Northern Light Sebasticook Valley Hospital

“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: 09447 Based on document reviews and interviews, the hospital failed to follow their policy and provide a medical screening examination with the capability of the hospital’s Emergency Department for a patient who was seeking care on 5/16/2025. (Patient #1) Findings: The NL Sebasticook Valley Hospital policy titled, ‘Emergency Treatment and Transfer Rules Policy’, last revised 4/1/2024, stated in part...”POLICY AND PROCEDURE I. HOSPITAL DUTY WITH RESPECT TO EMERGENCY MEDICAL CONDITION If an individual Comes to the Emergency Department, then the hospital must provide a Medical Screening Examination...” On 05/16/2025, Northern Light Sebasticook Valley Hospital self-reported a possible EMTALA violation stating,in part, “[Patient #1] brought to NL Sebasticook Valley Hospital (“SVH”) Emergency Department by SVH ambulance and Pittsfield police department for psychiatric evaluation. Individual was transported in handcuffs via ambulance. Upon entry to the hospital, Emergency Medical Services (“EMS”) and police explained to Emergency Department RN that the individual needed to be in handcuffs and supervised one-to-one. RN informed EMS and police that there was not sufficient staff to care for this individual, no beds available, and that the emergency department was unable to provide the requested one-to-one supervision services.” On 6/3/2025 at 6:30 AM a telephone interview was conducted with RN #1, ED Staff Nurse, regarding her involvement in the alleged EMTALA issue. She was asked if she worked 5/16/2025 when a policeman came into the ED and talked wither about a patient that was arriving. She stated yes. She explained that the ED was extremely busy that night, that there were 4 psych patients and patients being housed in the ASU area. She stated that the policeman told her a very disruptive patient was arriving and would need 1;1 and be restrained in a bed. She stated that she was overwhelmed and was not really thinking when she told the policeman that the ED did not have the capacity to take that patient.” Northern Light Sebasticook Valley Hospital identified the potential violation, self-reported the event, and put in measures to ensure that the Emergency Department staff would not deter a patient in the future from seeking care. These measures included a review of facility Emergency Medical Treatment and Active Labor Act (“EMTALA”) policies, online EMTALA training for staff, and in-person EMTALA reviews with Emergency Department staff. At the time of the on-site survey, surveyors determined, through observation, document reviews, and interviews, that Northern Light Sebasticook Valley Hospital was in compliance, but previously out of compliance with 42 CFR, Part 489, Responsibilities of Medicare Participating Hospitals in Emergency Cases. On 6/2/2025 at 1:00 PM, the VP of Nursing was interviewed. She stated in part...”all ED staff have a mandatory reeducation of EMTALA via HealthStream that needs to be completed by 6/14/2025. She stated the providers are included even though no provider was aware of the situation. She stated that the EMS crew will complete the EMTALA training as well. She stated that she has met with the new police chief in town and she is planning an Inservice for the entire police force in June...she said as soon as she knew the situation she called the ED and spoke to the[RN #1]. She said the nurse was very upset and didn’t realize that once the patient arrived they needed a medical screening exam. She was confused by the police being involved. She said that she counseled her on the phone.””

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 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: 09447 Based on review of documentation and interviews, the facility failed to provide an appropriate medical screening examination at the facility’s Emergency Department (“ED”) on 05/16/2025. (Patient #1) Findings: The Northern Light Sebasticook Valley Hospital policy titled, ‘Emergency Treatment and Transfer Rules Policy’, last revised 4/1/2024, stated in part...”POLICY AND PROCEDURE I. HOSPITAL DUTY WITH RESPECT TO EMERGENCY MEDICAL CONDITION If an individual Comes to the Emergency Department, then the hospital must provide a Medical Screening Examination...” On 05/16/2025, Northern Light Sebasticook Valley Hospital self-reported a possible EMTALA violation stating,in part, ...”[Patient #1] brought to NL Sebasticook Valley Hospital (“SVH”) Emergency Department by SVH ambulance and Pittsfield police department for psychiatric evaluation. Individual was transported in handcuffs via ambulance. Upon entry to the hospital, Emergency Medical Services (“EMS”) and police explained to Emergency Department RN that the individual needed to be in handcuffs and supervised one-to-one. RN informed EMS and police that there was not sufficient staff to care for this individual, no beds available, and that the Emergency Department was unable to provide the requested one-to-one supervision services.” On 6/3/2025 at 6:30 AM a telephone interview was conducted with RN #1, ED Staff Nurse, regarding her involvement in the alleged EMTALA issue. She was asked if she worked 5/16/2025 when a policeman came into the ED and talked wither about a patient that was arriving. She stated yes. She explained that the ED was extremely busy that night, that there were 4 psych patients and patients being housed in the ASU area. She stated that the policeman told her a very disruptive patient was arriving and would need 1;1 and be restrained in a bed. She stated that she was overwhelmed and was not really thinking when she told the policeman that the ED did not have the capacity to take that patient.” Northern Light Sebasticook Valley Hospital identified the potential violation, self-reported the event, and put in measures to ensure that the Emergency Department staff would not deter a patient in the future from seeking care. These measures included a review of facility Emergency Medical Treatment and Active Labor Act (“EMTALA”) policies, online EMTALA training for staff, and in-person EMTALA reviews with Emergency Department staff. At the time of the on-site survey, surveyors determined, through observation, document reviews, and interviews, that Northern Light Sebasticook Valley Hospital was in compliance, but previously out of compliance with 42 CFR, Part 489, Responsibilities of Medicare Participating Hospitals in Emergency Cases. On 6/2/2025 at 1:00 PM, the VP of Nursing was interviewed. She stated in part...” all ED staff have a mandatory reeducation of EMTALA via HealthStream that needs to be completed by 6/14/2025. She stated the providers are included even though no provider was aware of the situation. She stated that the EMS crew will complete the EMTALA training as well. She stated that she has met with the new police chief in town and she is planning an Inservice for the entire police force in June...she said as soon as she knew the situation she called the ED and spoke to the[RN #1]. She said the nurse was very upset and didn’t realize that once the patient arrived they needed a medical screening exam. She was confused by the police being involved. She said that she counseled her on the phone.””

