Changepoint Psychiatric Hospital

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 45202 Based on review of hospital records and staff interviews, it was determined that the hospital failed to comply with protecting and promoting patient’s rights as evidenced by: Cross reference A-0144: The hospital failed to ensure patient bedrooms and bathrooms were free from a conditions that could cause patient harm resulting in an Immediate Jeopardy. Cross reference A0196: The facility failed to ensure all direct care staff receive proper restraint training. The egregious nature of these deficient practices resulted in the facility’s failure to meet the requirement for the Condition of Participation for Patient Rights and provide a safe environment for patients to protect them from harm.”

“UTILIZATION REVIEW CFR(s): 482.30 The hospital must have in effect a utilization review (UR) plan that provides for review of services furnished by the institution and by members of the medical staff to patients entitled to benefits under the Medicare and Medicaid programs. This Condition is not met as evidenced by: 45202 Based on a review of documentation and interviews, it was determined the Governing Body failed to implement an effective utilization review plan that provided for review of services provided by the institution and the members of the medical staff to patients. Findings include: Cross reference A-0652 The Governing Body failed to convene a utilization review committee consisting of two or more practitioners. Cross reference A-0654 The governing body failed to implement the utilization review policy for review for Medicare and Medicaid patients. The cumulative effect of the systematic deficient practice resulted in the facility’s failure to meet the requirement for the Condition of Participation for Utilization Review, which poses a potential risk to the health and safety of patients when the facility fails to ensure appropriate utilization evaluation is ongoing for patients and reported to the Governing Body.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 45202 Based on observation on tour, review of policy, review of the facility plan of correction, and interview, the Administrator failed to ensure the facility was maintained in a condition that was free from a situation that may cause a patient to suffer physical injury by not maintaining a ligature free environment in patient bedrooms and bathrooms. This deficient practice can result in patient self harm and self asphyxiation resulting in harm or death. Findings include: Observation on June 10, 2025, revealed the facility’s non-compliance with State licensing requirements for environmental standards and physical plant standards to protect the health and safety of patients receiving treatment at the facility. Ligature risks were identified during the facility tour that included patient bathroom toilets and shower heads not installed flush with the wall, creating a tie off point, protruding screws creating a patient self harm opportunity, elbow joints connecting beds to walls for 16 beds creating a ligature point, and sink faucets not properly maintained creating a tie off point. The facility provided a plan of correction for the ligatures deficiencies dated September 13, 2024, that states with regards to ligatures, “...Conduct a thorough risk assessment of all existing areas to identify potential ligature points and other hazards ...Conduct training sessions for staff on recognizing and mitigating ligatures risks ....” The plan further addresses the installation of the new toilets stating “...Establish a regular maintenance schedule to ensure the ongoing functionality and safety of the new anti-ligature toilets ...develop a system for reporting and addressing any issues or repairs needed ...Conduct post-installation inspections to ensure proper installation ...address any issues or defects immediately ....” The facility failed to implement this plan of correction to ensure that ligatures were monitored and addressed in a timely manner. Interview with Employee #1 and Employee #4 on June 10, 2025, confirmed the findings on tour.