21 Tips for Ongoing Monitoring of EMTALA Compliance

Enforcement of EMTALA violations continues. Steps that can mitigate this risk include reviewing the policies governing compliance.

The following are 21 tips for Compliance Officers to ensure compliance in this risk area:

1. Verify that policies and procedures specifically address EMTALA compliance.
2. Verify that transfer policies and arrangements are being followed.
3. Determine whether there are long delays in the Emergency Department (ED).
4. Review triage and screening protocols and training.
5. Review on-call policies and contracts to ensure that the ED has adequate coverage.
6. Review bylaws related to who can conduct screens.
7. Ensure that staff members are not requesting payment prior to screening patients.
8. Review transfer forms and logs.
9. Conduct a medical record audit for screening and transfers.
10. Confirm whistleblower protections.
11. Review the internal reporting chain.
12. Review training materials and documentation.
13. Verify that specialists are on staff to meet the screening and stabilization requirements, as well as inpatient capabilities for stabilizing emergency patients.
14. Verify that policies prohibit retaliation against whistleblowers who make reports.
15. Verify a method to internally report (e.g., hotline) and address potential violations.
16. Check to see if there is a central log that is properly maintained for disposition and compliance with legal requirements.
17. Confirm that the physician on-call list reflects coverage of services available to inpatients.
18. Verify the triage of patients is being performed properly.
19. Verify that all physicians come to the facility when called and comply with the timeframes set forth in policies.
20. Confirm all transfers of individuals with unstabilized EMCs are initiated either by (a) a written request for transfer or (b) a physician certification regarding the medical necessity for the transfer.
21. Verify that there is an established transfer request log to capture the necessary information.

You can keep up-to-date with Strategic Management Services by following us on LinkedIn.

About the Author

Richard P. Kusserow established Strategic Management Services, LLC, after retiring from being the DHHS Inspector General, and has assisted over 3,000 health care organizations and entities in developing, implementing and assessing compliance programs.