PAGE: 1 of 5
POLICY DESCRIPTION: EMTALA – Hospital Based
Departments both On and Off Campus
REPLACES POLICY DATED: 1/1/2001; 1/30/2004
EFFECTIVE DATE: August 1, 2004
REFERENCE NUMBER: LL.EM.008
DEPARTMENT: Legal
SCOPE: All Company-affiliated facilities including hospitals and any entities operating under the
hospital’s Medicare Provider Number including, but not limited to, the following:
All Clinical Departments
Ancillary Services
Admitting/Registration
Employed Physicians
Hospital owned Medical Office Buildings
Hospital owned emergency vehicles
Nursing
Hospital Department (on and off campus)
Administration
Quality Management
Risk Management
Emergency Department
Urgent Care Centers/Clinics
Ambulatory Care Facilities
Finance
PURPOSE: To ensure that all individuals with potential emergency conditions, who present to a
department of the hospital other than the dedicated emergency department located on or off campus
and On-Campus hospital based departments, and request (or if in the absence of a request, the
individual’s appearance or behavior were such that a prudent layperson observer would believe the
individual needed examination or treatment for an emergency medical condition and that the
individual would request that examination or treatment if he or she were able to do so) examination
or treatment for an emergency medical condition, receive appropriate emergency medical care.
POLICY: The governing body of the hospital will assure that the hospital staff has written policies
and procedures in effect with respect to hospital based departments both on and off-campus for
appraisal of emergencies and referrals, when appropriate. Any individual who presents to a
department of the hospital, other than a dedicated emergency department, located on or off-campus
and on-campus provider-based departments and requests examination and treatment for an emergency
medical condition, will receive appropriate care according to the written policies and procedures and
guidelines established for off-campus non-emergency facilities and on-campus hospital-based
departments of the hospital.
PROCEDURE: Please refer to the EMTALA - Medical Screening Policy, LL.EM.001, for a
complete list of definitions pertaining to this policy.
1. EMTALA does not apply to an individual who presents to and requests care from a department
off the hospital’s main campus other than a dedicated emergency department. The off-campus
department should provide whatever assistance is within its capability and call the local
emergency medical service (“EMS”) to take the individual to the closest emergency department.
Under the Conditions of Participation, such off campus departments are still required to have
written policies and procedures for appraisal of emergencies and referrals where appropriate.
2. On-campus provider-based entities (such as rural health clinics or physician offices) are not
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PAGE: 2 of 5
POLICY DESCRIPTION: EMTALA – Hospital Based
Departments both On and Off Campus
REPLACES POLICY DATED: 1/1/2001; 1/30/2004
EFFECTIVE DATE: August 1, 2004
REFERENCE NUMBER: LL.EM.008
DEPARTMENT: Legal
subject to EMTALA.
3. Any individual who presents to an on or off-campus department or an on-campus hospital-based
department that qualifies as a dedicated emergency department and requests examination or
treatment for a medical condition will be provided with an appropriate emergency medical
screening examination and any necessary stabilizing treatment.
4. Any individual who presents to an on campus department or an on-campus hospital-based
department which is not a dedicated emergency department and requests examination or treatment
of an emergency medical condition will be provided a medical screening examination if he or she
requests one or if a request is made on their behalf.
5. The hospital must establish guidelines for appraisal of individuals who come to the on or offcampus departments and on campus hospital-based departments which are not dedicated
emergency departments and request care for emergency medical conditions. The Conditions of
Participation require that off-campus departments have written policies and procedures for
appraisal of emergencies for individuals who present to off-campus departments that are not
dedicated emergency departments.
6. EMTALA does not apply to provider-based entities such as Rural Health Clinics and Skilled
Nursing Facilities that are located on the hospital campus, therefore, a medical screening
examination is not required. Such entities should have written policies and procedures and
guidelines in place for dealing with individuals who come to the provider-based entity seeking
emergency care.
7. The capability of the department of the hospital located on campus and on-campus hospital-based
departments to provide screening, treatment and stabilization for emergency medical conditions
includes the capability of the hospital as a whole, not just the capability of the department of the
hospital located on or off campus and on-campus hospital based department.
8. The hospital is not required to add additional personnel or staff to a department of the hospital
located on or off campus and on-campus hospital-based departments to be on standby for possible
emergencies.
9. Personnel at a department of the hospital located on campus and on-campus hospital- based
departments which are not dedicated emergency departments must have direct contact with the
dedicated emergency department physician or personnel when an individual presents requesting
emergency medical care.
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PAGE: 3 of 5
POLICY DESCRIPTION: EMTALA – Hospital Based
Departments both On and Off Campus
REPLACES POLICY DATED: 1/1/2001; 1/30/2004
EFFECTIVE DATE: August 1, 2004
REFERENCE NUMBER: LL.EM.008
DEPARTMENT: Legal
10. The hospital may, when deemed appropriate by the emergency physician and the administratoron-call, dispatch practitioners from the main campus to the department of the hospital located on
campus to provide screening or stabilization services.
