Emtala and Patients With Psychiatric Emergencies a Review of Relevant Case Law
Note: This fabric beginning appeared in the Journal of Healthcare Adventure Management, Vol. 34, No. 2, pp. five – 12 (2014)
Introduction
The boarding of patients with behavioral bug in medical/surgical hospital emergency departments (EDs) is mutual in the United states of america. This is generally due to ii factors: the decrease in the number of inpatient beds for behavioral patients[1] and an increase in the number of patients who demand intensive psychiatric care in an inpatient setting.[2] States have cut 4,500 inpatient psychiatric beds, or 10% of the full supply.[3] Given the lack of inpatient intendance, there are three full general alternatives for patients with intensive psychiatric issues: emergency departments, prison[4] or the community. This pitiful country of affairs has led to long waits in the ED, oft measured in days, rather than hours.
Although the calibration of the problem may never be known, it is unremarkably believed that psychiatric units and facilities are increasingly selective regarding the patients they volition take for admission. Facilities will frequently turn down to accept forensic patients (those who have committed a law-breaking) or sexual predators, but may also refuse to accept patients without a payer source. This may have implications under the Emergency Medical Treatment and Labor Deed (EMTALA).[5] However, this is only true for hospitals that have signed a Medicare provider agreement.[half dozen] An entity is not subject to EMTALA if it does not participate in the Medicare program or is not licensed as a hospital.[vii] While this commodity is not meant to be an exhaustive treatise on the law of EMTALA, it volition discuss the issues surrounding the care and treatment of psychiatric patients by hospitals that take signed an agreement to participate in the Medicare program.
This is an issue that many psychiatric facilities and units announced to be overlooking. There appears to exist a widespread conventionalities in behavioral health facilities that EMTALA does not apply to them considering they practise not have an ED. Such facilities, if they are participating hospitals, may be acting at their peril.
Applicability of EMTALA to Psychiatric Facilities
General Requirements
The basic rule behind EMTALA is that, if a person comes to an ED and seeks care for what may be an emergency medical condition (EMC) and, if an emergency medical status is detected, the person is entitled to stabilizing care within the capabilities of the facility, or a transfer to a facility that can provide stabilizing care. Additionally, if a participating hospital offers specialized services and has the chapters to treat a patient, that facility is required to accept a patient needing those services in transfer, and may exist liable for "reverse dumping" if information technology fails to accept the transfer.[8] These are terms of art and have specific meaning in the law.
As noted in a higher place, EMTALA requires that the person have an emergency medical status in order to trigger the protections of the Act. The definition of emergency medical status includes:
(1) A medical condition manifesting itself past acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance corruption) such that the absence of immediate medical attention could reasonably exist expected to result in– (i) Placing the wellness of the individual *** in serious jeopardy; (two) Serious impairment to bodily functions; or (iii) Serious dysfunction of whatever bodily organ or part.[9]
It is clear that the statute intends that psychiatric and substance abuse disorders are covered as emergency medical conditions if the absenteeism of treatment would place the patient's wellness in jeopardy (e.g., past committing suicide).
Dedicated Emergency Department (DED)
Information technology is true that EMTALA but applies to hospitals that have emergency departments,[ten] simply CMS has enlarged what it means to have an emergency department. CMS has implemented regulations that land that if a hospital has a "dedicated emergency department," then it has an emergency section for the purposes of EMTALA. In society to be classified equally a dedicated emergency department, the facility must have an area that meets one of the post-obit requirements:
(1) Information technology is licensed by the Country in which information technology is located under applicable State police as an emergency room or emergency department;
(two) It is held out to the public (by proper name, posted signs, ad, or other ways) as a place that provides care for emergency medical atmospheric condition on an urgent footing without requiring a previously scheduled appointment; or
(three) During the calendar year immediately preceding the calendar twelvemonth in which a determination under this department is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one-third of all of its outpatient visits for the handling of emergency medical conditions on an urgent footing without requiring a previously scheduled engagement.[11]
Well-nigh psychiatric facilities have an intake are that may meet the requirements of either #2 or #3 above, since they are areas where patients with emergency medical conditions can be evaluated on an unscheduled basis. Thus, they commonly take a dedicated emergency department and that requires them to comply with EMTALA if they are hospitals or in hospitals that participate in the Medicare program.
