about the intake process for accepting patients to the hospital, she reported the nurses at the nurses' station take the phone call or obtains a fax from the referring facility. Each faxed referral also goes to all administrative personnel's email, including her email. If there is documentation on the referral information of insurance coverage, she will run the information and let the nurses know if the patient has coverage or not. When she was questioned on how she ran the insurance information to see if the patient had coverage, she reported the facility used the "MVP" system. The "MVP" system tells the provider if the patient has coverage and if they have used all their days. The "MVP" system gives the provider information on all insurances companies, Medicaid, Medicare, deductibles, and copayments. She reported she sometimes ran the patient through the "MVP" system prior to the patient being admitted and sometimes she didn't. S3URCoordinator reported the intake process during working hours as follows, "the intake information goes to my fax, to the nurses' station, and to everyone's email" . She (S3URCoordinator) would then verify the insurance information. She would call the nurses' station or the nurses would call her and she would report to them if the patient does or does not have insurance coverage. S3URCoordinator stated this was done before the facility accepts the patient. The nurses review the admission criteria and the denial of the patient is usually related to a medical issue or if substance abuse is the patient's primary diagnosis. They never say it is related to coverage. The intake process after hours is the nurses usually call S1Administrator or S2 DON prior to accepting a patient.


An interview was conducted with S11RN on 8/21/13 at 2:30 p.m. She stated she worked full time, straight day shift. She reported the intake process during the day as being: the referral information was faxed to the nurses' station and S3URCoordinator gets the referral information by email. The nurses look at the referral information to see if the patient meets admission criteria and then they double check with S3URCoordinator. Sometime S3URCoordinator will call the nurses' station and say don't bother reviewing a specific referral, or she says "it's not good" related to the insurance coverage. The nurses then will place a "9" code on the referral meaning it was an administrative denial. If the patient is accepted, the nurse calls the referring hospital to accept the patient. The nurse calls S8MD (Medical Doctor) to inform him of an admission. With an after-hours referral, the nurses have to call S1Administrator prior to accepting a patient.

S11RN stated when she started the job she had one day of orientation and she did not get orientated to the intake process. She stated the nurses get on the job training. She went on to report there was no cheat sheet to look at to determine what type of patients to accept or not to accept. "It is word of mouth and your personal judgment."

Review of the referral information for Patient #1 with S11RN revealed S11RN was listed as the nurse that reviewed the intake information and denied the patient admission. The patient was female with a history of a suicide attempt with an overdose of Lortab and Xanax. The denial code was listed as an "8" - level of care and a "9" -administrative. The only insurance information on the form was listed as pending. S11RN stated she could not remember why the patient was denied admission.


An interview was conducted with S9RN on 8/22/13 at 1:45 p.m. She reported she worked at night, the 7 p.m. to a.m. shift. She stated the intake process was that the referral would be faxed to the nurses' station and she would review the information. She would make sure they could take care of the patient with the staff they had and could take care of the patient related to the patient's acuity. She would then call S1Administrator to accept or not to accept the patient. She went on to report he typically doesn't disagree with the nurses' decision. She also stated she always called S8MD before accepting a patient.
When questioned what an administrative denial code was (a code "9" ), S9RN reported she didn't know; she didn't use that code because there was a note in the nurses' station not to use that code. She reported she obtained her training on the referral intake process by the last Director of Nurses. She went on to report there were no medical guidelines, just the nurses' judgment. When questioned if anyone spoke to her about a patient's payer source related to an admission; she stated, no.


An interview was conducted with S13RN on 8/21/13 at 2 p.m. She stated the intake process began when a referral from the Emergency Departments came over the fax machine in the nurses' station. The nurse was to document the time she reviewed the referral. S13RN stated she would look at the patient's age and presenting problems. Then she would look at bed availability. If she had any questions about the medical issues of the patient she would call S2DON. She went on to report the nurses only call S8MD to let him know the patient is on the unit. If the referral is received during work hours, S3URCoordinator is called. S3URCoordinator looks to see if the patient has any days left [of insurance benefits] and if the patient has [insurance] coverage. If the patient is ok to take from S3URCoordinator's point, the referral can be accepted. If the patient doesn't have days left, the referral cannot be accepted. When questioned on the percentage of patients that are denied related to their coverage or not having any days left, she said a wild guess would be 10% because she did not work all the time.