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(1) Training intervals. Staff must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion- (i) Before performing any of the actions specified in this paragraph; (ii) As part of orientation; and (iii) Subsequently on a periodic basis consistent with hospital policy. This Standard is not met as evidenced by: 45202 Based on facility policy and procedure, personnel files, and interview, the Department determined that the administrator failed to ensure two personnel members obtained in-service training for seclusion and restraint when required. This poses a potential risk that staff are not appropriately trained. Findings include: Policy #HR-160, titled “Employee Orientation, Staff Development and Training” last reviewed 10/02/2023, revealed: “...Administrative and support staff participate in annual continuing education and training to maintain skills and competencies to perform their job ....In-service training for staff is based on program and individual staff needs,...Behavioral Health Professionals, Behavioral Health Technicians and Residential Techs need to maintain current skills and knowledge obtain or enhance skills and knowledge in the behavioral health services the agency is authorized to provide,...” Employee #1 ’ s personnel record revealed the following: A document titled “Job title HOSPITAL ADMINISTRATOR/CRISIS SERVICES DIRECTOR”, which revealed: “...Skills/Abilities Required:...Trained in and effectively manages crisis intervention/behavior management ....” A certification for “Handle with Care” revealed: “...9/20/2023 This Certification Expires 1 Year From This Date ...” A certification for “De-escalation, Seclusion and Restraint Training” was completed 12/11/2024. Employee #6 ’ s personnel record revealed the following: A document titled “Job title Behavioral Health Para-Professional Residential Tech (BHPP)”, which revealed: “...Duties and Responsibilities ...Be trained in providing de-escalation, seclusion, and restraints ...” A certification for “Handle with Care” revealed: “...2/24/2023 This Certification Expires 1 Year From This Date ...” A certification for “De-escalation, Seclusion and Restraint Training” was completed August 20, 2024. Employee #15 confirmed in an interview conducted on June 11, 2025, that Employee #1 and Employee #6 did not obtain in-service training when it was required.”

“MEDICAL STAFF PERIODIC APPRAISALS CFR(s): 482.22(a)(1) The medical staff must periodically conduct appraisals of its members. This Standard is not met as evidenced by: 45202 Based on facility policy and procedure, provider files, and staff interviews, the Department determined that the hospital failed to complete peer reviews of medical personnel. This deficient practice poses a risk to the health and safety of patients if the hospital does not ensure proper oversight of medical decision making. Findings Include: Policy #PI-102, titled “Focused Professional Practice Evaluations and Ongoing Professional Practice Evaluations for Changepoint Psychiatric Hospital” last reviewed 09/18/2023, revealed: “...Professional Practice Evaluation 1. Ongoing Professional Practice Evaluation (OPPE) is a program that allows the medical staff to identify professional practice trends that impact quality of care and patient safety on a continuous basis ....” Further review of Policy #PI-102 revealed no evidence of a timeframe to complete OPPE ’ s for medical staff. Ongoing Professional Practice Evaluations for the past year were requested for Employee #9, #10, and #11 since 2022. None were provided by the end of the survey. Employee #2 confirmed in an interview conducted on June 11, 2025, that there was no documented Ongoing Professional Practice Evaluations for Employee #9, #10, or #11 for the past year to provide by the end of the survey.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 45202 Based on observation on tour, facility documents and interview, the Administrator failed to ensure there is at least one registered nurse present in the unit for the designated intake area. This deficient practice can result in insufficient personnel available to deal with an emergency. Findings include: Observation on tour revealed an observation stabilization unit which requires a registered nurse is present and provides direction for behavioral health observation/stabilization services in the designated area. Review of facility schedule for April and May 2025, revealed one RN on shift for each shift for the observation stabilization area. Interview with Employee #1 on June 10, 2025, confirmed that the RN for the observation stabilization area is the RN that completes intakes. This would require the RN to leave their duties as the RN assigned to the observation stabilization area, leaving it without an RN present any time there was an admission during the months of April and May 2025.”