Specific EMTALA Requirements for Psychiatric Facilities/Units
Emergency Medical Screening
If a patient comes to a DED seeking care for what may exist an emergency medical condition, or on whose behalf such intendance is sought, the patient must be screened to make up one's mind whether an EMC exists. This is an absolute obligation under EMTALA. The duty to stabilize (discussed below) is a conditional obligation: information technology arises when the facility detects an EMC. If the facility does non know the patient is suffering from an EMC, in that location is no duty to stabilize the patient's condition.
The rule of thumb is that the screening should not be discouraged, delayed or denied based on the patient'southward ability to pay.[12] It is, theoretically, acceptable to ask nigh insurance before the screening is completed every bit long as it does not delay or discourage the patient from having the screening, just in that location is a fine line here between following the statute and violating it. It is best to avoid talking almost payment until the screening has been completed.
The screening must be provided within the adequacy of the infirmary's dedicated emergency department, including coincident services routinely available to the dedicated emergency department, to determine whether or not an emergency medical condition exists.[13] Courts have generally required that the screening be "appropriate," by which they mean that it cannot exist different than the screening afforded to other, similarly situated, patients. EMTALA is not a federal medical malpractice statute: it does not require that the screening exist not-negligent (land malpractice police will comprehend it if it is negligent). It tin can generally be proved that the patient's screening was not disparate past the production of protocols, policies or assessment forms. If the facility cannot produce some form of documentation regarding what it considers to be an advisable screening, courts accept immune patients access to the medical records of other patients (with individually identifiable information redacted) to prove that the screenings provided to other patients were dissimilar than theirs.[fourteen]
It is sometimes the instance that patients volition be brought by family or law enforcement to a psychiatric facility for evaluation, and will not be in that location of their ain free will. These patients may refuse to be screened. This is a difficult issue. The general dominion is that competent persons have the right to turn down test or treatment, but persons suspected of having a psychiatric condition are often not competent to decline care. If the patient refuses the screening, and information technology appears that he or she is competent to do so, and information technology does not appear that he or she poses a risk of injury to self or others, it may exist possible to allow it. Notwithstanding, the facility needs to document the proposed examination and treatment in the patient's medical record and must seek to obtain written documentation of the patient'southward informed refusal of the screening. In social club to obtain the patient'due south informed refusal, providers must hash out the risks of foregoing intendance and the benefits of obtaining care with the patient.[15]
Stabilization
Stabilization should not be dislocated with curing. It may not exist possible to "cure" a psychiatric condition, simply it may exist possible to stabilize information technology and then that no material deterioration of the patient's status is likely to occur in the foreseeable future. In club to stabilize a patient for transfer, the facility must "provide such medical treatment of the condition every bit may be necessary to assure, within reasonable medical probability, that no fabric deterioration of the condition is likely to event from or occur during the transfer of the private from [the] facility."[sixteen] If the patient is admitted, the facility must do so in practiced faith with the intention of stabilizing the patient's condition.[17] It is rarely the case that a patient with an emergency psychiatric status can be discharged. If he or she is discharged, it should only exist in situations in which it is felt that the patient volition not pose a threat to self or others and can safely receive care in an outpatient setting. It may likewise be the case that a patient volition exist a threat to self if he or she is unable to function safely outside a safe environment.[eighteen]
Although it is a Medicare statute, EMTALA covers all patients, not just Medicare beneficiaries, including those who are unable to pay. If a facility performs an appropriate screening and detects an EMC, the facility must either transfer the patient (if information technology does not have the chapters to treat the patient) or admit the patient (if it does have the capacity to care for the patient). Chapters includes the facility'south licensed or staffed-to-operate beds, but may also include provisions for operating above capacity. According to the regulations, "Chapters encompasses such things as numbers and availability of qualified staff, beds and equipment and the infirmary's past practices of all-around boosted patients in excess of its occupancy limits."[19]
Signage
A participating hospital needs to mail a sign or signs advising patients of their rights under EMTALA in all locations where they volition exist noticed past patients coming onto the unit. Equally a full general dominion, no member of the public should exist able to access the unit without passing an EMTALA sign. In mutual areas, the sign should be legible at 20 feet by a person with normal eyesight. In smaller areas, such as intake cubicles or rooms, the signs may be smaller. In that location is currently no required verbiage for the sign, but language for the sign has been suggested.[twenty]
Transfers Out
If a psychiatric facility transfers a patient to another facility, it should occur because the transferring facility does not have the capacity to intendance for the patient. This is often not simply a question of available beds or staff. Information technology is not true that all psychiatric units should be equipped to care for all psychiatric patients. While most psychiatric units may be equipped to manage suicidal patients, they may not be equipped to handle forensic patients or sexual predators.
