Banner Behavioral Health Hospital

“DELAY IN EXAMINATION OR TREATMENT CFR(s): 489.24(d)(4-5) (4) Delay in treatment. (i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status. (ii)A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section. (iii) An emergency physician or nonphysician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph (e) of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual’s behalf) does not consent to the transfer. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual’s refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual. This Standard is not met as evidenced by: 51960 Based on review of Hospital policy and procedures, patient medical records, associated document requests, and employee interviews, it was determined the Hospital delayed examination and/or treatment for a patient who presented to the Hospital seeking emergency psychiatric treatment. Failure to provide timely medical examination and treatment poses a potential risk that a patient with an Emergency Medical Condition could worsen without medical treatment. Findings include: Hospital Policy titled “EMTALA - Medical Screening Examination and Stabilization Treatment” (Number: 1330, Version: 13), last review/revision date of 03/28/2024, revealed “...III. Policy ...A. Medical Screening Examination (“MSE”)...6. An MSE and Stabilizing Treatment, within the capabilities of the Hospital, will be provided to all individuals regardless of their ability to pay. Medical screening and stabilizing treatment will not be delayed to obtain payment or insurance information. Reasonable registration processes, including insurance information, may be followed as long as individuals are not unduly discouraged from remaining for further evaluation....” Hospital Document titled “EMTALA Log” from November 2025 revealed: Patient #6 arrival date 11/10/2025, “...Arrival time ...19:04...Exit time...19:04 ...Mode of Arrival ...Walk in...Disposition...LWOT....” Patient #6 ’ s medical record revealed the following: Hospital document titled “Condition of Admission and Treatment” revealed it was signed by the Patient and staff witness at 16:05 on 11/10/2025. Hospital document titled “Financial Agreement” revealed it was signed by the Patient and staff witness at 16:05 on 11/10/2025. Hospital document titled “Complaint / Grievance Problem Solving Process” revealed it was signed by the Patient and staff witness at 16:06 on 11/10/2025. Hospital document titled “Supplemental Medical Treatment Agreement” revealed it was signed by the Patient and staff witness at 16:06 on 11/10/2025. Hospital document titled “Specialty Pharmacy - Pharmacy Patient Advocacy Authorization for Release of Medical and Financial Information” revealed it was signed by the Patient and staff witness at 16:06 on 11/10/2025. Hospital document titled “Behavioral Health Client Rights” revealed it was signed by the Patient and staff witness at 16:07 on 11/10/2025. A request was made on November 18, 2025 for Patient #6 ’ s Medical Screening Exam. None was provided at the time of survey. Patient #6 confirmed in an interview on November 19, 2025 that they arrived at the Hospital as a walk-in, around 16:00 on November 10, 2025 until roughly 19:00. After inquiring how long the wait would be to be seen by a nurse, the patient promptly exited the facility. Patient #6 confirmed they waited roughly three (3) hours without seeing a nurse. Employee #1 confirmed in an interview on November 19, 2025 that there was no evidence of stabilizing treatment completed for Patient #6 and that the aforementioned documentation was signed by Patient #6 roughly three (3) hours prior to their arrival and exit time indicated on the EMTALA log.”

