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Based on a review of facility documents and staff interview (EMP), it was determined the facility failed to identify On Call requirements of the Medical Staff, failed to ensure that On Call Schedules were limited to physicians, failed to ensure that General Surgery On Call Schedules identified the physician responsible for Call, and failed to include On Call Schedules available to the Emergency Department were inclusive of Saturdays for four of eight months reviewed (May, June, July, August 2021), and failed to adopt policies in instances when on call physicians are on simultaneous call at other facilities.

Findings include:

Review of the "Penn Highlands Brookville Medical Staff Bylaws" adopted by Penn Highlands Brookville April 27, 2021. "... Article II Medical Staff Membership ... Section 2.6 Responsibilities of Membership ... C. Each staff member must participate in the on call coverage of the emergency service and other coverage programs including consultations for inpatients as determined by their department pursuant to the authority of the MEC and/or the Board of Directors to see that patient care needs are provided for. Members are exempt from call participation for services covered by contracted services call coverage; ... G. Each member must abide by the Bylaws, Rules and Regulations, and other policies, procedures, and plans of the Hospital and the Medical Staff, to assure all individual within the Hospital are treated courteously, respectfully, and with dignity. ... Article III. Categories of the Medical Staff Section 3.1 Active Medical Staff. A. Qualifications: Appointees to the category must: a. Admit or otherwise be involved in a minimum of fifty (50) patient contacts at the Hospital in a two-year period ... B. Prerogatives: Appointees to this Category may: a. Admit patients without limitation, except as otherwise provided in the Medical Staff Rules and Regulations, or by specific privilege restriction. b. Vote on all matters presented at the Hospital general and special meetings of the Medical Staff. Vote on all matters at the Hospital and system committees and department to which they are appointed; c. Hold office and/or be the chairperson or member of any committee, unless otherwise specified elsewhere in the Bylaws ... C. Responsibilities: Appointees to this category must: ... c. Participate in the emergency service and other special coverage programs as determined by the MEC based on a recommendation from the department chief. Section 3.2 Active Affiliate Medical Staff. A. Qualifications: Appointees to this category must: a. The Active Affiliate Category is reserved for practitioners who do not meet the eligibility requirements for the active category or choose not to pursue active status. Practitioners assigned to this category, may admit or otherwise be involved in the care or treatment of patients in providing consultations; ordering diagnostic or therapeutic services consistent with their Board approved privileges ... This category is also appropriate for those practitioners who may not have admitting privileges; but document other important efforts ...B. Prerogatives: Appointees to this category may: a. Admit patients to the Hospital in the same manner as an Active Medical Staff member, consistent with privileging criteria ... c. Not vote at General Medical Staff Meetings or hold office. d. Attend meetings of the General Medical Staff (without vote) and may attend and vote at the Hosptial or System committee and department, as appropriate to which he/she is an appointee ... C. Responsibilities: ... a. Appointees to this category may participate in emergency service and other specialty coverage programs, as determined by the MEC based on a recommendation from the department chief. ... ."
Review of "Penn Highlands Brookville Policy/Procedure Category: Patient Care EXE-01-09 Title: EMTALA Compliance (Transfer of Patients) Purpose: To outline policy and procedures for the expeditious transfer of patients who have an emergency medical condition into or out of Penn Highlands Brookville. References in the policy to "patient" shall include the patient's legally authorized representative as applicable. Policy: Penn Highlands Brookville has adopted the following policy and procedure according to state and federal law requiring the transfer of patients with an emergency medical condition including those that may be transferred into or out of this hospital. This policy and procedure further provides for stabilizing care of patients in and on all hospital grounds and property both on and off the main hospital campus. For purposes of this policy, emergency medical condition includes a patient in active labor and the unborn child. It Shall Be The Policy Of Penn Highlands Brookville To: 1. Perform a medical screening exam when a patient presents to the hospital requesting medical assistance to determine if the patient has an emergency medical condition, regardless of the patient's ability to pay. If it has been determined that the patient has an emergency medical condition: a. stabilizing treatment will be initiated within the capabilities of the staff and facilities available at the hospital. b. a specialist from the hospital's on-call medical staff roster will be contacted if appropriate; and/or c. arrangements will be made for transfer of the patient to a facility where appropriate treatment may be obtained. 2. Maintain an on-call roster of medical specialists with medical privileges available to the hospital's Emergency Department. 3. Have a response time that is reasonable as determined by Medical Staff and set forth by this policy ... On-Call Physician The on-call physician must respond, either by phone or in person, within 30 minutes of being requested. The on-call physician is not required to interrupt critical care - that is, care that requires his/her personal management - that he or she is providing to a specific patient. Immediately after the physician finishes caring for the specific patient, he or she contacts the requesting unit, responds if requested, and/or give an estimated time of arrival. The on-call physician must come to the Emergency Department when requested by the Emergency Department physician, another physician, a nurse, or any hospital worker making the request on behalf of a physician or nurse who is not available to call the on-call physician directly. Seeing the patient at the on-call physician's office or clinic is not an option until the patient is determined to be stable or not to have an emergency medical condition. The on-call physician accepts transfers of patients from other health care facilities who have an emergency medical condition that cannot be stabilized by the other health care facility if the on-call physician has the capability and capacity to care for the patient. The on-call physician is not authorized to accept a transfer on behalf of the Hospital and must contact the Unit Supervisor/Clinical Coordinator for Hospital acceptance. Medical Staff members comply with Emergency Department and Hospital policies and appropriate State and Federal statutes in the provision of emergency services and patient transfers in and out of the hospital. The on-call physician does not consider the patient's location, financial circumstances ot the patient's insurance or means of payment in the decision to respond to, treat, transfer, or accept the transfer of a patient with an emergency medical condition. Failure of an on-call physician to respond to the ED or come to the ED as requested shall be reported to the Administrator on-call for possible corrective action ... On-call Schedule The call schedule must identify the physician who is responsible for daily specialty coverage. Scheduling Procedure All available specialties and sub-specialties are on the schedule. All specialty services provided at the hospital are listed on the on-call schedule indicating times and dates of availability of each individual. If a needed specialty or sub-specialty is not available, the Emergency Department makes arrangements for an appropriate transfer to another facility. A call roster between physicians for coverage of their own patients is separate from the call roster for the Emergency Department. A physician who is on call for his/her inpatients is not automatically also on call for the Emergency Department. The actual name of the physician on call will be on the roster. Listing the name of a group or a physician's allied health professional rather than an individual physician is not acceptable ... Date of Review: ... 03/21 ... ."
1. Surveyors requested documentation of on call requirements by the applicable department chairs/Medical Executive Committee and/or Board of Directors, on September 21, 2021.
Interview with EMP13 on September 21, 2021, revealed they have no On call policy describing on call requirements, and further stated that Bylaws don't address call.
During review of Medical Staff List for Penn Highlands Brookville, it was noted that approximately 253 physician providers were listed. Of note, 10 of those physician providers were active medical staff, and approximately 129 were active affiliate staff.
Active Medical Staff included three ED physicians, one urologist, one anesthesiologist, one radiologist, two family practitioners, one cardiologist, and one surgeon.
During review of the Provider On Call Schedules dated February 1, 2021-September 30, 2021, revealed participation of on call for active staff members was limited to urology (Weekdays and Daytime only), and Surgery (Weekdays and Daytime only), and cardiology from February 1, 2021 to August 31, 2021, only.
The medical staff listing indicated that there were approximately 129 active affiliate physicians in approximately 27 provider specialties
Review of the On Call Schedules dated February 1, 2021 to August 31, 2021, revealed participation of on call for active affiliate medical staff was limited to four out of 27 provider specialty categories included on the Medical Staff List ( psychiatry, cardiology, urology, and pulmonology only)
Review of the On Call Schedule dated September 1-30, 2021, it was noted that Cardiology was no longer present on the schedule. Review of the Physician List of Credentialed Physicians provided by the facility, it was noted that one cardiologist (EMP20), is credentialed under the Active Category.
Surveyors were not provided with any documentation of on call requirements by the applicable department chairs/Medical Executive Committee and/or Board of Directors for any Active or Active Affiliate Medical Staff.