Information technology is important to develop a formal scope of services that specifically describes the types of patients for whom the psychiatric unit can provide care. This should be based on a realistic appraisal of the training and feel of the staff, the numbers and types of staff members available and the physical configuration of the unit. If a question arises regarding the facility's "dumping" of a patient, the facility should be able to point to its scope of services to show that it did not take the chapters to care for the patient.
The hospital that has been asked to have the patient in transfer must have the chapters to accept the patient and must accept the transfer. If the transferring facility feels that the transfer was wrongly rejected, it is required to report the aforementioned within 72 hours.[21]
Patients have the right to decline to consent to a transfer. If this happens, the facility must discuss the risks of remaining and the benefits of being transferred to some other facility.[22] However, if the patient has been involuntarily committed, he or she volition not have the correct to refuse a transfer. It is just in the case of a transfer for a voluntary admission that a patient has the correct to refuse.
Under no circumstances should a participating infirmary transfer a patient to some other facility based solely on the patient's ability to pay for care if the transferring facility has the chapters to intendance for the patient.
Transfers In
As noted above, in that location is a very real scarcity of psychiatric inpatient beds relative to the demand for them. This can make it very difficult for medical/surgical hospitals without a psychiatric unit of measurement to find placement for a psychiatric patient in its ED. Since a behavioral patient in an ordinary ED is not receiving care in a safe environment, it is critical to transfer the patient to an appropriate level of intendance every bit quickly equally possible.
Information technology is critical that the receiving facility base its decision to take or deny the transfer from another facility on its capacity to care for the patient. This is, again, where a formal scope of services tin can exist enormously beneficial. If the facility has fabricated an objective assessment of its capabilities and adamant that it cannot safely care for a particular category of patient, it is within its rights to deny the transfer.
If a facility believes that it has wrongly received a patient ("been dumped on"), it is required to report the incident within 72 hours.[23]
Under no circumstance should the personnel who are responsible for accepting or denying a transfer enquire nigh the patient's payer status. This decision should exist based solely on the facility's chapters to care for the patient in gild to foreclose an accusation of reverse dumping. A participating infirmary will be in violation of EMTALA if it refuses the transfer of a patient that it had the chapters to care for. Information technology will be particularly egregious if this decision was made on the basis of the patient'south payer condition.
Appropriate equipment
Transfers need to be accomplished using qualified personnel and appropriate equipment.[24] For patients with emergency medical (as opposed to psychiatric) conditions, this ordinarily means that they demand to exist sent past ambulance. An advisable transfer of a behavioral patient may be achieved by ambulance, but, more often it is accomplished past law enforcement personnel. Liability may attach for failure to employ appropriate equipment and staff to effect the transfer.[25] Information technology is well-nigh never advisable to transfer a patient with an unstabilized psychiatric condition by personal vehicle, despite the remonstrations of family members.
Considerations for Medical/Surgical Hospital EDs Prior to Transfer
Since medical/surgical hospitals are, through no want on their function to engage in this line of business concern, becoming de facto behavioral health units, there are a number of things that they should consider in keeping patients safe for the duration of their stay in the ED. Information technology is non always clear when EDs should implement prophylactic precautions for behavioral patients (e.g., must information technology wait until the screening has been completed?). This writer is of the opinion that precautions should be implemented as soon as the staff members take a reasonable suspicion that the patient may be a danger to self or others. It would certainly be preferable to defend a claim for fake imprisonment rather than wrongful decease.
At that place are both structural and staffing solutions to many of these safety issues.
Removal of Contraband
As presently as it is felt that the patient may be a danger to cocky or others, the patient should be searched for sharps and drugs, and shoelaces and belts should exist removed. Ideally, the patient should be placed in a gown, although some facilities let them to wearable scrubs. It must be remembered that patients may exist able to hang themselves using their pants. The search and removal of clothing and personal items should be done equally presently every bit possible afterwards a determination of a threat to self is made to avert allowing the patient to secrete chancy materials somewhere in the room or above the ceiling. Whenever a patient needs to use the bathroom, the bathroom should first be checked for contraband (razors, mouthwash, etc.).
