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Health and safety inspection report on Methodist Dallas Medical Center

Health and safety inspection report on Methodist Dallas Medical Center

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Published by reesedunklin
Findings from the top-to-bottom, health and safety inspection of Methodist Dallas Medical Center, including the hospital's written plan to correct "immediate jeopardy" problems that were uncovered.
Findings from the top-to-bottom, health and safety inspection of Methodist Dallas Medical Center, including the hospital's written plan to correct "immediate jeopardy" problems that were uncovered.

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Published by: reesedunklin on Sep 09, 2011
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01/15/2013

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A.BUILDING(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:STATEMENT OF DEFICIENCIESANDPLAN OF CORRECTION(X3) DATE SURVEYCOMPLETED
PRINTED: 08/27/2011FORM APPROVED
(X2)MULTIPLE CONSTRUCTIONB. WING _____________________________
 ______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESOMB NO. 0938-0391
450051
08/04/2011
C
DALLAS, TX 75203
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
METHODIST DALLAS MEDICAL CENTER
1441 NORTH BECKLEY AVENUE
PROVIDER'S PLAN OF CORRECTION(EACHCORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY)
(X5)COMPLETIONDATE
IDPREFIXTAG(X4)IDPREFIXTAGSUMMARY STATEMENT OF DEFICIENCIES(EACHDEFICIENCY MUST BE PRECEDED BY FULL REGULATORYORLSCIDENTIFYING INFORMATION)
A000 INITIAL COMMENTS A 000The CMS-2567 (Statement of Deficiencies) is anofficial, legal document. All information must remainunchanged except for entering the plan ofcorrection, correction dates, and the signaturespace. Any discrepancy in the original deficiencycitation(s) will be reported to the Dallas RegionalOffice (RO) for referral to the Office of the InspectorGeneral (OIG) for possible fraud. If information isinadvertently changed by the provider/supplier, theState Survey Agency (SA) should be notifiedimmediately.Anunannounced investigation was conducted onsite. An entrance conference was held with theCNO (Chief Nursing Officer) and other keypersonnel the afternoon of 06/29/11 to explain thepurpose and process of the survey. The hospitalrepresentative was informed that this investigationwould be conducted according to 42 CFR 482Conditions of Participation for Hospitals, 42 CFR489 and Section 5100 of the State OperationsManual.Survey findings were presented at an exitconference on 08/04/11with the CNO and other keypersonnel who was informed this complaintTX00146867 is substantiated. The hospitalrepresentative was informed that when the facilityreceives their survey findings, a plan of correctionfor any deficiencies cited should be sent to theArlington Zone office within 10 days of receipt.Recommend 23 day Termination. Not InCompliance with Conditions:
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE
(X6) DATE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that othersafeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date ofsurvey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date thesedocuments are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
FORM CMS-2567(02-99) Previous Versions Obsolete 1HCP11Event ID:Facility ID: 810029
If continuation sheet Page 1 of 89
Page 1
Introduction
MethodistDallasMedicalCenter(“theHospital”)iscommittedtoprovidingqualityhealthcareandfosteringacultureofcompliancewithallapplicablestateandfederallaws. InresponsetotheStatementofDeficienciesissuedtotheHospitalbytheCentersforMedicareandMedicaidServices(“CMS”),theHospitalhasundertakenanevaluationoftherelevantpolicies,procedures,andpracticestoassesstheHospital’scomplianceandtakenappropriatestepstoaddressalloftheconcernsraisedbyCMSintheStatementofDeficienciesandensurethattheHospitalcomplieswithallofitsobligationsunderstateandfederallaw.AsexplainedinfurtherdetailinthisPlanof Correction,theHospitalhastakenaseriesof significant,substantiveactionstoaddresstheconcernsraisedbyCMSintheStatementof Deficiencies. Thesestepsincludethefollowing:OnSeptember1,2011,theBoardofDirectorsapprovedanddirectedtheimplementationofapolicythatwillfurtherclarifyandpromotecompliancewiththerequirementsoftheEmergencyMedicalTreatmentandActiveLaborAct(“EMTALA”). ThepolicywillbetterensureEMTALAcompliance,includingspecificprovisionsthataredesignedtoensurethatappropriateMedicalScreeningExaminations(“MSEs”)areprovidedwithoutdelaybyQualifiedMedicalPersonneltoindividualswhocometotheHospital.TheQualityReviewCommittee,exercisingtheauthorityoftheBoardofDirectors,approvedrevisionstotheHospital’sComplaint/GrievancePolicy,MHS#191onJune28,2011,topromotecompliancewiththeCMSConditionsof 
 
