New requirement for psych admission: Lipid Panel

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@southerndoc while EMTALA applies to psychiatric hospitals and preempts state law, it's application is not simple since commitment involves curtailment of liberty and attendant constitutional protections. Do you have citations for EMTALA applying in cases involuntary treatment and transfer? Specifically, court findings that "refuses to consent" to treatment or transfer does not include when such refusal is product of mental illness or incapacitated?
There are no court findings. I'm guessing you are a psychiatrist. EMTALA violations are almost always settled with CMS/OIG/DOJ and rarely enter into the courts. Most health systems do not want to lose participation in Medicare while it makes its way through the courts.

I am unclear what you are asking. Most mental health-related EMTALA violations are due to involuntary treatment or inadequate stabilization/screening examinations. Here are some psychiatric cases from a database I keep. There have been more recent cases, but I have not transferred them over. I can look them up this weekend. Will try to more appropriately answer your question when I fully understand what you are asking. Sorry, still having some brain fog.

05-06-2019
Florida Hospital Settles Case Involving Patient Dumping Allegation


On May 6, 2019, Park Royal Hospital (Park Royal), Fort Meyers, Florida, entered into a $52,414 settlement agreement with OIG. The settlement agreement resolves allegations that, based on OIG's investigation, Park Royal violated the Emergency Medical Treatment and Labor Act (EMTALA) when it failed to accept a transfer of a patient with an unstablilized emergency medical condition, from the emergency department of another hospital. The patient presented to that hospital's emergency department following a suicide attempt and was diagnosed with lacerations to the wrist and an emergency psychiatric condition. Park Royal is a hospital with specialized psychiatric capabilities. OIG alleged that Park Royal refused to accept a transfer of the patient, despite having the specialized capabilities to stabilize the patient and the capacity at the time of transfer, because the patient's insurance was out of network. Senior Counsel Geeta Taylor represented OIG.

10-17-2017
Missouri Hospital Settles Case Involving Patient Dumping Allegations


On October 17, 2017, Southeast Missouri Hospital (SEM), Cape Girardeau, Missouri, entered into a $100,000 settlement agreement with OIG. The settlement agreement resolves allegations that SEM violated the Emergency Medical Treatment and Labor Act when it failed to provide an adequate medical screening examination and stabilizing treatment for two patients who presented to SEM's Emergency Department (ED) in 2011. OIG alleged that instead of being properly evaluated and treated, the patients were discharged with unstabilized emergency medical conditions to the custody of police pursuant to a hospital policy: if a patient had a blood alcohol level (BAL) above 100, the patient was given to local law enforcement and taken to jail. The first patient was 25 years old when she called a crisis hotline and an ambulance was dispatched to her residence. She was transported to SEM's ED for evaluation of a possible suicide attempt by overdose. The patient's BAL was 422 and the ED physician discharged her into the custody of local law enforcement where she was detained in jail and expected to see a counselor. The second patient was 41 years old when he presented to SEM after attempting suicide by overdose. The patient was depressed, had a history of psychiatric problems, and had recently been admitted for electroconvulsive therapy. The patient's BAL was 288 and he was discharged into the custody of local law enforcement and taken to jail. The next day the patient was seen by a counselor in jail and then released from custody. The patient returned to SEM that evening after again attempting suicide by overdose. The patient had slurred speech, was lethargic and had a flat affect and was admitted to the intensive care unit in guarded condition. Senior Counsel Sandra Sands represented OIG.

06-23-2017
South Carolina Hospital Settles Case Involving Patient Dumping Allegations