Interview with EMP5 on September 21, 2021, at 10:45AM, revealed regarding On call schedules, that they transfer through Amion, and that on weekends, they always go through the transfer center (Penn Highlands DuBois). Continued by stating that EMP11 and EMP12 are the only physicians that they ever see come in, and stated that they call the transfer center most of the time, and all others go through the transfer center.
Interview with EMP7 on September 21, 2021, at 11:05AM, revealed related to on call, and stated that they call through the transfer center and they talk to the physician. EMP7 stated that they have very limited services, and have a list of who's on call for each day.
Interview with EMP8 on September 21, 2021, at 11:20AM, revealed regarding On call schedules, that they contact whoever is on call and they do have a list, it's through Penn Highlands Group, and stated that they mostly need to contact DuBois, and stated that it is rare for the on call physician to come into the ER, and that they mostly transfer to another facility, DuBois.
Telephone interview with EMP1 and EMP14, on September 28, 2021, at 11:00AM, was conducted. When asked about the 10 Active Medical Staff members and on call coverage, EMP1 stated that Family Practice does not take call, as they don't typically admit, and that Anesthesiologists do not take call, and they are available through the day if needed. When asked about Specialities, such as Cardiology being removed from the September 2021, On call Schedule, EMP1 stated that they were not on call to come in to facility, that they were available for consult only. EMP1 also stated that Penn Highlands physicians are only required to request Active Medical Staff status for one hospital.
2. During review of Provider On Call Schedules dated February 1, 2021-September 30, 2021, revealed that On Call Schedules were noted to list allied health professionals (advanced practitioners) for call for hospitalist dayshift, and it was also noted that there were instances in which Cardiology Call also listed allied health professionals on the On Call list, rather than a physician.
3. During review of Provider On Call Schedules dated February 1, 2021-September 30, 201, it was also noted that instances in which General Surgery Day Call was available, the On Call list stated "EMP12 Office."
4.Review of On Call Schedules dated February 1, 2021-September 30, 2021, revealed that On Call Schedules available to the Emergency Department were not inclusive of Saturdays for four of eight months (May, June, July, August 2021),
5. Review of On Call Schedules and/or dated February 1, 2021-September 30, appeared to indicate documented simultaneous coverage between facilities relative to Psychiatry, and Urology. It was also noted that there were frequent references to contact the Penn Highlands DuBois Transfer Center.
Review of a "Who's On Call" document dated September 22, 2021, indicated that Hospitalist Night coverage is remote coverage from Penn Highlands DuBois.
Surveyors queried facility representatives if they have a Community Call Plan with other Penn Highlands System Hospitals. Per EMP1 they do not have a Community Call Plan with other Penn Highlands facilities.
Interview with EMP5 on September 21, 2021, at 10:45AM, revealed regarding On call schedules, that they transfer through Amion, and that on weekends, they always go through the transfer center (Penn Highlands DuBois). Continued by stating that EMP11 and EMP12 are the only physicians that they ever see come in, and stated that they call the transfer center most of the time, and all others go through the transfer center.
Interview with EMP8 on September 21, 2021, at 11:20AM, revealed regarding On call schedules, that they contact whoever is on call and they do have a list, it's through Penn Highlands Group, and stated that they mostly need to contact DuBois, and stated that it is rare for the on call physician to come into the ER, and that they mostly transfer to another facility, DuBois.

