Based on interviews and a review of hospital documents, it was determined the provider failed to be in compliance with §489.24, by failing to verify the qualifications/credentials of individuals conducting consultative services contributing to the medical screening examination and the determination of whether an emergency medical condition existed, for patients coming to the emergency department with mental health concerns/needs. See also Tag A-2406 for additional details. The findings were: The surveyor met with the Emergency Department (ED) Clinical Leader (Registered Nurse) and the Director of Quality and Risk Management (Registered Nurse) on 06/06/18 at 11:30 a.m. The ED Clinical Leader described that patients who presented to the ED with mental health related concerns/needs, received a "Mental Health Consultation," which was used in determining whether the mental health concern/need was an emergency medical condition. The ED Clinical Leader explained the individuals conducting the Mental Health Consultations were not hospital staff members, but were employees of a local mental health center also referred to as "Crisis." The surveyor met with the Chief Executive Officer (CEO) on 06/06/18 at 12:20 p.m. The CEO described, the hospital doesn't get to choose who provides the Mental Health Consultations. He/she explained, the state determines which mental health center provides that service for the hospital, and the mental health center decides which staff perform the consultations. The CEO acknowledged there was no process in place for verifying the credentials/qualifications of the mental health center's staff members who provided Mental Health Consultations, for patients with mental health concerns/needs in the hospital's ED. The surveyor reviewed (on 06/05/18) the hospital's "Medical Staff Bylaws" and "Rules and Regulations" last updated July 18, 2017. The Medical Staff Bylaws and Rules and Regulations did not address or determine, the required qualifications/credentials of non-hospital staff members conducting the Mental Health Consultations, which were used in determining whether a mental health emergency medical condition existed. The surveyor reviewed (on 06/05/18) the hospital's policy titled, "EMTALA (Screening, Stabilization and Management of Emergency Transfers)," last revised 02/2017. The hospital's EMTALA policy failed to address the use of the non-hospital staff members who conducted the Mental Health Consultations, which were used in determining whether a mental health emergency medical condition existed. The EMTALA policy failed to define a process for verifying the qualifications/credentials of the mental health center's staff members who conducted the Mental Health Consultations. The surveyor met with the ED Clinical Leader and the Director of Quality and Risk Management again on 06/06/18 at 5:40 p.m. The ED Clinical Leader and the Director of Quality and Risk Management acknowledged there was no process in place for verifying the qualifications/credentials of the mental health center's staff members who conducted the Mental Health Consultations.

Based on interviews and a review of hospital documents, it was determined the hospital staff failed to verify the qualifications/credentials of mental health workers providing consultative services contributing to the medical screening examination and determination of whether an emergency medical condition existed, for patients coming to the emergency department with mental health concerns/needs. The findings were: The surveyor met with the Emergency Department (ED) Clinical Leader (Registered Nurse) and the Director of Quality and Risk Management (Registered Nurse) on 06/06/18 at 11:30 a.m. The ED Clinical Leader described that patients who presented to the ED with mental health related concerns/needs, received a "Mental Health Consultation," which was used in determining whether the mental health concern/need was an emergency medical condition. The ED Clinical Leader explained the individuals conducting the Mental Health Consultations were not hospital staff members, but were employees of a local mental health center also referred to as "Crisis." The Director of Quality and Risk Management stated the local mental health center (also known as Crisis) provided crisis intervention for mental health issues and addiction issues. The Director of Quality and Risk Management stated he/she would need to check with someone about how the hospital verified the credentials/qualifications of the individuals conducting the Mental Health Consultations, as he/she was not sure how that was handled. The Director of Quality and Risk Management left the conference room and returned a short time later. He/she described there was no current process in place, for verifying the qualifications/credentials of the mental health center's staff members who conducted the aforementioned Mental Health Consultations. The surveyor met with the Chief Executive Officer (CEO) on 06/06/18 at 12:20 p.m. The CEO described, the hospital doesn't get to choose who provides the Mental Health Consultations. He/she explained, the state determines which mental health center provides that service for the hospital, and the mental health center decides which staff perform the consultations. The CEO stated that since the arrangement was state mandated, he/she didn't think they (the hospital) had the right to ask for the qualifications of the mental health center's staff who perform the Mental Health Consultations. The CEO described that, in the past he/she had inquired as to whether they could change mental health center's and he/she was told that wasn't possible. He/she stated having concerns the mental health center would be reluctant to provide the documents verifying the credentials/qualifications of all staff who perform the Mental Health Consultations. The CEO acknowledged there was no process in place for verifying the credentials/qualifications of the mental health center's staff members who provided Mental Health Consultations, for patients with mental health concerns/needs in the hospital's ED. The surveyor reviewed (on 06/05/18) the hospital's "Medical Staff Bylaws" and "Rules and Regulations" last updated July 18, 2017. The Rules and Regulations (page 28) included a section titled, "Emergency Services" which included, in part, the following: "Qualified medical personnel who can perform medical screening examinations within applicable Hospital policies and procedures are defined as:" ..."members of the Medical Staff with clinical privileges in Emergency Medicine; other Active Staff members; and appropriately credentialed allied health professionals." The Medical Staff Bylaws and Rules and Regulations did not address or determine, the required qualifications/credentials of non-hospital staff members conducting the Mental Health Consultations, which were used in determining whether a mental health emergency medical condition existed. The surveyor reviewed (on 06/05/18) the hospital's policy titled, "EMTALA (Screening, Stabilization and Management of Emergency Transfers)," last revised 02/2017. The policy included, in part, the following on page 6 of 12: ..."A Medical Screening Examination is the process required to reach, within reasonable clinical confidence, the point at which it can be determined whether an Emergency Medical Condition exists." ..."A medical record documenting the history and physical examination, and any special reports such as consultations, clinical laboratory, x-ray, etc. will be created to document the screening exam." ..."The Medical Screening Exam is not triage. The exam must be performed by qualified personnel as defined in the Medical Staff Bylaws." The hospital's EMTALA policy failed to address the use of the non-hospital staff members who conducted the Mental Health Consultations, which were used in determining whether a mental health emergency medical condition existed. The EMTALA policy failed to define a process for verifying the qualifications/credentials of the mental health center's staff members who conducted the Mental Health Consultations. The surveyor met with the ED Clinical Leader and the Director of Quality and Risk Management again on 06/06/18 at 5:40 p.m. The ED Clinical Leader and the Director of Quality and Risk Management acknowledged there was no process in place for verifying the qualifications/credentials of the mental health center's staff members who conducted the Mental Health Consultations.