On June 23, 2017, AnMed Health (AnMed), in Anderson, South Carolina, entered into a $1,295,000 settlement agreement with OIG. The settlement agreement resolves allegations that, in 36 incidents investigated by OIG, AnMed violated the Emergency Medical Treatment and Labor Act (EMTALA). In these incidents, individuals presented to AnMed's Emergency Department (ED) with unstable psychiatric emergency medical conditions. Instead of being examined and treated by an on-call psychiatrist, and despite empty beds in its psychiatric unit to which the patients could have been admitted for stabilizing treatment, the patients were involuntarily committed and kept in AnMed's ED for between 6 and 38 days each. The following is an example of one such incident. A patient presented to AnMed's ED via law enforcement with psychosis and homicidal ideation and was involuntarily committed. The patient did not receive psychiatric examination or treatment by available AnMed psychiatrists and was not admitted to the psychiatric unit for stabilizing treatment. Instead, the patient was kept in the ED for 38 days and at one point was seen by a psychiatrist from another facility that was familiar with her condition. The psychiatrist prescribed a variety of medications for agitation. The patient eventually was discharged home. Senior Counsel Sandra Sands represented OIG.

11-28-2016
Missouri Hospital Settles Case Involving Patient Dumping Allegations


On November 28, 2016, Research Medical Center (RMC) in Kansas City, Missouri, entered into a $360,000 settlement agreement with OIG. The settlement agreement resolves allegations that RMC violated the Emergency Medical Treatment and Labor Act (EMTALA) when it failed to provide an adequate medical screening examination and improperly transferred a patient. The patient presented to RMC's Emergency Department (ED) with a psychiatric emergency medical condition. Without providing stabilizing treatment, RMC transferred the patient to a nearby facility by private vehicle; en route, the patient exited the vehicle and was struck by another vehicle. RMC self-disclosed the incident involving this patient. Based on its investigation, OIG concluded that RMC implemented a transfer policy applicable to patients who presented to RMC's ED with psychiatric emergency medical conditions that also resulted in multiple violations of EMTALA. Specifically, OIG found seventeen occasions where RMC failed to provide adequate medical screening examinations and improperly transferred or discharged, without providing stabilizing treatment, patients who presented to RMC's ED with psychiatric emergency medical conditions. At the time each patient presented, RMC had the capacity to treat, stabilize, or admit each patient. Senior Counsel Geeta Taylor represented OIG.

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There are no court findings. I'm guessing you are a psychiatrist. EMTALA violations are almost always settled with CMS/OIG/DOJ and rarely enter into the courts. Most health systems do not want to lose participation in Medicare while it makes its way through the courts.

I am unclear what you are asking. Most mental health-related EMTALA violations are due to involuntary treatment or inadequate stabilization/screening examinations. Here are some psychiatric cases from a database I keep. There have been more recent cases, but I have not transferred them over. I can look them up this weekend. Will try to more appropriately answer your question when I fully understand what you are asking. Sorry, still having some brain fog.

05-06-2019
Florida Hospital Settles Case Involving Patient Dumping Allegation


On May 6, 2019, Park Royal Hospital (Park Royal), Fort Meyers, Florida, entered into a $52,414 settlement agreement with OIG. The settlement agreement resolves allegations that, based on OIG's investigation, Park Royal violated the Emergency Medical Treatment and Labor Act (EMTALA) when it failed to accept a transfer of a patient with an unstablilized emergency medical condition, from the emergency department of another hospital. The patient presented to that hospital's emergency department following a suicide attempt and was diagnosed with lacerations to the wrist and an emergency psychiatric condition. Park Royal is a hospital with specialized psychiatric capabilities. OIG alleged that Park Royal refused to accept a transfer of the patient, despite having the specialized capabilities to stabilize the patient and the capacity at the time of transfer, because the patient's insurance was out of network. Senior Counsel Geeta Taylor represented OIG.