Based on a review of facility documents, it was determined that Penn Highlands Brookville failed to maintain a Control Register of individuals who presented to the Emergency Department (ED) seeking assistance for one of one patients identified. (PT1)

Findings include:

"Penn Highlands Brookville Policy/Procedure Category: Patient Care EXE-01-09 Title: EMTALA Compliance (Transfer of Patients) Purpose: To outline policy and procedures for the expeditious transfer of patients who have an emergency medical condition into or out of Penn Highlands Brookville. References in the policy to "patient" shall include the patient's legally authorized representative as applicable. Policy: Penn Highlands Brookville has adopted the following policy and procedure according to state and federal law requiring the transfer of patients with an emergency medical condition including those that may be transferred into or out of this hospital. This policy and procedure further provides for stabilizing care of patients in and on all hospital grounds and property both on and off the main hospital campus ... The hospital will maintain a central log on each patient who comes to the hospital seeking assistance showing whether the individual refused treatment or was transferred, admitted and treated, stabilized and transferred, or discharged. This log will be retained in the Health Information Department ... Date of Review: ... 03/21 ... ."
"Control Register", dated April 2021, which stated "... Policy: A control register is continuously maintained and includes the following information: 1. Pt ID number 2. Time of Arrival 3. Patient name 4. Triage time 5. Time seen by physician 6. Emergency Physician and Personal Care Physician 7. Age/Sex 8. Nursing triage classification 9. Mode of Entry 10. Diagnosis 11. Disposition 12. Nurse Responsible initials 13. Time of discharge Procedure: 1. All patients receiving care in the Emergency Department are entered into the control register each shift utilizing the electronic medical records system and blue patient log book ... ."