11. For a department of the hospital located on or off campus and on-campus hospital- based
departments such as urgent care centers, primary care centers or other facilities that meet the other
criteria for a dedicated emergency department the following apply:
a. at least one individual on duty at the department during its regular hours of operation must
either be a physician or be designated by the hospital governing board as a qualified medical
personnel for the purposes of performing a medical screening examination and necessary
stabilization;
b. if there is a physician on duty, the physician will perform the screening examination on any
individual who presents and requests screening and/or treatment for an emergency medical
condition;
c. if the designated qualified medical personnel is a registered nurse, guidelines must be
established by the medical staff and approved by the hospital governing board for conduct of
the medical screening examination; and
d. necessary education, training and validation of competence of the qualified medical personnel
must be conducted and documented.
i.
The physician or qualified medical personnel must initiate the screening of any
individual who comes to the department of the hospital located on campus and oncampus provider based department and requests screening or treatment for an emergency
medical condition.
ii.
With consultation from the hospital emergency physician, the physician or qualified
medical personnel must either complete the screening and provide any necessary
stabilizing treatment at the department of the hospital located on campus or on campus
provider based department; move the patient to the hospital; or arrange an appropriate
transfer to another facility.
12. For a department of the hospital located on campus and on-campus hospital-based departments
such as physical therapy, radiology, or other departments not routinely staffed with physicians,
RNs, or LPNs:
a. guidelines must be established directing the department’s personnel to contact emergency
personnel at the hospital for direction; and
b. at a minimum, personnel in the department of the hospital located on campus or on campus
provider based departments must:
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PAGE: 4 of 5
POLICY DESCRIPTION: EMTALA – Hospital Based
Departments both On and Off Campus
REPLACES POLICY DATED: 1/1/2001; 1/30/2004
EFFECTIVE DATE: August 1, 2004
REFERENCE NUMBER: LL.EM.008
DEPARTMENT: Legal
i.
ii.
iii.
iv.
v.
vi.
vii.
contact the dedicated emergency department and speak to the individual responsible for
conversing with Emergency Medical System personnel;
describe patient appearance;
report all symptoms;
at the direction of the emergency physician at the dedicated emergency department,
either arrange for transportation of the individual to the dedicated emergency department
or assist in the appropriate transfer of the individual to another hospital;
if the movement of the individual to the dedicated emergency department would not
significantly jeopardize the life or health of the individual, the personnel at the
department of the hospital located on campus or on campus hospital-based departments
must assist in arranging this movement (which is not considered a transfer); and
if the transfer of an individual with a potential emergency medical condition to a
medical facility other than the hospital is warranted, either because the hospital does not
have the specialized capability or facilities required by the individual, or because the
individual’s condition is deteriorating so rapidly that movement to the hospital would
significantly jeopardize the life or health of the individual, personnel at the department
of the hospital located on campus or on campus provider based departments must assist
in arranging an appropriate transfer of the individual to a medical facility other than the
hospital.
The physician or qualified medical provider must initiate the transfer in accordance with
the provisions for transfer delineated in the EMTALA - Transfer Policy, LL.EM.003.
13. Off-campus hospital-based departments that do not routinely offer services for emergency
medical conditions would not be subject to EMTALA. However, for those individuals who may
occasionally present to the off-campus hospital based department seeking emergency medical
care, the hospital should have in place the following;
a. written policies and procedures in effect for appraisal of emergencies and referrals for
individuals who come to the off-campus non-emergency facilities to seek emergency care; and
b. for those individuals who come to the off-campus non-emergency hospital based department
seeking emergency care, the department should:
i.
call an emergency medical service (“EMS”)
ii.
provide whatever assistance it can to the individual while awaiting arrival of the EMS
personnel
iii.
document such assistance provided in the medical record.
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PAGE: 5 of 5
POLICY DESCRIPTION: EMTALA – Hospital Based
Departments both On and Off Campus
REPLACES POLICY DATED: 1/1/2001; 1/30/2004
EFFECTIVE DATE: August 1, 2004
REFERENCE NUMBER: LL.EM.008
DEPARTMENT: Legal
REFERENCES:
EMTALA Medical Screening Policy, LL.EM.001
EMTALA Stabilization Policy, LL.EM.002
EMTALA Transfer Policy, LL.EM.003
EMTALA Signage Policy, LL.EM.004
EMTALA Central Log Policy, LL.EM.005
EMTALA Duty to Accept Policy, LL.EM.006
EMTALA Provision of On-Call Coverage Policy, LL.EM.007
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