10-17-2017
Missouri Hospital Settles Case Involving Patient Dumping Allegations


On October 17, 2017, Southeast Missouri Hospital (SEM), Cape Girardeau, Missouri, entered into a $100,000 settlement agreement with OIG. The settlement agreement resolves allegations that SEM violated the Emergency Medical Treatment and Labor Act when it failed to provide an adequate medical screening examination and stabilizing treatment for two patients who presented to SEM's Emergency Department (ED) in 2011. OIG alleged that instead of being properly evaluated and treated, the patients were discharged with unstabilized emergency medical conditions to the custody of police pursuant to a hospital policy: if a patient had a blood alcohol level (BAL) above 100, the patient was given to local law enforcement and taken to jail. The first patient was 25 years old when she called a crisis hotline and an ambulance was dispatched to her residence. She was transported to SEM's ED for evaluation of a possible suicide attempt by overdose. The patient's BAL was 422 and the ED physician discharged her into the custody of local law enforcement where she was detained in jail and expected to see a counselor. The second patient was 41 years old when he presented to SEM after attempting suicide by overdose. The patient was depressed, had a history of psychiatric problems, and had recently been admitted for electroconvulsive therapy. The patient's BAL was 288 and he was discharged into the custody of local law enforcement and taken to jail. The next day the patient was seen by a counselor in jail and then released from custody. The patient returned to SEM that evening after again attempting suicide by overdose. The patient had slurred speech, was lethargic and had a flat affect and was admitted to the intensive care unit in guarded condition. Senior Counsel Sandra Sands represented OIG.

06-23-2017
South Carolina Hospital Settles Case Involving Patient Dumping Allegations


On June 23, 2017, AnMed Health (AnMed), in Anderson, South Carolina, entered into a $1,295,000 settlement agreement with OIG. The settlement agreement resolves allegations that, in 36 incidents investigated by OIG, AnMed violated the Emergency Medical Treatment and Labor Act (EMTALA). In these incidents, individuals presented to AnMed's Emergency Department (ED) with unstable psychiatric emergency medical conditions. Instead of being examined and treated by an on-call psychiatrist, and despite empty beds in its psychiatric unit to which the patients could have been admitted for stabilizing treatment, the patients were involuntarily committed and kept in AnMed's ED for between 6 and 38 days each. The following is an example of one such incident. A patient presented to AnMed's ED via law enforcement with psychosis and homicidal ideation and was involuntarily committed. The patient did not receive psychiatric examination or treatment by available AnMed psychiatrists and was not admitted to the psychiatric unit for stabilizing treatment. Instead, the patient was kept in the ED for 38 days and at one point was seen by a psychiatrist from another facility that was familiar with her condition. The psychiatrist prescribed a variety of medications for agitation. The patient eventually was discharged home. Senior Counsel Sandra Sands represented OIG.

11-28-2016
Missouri Hospital Settles Case Involving Patient Dumping Allegations


On November 28, 2016, Research Medical Center (RMC) in Kansas City, Missouri, entered into a $360,000 settlement agreement with OIG. The settlement agreement resolves allegations that RMC violated the Emergency Medical Treatment and Labor Act (EMTALA) when it failed to provide an adequate medical screening examination and improperly transferred a patient. The patient presented to RMC's Emergency Department (ED) with a psychiatric emergency medical condition. Without providing stabilizing treatment, RMC transferred the patient to a nearby facility by private vehicle; en route, the patient exited the vehicle and was struck by another vehicle. RMC self-disclosed the incident involving this patient. Based on its investigation, OIG concluded that RMC implemented a transfer policy applicable to patients who presented to RMC's ED with psychiatric emergency medical conditions that also resulted in multiple violations of EMTALA. Specifically, OIG found seventeen occasions where RMC failed to provide adequate medical screening examinations and improperly transferred or discharged, without providing stabilizing treatment, patients who presented to RMC's ED with psychiatric emergency medical conditions. At the time each patient presented, RMC had the capacity to treat, stabilize, or admit each patient. Senior Counsel Geeta Taylor represented OIG.
I did residency at AnMed. That was absolutely going on when I was there around 2012.
 
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Emtala keeps the stabilizing treatment very vague. Someone has a blood alcohol level in the 200s they could be a chronic alcoholic.
 
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Ridiculous anecdote from the other night. As I'm coming in for the night, EMS is packaging a patient up for transfer to a psych facility. Boomer dingbat with a personality disorder and Rx opiate abuse threatening conditional suicide. For some reason she had come in after an outpatient BH eval on an involuntary hold. She'd agreed to voluntary admission (all patients in this state are given the option for voluntary status prior to invoking involuntary holding) so she's transferred 90 miles away to a psych facility in another county.

