Basic Compliance and
Risk Management Points
THE "20 Commandments"
OF COBRA/EMTALA
Version 4.0 -- 11/2003
Copyright 1998-2003
Frew Consulting Group, Ltd.
Loves Park, IL 61132
1. THOU SHALL: Log in every patient who presents, together with
complaint/diagnosis and disposition. A patient presents when they enter
into a dedicated emergency department of the hospital, including remote
sites, or upon the campus within 250 yards of the main buildings seeking
care or under circumstances when a reasonable layperson would conclude that
the patient required care or evaluation for an emergency medical condition.
A dedicated emergency department includes the hospital emergency department,
OB department, and other departments and remote sites that see 1/3rd of
their patients on a walk-in basis for assessment of emergency medical
conditions or have a name that suggests that patients should seek care there
or are held out to the public as such --i.e. urgent care, immediate care, or
by broad advertising references in print or electronic form.
2. THOU SHALL: Provide a medical screening examination (MSE) by
physician
(preferably) IN THE HOSPITAL OR DEDICATED EMERGENCY DEPARTMENT SITE, beyond
triage, to all patients regardless of acuity who present as specified in #1,
above. The MSE is an on-going process sufficient to reach a definitive
exclusion of legally defined emergency medical conditions and is NOT a fixed
point in the evaluation that allows termination of services or redirection
of the patient to other sites.
3. THOU SHALL NOT: Delay the MSE in order to obtain financial
information nor induce the patient to leave without MSE by drawing payor
issues or financial demands to the attention of patient or family prior to
the completion of the MSE and initiation of stabilizing care. Care may not
be denied based on denial of pre-authorization. Financial questions,
documents, and pre-authorization is at your own peril.
4. THOU SHALL: As a portion of the MSE, provide necessary testing
within the capability of the hospital (including on-call services) as needed
to exclude the presence of a legally defined emergency medical condition.
Testing necessary for exclusion may not be deferred to more convenient times
or locations. Abnormal findings should be normalized via treatment and
documented by serial values or explained away prior to discharge.
5. THOU SHALL: To the extent of the capabilities of the hospital
and/or the dedicated emergency department located off-campus, provide
stabilizing care, such that the patient is not likely to deteriorate from or
during transfer or discharge. In the case of OB patients with contractions
present, the patient is deemed unstable until contractions cease or baby and
placenta are delivered. If the site is not capable of appropriate
stabilization, a medically appropriate transfer must be effected.
6. THOU SHALL: Provide on-call coverage schedules listing on-call
physicians by individual name for all medical specialties generally engaged
in the delivery of care necessary to serve the community needs under
Medicare Conditions of Participation; to provide policies and procedures for
cross-coverage, back-up or transfer for occasions when an on-call physician
is not on-call or is unable to respond due to circumstances beyond their
control; and to maintain the list for 5 years for enforcement purposes.
On-call physicians may not decline to accept patients for evaluation or
treatment in the dedicated emergency department(s) or for acceptance of
EMTALA transfer.
7. THOU SHALL: Require on-call specialists to respond to the hospital
to attend the patient in timely manner and to provide legally defined
stabilizing care (generally definitive care) to presenting patients and
those being transferred to a higher level of care under EMTALA. This
obligation exists without regard to means or ability to pay. The hospital
must enforce this obligation by necessary policies, procedures, bylaws, and
enforcement actions including actions against the privileges of physicians
who violate this obligation.
8. THOU SHALL: Transfer all EMTALA patients for only services or care
not available at your facility or upon patient request documented to EMTALA
requirements and ACCEPT TRANSFERS of patients for specialty services not
available at the hospital where they originally presented.
9. THOU SHALL: Provide MSE to OB patients, patients with undiagnosed
acute pain, symptoms of substance abuse, or symptoms of psychiatric
disturbances sufficient to first rule out general medical, toxic, or
traumatic conditions and thereafter to adequately evaluate and treat these
specific conditions.
10. THOU SHALL: Obtain and document advanced acceptance from the
receiving hospital.
11. THOU SHALL: Provide physician certification that the risks of
transfer are outweighed by benefits of transfer prior to transfer to another
facility and list the specific risks and benefits to this specific patient.
Discharge instructions to go to another facility are improper transfers
under EMTALA.
12. THOU SHALL: Provide transfer by medically appropriate vehicles,
personnel and life support equipment to the destination hospital. A private
auto does not meet these standards, even if the physician thinks is
acceptable, unless the patient has signed a refusal of ambulance.
13. THOU SHALL: Provide medical records, labs, reports, and consultation
records to accompany the patient on EMTALA transfers.
14. THOU SHALL: List the name of any on-call physician who refused or
failed to respond in timely manner, thereby requiring the patient to be
transferred for necessary evaluation or care.
15. THOU SHALL: Obtain written consent to transfer from the patient or
responsible party or provide reasonable documentation to justify the failure
to obtain written consent.
16. THOU SHALL: Obtain written refusal of services by a patient -- if
able -- and if not able, from a responsible person --if the patient/person
refuses, exam, treatment, ambulance, or transfer. The refusal must contain
specific risks of refusal and the advantages of consent.
17. THOU SHALL: Document all history, physical exam, monitoring and
interventions provided to the patient. Failure to document intake and
discharge vitals are not mandated by EMTALA but have repeatedly resulted in
citations for inadequate assessment where both intake and discharge vitals
are not noted. Failure to document is a violation of Medicare conditions of
participation and is frequently the basis of citations.
18. THOU SHALL: Periodically reassess patients as their category or
condition warrants and document those observations in the record. Failure
to reassess during extended waiting times and during the course of treatment
frequently results in citation.
19. THOU SHALL: Post EMTALA signs in all public entrances, waiting
areas, registration and care areas (rooms) in any area of the hospital or
remote site that qualifies as a dedicated emergency department under EMTALA.
20. THOU SHALL: Report any suspected, possible violations of EMTALA by
another facility that results in your facility improperly receiving a
patient without EMTALA compliance or in refusal of transfer of a patient of
your hospital by an appropriate destination hospital with specialized
services not available at your facility.
For informational and educational purposes only. Be certain to consult your hospital counsel for legal advice regarding policies, procedures, and legal obligations under this and other laws.
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