1. Review of the Patient Associated with Allegations (PT1), Penn Highlands DuBois QCare Medical Record dated July 31, 2021 (MR22), revealed "... Chief Complaint ... Patient presents to the clinic with history of shortness of breath over the past week. Patient states [they are] in end-stage COPD. States ... initial pulse ox read 82 on room air. Patient placed on nasal O2 at 2 L pulse ox shows a pulse of 157. Patient advised would be best if ... be evaluated in the emergency room rapid Covid test was done which was negative. Patient states ... wants to drive ... to Brookville emergency room explained with ... vital signs as they are that would not be safe. Advised to call a family member or ambulance. Patient refusing to call an ambulance states that ... [family member] will take ... to Brookville Hospital. Explained to [family member] the situation ... is agreeable to drive ... to Brookville ER. Report was given to (EMP6) at the Brookville emergency room. Patient's pulse ox on the pulse ox read between 157 and at 1 point dropped to 43 and then returned to 146 ... Assessment and Plan. 1. COPD Stage 3 Severe ... Plan: to go to er. 2. SVT ... 3. Bradycardia ... ."
2. Documentation provided by the facility revealed "... August 3, 2021 ... I was able to speak with 2 of the staff working on Saturday 7/31/21, when the patient in question came presented to the ED ... EMP5 stated the Punxsutawney Q-care had called regarding a patient that was coming to Penn Highlands Brookville ER and was giving report. Upon presentation of this information to the Physician on duty, the decision was made to call q-care and have patient go to Penn Highlands Dubois. Patient had already departed from the q-care at that time. When patient presented to Penn Highlands Brookville ED, EMP5 was preparing to get the information when EMP6 told the patient they were more than welcome to be seen but if the patient needed transferred they could be waiting for a long time. The patient was told that they may be better off going directly to Penn Highlands DuBois. EMP5 stated the patient was told multiple times they were more than welcome to be seen. Per EMP5 the family member with patient stated they may as well just go to Dubois. Patient information was not entered onto Tracker and withdrawal for request for emergency care form was not completed ... ."

3. Interview with EMP3, on September 20, 2021, at 1:00PM, revealed "... EMP4 emailed me or called me, and questioned if I was aware of a possible EMTALA violation. The patient was in our ER and told better to go to DuBois ... ."

4. Interview with EMP6, on September 21, 2021, at 10:10 AM, revealed "I was working. I had gotten a call from Punxsy QCare that patient may be arriving. The patient complained of shortness of breath with walking, sats were low and HR was low. It was a usual day. We see people, assess situation, most of the time they wait in the car. It was busy. I saw someone go the window, and [they] said they told [the patient] to come in and be evaluated ... I said I'm sorry, we will take care of you, please be patient. I told [the patient] we won't have a bed. [The patient] grumped around. We will get you back as soon as possible. I told [the patient] I will gladly take care of him. [The patient] appeared stable, no color changes. They said we're going to go to DuBois. Physicians don't put patients on the board. One of the nurses or helpers put someone on the board. If there's no unit clerk, sometimes respiratory will help us. I did a quick eye ball, [the patient] made lots of comments, and was frustrated ... ."
5. Interview with EMP5 on September 21, 2021, at 10:45AM, revealed "... Punxsy was calling to and speaking to EMP6 after patient was sent this way. The patient and [family member] came to the window, yes they wanted to be seen and EMP6 came to the window to speak with them. [EMP6] offered and asked multiple questions. It was better to go DuBois, and they left. We have a huge delay in transfers, it's a lengthy process even to get docs to call back. EMP6 was in the best interest of this patient ... ."
6. Telephone Interview with EMP4, on September 21, 2021, at approximately 11:15AM, revealed "I was working in department and happened to see patient, and wife and during initial interview on the initial presentation to Brookville [the patient] presented to the window area with complaint and essentially were told we could see you but just so you know if seen here due to increased complaints, could take some time to get transferred to DuBois, they were told that and they elected to go home instead of going to DuBois. A few days later, still not feeling well, drove themselves to DuBois ... ."
7. A review of the ED Log dated July 31, 2021, revealed the patient associated with the allegations (PT1, MR22), was not present on the ED Log.

Based on a review of facility documents, it was determined that Penn Highlands Brookville failed to ensure that a medical screening examination was provided for one of one patients who presented to the Emergency Department. (PT1)