An interview was conducted on 8/20/13 at 4 p.m. with S5RN. She reported the intake process starts when the referring hospital sends an inquiry over the fax machine to the nurses' station. The nurses will review the referral and take into consideration if the patient is violent, who is appropriate for the unit, and if they had a male or female bed available. Sometime S3URCoordinator will call the nurses' station and ask the nurses to look at a referral. S3URCoordinator verifies the patient's insurance and obtains prior authorizations. S3URCoordinator doesn't make recommendations; the nurses have to look at the whole picture of the patient to see if the patient is an appropriate fit for the unit. The patient cannot have a primary diagnosis of substance abuse and must be able to perform self-care activities. The patient can't use a cane, walker, or prosthesis because that could be used as a weapon. Also, we can't take patients that have medical needs like trachs (tracheotomies), nebulizers, and intravenous antibiotics. We mostly take young adults (18 years and older). The hospital takes all types of insurance. S3URCoordinator lets us know if the patient has insurance coverage and if the coverage is good. The hospital can't be expected to take all patients that are nonpaying. Currently we have 3 self-pay patients. The decision to accept a patient is not just based on the patient's insurance; it has to be a multifaceted decision.


An interview was conducted with S2DON on 8/22/13 at 3 p.m. S2DON reported the intake process on a referral began with a referral being faxed to the nurses' station. The nurses will pull the fax and take about 5 to 10 minutes to review the medical information. After the nurses review the patient information, they pass the referral on to S3URCoordinator. If the nurses have questions about the medical information related to being able to accept the patient, the nurses will call her, S2DON. If everything is OK, the nurses will accept the patient. The nurses complete the inquiry form and fill in the information in the referral log located in a binder in the nurses' station. When questioned why the nurses were calling S3URCoordinator prior to accepting the patient, S2DON reported that S3URCoordinator informs the nurses if the patient has insurance or not. S3URCoordinator doesn't tell them if they can or cannot accept the patient. The nurses call S3URCoordinator because that is the process that is in place. The nurses call either S3URCoordinator, S1Administrator, or S2DON with every referral. S2DON reported the medical reasons the hospital doesn't accept specific patients are, for example, if the patient has extensive wounds that require a wound vac. The facility doesn't usually take patients with catheters. If they cannot participate in the scheduled activities, the referrals are not accepted. In addition, the hospital doesn't accept patients with a primary diagnosis of substance abuse. They typically don't accept elderly patients, but they have taken patients with ambulatory assistive devices like walkers and canes. If the nurses call her to review a referral it is related to the medical issue of the patient and the denial would be coded as a "9" , administrative. When questioned if S1Administrator reviewed the referral and it is coded as a "9", why was the patient denied. S2DON stated the surveyor would need to ask him. S2DON stated the payer source is on the referral information that is sent to the hospital to review, but she is unaware of anyone being denied admission related to their coverage/payer source. S2DON reported the nurses received a full day of orientation as a new hire. The charts, the intake process, the abuse policy, restraint and seclusion procedure, suicide precautions and the policy and procedure manual are reviewed. For the first day on the unit, the new nurses are assigned to a preceptor, which is a seasoned nurse working on the unit. S2DON stated there was no formal EMTALA training for the nurses.


An interview was conducted with S1Administrator on 8/22/13 at 3:55 p.m. S1Administrator stated the intake process is a fax is received in the nurses' station and the nurse reviews the patient's information. The nurse will call the doctor every time the hospital gets an admission. During the day shift the nurses call S3URCoordinator to give her the "heads up" that a patient will be admitted and that she may need to do a utilization review on the patient. S3URCoordinator looks at the insurance and verifies the insurance, but does give an approval or not. The nurse is the one that approves the patient's admission to the hospital. During the night shift the nurses call me, S1Administrator. The nurses let me know if the patient is medically stable and if they think we can treat the patient. It is not policy to review payer source(s) prior to admission. Prior authorization and benefit review happens concurrently with admission. When the Emergency Departments send out a referral, they send the referral to 10 hospitals; the hospital doesn't have a lot of time to assess the patient to see if they have bed capacity. On the intake referral sheet the administrative denial code "9" means usually the acuity on the unit is too high to accept the patient. Administration needs to be in the loop about the hospital's census. The hospital takes Medicaid, patients that have used up all their benefits, and the uninsured. S1Administrator said he has never heard of any patient being denied due to payer source. He went on to report you can't help but see the payer source because it is on the face sheets the emergency departments sends to the hospital. S3URCoordinator does not make any decision related to admitting the patient or not to admitting the patient. S1Administrator stated if the nurse had questions medically as to whether or not they could admit a patient or not, they can call S8MD. The decision to admit a patient based on the admission criteria is different from nurse to nurse.


