| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 010006 | (X3) Date Survey Completed 02/07/2025 |
| Name of Provider or Supplier North Alabama Medical Center | Street Address, City, State 1701 Veterans Drive, Florence, AL | |
| For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. | ||
| (X4) ID Prefix Tag | Summary Statement of Deficiencies
(Each deficiency should be preceded by full regulatory or LSC identifying information) |
| A0000 | An unannounced federal Emergency Medical Treatment and Labor Act (EMTALA) complaint survey, AL00050005, was conducted at North Alabama Medical Center on 2/4/25 to 2/7/25, specifically for the review of EMTALA requirements. The hospital was found to be not in compliance with the Federal Regulations at 42 CFR 489.20 and 489.24, Responsibilities of Medicare Participating Hospitals in Emergency Cases. The following is a description of the non-compliance. Please refer to findings at A 2400 and A 2406 . |
| A2400 | 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: Based on review of Medical Staff Bylaws and Rules and Regulations, hospital policy, and interview, it was determined North Alabama Medical Center failed to identify and approve individual(s) qualified to perform the medical screening examination (MSE) in the hospital medical staff bylaws or rules and regulations. This had the potential to affect all patients presenting to the emergency department (ED). Refer to A2406 for findings. |
| A2406 | 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: Based on review of the hospital's Rules and Regulations of the Medical Staff, Medical Staff Bylaws, hospital policy and interview, it was determined the hospital failed to identify the Qualified Medical Personnel (QMP) determined qualified to provide an appropriate Medical Screening Exam (MSE) in their Rules and Regulations of the Medical Staff and/or Medical Staff Bylaws. Findings include: Hospital Policy: EMTALA (Emergency Medical Treatment and Labor Act) - Medical Screening and Treatment of Emergency Medical Conditions (EMC) Policy Number: 14184194 Last Revised : 08/2023 Purpose: To ensure that individuals...receive an appropriate MSE as required by...EMTALA. Definitions: ...R. QMP means an individual other than a licensed physician who has demonstrated current competence in the performance of MSE's and been approved by the main hospital provider's governing board...The categories of non-physician practitioners who may be designated as QMP's is set forth in Medical Staff Bylaws or Rules and Regulations... 1. A review of the hospital's Rules and Regulations of the Medical Staff, and Medical Staff Bylaws conducted on 2/5/25 revealed there was no definition of the QMP approved to perform the MSE and determine whether or not an EMC existed for patients who presented to the Emergency Department (ED). An interview was conducted on 2/5/25 at 3:15 PM with Employee Identifier # 1, ED Director, who confirmed the QMP approved to perform the MSE's in the ED were not defined in the hospital's Rules and Regulations of the Medical Staff nor the Medical Staff Bylaws. |