“UTILIZATION REVIEW COMMITTEE CFR(s): 482.30(b) A UR committee consisting of two or more practitioners must carry out the UR function. At least two of the members of the committee must be doctors of medicine or osteopathy. The other members may be any of the other types of practitioners specified in §482.12(c)(1). (1) Except as specified in paragraphs (b)(2) and (3) of this section, the UR committee must be one of the following: (i) A staff committee of the institution; (ii) A group outside the institution-- (A) Established by the local medical society and some or all of the hospitals in the locality; or (B) Established in a manner approved by CMS. (2) If, because of the small size of the institution, it is impracticable to have a properly functioning staff committee, the UR committee must be established as specified in paragraph (b)(1)(ii) of this section. (3) The committee or group’s reviews may not be conducted by any individual who-- (i) Has a direct financial interest (for example, an ownership interest) in that hospital; or (ii) Was professionally involved in the care of the patient whose case is being reviewed. This Standard is not met as evidenced by: 45202 Based on review of hospital policy, hospital documents, and staff interviews, it was determined the hospital failed to have a Utilization Review committee with two or more practitioners. This deficient practice poses a risk to the health and safety of the patients, when there are not at least two doctors on the Utilization Review Committee to evaluate a patient’s continued hospital stay and/or discharge. Findings include: Policy #QM-100, titled “Quality Management Plan 2024-2025” last reviewed 08/21/2024, revealed: “...Organization The Governing Board has ultimate authority and responsibility through the collaboration of the Chief Executive Officer, Chief Financial Officer, and Quality Management Manager for overseeing ...” Documents titled “Quality/Patient Safety (Utilization Management) Committee Meeting Minutes” for the past year were presented on June 12, 2025. Quality/Patient Safety (Utilization Management) Committee Meeting attendees for May 14, 2025, March 18, 2025, January 21, 2025, September 17, 2025, and June 12, 2025, included a list of “Attendees” which included no doctors of medicine or osteopathy. Employee #2 confirmed in an interview conducted on June 12, 2025, that there were no doctors of medicine or osteopathy present during the Quality/Patient Safety (Utilization Management) Committee Meetings for the past year.”

“SCOPE AND FREQUENCY OF REVIEW CFR(s): 482.30(c) (1) The UR plan must provide for review for Medicare and Medicaid patients with respect to the medical necessity of-- (i) Admissions to the institution; (ii) The duration of stays; and (iii) Professional services furnished including drugs and biologicals. (2) Review of admissions may be performed before, at, or after hospital admission. (3) Except as specified in paragraph (e) of this section, reviews may be conducted on a sample basis. (4) Hospitals that are paid for inpatient hospital services under the prospective payment system set forth in Part 412 of this chapter must conduct review of duration of stays and review of professional services as follows: (i) For duration of stays, these hospitals need review only cases that they reasonably assume to be outlier cases based on extended length of stay, as described in §412.80(a)(1)(i) of this chapter; and (ii) For professional services, these hospitals need review only cases that they reasonably assume to be outlier cases based on extraordinarily high costs, as described in §412.80(a)(1)(ii) of this chapter. This Standard is not met as evidenced by: 45202 Based on review of hospital policy, hospital documents, and staff interviews, it was determined the hospital failed to implement a Utilization Review process. This deficient practice poses a risk to the health and safety of the patients, when there is not a Utilization Review Committee to evaluate a patient’s continued hospital stay and/or discharge. Findings include: Policy #QM-100, titled “Quality Management Plan 2024-2025” last reviewed 08/21/2024, revealed: “...Our Performance Improvement system is an integrated process that combines the review functions associated with quality assessment. These activities are enhanced by an information system that strives to streamline and coordinate at a minimum the following functions: Utilization Management involving a process improvement indicator and payor utilization,...The priorities, scope, design, and documentation of effectiveness of the PI system are evaluated and revised at least annually, or more frequently if the need is identified. Activities include but is not limited to:...Utilization Review ...” Documents titled “Quality/Patient Safety (Utilization Management) Committee Meeting Minutes” for the past year were presented on June 12, 2025. Evidence of review of admissions and durations of stay, professional services furnished including drugs and biologicals, or of admissions may be performed before, at, or after hospital admission were requested on June 12, 2025. None were provided by the end of the survey. Employee #2 confirmed in an interview conducted on June 12, 2025, that there was no evidence of review of admissions and durations of stay, professional services furnished including drugs and biologicals, or of admissions may be performed before, at, or after hospital admission documented in the Quality/Patient Safety (Utilization Management) Committee Meeting Minutes.”