Behavioral Observation Units
If a facility has a high volume of behavioral patients that it is boarding at all times, it may exist practical to movement them out of the ED birthday. A bed in the ED is a valuable piece of real estate and it should turn over apace in society to keep the ED performance properly. It is possible to fix an observation unit where behavioral patients can exist housed pending a transfer. It is of import to designate this as an observation unit. If it is designated an inpatient unit and the patients are "admitted" to it, the facility will detect itself in the business of caring for behavioral patients and will be required to accept transfers of behavioral patients from other facilities. If it is technically a part of the ED and patients take not been admitted, information technology is not a behavioral health unit.
If the unit is fix equally a safe environment,[26] the unit can have lower staffing levels than would be possible using sitters in the ED. It is typically the example that sitters cannot effectively attend to more than two or 3 behavioral patients in the ED. In a behavioral observation unit, the facility may be able to operate effectively with a much college staff to patient ratio. It too allows the facility to hire nurses with a groundwork in behavioral health or to train current nurses more extensively in behavioral health. Although there is certainly an expense involved in setting upward a unit to exist a safety unit, there may be savings in the long term if the volume of behavioral patients remains high.
If the ascertainment unit is secured or has other features that would impede egress in an emergency (e.g., locked doors that only open with a key or card unless the burn warning is activated; secured fire extinguishers and alarm boxes, etc.), the facility should obtain the approval of the local burn down marshal having jurisdiction before occupying the unit.
Condom Rooms
An alternative to setting up a behavioral observation unit is to institute safe rooms in the ED in which to provide care for behavioral patients. If safe rooms are developed, it may be possible to allow sitters to watch more than patients than would be possible in a non-safety environment. Some ideas for making a room safe would be to include as many of the following features as possible:
(a) Furniture should be heavy or immovable (to forestall barricading the door);
(b) Door can exist secured to prevent unauthorized egress;
(c) No projections that could support the weight of a homo body;
(d) Sharps container removable or can exist secured; all sharps removed from room;
(e) Zippo present that could exist used as a weapon;
(f) Ceiling is solid or tiles are clipped in place;
(yard) Room is configured then that staff tin can monitor patient;
(h) Hinges on door are continuous and sloped downward at the superlative;
(i) Inside handle on door is sloped downward;
(j) No cabinets, or if present, tin be secured;
(k) No cords or lines are nowadays, or they can be secured prior to apply;
(l) No grates or grilles or grates/grilles have modest enough openings that nothing can be threaded through them;
(m) Lite fixtures are recessed with unbreakable encompass and tamper-proof screws;
(north) Panic push is present (may exist secured) or staff carry personal alarm devices while in room;
(o) No smoke detector or smoke detector is recessed;
(p) No wastebasket or wastebasket that does not have plastic liner;
(q) No sprinkler caput or sprinkler head is recessed or tamper resistant;
(r) No vision panel in door, or if nowadays, is impact resistant; and
(s) No mirrors or mirrors made of unbreakable substance.
Again, as with the behavioral observation unit of measurement, many of these features in a safe room should be approved by the fire marshal.
It is certainly possible to render an ordinary examination room safe when a prophylactic room is required. If the facility chooses this route, it should endeavor to implement as many of the higher up safety features as possible into the convertible safe room.
Safety rooms tin can reduce the number of sitters necessary to watch behavioral patients, but they exercise not obviate the need for sitters. Sitters should still provide an appropriate level of supervision for behavioral patients.
S itters/Observers[27]
It is preferable to have someone, such every bit a sitter, whose job it is to watch the patient to ensure that he or she does not try to leave or to injure himself or herself. Facilities sometimes place behavioral patients where they can be directly observed from the nurses' station, but, equally the aphorism goes, when something is everybody's job it is nobody's task. It is best to assign this responsibleness to someone.
Sitters may exist required in any environment, although the college the level of rubber, the lower the number of sitters for a given number of patients. Sitters can be nurses, CNAs or security officers. Although security officers are used in many EDs, it is preferable to use people with some clinical background to part as sitters. It is probably not appropriate to utilise volunteers or non-clinical staff (other than security officers) to office as sitters. If security officers are used as sitters, they need to empathise that CMS forbids the employ of tazers or other non-lethal devices as a method to control patient beliefs.[28]
The function of the sitter is, simply, to scout the patient. The number of patients that one sitter can sentry may be variable. If the patients are asleep at night and the patients are in adjacent rooms, one sitter may exist able to watch 3 patients. During the day, and, once again, if the rooms are next, one sitter may be able to watch 2 patients, unless the sitter is required to go on the patient within arm's length at all times. If all of the patients are in safety rooms, the number of patients that a sitter could watch could be higher.