A.BUILDING(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:STATEMENT OF DEFICIENCIESANDPLAN OF CORRECTION(X3) DATE SURVEYCOMPLETED
PRINTED: 08/27/2011FORM APPROVED
(X2)MULTIPLE CONSTRUCTIONB. WING _____________________________
 ______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESOMB NO. 0938-0391
450051
08/04/2011
C
DALLAS, TX 75203
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
METHODIST DALLAS MEDICAL CENTER
1441 NORTH BECKLEY AVENUE
PROVIDER'S PLAN OF CORRECTION(EACHCORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY)
(X5)COMPLETIONDATE
IDPREFIXTAG(X4)IDPREFIXTAGSUMMARY STATEMENT OF DEFICIENCIES(EACHDEFICIENCY MUST BE PRECEDED BY FULL REGULATORYORLSCIDENTIFYING INFORMATION)
A000 INITIAL COMMENTS A 000The CMS-2567 (Statement of Deficiencies) is anofficial, legal document. All information must remainunchanged except for entering the plan ofcorrection, correction dates, and the signaturespace. Any discrepancy in the original deficiencycitation(s) will be reported to the Dallas RegionalOffice (RO) for referral to the Office of the InspectorGeneral (OIG) for possible fraud. If information isinadvertently changed by the provider/supplier, theState Survey Agency (SA) should be notifiedimmediately.Anunannounced investigation was conducted onsite. An entrance conference was held with theCNO (Chief Nursing Officer) and other keypersonnel the afternoon of 06/29/11 to explain thepurpose and process of the survey. The hospitalrepresentative was informed that this investigationwould be conducted according to 42 CFR 482Conditions of Participation for Hospitals, 42 CFR489 and Section 5100 of the State OperationsManual.Survey findings were presented at an exitconference on 08/04/11with the CNO and other keypersonnel who was informed this complaintTX00146867 is substantiated. The hospitalrepresentative was informed that when the facilityreceives their survey findings, a plan of correctionfor any deficiencies cited should be sent to theArlington Zone office within 10 days of receipt.Recommend 23 day Termination. Not InCompliance with Conditions:
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE
(X6) DATE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that othersafeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date ofsurvey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date thesedocuments are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
FORM CMS-2567(02-99) Previous Versions Obsolete 1HCP11Event ID:Facility ID: 810029
If continuation sheet Page 1 of 89
Page 2
Participation. SinceJune28,2011,theRiskManagementDepartmenthasbeenmonitoringtheHospital’scomplaint/grievancedatabaseregularlytoensurethatcomplaintsandgrievancesareproperlyaddressed.TheHospitalhasprovidedextensiveeducationandtrainingtoemployeesandmedicalstaff memberstoaddresstheconcernsraisedbyCMSintheStatementofDeficiencies. Inaddition,theHospitalhasexpandeditsauditandmonitoringsystemtoensurecontinuedcompliancewithallHospitalpoliciesandproceduresandapplicablestateandfederallaws.
 
A.BUILDING(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:STATEMENT OF DEFICIENCIESANDPLAN OF CORRECTION(X3) DATE SURVEYCOMPLETED
PRINTED: 08/27/2011FORM APPROVED
(X2)MULTIPLE CONSTRUCTIONB. WING _____________________________
 ______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESOMB NO. 0938-0391
450051
08/04/2011
C
DALLAS, TX 75203
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
METHODIST DALLAS MEDICAL CENTER
1441 NORTH BECKLEY AVENUE
PROVIDER'S PLAN OF CORRECTION(EACHCORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY)
(X5)COMPLETIONDATE
IDPREFIXTAG(X4)IDPREFIXTAGSUMMARY STATEMENT OF DEFICIENCIES(EACHDEFICIENCY MUST BE PRECEDED BY FULL REGULATORYORLSCIDENTIFYING INFORMATION)
A000Continued From page 1A000482.11 Compliance With Laws482.12 Governing Body482.13 Patient rights482.24 Medical Record Services489.20 Compliance with 489.24A020482.11 COMPLIANCE WITH LAWSCompliance with Federal, State and Local LawsThis CONDITION is not met as evidenced by:A020Based on observation, review of records andinterviews, the hospital failed to meet theEmergency Medical Treatment and Labor Act(EMTALA) statute codified at §1867 of the SocialSecurity Act (the Act), and the implementingregulations at 42 CFR §489.24 and the relatedrequirements at 42 CFR 489.20 ( l ), (q), and (r)from 01/01/11 to 06/29/11.Findings Included:Hospital policies and procedures were not adoptedand enforced to ensure compliance with theEMTALA requirements;The dedicated Emergency Department (ED) of thehospital did not provide an appropriate medicalscreening examination (MSE) by a QualifiedMedical Professional (QMP) to determine whetheror not an emergency medical condition (EMC)existed to all individuals who came to the EDrequesting an examination for a medical condition;Hospital policies and procedures were not adoptedand in place to ensure emergency services areavailable to meet the needs of the individuals withemergency medical conditions
FORM CMS-2567(02-99) Previous Versions Obsolete 1HCP11Event ID:Facility ID: 810029
If continuation sheet Page 2 of 89
Page 3
8-29-11
EMTALAPoliciesandProcedures/QMPs
IncollaborationwiththeEmergencyDepartmentMedicalDirector,theMedicalExecutiveCommittee(MEC)approvedthefollowingpoliciesrelatedtoMedicalScreeningExaminations:1.)TheEmergencyMedicalTreatmentandLaborpolicy(EMTALApolicy)wasadoptedwhichoutlines;theHospitalandmedicalstaff responsibilitiesinprovidingmedicalscreeningexams,whocanperformmedicalscreeningexams(MSE)intheEmergencyDepartmentandLaborandDeliveryUnit,theprocesstakenbythemedicalstaffandBoardofDirectorsforapprovalofqualifiedmedicalpersonnel(QMP),documentationrequirements,notification(signage)andmedicalstaffon-callresponsibilities.ThepolicyclarifiedthatallmedicalstaffphysiciansmayperformMSEs.Qualifiedresidents,nursepractitionersandphysicianassistantswereapprovedtoperformMSEsatMethodistDallasMedicalCenterbytheMedicalExecutiveCommittee.2.)PatientTransfers,MHSpolicy#206,wasrevisedtospecificallyoutlinetheprocessandresponsibilitiesrelatedtotransferringpatientsoutof,andinto,theHospital.8-31-11EMTALAandTransferpoliciesandalistof individualsdefinedasQMPsapprovedbyMethodistHealthSystemCorporateMedicalBoard.SlateofindividualsapprovedasQMPsforprovidingMedicalScreeningExaminationsat

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