“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: 51960 Based on review of policies and procedures and staff interview, it was determined the hospital failed to: (1) Comply with EMTALA regulations by not requiring formal In-service training to all intake staff. (2) Define who a Qualified Medical Professional (QMP) is in facility Medical ByLaws and facility policy. (3) Establish policy and procedures for EMTALA requirements. These deficient practices could result in patient harm from staff not being adequately trained on emergency medical conditions and medical screening examinations, services being provided by unqualified personnel, and staff not being aware or trained on facility procedures regarding a patient having a medical emergency the hospital is not equipped to handle. Findings Include: (1) Failure to comply with EMTALA regulations by not requiring formal In-service training to all intake staff: Hospital policy titled “Employee Orientation, Staff Development and Training” policy #HR-160 last revised 10/02/2023 did not address EMTALA training specifically in section “A. Orientation of Staff” or in section “B. Staff Development and Training”. Employee #1 provided a document titled “EMTALA Staff Training” and that it was reviewed with and signed by all staff. Employee #16 ’ s personnel record revealed no facility document titled “EMTALA Staff Training”. Employee #17 ’ s personnel record revealed no facility document titled “EMTALA Staff Training”. Employee #18 ’ s personnel record revealed no facility document titled “EMTALA Staff Training”. Employee #19 ’ s personnel record revealed no facility document titled “EMTALA Staff Training”. Employee #20 ’ s personnel record revealed no facility document titled “EMTALA Staff Training”. A request was made for Employees #16, 17, 18, 19 and 20 “EMTALA Staff Training” documentation and none was provided at the time of survey. Employee #1 confirmed in an interview on June 12, 2025 that Employees #16, 17, 18, 19 and 20 did not have the “EMTALA Staff Training” present in their personnel records for review. (2) Failure to define who a Qualified Medical Professional (QMP) is in facility Medical Bylaws and facility policy: Hospital document titled “Bylaws Of The Medical Staff Of ChangePoint Psychiatric Hospital” did not define who a QMP is. A request was made for facility policy and procedure regarding QMPs. None was provided at the time of survey. Employee #2 confirmed in an interview on June 10, 2025 that a facility policy regarding QMPs was not available. (3) Failure to establish policy and procedures for EMTALA requirements. Hospital policy titled “Admission To Hospital” policy #CC-104 last reviewed 06/02/2025, revealed “...III. PROCEDURE: ...C. Emergency Medical Treatment and Labor Act (42 USC 1395dd)-EMTALA While EMTALA traditionally addresses the transfer of members for Emergency medical care between participating hospitals, there are some interpretative guidelines that also reference participating hospitals with “specialized capabilities”...To this end, ChangePoint Psychiatric Hospital considers EMTALA when the following provisions are met:...1. The member has not been admitted to the sending hospital;...2. The member is medically stable;...3. The member is psychiatrically unstable (currently defined as suicidal, homicidal, psychotic beyond baseline, or clinically indicated psychiatric care;...4. The sending hospital is unable to provide stabilizing psychiatric care ...5.The admitting Medical Officer at the Hospital agrees that the member meets Admission Criteria as established by the Program Description;...6. The Hospital has the resources and capacity to meet the needs of the member including physical environment, equipment, appropriate staff on-site or available;...7. The referring physician has documented that the medical risks of transfer are outweighed by the medical benefits of the transfer;...8. The member/guardian has agreed to the transfer after reviewing the risks and benefits of the proposed transfer and is willing to provide Informed Consent for Treatment at ChangePoint Psychiatric Hospital;....” A request was made for an EMTALA policy regarding patients experiencing a medical emergency, initial treatment within the hospital ’ s capabilities and capacity and the making of an appropriate referral to another hospital that is capable of providing necessary emergency services. None was provided at the time of survey. Employee #1 and #2 both confirmed in interviews on June 9, 2025 through June 12, 2025 that the above policy provided was the only EMTALA policy for review at the time of survey.”

