The Condition of Participation for Emergency Services was not met. Findings included: The Emergency Services failed to ensure the integration of psychiatric patient care in the Emergency Departments into the Quality Assessment and Performance (QAPI) Program. Refer to TAG: A-1103 The Emergency Services failed to ensure qualified personnel in emergency care met the needs of psychiatric patients in the Emergency Department. Refer to TAG: A-1112

Based on records reviewed and interviews, the Emergency Services failed to ensure for 9 of 12 patients (Patients #1, #3, #4, #5, #7, #8, # 10, #11 and #12), to integrate the care of psychiatric patients in the Emergency Department into the Quality Assessment and Performance (QAPI) Program. Findings included: The Surveyor interviewed the Chief Operating Officer at 2:45 P.M. on 1/18/17. The Chief Operating Officer said that the Hospital did not perform quality monitoring regarding the Emergency Service Program (ESP) Contracted Services. The Hospital did not provide documentation to indicate QAPI activities that collected quality improvement psychiatric patient-care data or monitored and tracked performance for quality psychiatric patient care of the two ESP Contracted Services or the 2 Emergency Department Physician Contracts responsible for psychiatric patient care in the Emergency Departments.

Based on records reviewed and interviews, the Hospital failed to ensure for 9 of 12 patients(Patients #1, #3, #4, #5, #7, #8, # 10, #11, #12), that qualified personnel in emergency care met the needs of psychiatric patients in the Emergency Department. Findings included: The Hospital policy titled Emergency Department Scope of Care, dated 12/2007, indicated that emergency care was delivered by qualified staff. The Hospital policy titled Emergency Medical Treatment and Active Labor Act (EMTALA), dated 5/5/16, indicated that a qualified medical provider (physician or non-physician practitioner) must perform an appropriate medical screening examination. The EMTALA policy indicated that a licensed independent practitioner (non-physician practitioners, Allied Health Professionals) with clinical privileges in the Emergency Department as designated by Medical Staff bylaws performed the medical screening examination. Medical Staff bylaws, dated 11/19/14, indicated that Allied Health Professionals were Clinical Psychologists, Advanced Registered Nurse Practitioners, Certified Registered Nurse Anesthetists, Certified Nurse Midwives and Physician Assistants; approved by the Governing Body and the Medical Staff credentialing process were permitted to practice medicine at the Hospital. Medical Staff bylaws did not indicate that individuals who signed Emergency Psychiatric Evaluations with the initials of LCSW (undefined), LMHC (undefined), MSW (undefined), and MA (undefined) were Allied Health Professionals that were approved by the Governing Body and Medical Staff credentialing process to provide psychiatric evaluations at the Hospital. Medical Staff bylaws did not indicate that Hospital Social Workers were approved by the Governing Body and Medical Staff credentialing process to provide psychiatric evaluations at the Hospital. Nine of twelve medical records reviewed (Patients #1, #3, #4, #5, #7, #8, # 10, #11, #12), indicated Hospital Social Workers and ESP Contracted Service Clinicians provided Emergency Psychiatric Evaluations. The Surveyor interviewed the Executive Director of Risk Services and the Associate Chief Nursing Officer, at 10:20 A.M. on 1/13/17. The Executive Director of Risk Services and the Associate Chief Nursing Officer said the Hospital did not credential (grant Medical Staff privileges or appoint to the Medical Staff) ESP Clinicians and Hospital Social Workers who provided Emergency Psychiatric Evaluations in the Emergency Departments. The Hospital did not provide documentation to indicate Medical Staff credentialing procedures, competency review, nor granting and delineation of clinical privileges based on licensure, training, experience, capacity to perform or evidence of current competency for the ESP Contracted Service Clinicians or Hospital Social Workers, who provided Emergency Psychiatric Evaluations to nine Emergency Department patients (Patients #1, #3, #4, #5, #7, #8, #10, #11 and #12), in accordance with State law and Medical Staff bylaws. The Hospital did not provide documentation to indicate Medical Staff credentialing procedures or competency review for the Hospital Licencened Independent Clinical Social Workers who performed and authorized Section 12A's (emergency restraint and hospitalization of patients posing risk of serious harm due to psychiatric illness).