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Based on review of policies and procedures, hospital documents, clinical records, and staff interviews, it was determined the hospital failed to enforce policies and procedures that comply with the requirements of 42CFR §489.20 and 42 CFR §489.24, responsibilities of Medicare participating hospitals in emergency cases.


Findings Include:

Hospital policy titled, "Receiving Transfers of Emergency Cases From Other Hospitals", revealed: " ...III Procedure: 1. Intake Coordinator: a. Receives the call and Valley Hospital will only consider referrals that are accompanied by a referral by phone call. b. Requests the information to be used in determining whether Valley Hospital may accept the transfer. c. If necessary, notifies the Director of Intake, Assistant Director of Intake, Nurse Manager or designee in order to determine current capability and capacity. d. Contacts the physician on call or designee once current capability and capacity are determined to provide all clinical medical information necessary to determine the appropriateness of the transfer ...."

A total of twenty (20) ED medical records were randomly selected for review of patient who present to the facility were reviewed. There were four (4) out of the twenty (20) medical records where the physician was contacted after the patients were admitted to the facility.

Employee #1 confirmed on 07/11/2023 that the policy states that the physician will be contacted to determine the appropriateness of the transfer to the facility.

Based on review of records, policies and procedures, hospital documents and staff interviews, it was determined the hospital failed to have a qualified medical person sign receiving transfer documents.

Findings Include:

Hospital policy titled, "Initial Medical Screen and Level of Care Assessment", revealed: " ...II Policy It is the policy of Valley Hospital to provide an Initial Medical Screen and Level of Care Assessment to any individual who presents at the hospital seeking treatment on an urgent basis without delay to inquire as to the individual's ability to pay or to seek authorization from the individual's insurer. If the Initial Medical Screen and Level of Care Assessment results in a determination that the patient is experiencing an emergency medical condition and stabilizing treatment is within the capabilities of the hospital, the hospital will provide treatment within its capabilities to stabilize the condition ...III Procedure 1. The Initial Medical Screen and Level of Care Assessment will be provided to individuals, regardless of their ability to pay, who come to the hospital and request an examination or treatment of a medical condition. 2. The Initial Medical Screen and Level Of Care Assessment shall be appropriate to the individual's presenting signs and symptoms, as well as the capability and capacity of the hospital. 3. The Initial Medical Screening and Level of Care Assessment shall be the same screen and assessment the hospital would perform on any individual presenting at the hospital with the same signs and symptoms, regardless of the individual's ability to pay for medical care, or diagnosis, race, color, national origin, and/or disability. 4. The Initial Medical Screen and Level of Care Assessment shall be conducted by a qualified mental health professional (QMHP) as defined by the hospital's Medical Staff Rules and Regulations ...."

Hospital document titled, "Valley Hospital Medical Staff Bylaws", revealed: " ...Article 5 Allied Health Professionals ...5.3 Prerogatives ...5.3.5 only Physicians, Licensed Psychologists, Psychological Associate, Licensed Masters Social Workers, Licensed Professional Counselors, Registered Nurses, Licensed Social Workers, Licensed Marriage and Family Counselors, (collectively, "Qualified Mental Health Professionals") and Physician Assistants shall have the Prerogative to perform assessments as appropriate to their license and Privileges. All Qualified Mental Health Professionals and Physician Assistants may perform pre-admission assessments. Final determination of the need for services may be assessed by appropriately privileged Staff Members Only ...."

Hospital Document titled, "Nurse to Nurse", revealed: " ...Time Intake Notified by Hospital: ...Time Unit Notified: ...Transferring Facility: ... Chief Complaint/Reason for Transfer/Mental Status: ...Medical Conditions/Diagnosis/Status: ....Any Exclusionary Criteria: ....Nursing Receiving Report: Name/Signature: _______ Time: _______....."


A total of twenty (20) ED medical records were randomly selected for review included patients who were transferred, admitted, or left before Medical Screening Examinations. Two (2) of the twenty (20) had Nurse to Nurse forms signed by an individual with M.Ed (Master of Education) credentialing.

Employee #4 confirmed on 07/11/2023 that on nights and weekends the facility will use a service in North Carolina and Georgia who will provide support in processing intakes for incoming transfers. Employee #4 confirmed that not all of the individuals who are processing the intake are Registered Nurses. Employee #4 expressed concern that individuals who are not Registered Nurses are signing off on the intakes.

Employee #1 confirmed on 07/11/2023 that a service is used to provide support in processing intakes for incoming transfers. Employee #1 further confirmed that the service is not located in the state of Arizona. Employee #1 confirmed that they are in the process of moving the service to Arizona. Employee #1 confirmed that the Nurse to Nurse form was signed by an individual who was not a Registered Nurse.