“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: 51960 Based on review of policies and procedures, medical records and staff interview, it was determined the hospital failed to ensure a medical screening exam (MSE) was completed for patients coming to the facility to determine whether or not an emergency medical condition exists. This deficient practice poses a potential risk to the health and safety of patients if life-threatening conditions are not recognized in a timely manner thus possibly delaying stabilizing treatment. Findings include: Hospital policy titled “Admission Process” policy #CC-104, last revised 04/04/2022 revealed “...III. PROCEDURE:...B. Crisis Assessment ...1. The clinician/staff member assessing the member in crisis completes a crisis assessment to determine if the member meets basic requirements for admission to a Psychiatric Specialty Hospital....” A total of 20 Hospital medical records were randomly selected for review, ten (10) out of 20 patient medical records contained either incomplete or missing medical screening exams. Patient #1 ’ s medical record revealed the following: Hospital document titled “30 Minute CSU Nursing Physician Examination” dated 3/28/2025 revealed it was incomplete. The time of which the assessment was completed was missing. Patient #3 ’ s medical record revealed the following: Hospital document titled “30 Minute CSU Nursing Physician Examination” dated 5/1/2025 at 14:55 revealed it was incomplete. The vital signs section was left blank. Patient #5 ’ s medical record revealed the following: Hospital document titled “30 Minute CSU Nursing Physician Examination” dated 5/14/2025 revealed it was incomplete. The vital signs were not completely filled out and the time of which the assessment was completed was missing. Patient #13 ’ s medical record revealed the following: No hospital document titled “30 Minute CSU Nursing Physician Examination” was in Patient #13 ’ s medical record. Patient #14 ’ s medical record revealed the following: Hospital document titled “30 Minute CSU Nursing Physician Examination” dated 4/23/2025 revealed it was incomplete. The time of which the assessment was completed was missing. Patient #16 ’ s medical record revealed the following: Hospital document titled “30 Minute CSU Nursing Physician Examination” dated 5/13/2025 at 06:10 revealed it was incomplete. The vital signs section was left blank. Patient #17 ’ s medical record revealed the following: Hospital document titled “30 Minute CSU Nursing Physician Examination” dated 6/9/2025 revealed it was incomplete. The time of which the assessment was completed was missing. Patient #18 ’ s medical record revealed the following: Hospital document titled “30 Minute CSU Nursing Physician Examination” dated 5/24/2025 at 09:32 revealed it was incomplete. The vital signs were not completely filled out. Patient #19 ’ s medical record revealed the following: No hospital document titled “30 Minute CSU Nursing Physician Examination” was in Patient #19 ’ s medical record. Patient #20 ’ s medical record revealed the following: No hospital document titled “30 Minute CSU Nursing Physician Examination” was in Patient #20 ’ s medical record. Employee #2 confirmed during an interview on June 9, 2025 through June 10, 2025 that Patient #1, 3, 5, 14, 16, 17 and 18 had incomplete MSEs while Patients #13, 19 and 20 were missing an MSE all together.”

