Based on interviews and facility document review, it was determined the facility staff failed to comply with §489.24 - Special Responsibilities of Medicare Hospitals in Emergency Cases. The findings include: The facility staff failed to ensure the facility's bylaws and/or rules and regulations included language to detail who were determined qualified to conduct medical screening exams on emergency patients. The facility staff failed to ensure the facility's written policies and procedures for 'on-call physicians' addressed: (a) what to do when a particular specialty is not available, (b) what to do when the on-call physician is unable to respond, (c) if an on-call physician is allowed to schedule elective surgery during the time he/she is on call, and (d) if an on-call physician is allowed to have simultaneous on-call duties. Please see Tag A2404 and Tag A2406 for additional information.

Based on interviews and facility document review, it was determined the facility staff failed to ensure the facility's written policies and procedures for 'on-call physicians' addressed: (a) what to do when a particular specialty is not available, (b) what to do when the on-call physician is unable to respond, (c) if an on-call physician is allowed to schedule elective surgery during the time he/she is on call, and (d) if an on-call physician is allowed to have simultaneous on-call duties. The findings include: The facility's policy and procedure entitled "On Call Physician 56-56-24" [sic] (was provided to the surveyor by the facility's Chief Executive Officer (CEO) on 9/21/16 at 10:37AM. This policy did not address: (a) what to do when a needed specialty does not have a physician on-call, (b) what to do when an on-call physician is unable to respond, (c) if an on-call physician is allowed to schedule elective surgery during the time he/she is on call, and (d) if an on-call physician is allowed to have simultaneous on-call duties. The facility's Rules and Regulations (an Addendum to the Bylaws of the Medial Staff) was reviewed for the aforementioned 'on-call physician' areas that were not addressed by the facility's policies and procedures. The Rules and Regulations failed to address the areas but the following information was found: "Members of the staff shall, however, have an obligation to serve on the roster as reasonably requested and to assume their fair share of any burden associated with this responsibility. Failure to meet this responsibility, or to respond promptly (within thirty (30) minutes) when on call to a request to come to the Emergency Department to see a patient, shall be a basis for disciplinary action including possible suspension or revocation of privileges and staff membership. Physicians and other practitioners on call are required to be available within a reasonable time (30 minutes). If the physician or other practitioner is not available, the on call roster will be followed. (Refer to Medical Staff Policy and Procedure 56-56-24 for more information)." On 9/21/16 at 11:12AM, the surveyor discussed the failure of the facility's policies and procedures to address the aforementioned areas with the facility's Chief Executive Officer (CEO). The CEO stated that if the on-call physician was not available the patient would be transferred. The CEO reported that elective surgeries could be performed while the surgeon was on-call. The CEO also acknowledged policies and procedures do not prohibit a physician to be on-call for more than one facility simultaneously but the CEO explained that due to the geographic location of the facility it would not be an issue because no other facility was close enough for the physicians to be on call at more than one facility at the same time. On 9/22/16 at 11:45AM, the surveyor discussed the missing components of the facility's policies and procedures addressing 'on-call physician' coverage for a final time with the facility's CEO; no additional information was provided to the surveyor.

Based on interviews and facility document review it was determined that neither the facility's bylaws nor the facility's rules and regulations defined who was determined to be qualified to perform medical screening exams. The findings include: Review of the facility's Medical Staff Bylaws and the facility's Rules and Regulation (an addendum to the Medical Staff Bylaws) failed to reveal a statement of who was determined to be qualified to perform medical screening exams for emergency patients. The following statement was found in the facility's Rules and Regulations: "All patients registered for services in the Emergency Department must, prior to discharge, be personally seen by a physician, or other practitioner on the medical staff, or by an individual designated by the patient's physician, dentist or podiatrist who is qualified and credentialed by the Hospital to assess a patient's condition acting in consultation with an Emergency Department physician." The following statement was found in the facility's policy and procedure entitled "Transfer to or from (facility ' s name omitted)": "A. The emergency department is to provide an "appropriate" medical screening examination in accordance with the individual's apparent needs and with the hospital's capabilities (which include all customary ancillary services provided to such persons presenting to the hospital with the individual's needs) for anyone who comes to the emergency department for examination or treatment before consideration of ability to pay for these services. .... B. The screening examination must be performed by a physician or licensed practitioner designated by the Board." During an interview with the facility's Chief Executive Officer (CEO) on 9/21/16 at 10:15AM, the CEO was asked who was allowed to perform a medical screening exam (MSE). The CEO reported the facility's board had determined who was allowed to do the MSEs. The CEO also reported the decision on who could do MSEs might be documented in a facility policy. On 9/21/16 at 11:07AM, the facility's CEO and Director of Emergency Department (DED) were asked who were doing the MSEs; the DED stated that physicians, nurse practitioners, and physician assistants were allowed to do the MSEs. During an interview with the facility's CEO on 9/22/16 at 11:07AM, the CEO reported he/she was unable to find the board meeting minutes for the meeting when the facility's board defined who was qualified to do the MSE for emergency patients. The CEO reported that he/she remembered the meeting when the board determined who could do the MSEs; he/she guessed it was approximately 15 years ago when the meeting took place.