Ten Steps for Conducting EMTALA Risk Assessments
The Emergency Medical Treatment and Labor Act (EMTALA) is a federal law designed to ensure public access to emergency medical services regardless of a person’s ability to pay or their insurance status. As such, it represents a high-risk compliance area for hospitals, requiring regular risk assessments to evaluate compliance, identify areas of potential noncompliance, and mitigate legal and financial exposure. Conducting these assessments helps ensure that the hospital: (a) provides emergency medical screening and stabilizing treatment regardless of ability to pay; (b) does not improperly transfer or discharge emergency patients; and (c) avoids civil monetary penalties and potential exclusion from Medicare. Conducting the EMTALA Risk Assessment involves the following steps:
- Understand the key areas of Compliance including: (a) Medical Screening Examination (MSE) for anyone who comes to the Emergency Department (ED); (b) Stabilizing treatment before transfer or discharge; (c) Appropriate transfers when the hospital lacks capability; and (d) On-call physician coverage for further evaluation or treatment.
- Identify areas where EMTALA responsibilities apply including the ED, Labor and Delivery, the hospital’s main entrance (especially off-hours), and hospital-owned ambulatory settings with emergency capability.
- Review policies and procedures to confirm the existence and adequacy of: (a) Written EMTALA policies (including triage, transfer, and refusal protocols); (b) Policies on MSE and stabilization; (c) On-call physician coverage and response expectations; and (d) Required signage clearly displaying patient rights in the ED.
- Assess staffing and training to verify all clinical staff receive initial and ongoing EMTALA training. Evaluate knowledge of EMTALA responsibilities among the ED physicians and nurses, registration clerks, security personnel, and on-call specialists.
- Review Medical Screening and Stabilization practices of ED visits to confirm: (a) MSEs were performed timely by qualified personnel; b) Stabilization was attempted or completed prior to discharge or transfer; and (c) Documentation supports decision-making and timelines.
- Evaluate transfers to ensure that: (a) The patient was stabilized before transfer; (b) The patient risks and benefits were explained and documented; (c) The receiving facility was contacted and accepted the transfer; and (d) The appropriate transport was used.
- Inspect all ED and entrance areas for required EMTALA signage, ensuring that signs are legible and clearly state patient rights.
- Examine complaint logs related to potential EMTALA violations, review root cause analyses, and confirm that corrective actions taken and check whether incidents were reported to CMS when appropriate.
- Identify and address any EMTALA compliance gaps, updating policies, procedures, and training as needed.
- Establish a regular schedule for future EMTALA risk assessments and implement tracking systems (e.g., ED logs, transfer logs) to proactively identify and mitigate risks.
For more information on this subject, contact Richard Kusserow at [email protected].