“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 policies and procedures, medical records, and staff interviews, it was determined the Hospital delayed examination and treatment for Patients #1, 5, 14 and 17 who presented to the facility seeking medical and/or psychiatric treatment. Failure to provide timely medical examination and treatment poses a potential risk that a patient is denied necessary medical treatment. Findings include: Hospital policy titled “Admission Process” policy #CC-104, last revised 04/04/2022 revealed “...III. PROCEDURE:...B. Crisis Assessment ...1. The clinician/staff member assessing the member in crisis completes a crisis assessment to determine if the member meets basic requirements for admission to a Psychiatric Specialty Hospital....” Patient #1 ’ s medical record revealed the following: Hospital document titled “30 Minute CSU Nursing Physician Examination” dated 3/28/2025 revealed the time of which the assessment was completed was missing. Hospital document titled “Referral/Intake Log” revealed Patient #1 arrived at the hospital on 3/28/2025 at 19:15. Patient #5 ’ s medical record revealed the following: Hospital document titled “30 Minute CSU Nursing Physician Examination” dated 5/14/2025 revealed the time of which the assessment was completed was missing. Hospital document titled “Referral/Intake Log” revealed Patient #5 arrived at the hospital on 5/14/2025 at 17:55. Patient #14 ’ s medical record revealed the following: Hospital document titled “30 Minute CSU Nursing Physician Examination” dated 4/23/2025 revealed the time of which the assessment was completed was missing. Hospital document titled “Referral/Intake Log” revealed Patient #14 arrived at the hospital on 4/23/2025 at 19:00. Patient #17 ’ s medical record revealed the following: Hospital document titled “30 Minute CSU Nursing Physician Examination” dated 6/9/2025 revealed the time of which the assessment was completed was missing. Hospital document titled “Referral/Intake Log” revealed Patient #17 arrived at the hospital on 6/09/2025 at 11:10. Employee #1 confirmed during an interview on June 9, 2025 that hospital document titled “30 Minute CSU Nursing Physician Examination” is the hospital ’ s medical screening exam that is completed, dated, timed and signed within 30 minutes of patient arrival to the hospital by a registered nurse.”

“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: 51960 Based on policies and procedures, medical records and staff interview, it was determined the hospital failed to ensure patient transfers occurred pursuant to hospital policy. This deficient practice poses the potential risk that patients will receive inappropriate transfers and health needs will not be met as a result. Findings include: Hospital policy titled “Discharge/Refer/Transfer” policy #CC-117, last reviewed 10/07/2024 revealed “...e. Prior to transport medical staff (RN or Medical Officer) explains risk and benefit of a transport to the member or their representative based on their medical condition and chosen mode of transport ...g) Documentation in the member ’ s record includes:...i) Consent for transfer by member or their representative, except in emergency ...ii) Acceptance of member by, and communication with, an individual at the receiving health care institution ...iii) Date and time of transfer to the receiving health care institution ...iv) Mode of transportation ...v) Type of professional assisting in the transfer if an order requires that a member be assisted during transfer ....” A total of 20 Hospital medical records were randomly selected for review including patients who were transferred to another facility due to hospital lack of capability to treat a patient’s emergency medical condition. Four (4) of four (4) transfers reviewed contained incomplete transfer documentation. Review of Patient #2 ’ s medical record revealed incomplete transfer documentation. Provider transferred Patient #2 to Summit Healthcare Emergency Room via EMS on May 8, 2025 at 16:30pm due to “severe hypoxemia”. Patient consented to transfer. Documentation of communication with an individual at the receiving hospital was missing. Review of Patient #7 ’ s medical record revealed incomplete transfer documentation. Provider transferred Patient #7 to Summit Healthcare Emergency Room via EMS on April 13, 2025 at 13:48pm due to “alcohol withdrawal and intoxication”. Patient consented to transfer. Documentation of communication with an individual at the receiving hospital was missing. Review of Patient #8 ’ s medical record revealed incomplete transfer documentation. Provider transferred Patient #8 to Summit Healthcare Emergency Room on May 19, 2025 for “medical clearance for her and baby”. Documentation was missing time of transfer, mode of transfer, if the patient consented to transfer and communication with an individual at the receiving hospital. Review of Patient #11 ’ s medical record revealed incomplete transfer documentation. Provider transferred Patient #11 to Summit Healthcare Emergency Room via non-emergency EMS on May 31, 2025 at 14:30pm for medical clearance due to “acute alcohol intoxication”. Patient consented to transfer. Documentation of communication with an individual at the receiving hospital was missing. Employee #2 confirmed during an interview on June 9, 2025 through June 10, 2025 that all transfer documentation was incomplete for Patients #2, 7, 8 and 11.”