“HOSPITAL MUST MAINTAIN RECORDS CFR(s): 489.20(r)(1) [The provider agrees,] in the case of a hospital as defined in §489.24(b), (including both the transferring and receiving hospitals), to maintain medical and other records related to individuals transferred to or from the hospital for a period of 5 years from the date of the transfer. This Standard is not met as evidenced by: 49638 Based on hospital policy and procedure, medical record request and employee interview, it was determined that the hospital failed to ensure a patient medical record was maintained with all required documentation for at least 5 years. This deficient practice can result in a patient not getting appropriate psychiatric and medical care if they need further treatment. Findings Include: Hospital policy titled “BYLAWS OF THE MEDICAL STAFF,” Amended by the Board of Directors 10/14/21, revealed “ ...3.3 BASIC OBLIGATIONS OF INDIVIDUAL STAFF MEMBERSHIP ...Each staff member, regardless of assigned staff category, and each practitioner exercising temporary privileges under these Bylaws, shall: ...(e) Prepare and complete in a timely fashion, according to these Bylaws and to Hospital policies, the electronic medical record and other required records for all patients to whom the practitioner provides care in the Hospital, or within its facilities, services, or departments ...” Hospital policy titled “Qualified Medical Personnel Authorized to Perform Medical Screening Examinations,” Policy #1196, Version 10, Last Review/Revision Date: 09/25/2024, revealed “ ...G. The QMP (Qualified Medical Personnel) may not transfer a patient from the hospital or Urgent Care Center to another facility until he or she has: 1. performed a medical screening examination ...4. documented the screening examination, interventions, physician orders, disposition of the patient ....” Hospital policy titled “EMTALA - Medical Screening Examination and Stabilization Treatment,” Policy #1330, Version 13, Last Review/Revision Date: 03/28/2024, revealed “ ...4. Documentation ...The documentation applicable to the following events should contain, at a minimum, the following information: ...b. Medical Screening Exam ...i. Physician/QMP assessment and orders ...ii. Interventions/treatments ...iii Patient ...response to treatment ...iv. Continued monitoring ...f. Transfer of Unstable Patient to Another Facility: ...iv. Notification to Receiving Facility: ...(iii) Copies of relevant portions of Medical Records sent ....” A request was made for hospital medical records, including medical screening examination and transfer documentation, pursuant to hospital policy, for Patients #3, #4, and #9. No medical records, including medical screening examination and transfer documentation, pursuant to hospital policy, were provided for these patients. Employees #1 and #3 confirmed, during a joint interview conducted on September 18, 2025, that no medical records, including medical screening examination and transfer documentation, for Patients #3, #4, and #9 were available for review at the time of the survey.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 45202 Based on facility policy, medical record review and staff interviews, it was determined the hospital failed to enforce policies and procedures that comply with the requirements of 42CFR §489.20 and 42 CFR §489.24, responsibilities of Medicare participating hospitals in emergency cases. Findings Include: Policy title “EMTALA- Medical Screening Examination and Stabilization,” Review date 03/28/2024, revealed; “ ...III A. 5 An MSE will be conducted to determine whether the Patient has an EMC(sic). The Hospital will conduct a consistent MSE, in nondiscriminatory matter, for all Patients with similar medical conditions. The MSE is an ongoing process requiring continuing monitoring based upon the Patient’s needs and must continue until the EMC is stabilized or the Patient is admitted or appropriately transferred ....” Medical record review revealed the facility failed to provide Medical Screening Exams for Patients #8, #13, and #19. Cross reference tag #2406 Medical Screening Exam. Employee #33 and #34 confirmed in interview, conducted on 6/19/2025, that no Medical Screening Exams were available for review for Patients #8, #13, and #19 This deficient practice can result in a delay in care and patient harm, and resulted in the facilities failure to meet the responsibilities of Medicare participating hospitals in emergency cases.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 52829 Based on Hospital policy review, Patients medical record review, document request, and employee interview, it was determined that the Hospital failed to implement and enforce Hospital policy for screening of patients to determine the presence of an Emergent Medical Condition. This deficient practice poses a potential risk to the health and safety of patients if life-threatening or potentially life-threatening conditions are not recognized and stabilizing treatment provided. Findings include: Policy title “EMTALA- Medical Screening Examination and Stabilization,” Review date 03/28/2024, revealed; “ ...III A. 5 An MSE will be conducted to determine whether the Patient has an EMC(sic). The Hospital will conduct a consistent MSE, in nondiscriminatory matter, for all Patients with similar medical conditions. The MSE is an ongoing process requiring continuing monitoring based upon the Patient’s needs