An interview was conducted with S8MD on 8/22/13. He reported that 85 % of the hospital referrals come from Emergency Department and the last 15 % come from treating medical doctors or outpatient programs. He went on to report the hospital admits substance abuse patients if the withdrawal symptoms are not too medically complicated. He also reported the hospital has only 1 seclusion room and restraint room so they are limited to number of violent patients they can accept. The general medical categories the hospital does not accept are: active infections, intravenous therapy, wound management, extensive burns, extensive assistance needed in activities of daily living, no gastrostomy tubes and they do not accept patients that cannot feed themselves. He went on to state the hospital does not have any problems admitting mentally retarded patients; typically they need a medication regiment.

S8MD reported the intake process was the patient must first meet the hospital's criteria then S3URCoordinator oks the admission and the referring hospital is then called to accept the patient. The nurse then calls me to do the admission orders. He went on to report that he didn't know if the hospital screened the patients based on the source of payment. S8MD stated he knows they have taken patients with expired cards because sometimes the patient doesn't know if their card is expired or not.


30420

Based on interviews and review of policy and procedures the hospital failed to accept appropriate emergency patient transfer requests for which the hospital had the capacity and specialized capability to treat as evidenced by reviewing patients' payor source prior to accepting patients.
Findings:

Review of the hospital's policy titled: Emergency Room Referrals revealed in part, "It is the policy of the Hospital to act as a resource for psychiatric patients identified in an Emergency Room (ER)...Procedure:
1. When a psychiatric patient is identified by ER staff at a referring facility, the Hospital may be contacted for potential placement.
2. The Hospital staff will complete the Emergency Medical Treatment and Active Labor Act (EMTALA) log as required by the Center for Medicare and Medicaid Services (CMS) referencing 42 C.F.R. 489.24 (e) along with Inquire Log form and notify the Administrator on-call of the patient's presence in an ER.
3. The attending Psychiatrist will be notified of an inquiry.
4. A Pre-Admission Assessment by telephone will be completed by the RN on duty.
5. If the Attending Psychiatrist, determines that the patient is medically stable and admission is indicated, the clinician will;

a. Contact the Director of Nursing or his/her designee;
b. Contact the patient's private physician and/or psychiatrist; if necessary.
c. If the patient is not under the care of a psychiatrist, the psychiatrist on-call will be contacted;
d. Once notified, the psychiatrist will determine appropriateness for admission; and
e. When the patient is ready for admission to the hospital, the referring ER will arrange transport of the patient to the Hospital..."

Review of the hospital's policy and procedure titled, Admission Criteria, revealed in part, "Policy: It is the policy of the Hospital to admit patients, aged 18 years and older, whose mental condition warrants acute, inpatient psychiatric care. Patients appropriate for admission are accepted regardless of third party reimbursement status, ability to pay for services, race, religion, gender, sexual orientation, ethnicity, or disability ...

3. Patients who show evidence of symptoms of acute psychiatric disorder will be accepted for admission if they are medically cleared and who are over 18 years of age. Such conditions include but are not limited to:
-Suicide attempt or risk
-Homicide ideation, intent, or risk of violent/assaultive behavior as a result of a psychiatric disorder.
-Psychiatric symptoms such as hallucinations, delusion, catatonia, mania, depression which are severe enough to cause disordered/bizarre behavior or psychomotor agitation or retardation resulting in functional problems in daily living
-Self-destructive or self-mutilating behavior
-Memory impairment and/or disorientation that might endanger welfare of self or others
-Inability to maintain adequate nutrition, severe enough to threaten life or vital body functions.
-Mental disorder not responding to outpatient therapy or noncompliance with outpatient therapy resulting in severe psychiatric symptoms.
-Patients with chronic, organic mental conditions who are also experiencing severe psychiatric symptoms such as psychosis or disordered/bizarre behavior.
-Patients who are deemed gravely disabled
-Have demonstrated a serious intent to harm, self, others, or property within 72 hours prior to admission.

