Based on staff interviews and facility document reviews, it was determined the facility staff failed to comply with 489.24 - Special Responsibilities of Medicare Hospitals in Emergency Cases. The findings include: A. The facility staff failed to ensure the facility's written policies and procedures for on call physicians addressed: (a) if an on-call physician was allowed to schedule elective surgery during the time he/she is on call, and (b) if an on-call physician was allowed to have simultaneous on-call duties. Please see Tag A-2404 for additional information.

Based on facility document review and staff interviews it was determined the facility staff failed to ensure their written policies and procedures for on-call physicians addressed: (a) if an on-call physician was allowed to schedule elective surgeries while on-call, and (b) if an on-call physician was allowed to have simultaneous on-call duties. The findings were: The facility's policy titled, "Transfer EMTALA" (last updated April 2017) was provided by the facility's chief compliance officer (CCO) and was reviewed by one surveyor on 11/16/18 at 8:30 a.m. The policy did not address whether on-call physicians would be allowed to schedule elective surgeries while they were on-call or whether on-call physicians would be allowed to have simultaneous on-call duties. At 10:15 a.m. on 11/16/18, the facility's chief compliance officer and director of quality and patient safety were interviewed. The CCO stated he/she thought that the "Transfer EMTALA" policy was the only facility policy that addressed on-call physicians' responsibilities at all but would continue looking. The CCO pointed to an area within the policy that read in part, "C. Stabilization and Treatment Beyond The Capability Of The ED... 8. The Patient will remain the responsibility of the accepting on-call Physician (or the Physician requested by the Patient, if the Physician requested by the Patient has assumed responsibility for the Patient) until the episode of illness or injury that prompted the Patient's assignment to the Physician is satisfactorily resolved and the Patient has been discharged or transferred." The CCO acknowledged the "Transfer EMTALA" policy did not specifically address whether on-call physicians were allowed to schedule elective surgeries while on-call nor did the policy address whether on-call physicians were allowed to take simultaneous call at more than one location. At 1:20 p.m. the same day, the facility's chief compliance officer acknowledged he/she had had enough time to look for all documents pertaining to this subject and had not found any other policy/procedure. The CCO said the facility does allow physicians to perform elective surgeries while on-call and that it's the responsibility of the on-call physician along with the emergency department (ED) physician to determine if the on-call physician's response time was appropriate (i.e. when called, was the physician at the beginning of a surgery versus the end of a surgery?) and if not, the on-call physician had the responsibility for making arrangements for coverage. The CCO stated there were no physicians who took simultaneous call that the facility administration was aware of but he/she did not know for sure. The CCO added the facility had not experienced a problem with on-call physician coverage.