3 hours later we get a call from the EMTs that they're bringing her back b/c the facility is now refusing her. WTF? Evidently, the facility is 'voluntary only' and the patient refused to check herself in after they told her they wouldn't give her pain meds not currently on her med list.
 
There are no court findings. I'm guessing you are a psychiatrist. EMTALA violations are almost always settled with CMS/OIG/DOJ and rarely enter into the courts. Most health systems do not want to lose participation in Medicare while it makes its way through the courts.

I am unclear what you are asking. Most mental health-related EMTALA violations are due to involuntary treatment or inadequate stabilization/screening examinations. Here are some psychiatric cases from a database I keep. There have been more recent cases, but I have not transferred them over. I can look them up this weekend. Will try to more appropriately answer your question when I fully understand what you are asking. Sorry, still having some brain fog.

05-06-2019
Florida Hospital Settles Case Involving Patient Dumping Allegation


On May 6, 2019, Park Royal Hospital (Park Royal), Fort Meyers, Florida, entered into a $52,414 settlement agreement with OIG. The settlement agreement resolves allegations that, based on OIG's investigation, Park Royal violated the Emergency Medical Treatment and Labor Act (EMTALA) when it failed to accept a transfer of a patient with an unstablilized emergency medical condition, from the emergency department of another hospital. The patient presented to that hospital's emergency department following a suicide attempt and was diagnosed with lacerations to the wrist and an emergency psychiatric condition. Park Royal is a hospital with specialized psychiatric capabilities. OIG alleged that Park Royal refused to accept a transfer of the patient, despite having the specialized capabilities to stabilize the patient and the capacity at the time of transfer, because the patient's insurance was out of network. Senior Counsel Geeta Taylor represented OIG.

10-17-2017
Missouri Hospital Settles Case Involving Patient Dumping Allegations


On October 17, 2017, Southeast Missouri Hospital (SEM), Cape Girardeau, Missouri, entered into a $100,000 settlement agreement with OIG. The settlement agreement resolves allegations that SEM violated the Emergency Medical Treatment and Labor Act when it failed to provide an adequate medical screening examination and stabilizing treatment for two patients who presented to SEM's Emergency Department (ED) in 2011. OIG alleged that instead of being properly evaluated and treated, the patients were discharged with unstabilized emergency medical conditions to the custody of police pursuant to a hospital policy: if a patient had a blood alcohol level (BAL) above 100, the patient was given to local law enforcement and taken to jail. The first patient was 25 years old when she called a crisis hotline and an ambulance was dispatched to her residence. She was transported to SEM's ED for evaluation of a possible suicide attempt by overdose. The patient's BAL was 422 and the ED physician discharged her into the custody of local law enforcement where she was detained in jail and expected to see a counselor. The second patient was 41 years old when he presented to SEM after attempting suicide by overdose. The patient was depressed, had a history of psychiatric problems, and had recently been admitted for electroconvulsive therapy. The patient's BAL was 288 and he was discharged into the custody of local law enforcement and taken to jail. The next day the patient was seen by a counselor in jail and then released from custody. The patient returned to SEM that evening after again attempting suicide by overdose. The patient had slurred speech, was lethargic and had a flat affect and was admitted to the intensive care unit in guarded condition. Senior Counsel Sandra Sands represented OIG.

06-23-2017
South Carolina Hospital Settles Case Involving Patient Dumping Allegations


On June 23, 2017, AnMed Health (AnMed), in Anderson, South Carolina, entered into a $1,295,000 settlement agreement with OIG. The settlement agreement resolves allegations that, in 36 incidents investigated by OIG, AnMed violated the Emergency Medical Treatment and Labor Act (EMTALA). In these incidents, individuals presented to AnMed's Emergency Department (ED) with unstable psychiatric emergency medical conditions. Instead of being examined and treated by an on-call psychiatrist, and despite empty beds in its psychiatric unit to which the patients could have been admitted for stabilizing treatment, the patients were involuntarily committed and kept in AnMed's ED for between 6 and 38 days each. The following is an example of one such incident. A patient presented to AnMed's ED via law enforcement with psychosis and homicidal ideation and was involuntarily committed. The patient did not receive psychiatric examination or treatment by available AnMed psychiatrists and was not admitted to the psychiatric unit for stabilizing treatment. Instead, the patient was kept in the ED for 38 days and at one point was seen by a psychiatrist from another facility that was familiar with her condition. The psychiatrist prescribed a variety of medications for agitation. The patient eventually was discharged home. Senior Counsel Sandra Sands represented OIG.