"Penn Highlands Brookville Policy/Procedure Category: Patient Care EXE-01-09 Title: EMTALA Compliance (Transfer of Patients) Purpose: To outline policy and procedures for the expeditious transfer of patients who have an emergency medical condition into or out of Penn Highlands Brookville. References in the policy to "patient" shall include the patient's legally authorized representative as applicable. Policy: Penn Highlands Brookville has adopted the following policy and procedure according to state and federal law requiring the transfer of patients with an emergency medical condition including those that may be transferred into or out of this hospital. This policy ad procedure further provides for stabilizing care of patients in and on all hospital grounds and property both on and off the main hospital campus. For purposes of this policy, emergency medical condition includes a patient in active labor and the unborn child. It Shall Be The Policy Of Penn Highlands Brookville To: 1. Perform a medical screening exam when a patient presents to the hospital requesting medical assistance to determine if the patient has an emergency medical condition, regardless of the patient's ability to pay... Definitions: Emergency Medical Condition Means: 1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in: a. serious jeopardy to the health of the individual (or, with respect to a pregnant woman, the health of the woman or the unborn child) b. serious impairment to bodily function c. serious dysfunction of any bodily organ or part; or 2. With respect to a pregnant woman who is having contractions: a. that there is inadequate time to effect a safe transfer to another hospital before delivery; or b. the transfer may pose a treat to the health or safety of the woman or the unborn child. Stabilize means, with respect to an Emergency Medical Condition as defined in subparagraph 1 above: 1. To provided such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result or occur during the transfer of the individual from a facility; or 2. With respect to an Emergency Medical Condition involving a pregnant woman, that the woman has delivered (including the placenta). Procedure: Initial Medical Screening Procedures An initial triage assessment is completed by a Registered Nurse. A medical screening examination is performed by the ED Physician. It includes a history, vital signs, and examination of the injury and a medical assessment to determine whether an acute medical emergency exists. If an RN performing the initial triage assessment determines the patient to be unstable, the screening examination is immediately continued in the Emergency Department. The initial medical screening examination is performed uniformly on all patients who come to the Emergency Department requesting medical care. The following guidelines are considered in the initial medical screening examination. A. Chief symptom: chronic condition or acute onset b. Vital signs c. Mental status: evidence of change; emotional status d. General appearance e. Degree of pain-utilizing pain scale rating f. skin-evidence of dehydration, poor perfusion g. Physical exam findings - cardiovascular, respiratory, gastrointestinal, genitourinary, and musculoskeletal h. past medical history i. Current medication regimen and allergies j. Ability to walk ... Date of Review: ... 03/21 ... ."

"Scope of Service", which stated "... It is the function of the Emergency Department to provide twenty-four care to individuals who require treatment of illness and injury, initially presenting as an outpatient. Qualified medical and nursing personnel provide expertise in managing life threatening as well as serious illness and injury ... Department Responsibility/Goals. It is the function of the Emergency Department to deliver 24-hour quality care for patients suffering emergent, urgent and non-emergent illness or injury ... II. Procedures and Treatments Provided in the Emergency Department ... Services Provided: 1. Triage of patient by acuity 2. Medical evaluation by acuity 3. Nursing care 4. Emergency treatment of acute illness or injury 5. Patient stabilization, admission, transfer or discharge ... Any patients presenting to the Emergency Department will be treated by Penn Highland Brookville personnel ... ."

1. Review of the Patient Associated with Allegations (PT1), Penn Highlands DuBois QCare Medical Record dated July 31, 2021 (MR22), revealed "... Chief Complaint ... Patient presents to the clinic with history of shortness of breath over the past week. Patient states [they are] in end-stage COPD. States ... initial pulse ox read 82 on room air. Patient placed on nasal O2 at 2 L pulse ox shows a pulse of 157. Patient advised would be best if ... be evaluated in the emergency room rapid Covid test was done which was negative. Patient states ... wants to drive ... to Brookville emergency room explained with ... vital signs as they are that would not be safe. Advised to call a family member or ambulance. Patient refusing to call an ambulance states that ... [family member] will take ... to Brookville Hospital. Explained to [family member] the situation ... is agreeable to drive ... to Brookville ER. Report was given to (EMP6) at the Brookville emergency room. Patient's pulse ox on the pulse ox read between 157 and at 1 point dropped to 43 and then returned to 146 ... Assessment and Plan. 1. COPD Stage 3 Severe ... Plan: to go to er. 2. SVT ... 3. Bradycardia ... ."
2. Documentation provided by the facility revealed "... August 3, 2021 ... I was able to speak with 2 of the staff working on Saturday 7/31/21, when the patient in question came presented to the ED ... EMP5 stated the Punxsutawney Q-care had called regarding a patient that was coming to Penn Highlands Brookville ER and was giving report. Upon presentation of this information to the Physician on duty, the decision was made to call q-care and have patient go to Penn Highlands Dubois. Patient had already departed from the q-care at that time. When patient presented to Penn Highlands Brookville ED, EMP5 was preparing to get the information when EMP6 told the patient they were more than welcome to be seen but if the patient needed transferred they could be waiting for a long time. The patient was told that they may be better off going directly to Penn Highlands DuBois. EMP5 stated the patient was told multiple times they were more than welcome to be seen. Per EMP5 the family member with patient stated they may as well just go to Dubois. Patient information was not entered onto Tracker and withdrawal for request for emergency care form was not completed ... ."