Whoever is used as a sitter, sitters need to be carefully trained on how to perform their function. They must understand that the patient must always be inside the zone of observation and supervision (e.g., ane:i, intensive ascertainment, continuous observation, etc.). This includes when the patient is in the bathroom. The bathroom should also be rubber (no sharps, plastic trash tin can liners or hazardous liquids) and have zilch that would allow the weight of a human being body to be suspended from information technology (eastward.yard., shower heads, shower rods, faucets, toilet hardware, and take hold of confined). Many of these items can be obtained commercially,[29] including grab bars around which nothing tin be tied. Information technology may exist acceptable to allow the sitter to stand or sit outside the bathroom door with the door ajar. If the patient is allowed to fume, the sitter should back-trail him or her outside and have control of smoking paraphernalia (cigarettes, lighters and matches) at all times. The patient should never be left to smoke unattended exterior the ED, fifty-fifty if it is in an enclosed courtyard. If the sitter is engaged in an activity involving a patient that takes him or her away from other patients he or she is supposed to exist watching, someone should be required to fill up in for the sitter.
Sitters also need to be aware that they demand to devote their attention to the patient. Sitters should not read magazines or newspapers, or check their east-mail on their phones. Sitters should non be asked to do other work while performing the duties of a sitter.
One of the principal obligations of a sitter is to exist the eyes and ears of the ED medical and nursing staff. They should regularly update other staff members on the status of the patient, peculiarly if they note whatever changes in the patient'south condition or beliefs that could be cause for business organisation.
Stabilization
This is an issue for medical/surgical hospitals that board psychiatric patients in their EDs as well as for psychiatric facilities. EMTALA requires that the transferring hospital provide stabilizing care within its capabilities prior to transfer.[30] Most EDs can practise something to try to stabilize a behavioral patient beyond simply property them. Thus, a boarding hospital could use telepsychiatric resources for an cess or brainstorm a medication regimen to endeavor to stabilize the patient. This must be done in accord with the psychiatric facility that volition ultimately receive the patient to ensure that the expectations of both entities are synchronized. EDs need to be careful to avoid doing annihilation that might conflict with the receiving facility's conception of medical clearance. As well frequently, medical/surgical hospitals believe that their only responsibility is to keep the patient safe.
Restraints
A detailed word of the use of restraints in an ED is across the scope of this posting. Staff members need to exist aware of the rules regarding restraints to avoid liability or patient injury. Facilities are directed to the CMS Interpretive Guidelines for further data on this subject area.[31]
Enforcement
Both hospitals and physicians can be liable for penalties nether the Act. If a hospital has fewer than 100 licensed beds, the penalisation per violation volition be not more than $25,000. Nevertheless, for hospitals with 100 or more licensed beds, or for physicians, who violate the Act, the penalty may exist not more than $50,000.[32] It must be remembered that these are civil penalties, which are normally non covered by insurance.
Hospitals, but not physicians, can exist liable for civil amercement to the injured patient if the injury was caused by the violation of the statute.[33] In general, courts have upheld caps on amercement in state law medical malpractice actions in states that have such caps.[34]
CMS also may exclude a dr. from further participation in Medicare and Medicaid as penalisation for a violation of certain aspects of the statute.[35] This can be a financial death sentence for many physicians.
Conclusion
EMTALA is fully applicable to psychiatric facilities if they are licensed as, or function inside, a hospital that participates in the Medicare Plan. Behavioral patients tin exist vulnerable and may certainly be difficult to manage safely and effectively. It is of import that facilities understand the requirements of EMTALA in caring for behavioral patients in guild to avoid layering this potential liability over the potential liabilities inherent in caring for behavioral patients. It is only through the careful application of due diligence that liability tin be minimized and patient safe maximized.
[1] The number of inpatient psychiatric beds decreased by 32.five% betwixt 1995 and 1012. The number went from 160,645 to 108,317. American Hospital Association, Annual Survey of Hospitals, 1995 – 2012.
[ii] In 1995, in that location were 7.9 meg seriously mentally ill adults who needed inpatient intendance; in 2012, there were 9.six million people who required such care. U.s.a. Today, "Psychiatric beds disappear despite growing demand" (May 12, 2014)
[3] Id.