“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: 09447 Based on review of documentation and interviews, the facility failed to provide an appropriate transfer at the facility’s Emergency Department (“ED”) on 05/16/2025. (Patient #1) Findings: The NL Sebasticook Valley Hospital policy titled, ‘Emergency Treatment and Transfer Rules Policy’, last revised 4/1/2024, stated in part...”POLICY AND PROCEDURE... Before transfer, the ED (or Labor & Delivery Department) must, except as noted below, provide either: 1. Treatment within the abilities of the staff and facilities available at the hospital to Stabilize the medical condition and documentation thereof on the Interhospital Transfer Form; or 2. Transfer to another medical facility in accordance with specified rules. An individual who has been Stabilized may be transferred as provided by departmental policy. An individual who has not been Stabilized may be transferred only if one of the following three (3) requirements is met and documented on the Interhospital Transfer Form at the time of transfer: (a) The individual or a legally responsible person acting on the individual’s behalf, after being informed of the hospital’s obligations under this section to Stabilize the individual and also after being informed of the risks and benefits of transfer, versus admission to the hospital, requests, in writing, the transfer to another medical facility...” On 05/16/2025, Northern Light Sebasticook Valley Hospital self-reported a possible EMTALA violation stating,in part, “Patient #1 brought to NL Sebasticook Valley Hospital (“SVH”) Emergency Department by SVH ambulance and Pittsfield police department for psychiatric evaluation. Individual was transported in handcuffs via ambulance. Upon entry to the hospital, Emergency Medical Services (“EMS”) and police explained to Emergency Department RN that the individual needed to be in handcuffs and supervised one-to-one. RN informed EMS and police that there was not sufficient staff to care for this individual, no beds available, and that the emergency department was unable to provide the requested one-to-one supervision services.” On 6/3/2025 at 6:30 AM a telephone interview was conducted with RN #1, ED Staff Nurse, regarding her involvement in the alleged EMTALA issue. She was asked if she worked 5/16/2025 when a policeman came into the ED and talked wither about a patient that was arriving. She stated yes. She explained that the ED was extremely busy that night, that there were 4 psych patients and patients being housed in the ASU area. She stated that the policeman told her a very disruptive patient was arriving and would need 1;1 and be restrained in a bed. She stated that she was overwhelmed and was not really thinking when she told the policeman that the ED did not have the capacity to take that patient.” Northern Light Sebasticook Valley Hospital identified the potential violation, self-reported the event, and put in measures to ensure that the Emergency Department staff would not deter a patient in the future from seeking care. These measures included a review of facility Emergency Medical Treatment and Active Labor Act (“EMTALA”) policies, online EMTALA training for staff, and in-person EMTALA reviews with Emergency Department staff. At the time of the on-site survey, surveyors determined, through observation, document reviews, and interviews, that Northern Light Sebasticook Valley Hospital was in compliance, but previously out of compliance with 42 CFR, Part 489, Responsibilities of Medicare Participating Hospitals in Emergency Cases. On 6/2/2025 at 1:00 PM, the VP of Nursing was interviewed. She stated in part...” all ED staff have a mandatory reeducation of EMTALA via HealthStream that needs to be completed by 6/14/2025. She stated the providers are included even though no provider was aware of the situation. She stated that the EMS crew will complete the EMTALA training as well. She stated that she has met with the new police chief in town and she is planning an Inservice for the entire police force in June...she said as soon as she knew the situation she called the ED and spoke to the[RN #1]. She said the nurse was very upset and didn’t realize that once the patient arrived they needed a medical screening exam. She was confused by the police being involved. She said that she counseled her on the phone.””