In a Colorado hospital citation, CMS cited the practice of listing on-call by group names and answering service numbers.
The on-call list of physicians and specialists for the time period in question were [sic] reviewed and revealed the on-call list for urology and cardiology did not contain the name of the physician on call each day. These lists only contain the names of the practice groups and the phone numbers for the answering services for the practice groups.
CMS reported: Subsequent conversations with the chief medical officer indicated that a second list for the ED contained specific names. This list was reviewed and it was determined that during certain days of the month the cardiology calendar still contains some days in which a cardiac clinic was on call with the legend at the bottom stating that the clinic’s calendar should be checked for specific physicians.
The CMS citation also reported:
The director of quality improvement stated that they had gotten away from the requiring specific names on call list because they found that the person on-call frequently changed from when they receive the calendar, so that they wasted contact time calling the wrong doctor through the answering services
COMMENTS: In an unrelated case in Texas, CMS cited the hospital for maintaining the on-call list only in the computer system, due to the inaccessibility of the list if the system were to go down.
Other basic rules for the on-call list are:
- On-call lists need to be available for each specialty on the medical staff, regardless of whether there is one specialist or many.
- The list must be posted in the ED (The call list may be posted on a white board or screen in the ED, but a hard copy must be available in the department and retained as noted below.
- The list must be by individual physician name and direct contact phone (I recommend several contacts: direct office, direct personal cell, and pager)
- The list must be updated as each change occurs both in the ED and on the hard copy
- The physician and NOT the PA/ANP must be listed
- The list and amendments must be maintained in hard copy form and be able to be presented to CMS investigators for up to 5 years
- The on-call physician is responsible for being able to receive and respond to calls, pages, and requests to respond within the mandated response time. (see comments below)
COMMENT: The mechanism for creating the call list should be addressed in the medical staff bylaws. Some hospitals draw up the schedule in the Medical Staff Office, while others leave the responsibility to each department to submit their call list. Once the list is generated, changes become the responsibility of the assigned doctor to arrange and report to the hospital in whatever manner the hospital requires.
CMS will hold the individual physician listed on call responsible for EMTALA response. Response time is measured from the time that the hospital makes the first attempt to contact the physician until the time the physician is present at the patient bedside.
A2404-11-7-21-CO — Cited violation of Tag A2404 based on an investigation July 21, 2011 in the State of Colorado.
NOTE: Citations issued by CMS for EMTALA violations are allegations that have not been proven in any court and the information is presented here in summary format for educational purposes only to demonstrate the circumstances which in the view of CMS constitute EMTALA violations. Identifying information is removed to focus on the allegation without prejudicing the facility.