[iv] There are reportedly 1.25 million people in prison with a diagnosable psychiatric condition, as opposed to twoscore,000 in inpatient facilities. Business Insider, "Life is hard for the 1.3 1000000 mental patients behind bars in the U.s.a." (May 23, 2012).
[5] 42 U.S.C. §1395dd.
[6] U.S. DHHS, Centers for Medicare and Medicaid Services, "Land Operations Manual, Appendix V, Interpretive Guidelines, Responsibilities of Medicare Participating Hospitals in Emergency Cases" (available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107ap_v_emerg.pdf)
[7] According to the CMS regulations, "participating infirmary means (ane) a hospital or (ii) a disquisitional access hospital as defined in section 1861(mm)(1) of the [Social Security] Act that has entered into a Medicare provider agreement under department 1866 of the Human activity." 42 C.F.R. §489.24(b).
[eight] 42 C.F.R. §489.24(f); come across also St. Anthony Hospital 5. DHHS, 309 F.3d 680 (xth Cir. 2002)
[9] 42 C.F.R. §489.24(b)
[10] Id.
[11] Id.
[12] 42 C.F.R. §489.24(d)(iv)(iv)
[13] 42 C.F.R. §489.24(a)(i)
[14] Encounter, e.thou., Southard v. United Regional Health System, No. seven:06-CV-011-R (N. D. Tex. August 14, 2007)
[15] 42 C.F.R. §489.24(d)(3)
[16] 42 U.South.C. §1395dd(east)(3)
[17] 42 C.F.R. §489.24(d)(2); See, due east.chiliad., Morgan v. North Mississippi Medical Eye, Inc., Civil No. 05-0499 (Southward. D. Ala. December 2, 2005)
[eighteen] Encounter, e.g., Thomas v. Christ Hospital and Medical Heart, 328 F. 3d 890 (7th Cir. 2003)
[19] 42 C.F.R. §489.24(b)
[xx] See, eastward.g., http://www.medlaw.com/healthlaw/EMTALA/signs/index.shtml
[21] U.S. DHHS, Centers for Medicare and Medicaid Services, "Land Operations Manual, Appendix Five, Interpretive Guidelines, Responsibilities of Medicare Participating Hospitals in Emergency Cases"
[22] 42 United statesC. §1395dd(b)(3)
[23] 42 C.F.R. §489.twenty(m); U.S. DHHS, Centers for Medicare and Medicaid Services, "State Operations Transmission, Appendix V, Interpretive Guidelines, Responsibilities of Medicare Participating Hospitals in Emergency Cases"
[24] 42 C.F.R. §489.24(e)
[25] See, east.g., Burrows v. Redbud Community Infirmary, F. Supp. , No. C96-4345 SI (N.D. Cal. January thirteen, 1998)
[26] For an splendid reference on pattern features for a behavioral unit, please see Chase, JM and Sine, DM, Design Guide for the Congenital Surroundings of Behavioral Health Facilities, National Clan of Psychiatric Health Systems (available at https://world wide web.naphs.org/resources/home.aspx?product-tab=ane)
[27] The behavioral health community prefers the term "observers" over the term "sitters," although the writer's feel has been that EDs normally employ the term sitters. For the purposes of this article, the term "sitters" volition exist used for both types of people.
[28] U.S. DHHS, Centers for Medicare and Medicaid Services, State Operations Transmission Appendix A – Survey Protocol, Regulations and Interpretive Guidelines for Hospitals (available at http://world wide web.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107ap_a_hospitals.pdf)
[29] Hunt, JM and Sine, DM, Design Guide for the Built Environment of Behavioral Wellness Facilities
[thirty] 42 C.F.R. §489.24(due east)(2)(i)
[31] U.S. DHHS, Centers for Medicare and Medicaid Services, State Operations Manual Appendix A – Survey Protocol, Regulations and Interpretive Guidelines for Hospitals §§482.thirteen(e) and 482.13(f) (bachelor at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107ap_a_hospitals.pdf)
[32] 42 U.Southward.C. §1395dd(d)(1)
[33] 42 U.S.C. §1395dd(d)(2)
[34] See Barris v. County of Los Angeles, twenty Cal.4th 101, 83 Cal. Rptr. 2d 145, 972 P.2d 966 (Cal. 1999); Ability five. Arlington Hospital Association, 42 F.3d 851 (quaternary Cir. 1994)
[35] 42 United states of americaC. §1395dd(d)(ane)(B)
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