11-28-2016
Missouri Hospital Settles Case Involving Patient Dumping Allegations


On November 28, 2016, Research Medical Center (RMC) in Kansas City, Missouri, entered into a $360,000 settlement agreement with OIG. The settlement agreement resolves allegations that RMC violated the Emergency Medical Treatment and Labor Act (EMTALA) when it failed to provide an adequate medical screening examination and improperly transferred a patient. The patient presented to RMC's Emergency Department (ED) with a psychiatric emergency medical condition. Without providing stabilizing treatment, RMC transferred the patient to a nearby facility by private vehicle; en route, the patient exited the vehicle and was struck by another vehicle. RMC self-disclosed the incident involving this patient. Based on its investigation, OIG concluded that RMC implemented a transfer policy applicable to patients who presented to RMC's ED with psychiatric emergency medical conditions that also resulted in multiple violations of EMTALA. Specifically, OIG found seventeen occasions where RMC failed to provide adequate medical screening examinations and improperly transferred or discharged, without providing stabilizing treatment, patients who presented to RMC's ED with psychiatric emergency medical conditions. At the time each patient presented, RMC had the capacity to treat, stabilize, or admit each patient. Senior Counsel Geeta Taylor represented OIG.

Thank you, sorry for not being clear in my original post.

Involuntary retention, particularly psychiatric civil commitment, involves constitutional liberty interests and due process protections. As such, only "explicit statute" (i.e. statute and court decisions/interpretations) are relevant when determining if involved curtailments of liberty are legally privileged. While CMS might be able to broadly apply EMTALA based on its own interpretation generally, its interpretations have no legal weight when it comes to liberty and due process matters. Also, although EMTALA preempts state law, not abiding by the due process for involuntary retention described in state law would violate the patient's liberty, so state law would effectively be overriding (else EMTALA would violate the Constitution).

Settlements aren't findings of law, and actually may contradict it. For example, in the Missouri case, given the choice between retaining intoxicated patients in the hospital vs remanding them to police custody, the hospital might be obligated to do that latter (assuming police were legally allowed to retain such patients in jail) because it would be a lesser curtailment of liberty, as jail is a less restrictive setting than a hospital (in this legal context).

There are many reasons to state that EMTALA does not and cannot privilege involuntary retention or transfer, such as:
- EMTALA is an action of the Federal Government representing its interests, while psychiatric commitment and treatment over objection are based on state interests, specifically the state's parens patriae interests (or police powers). As such the federal government would not have sufficiently compelling interest to allow it to curtail the patient's liberty.
- EMTALA is clearly intended to impose duties on the hospital, not to restrict patients. There is no reasonable basis to state the Congress intended for EMTALA to serve as a federal civil commitment statute.
- There are no due process provisions within EMTALA, so restrictions of liberty under it would be unconstitutional.
- If EMTALA privileged retention, transfer and treatment over objection, it would grant these powers to physicians arbitrarily based on whether they signed a contract with Medicare, which is not reasonable basis.
-- Further, it is not actually granting these powers to physicians but to the hospital itself, and psychiatric restriction of liberty always relies on a clinicians judgment and evaluation, never on an organizations.

It's also fairly easy for a transfer request to meet requirements under EMTALA but to be impermissible under state law in a way that implicates liberty interests, even if the patient is voluntary, since even voluntary patients on psychiatric units may be potentially subject to restraint in ways that other patients would not be. EMTALA only requires the allegation that patient has an emergency medical condition and requires specialized treatment to create obligation for on the receiving facility to accept, but state law has additional criteria that may be required to accept the patient, even if the patient is requesting admission.
 