and must continue until the EMC is stabilized or the Patient is admitted or appropriately transferred ....” Document titled “EMTALA Log” revealed: Patient #13 arrival time, 4/3/2025 at 1840 “mode of arrival ...walk in ...sent for medical clearance ....” Patient #8 arrival time, 2/20/2025 at 2234 “mode of arrival ...ambo ...inpatient ....” Patient #19 arrival time, 5/24/2025 at 0037 “mode of arrival ...ambo ...Refused/Declined Admission ....” A total of 20 patient medical records, including Patients #8, #13, and #19, were randomly selected for review from the Hospital’s EMTALA Log. Request were made on 6/17/2025 through 6/20/2025 for Medical Screening Exam for Patients #8, #13, and #19, none provided at time of survey. Employee #33 and #34 confirmed in interview, conducted on 6/19/2025, that no Medical Screening Exams were available for review for Patients #8, #13, and #19”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 52829 Based on review of Hospital policy and procedure, medical record review, associate document request, and employee interview, it was determined that the Hospital failed to implement and enforce Hospital policy that specifies the process by which the Hospital coordinates transfers to another facility. This deficient practice poses a potential risk of harm to a patient when coordination of care activities for patient transfer are not completed pursuant to Hospital policy. Findings include: Policy title “EMTALA- Medical Screening Examination and Stabilization,” Review date 03/28/2024. Revealed; “ ...III M 4. F. “ ...Signage and Documentation Requirements ...Transfer of Unstable Patient to Another Facility: i. Certification. (i) ii. iii. Risk and benefits upon which the certification is based for Transfer. Patient Request/Consent to Transfer. Transfer Acceptance by a Receiving Facility: (i) Accepting Physician or authorized person. (ii) Person contacted in admission department. (iii) Time contacted. iv. Notification to Receiving Facility: (i) Patient report given to staff. (ii) Time of report. (iii) Copies of relevant portions of Medical Records sent. (iv) If applicable, name of the On-Call physician who refused or failed to respond when requested. (v) Mechanism of Transfer, and any special equipment or personnel being utilized to facilitate a safe Transfer ....” Medical Record of Patient 3# revealed, Document titled “BeH Adult Crisis Assessment Form” “ ...Patient presented with slurring speech and gate unsteady. BAL 0.358 V/S stable. Pt reported HX of Alcohol seizures and history of heart disease. Patient alert and orientation X4 no signs of altered mental status Pt will be sent to BDMC for medical clearance due to high alcohol intoxicated ...” Documentation of coordination of transfer was requested. None was provided. Medical record of Patient #8 revealed, Document titled “BeH Adult Crisis Assessment Form” “ ...Date and Time of Service 3/21/2025. 1835 ...Patient presents to BBHH to receive alcohol detox ... Denies SI, HI, DTO/DTS, currently does not perform self-harming acts ... transferred for medical clearance. Transferred to BDMC due to. BAC > 0.412 ....” Documentation of coordination of transfer was requested. None was provided. Medical record of Patient #11 revealed, Document titled “BeH Adult Crisis Assessment Form” “ ... Depression, Anxiety, past hospitalization Suicide attempt ... untimed document trans from BBHH to BDMC, timed doc @ 1647 Transfer from BDMC to BBHH ....” Documentation of coordination of transfer was requested. None was provided. Medical record of Patient #13 revealed, Document titled “BeH Adult Crisis Assessment Form” “ ... Pt reported HX of prediabetic and has UTI. Pt obsessed with delusional thoughts reports HX of SMI ... On call psychiatrist was notified and recommended for medical clearance ....” Documentation of coordination of transfer was requested. None was provided. Medical record for Patient #18 revealed Document titled “BeH Adult Crisis Assessment Form” which stated “ ... seeking help with increased psychosis ... recommended for level 1 admission with the primary focus of care being mental health ... Pt was staffed with (Employee #41), who recommends level one admission for psychosis/OTO behaviors, sleep disturbance. However, Patient will need a medically attached facility and medical clearance prior to level one placement....” Documentation of coordination of transfer was requested. None was provided. Medical record for Patient #20 revealed Document titled “BeH Adult Crisis Assessment Form” which stated “ ...Pt reported, he/she has been relying on wheelchair, unable to push or rolling ... move forward on wheelchair independently he/she reported, totally requires assistant with mobility .... (Employee #3) recommended admission to level one inpatient treatment ... transfer to Banner Desert Medical Center - medical clearance and admit to medical ....” Documentation of coordination of transfer was requested. None was provided. A total of 20 patient medical records, including Patients #3, #8, #11, #13, #18, and #20, were randomly selected for review from the Hospital’s EMTALA Log. Request made, 6/17/2025 through 6/20/2025 for documentation of transfer for Patients #3, #8, #11, #13, #18, and #20, none provided at time of survey. Employee #33 and #34 confirmed in interview, conducted on 6/19/2025, that no documentation of transfer was available for review for Patients #3, #8, #11, #13, #18, and #20”