3. Interview with EMP3, on September 20, 2021, at 1:00PM, revealed "... EMP4 emailed me or called me, and questioned if I was aware of a possible EMTALA violation. The patient was in our ER and told better to go to DuBois ... ."

4. Interview with EMP6, on September 21, 2021, at 10:10 AM, revealed "I was working. I had gotten a call from Punxsy QCare that patient may be arriving. The patient complained of shortness of breath with walking, sats were low and HR was low. It was a usual day. We see people, assess situation, most of the time they wait in the car. It was busy. I saw someone go the window, and [they] said they told [the patient] to come in and be evaluated ... I said I'm sorry, we will take care of you, please be patient. I told [the patient] we won't have a bed. [The patient] grumped around. We will get you back as soon as possible. I told [the patient] I will gladly take care of him. [The patient] appeared stable, no color changes. They said we're going to go to DuBois. Physicians don't put patients on the board. One of the nurses or helpers put someone on the board. If there's no unit clerk, sometimes respiratory will help us. I did a quick eye ball, [the patient] made lots of comments, and was frustrated ... ."
5. Interview with EMP5 on September 21, 2021, at 10:45AM, revealed "... Punxsy was calling to and speaking to EMP6 after patient was sent this way. The patient and [family member] came to the window, yes they wanted to be seen and EMP6 came to the window to speak with them. [EMP6] offered and asked multiple questions. It was better to go DuBois, and they left. We have a huge delay in transfers, it's a lengthy process even to get docs to call back. EMP6 was in the best interest of this patient ... ."
6. Telephone Interview with EMP4, on September 21, 2021, at approximately 11:15AM, revealed "I was working in department and happened to see patient, and wife and during initial interview on the initial presentation to Brookville [the patient] presented to the window area with complaint and essentially were told we could see you but just so you know if seen here due to increased complaints, could take some time to get transferred to DuBois, they were told that and they elected to go home instead of going to DuBois. A few days later, still not feeling well, drove themselves to DuBois ... ."
7. Facility could provide no documentation that a medical screening examination was completed for PT1.

Based on a review of facility documents and medical records (MR), it was determined that Penn Highlands Brookville failed to ensure an appropriate transfer for one of one patients. (PT1)

Findings include:

"Penn Highlands Brookville Policy/Procedure Category: Patient Care EXE-01-09 Title: EMTALA Compliance (Transfer of Patients) Purpose: To outline policy and procedures for the expeditious transfer of patients who have an emergency medical condition into or out of Penn Highlands Brookville. References in the policy to "patient" shall include the patient's legally authorized representative as applicable. Policy: Penn Highlands Brookville has adopted the following policy and procedure according to state and federal law requiring the transfer of patients with an emergency medical condition including those that may be transferred into or out of this hospital. This policy and procedure further provides for stabilizing care of patients in and on all hospital grounds and property both on and off the main hospital campus. For purposes of this policy., emergency medical condition includes a patient in active labor and the unborn child. It Shall Be The Policy Of Penn Highlands Brookville To: 1. Perform a medical screening exam when a patient presents to the hospital requesting medical assistance to determine if the patient has an emergency medical condition, regardless of the patient's ability to pay. If it has been determined that the patient has an emergency medical condition: a. stabilizing treatment will be initiated within the capabilities of the staff and facilities available at the hospital. b. a specialist from the hospital's on-call medical staff roster will be contacted if appropriate; and/or c. arrangements will be made for transfer of the patient to a facility where appropriate treatment may be obtained. 2. Maintain an on-call roster of medical specialists with medical privileges available to the hospital's Emergency Department. 3. Have a response time that is reasonable as determined by Medical Staff and set forth by this policy. 4. Make arrangements for transfer if: a. the appropriate specialist is not available on the on-call schedule, b. the hospital does not have the necessary staff or facilities to stabilize the patient, or c. the patient requests transfer, after providing medical treatment within its capacity to minimize risks during transfer; and assuming adequate care while in transit. 5. Assure that there is a receiving physician and a receiving hospital who have agreed to accept the patient being transferred ... Stabilize means, with respect to an Emergency Medical Condition as defined in subparagraph 1 above: 1. To provided such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result or occur during the transfer of the individual from a facility; or 2. With respect to an Emergency Medical Condition involving a pregnant woman, that the woman has delivered (including the placenta). Procedure: Initial Medical Screening Procedures An initial triage assessment is completed by a Registered Nurse. A medical screening examination is performed by the ED Physician. It includes a history, vital signs, and examination of the injury and a medical assessment to determine whether an acute medical emergency exists. If an RN performing the initial triage assessment determines the patient to be unstable, the screening examination is immediately continued in the Emergency Department. The initial medical screening examination is performed uniformly on all patients who come to the Emergency Department requesting medical care. The following guidelines are considered in the initial medical screening examination. A. Chief symptom: chronic condition or acute onset b. Vital signs c. Mental status: evidence of change; emotional status d. General appearance e. Degree of pain-utilizing pain scale rating f. skin-evidence of dehydration, poor perfusion g. Physical exam findings - cardiovascular, respiratory, gastrointestinal, genitourinary, and musculoskeletal h. past medical history i. Current medication regimen and allergies j. Ability to walk ... All request for transfers from other facilities are made through the appropriate on-call physician, or if appropriate the ED physician. Transfer of patients from other healthcare facilities who have an emergency medical condition that cannot be stabilized by the other healthcare facility are accepted if the on-call physician has the capability to care for the patient and if the hospital provides the services and has beds and the staff to care for the patient ... Patient Rights A written Consent to Transfer will be obtained from the patient outlining the need for transfer, risks and benefits of the transfer, and alternatives to transfer. If the hospital is aware that an individual intends to leave prior to the screening examination, or refuses treatment and/or transfer, it will take the following steps: 1. Offer the individual further medical examination and treatment within the facilities available (sic) to identify and stabilize an emergency medical condition; 2. Inform the individual of the risk and benefits of the examination, treatment, and/or transfer and of the risks of withdrawal prior to receiving the examination, treatment and/or transfer. 3. Take all reasonable steps to secure the individual's written informed refusal of the examination, treatment, and/or transfer. In the case of a refusal of transfer, the patient must state the reason for the refusal. The medical record shall contain a description of the examination, treatment, and/or transfer that was refused. Documentation A Consent to Transfer is completed on all patients transferred out of Penn Highlands Brookville. Likewise, for transfers into Brookville Hospital, a Consent to Transfer will be required of the transferring hospital and will accompany the patient along with pertinent medical record information. The hospital will maintain a central log on each patient who comes to the hospital seeking assistance showing whether the individual refused treatment or was transferred, admitted and treated, stabilized and transferred, or discharged. This log will be retained in the Health Information Department. Transfer to Other Facilities Transfer of patients from Penn Highlands Brookville to other facilities is done in a medically appropriate manner, The transfer of a patient may nit be predicted upon arbitrary, capricious, or unreasonable discrimination based upon race, religion, national origin, age, sex, physical condition or economic status. Physician Duties: The transferring physician will personally examine and evaluate the patient before an attempt to transfer is made. The transferring physician determines and orders life support measures which are medically appropriate to stabilize the patient prior to transfer and sustain the patient during transfer. The transferring physician determines and orders the utilization of appropriate personnel and equipment for the transfer. In determining the use of medically appropriate life support measures, personnel, and equipment; the transferring physician exercises that degree of care which is reasonable and prudent physician exercising ordinary care in the same or similar locality would use for the transfer. Prior to transfer, the transferring physician secures a receiving physician ad a receiving hospital that are appropriate to the medical needs of the patient and that will accept responsibility for the patient's medical treatment and hospital care. Administrative Duties: The hospital recognizes the right of an individual to request transfer into the care of a physician and a hospital of his own choosing; however, if a patient is transferred for economic reasons and the patient's choice is predicted upon or influenced by representations made by the transferring physician or hospital administration regarding the availability of medical care and hospital services at a reduced cost or at on cost to the patient, the physician or hospital administration must fully disclose to the patient the eligibility requirements established by the "patient: chosen physician or hospital. ... Medical Record: The hospital will provide to the receiving physician and receiving hospital a copy of those portions of the patient ' s medical record which are available and relevant to the transfer and to the continuing care of the patient. ... Consent to Transfer: The hospital will provide a Consent to Transfer, as prescribed by the Pennsylvania Department of Health, to be completed for every patient who is transferred for admission. ... Date of Review: ... 03/21 ... ."

"Scope of Service", which stated "... It is the function of the Emergency Department to provide twenty-four care to individuals who require treatment of illness and injury, initially presenting as an outpatient. Qualified medical and nursing personnel provide expertise in managing life threatening as well as serious illness and injury ... Department Responsibility/Goals. It is the function of the Emergency Department to deliver 24-hour quality care for patients suffering emergent, urgent and non-emergent illness or injury ... II. Procedures and Treatments Provided in the Emergency Department ... Services Provided: 1. Triage of patient by acuity 2. Medical evaluation by acuity 3. Nursing care 4. Emergency treatment of acute illness or injury 5. Patient stabilization, admission, transfer or discharge ... Any patients presenting to the Emergency Department will be treated by Penn Highland Brookville personnel ... ."