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Ridiculous anecdote from the other night. As I'm coming in for the night, EMS is packaging a patient up for transfer to a psych facility. Boomer dingbat with a personality disorder and Rx opiate abuse threatening conditional suicide. For some reason she had come in after an outpatient BH eval on an involuntary hold. She'd agreed to voluntary admission (all patients in this state are given the option for voluntary status prior to invoking involuntary holding) so she's transferred 90 miles away to a psych facility in another county.

3 hours later we get a call from the EMTs that they're bringing her back b/c the facility is now refusing her. WTF? Evidently, the facility is 'voluntary only' and the patient refused to check herself in after they told her they wouldn't give her pain meds not currently on her med list.

Interesting case that would get into the nitty-gritty of state laws. In my state, the facility would probably have to accept her as voluntary, then treat her as any other voluntary patient and be obliged to either release her (to freedom, not back to ED) or retain her. In my state, while you can finagle being a 'voluntary only' hospital, even such hospitals would still have both (and only) those two options. It would get complicated, but they would never (legally) have the option to simply send her back to your ED on a hold.
 
Also, although EMTALA preempts state law, not abiding by the due process for involuntary retention described in state law would violate the patient's liberty, so state law would effectively be overriding (else EMTALA would violate the Constitution).
EMTALA does violate the Constitution. It forces emergency workers to treat individuals without remuneration. Some politicians have called it forced labor, which is a violation of the Constitution.
Settlements aren't findings of law, and actually may contradict it. For example, in the Missouri case, given the choice between retaining intoxicated patients in the hospital vs remanding them to police custody, the hospital might be obligated to do that latter (assuming police were legally allowed to retain such patients in jail) because it would be a lesser curtailment of liberty, as jail is a less restrictive setting than a hospital (in this legal context).

There are many reasons to state that EMTALA does not and cannot privilege involuntary retention or transfer, such as:
- EMTALA is an action of the Federal Government representing its interests, while psychiatric commitment and treatment over objection are based on state interests, specifically the state's parens patriae interests (or police powers). As such the federal government would not have sufficiently compelling interest to allow it to curtail the patient's liberty.
- EMTALA is clearly intended to impose duties on the hospital, not to restrict patients. There is no reasonable basis to state the Congress intended for EMTALA to serve as a federal civil commitment statute.
- There are no due process provisions within EMTALA, so restrictions of liberty under it would be unconstitutional.
- If EMTALA privileged retention, transfer and treatment over objection, it would grant these powers to physicians arbitrarily based on whether they signed a contract with Medicare, which is not reasonable basis.
-- Further, it is not actually granting these powers to physicians but to the hospital itself, and psychiatric restriction of liberty always relies on a clinicians judgment and evaluation, never on an organizations.

It's also fairly easy for a transfer request to meet requirements under EMTALA but to be impermissible under state law in a way that implicates liberty interests, even if the patient is voluntary, since even voluntary patients on psychiatric units may be potentially subject to restraint in ways that other patients would not be. EMTALA only requires the allegation that patient has an emergency medical condition and requires specialized treatment to create obligation for on the receiving facility to accept, but state law has additional criteria that may be required to accept the patient, even if the patient is requesting admission.
You're going about this the wrong way. You're trying to justify EMTALA and how it fits with law. The reality is EMTALA is its own beast, it doesn't really follow the law, it imposes fines based on cursory investigations, and often times simply doesn't make clinical or common sense as to why a facility was fined (or settled).
 
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They are 100% bound by EMTALA. What most of us run into is that if they are part of our hospital, they may have circumvented emtala. for example I'm at one campus of a multi-campus county system. As a legal design, all of the campuses are considered 'one hospital' but very clearly are multiple hospitals. This is designed for (among other things) making sure transfers for psych fall into the legal category of inter-departmental transfers (that require an ambulance and a 15 mile ride) and not EMTALA hospital-to-hospital transfers. I find I get 7,000x more resistance transferring inside of my own system than when all the beds are full and i need to send the patient to another hospital system, where immediately EMTALA would come into play and they bend over backwards to make it work out so they can address the psych issue.
Are you at one of the JMH facilities??

I always knew you were south fl but didn’t realize same system!
 
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