Contradictions to Admission:
-Patient with a primary diagnosis of alcoholism or substance abuse.
-Uncomplicated brain dysfunction/dementia or Alzheimer's type with no psychiatric symptomatology.
-Patients under the age of 18.
-Is criminally insane.
-Is medically unstable (as determined by a physician).
-Has a primary diagnosis of severe organic brain dysfunction or dementia.
-Has a primary diagnosis of I-II-III-IV-V Codes.
-Have medical devices that would conflict with or prevent therapeutic goals.
-Have a need for ECT (Electroconvulsive Therapy).
-Has an acute/critical medical/surgical status (as determined by a physician).
Patients must be medically stable prior to admission. The attending psychiatrist will evaluate the appropriateness of all potential patients. Patient's medical conditions must allow for the rigorous schedule of the program. Patients are expected to be able to physically and cognitively tolerate the milieu of the program ... "


Review of a Fax Referral Disposition Form revealed blanks for the following information:

Date, Referral Fax Arrived at(time):, final disposition time, information reviewed by, referral source, patient name, DOB (date of birth), age, sex, and presenting problem. Below the presenting problem information were the following words typed: Harm to Self, Harm to Others, Gravely Disabled, Depressed, Psychotic, Agitated, Violent, Changes in: Eating, Sleeping, Social Life, Paranoid, Delusional, Hallucinating Visual, and Hallucinating Audio. A space to list current medical problems followed and the following words were typed under that area: Diabetic, HTN, Seizure D/O (disorder), Wound, Heart Problem, Surgery, Dialysis, Ambulatory, Wheelchair/Walker, Bed Rest, Self- Care, Incontinent, and Fall Risk.
Under these conditions were noted blanks and information as follows: Contacted Administration on Call and time, Contacted Psychiatrist on Call, Admission Approved: yes/no, If no, why?, If no, admission denial reason code, and under the statement, " ...reviewed the referral packet and discussed the information with the Clinical and Administrative team collectively made the above decision " . A signature line with date and time was noted.

Further review revealed a key to the Admission Denial Reason code as follows: 1)Patient/Family refused; 2)-Already Placed; 3)-No bed available: 4)-Medical; 5)-Gender; 6)-Isolation; 7)-Admission Criteria; 8)-Level of care; 9)-Administrative; 10)Substance Abuse Primary; and 11)-No capacity to handle the patient at the present time.

Review of the personnel file of S3URCoordinator (Utilization Review Coordinator) revealed an UR/Intake/QAPI checklist dated 1/14=1/25 that included Intake Coordination. The skills listed on the checklist were as follows:
-Familiar with Intake process and various methods referrals are obtained
-Appropriately locates and verifies potential admissions financial status as part of the intake process
-Appropriately defers to clinical staff for determination as to whether patient is appropriate for services and that their needs can be met.
Further review revealed that S3URCoordinator checked "never done" under self-assessment, and documentation of method of instruction for all skills listed was protocol/procedure review, education, clinical practice, and demonstration with an evaluation method of observation noted.

In an interview 8/20/13 at 2:00 p.m. S4RN (Registered Nurse) reported that she worked as a staff RN and had been employed for not quite 2 weeks at the hospital. When asked to explain the Referral and Intake Screening process she reported that the nurse received a faxed request for admission from an ER. She stated that the fax is received via a fax machine located in the nurses' station. The nurse will call the (referring) facility and request more information on a potential patient if there is not enough information sent to evaluate the patient for admission. She stated that she looks at the patient's medical conditions, makes sure they are not very violent, and reviews lab results. She further stated that she would ask the ER to fax additional information such as a PEC form (Physician's Emergency Certificate), labs, face sheet for age and sex, and medications the patient was taking. S4RN reported that the screening is done between the nurses and S3URCoordinator. She further reported that S3URCoordinator did more with insurance verification. S4RN reported that sometimes the URCoordinator would get the referral before the nurses would get it. She stated that S3URCoordinator handled insurance verification criteria; if the insurance is good and the patient meets the (admission) criteria then the patient would be accepted. The nurses would then call referring ER/hospital to notify them that the hos