1. Review of the Patient Associated with Allegations (PT1), Penn Highlands DuBois QCare Medical Record dated July 31, 2021 (MR22), revealed "... Chief Complaint ... Patient presents to the clinic with history of shortness of breath over the past week. Patient states [they are] in end-stage COPD. States ... initial pulse ox read 82 on room air. Patient placed on nasal O2 at 2 L pulse ox shows a pulse of 157. Patient advised would be best if ... be evaluated in the emergency room rapid Covid test was done which was negative. Patient states ... wants to drive ... to Brookville emergency room explained with ... vital signs as they are that would not be safe. Advised to call a family member or ambulance. Patient refusing to call an ambulance states that ... [family member] will take ... to Brookville Hospital. Explained to [family member] the situation ... is agreeable to drive ... to Brookville ER. Report was given to (EMP6) at the Brookville emergency room. Patient's pulse ox on the pulse ox read between 157 and at 1 point dropped to 43 and then returned to 146 ... Assessment and Plan. 1. COPD Stage 3 Severe ... Plan: to go to er. 2. SVT ... 3. Bradycardia ... ."
2. Documentation provided by the facility revealed "... August 3, 2021 ... I was able to speak with 2 of the staff working on Saturday 7/31/21, when the patient in question came presented to the ED ... EMP5 stated the Punxsutawney Q-care had called regarding a patient that was coming to Penn Highlands Brookville ER and was giving report. Upon presentation of this information to the Physician on duty, the decision was made to call q-care and have patient go to Penn Highlands Dubois. Patient had already departed from the q-care at that time. When patient presented to Penn Highlands Brookville ED, EMP5 was preparing to get the information when EMP6 told the patient they were more than welcome to be seen but if the patient needed transferred they could be waiting for a long time. The patient was told that they may be better off going directly to Penn Highlands DuBois. EMP5 stated the patient was told multiple times they were more than welcome to be seen. Per EMP5 the family member with patient stated they may as well just go to Dubois. Patient information was not entered onto Tracker and withdrawal for request for emergency care form was not completed ... ."

3. Interview with EMP3, on September 20, 2021, at 1:00PM, revealed "... EMP4 emailed me or called me, and questioned if I was aware of a possible EMTALA violation. The patient was in our ER and told better to go to DuBois ... ."

4. Interview with EMP6, on September 21, 2021, at 10:10 AM, revealed "I was working. I had gotten a call from Punxsy QCare that patient may be arriving. The patient complained of shortness of breath with walking, sats were low and HR was low. It was a usual day. We see people, assess situation, most of the time they wait in the car. It was busy. I saw someone go the window, and [they] said they told [the patient] to come in and be evaluated ... I said I'm sorry, we will take care of you, please be patient. I told [the patient] we won't have a bed. [The patient] grumped around. We will get you back as soon as possible. I told [the patient] I will gladly take care of him. [The patient] appeared stable, no color changes. They said we're going to go to DuBois. Physicians don't put patients on the board. One of the nurses or helpers put someone on the board. If there's no unit clerk, sometimes respiratory will help us. I did a quick eye ball, [the patient] made lots of comments, and was frustrated ... ."
5. Interview with EMP5 on September 21, 2021, at 10:45AM, revealed "... Punxsy was calling to and speaking to EMP6 after patient was sent this way. The patient and [family member] came to the window, yes they wanted to be seen and EMP6 came to the window to speak with them. [EMP6] offered and asked multiple questions. It was better to go DuBois, and they left. We have a huge delay in transfers, it's a lengthy process even to get docs to call back. EMP6 was in the best interest of this patient ... ."
6. There was no documentation relative to PT1 that appropriate transfer arrangements occurred.
7. Telephone Interview with EMP4, on September 21, 2021, at approximately 11:15AM, revealed "I was working in department (Penn Highlands DuBois ED) and happened to see patient, and wife and during initial interview on the initial presentation to Brookville [the patient] presented to the window area with complaint and essentially were told we could see you but just so you know if seen here due to increased complaints, could take some time to get transferred to DuBois, they were told that and they elected to go home instead of going to DuBois. A few days later, still not feeling well, drove themselves to DuBois ... ."
8. Review of MR21, revealed PT1 presented to Penn Highlands DuBois ED on August 3, 2021, and was subsequently admitted.