Emergency Services, Emergency Procedures and EMTALA Obligations: 2025 CMS Hospital Conditions of Participation

Emergencies happen every day in a hospital – not just in the emergency department. Regardless of a hospital’s size or location, provisions must be in place to address and treat emergency care issues for patients. This program will address the CMS Conditions of Participation for both acute and critical access hospitals.

Every hospital that has a dedicated emergency department and accepts Medicare and Medicaid payment must follow the federal law and the Center for Medicare and Medicaid Services (CMS) Conditions of Participation Interpretive Guidelines on the Emergency Medical Treatment and Labor Act (EMTALA).

Hospitals without such emergency departments must comply with EMTALA if they have specialized capabilities. For example, EMTALA can impact obstetrical patients and behavioral health patients.

This program will provide an overview of the Federal Law and CMS requirements for hospitals in meeting those requirements. There will also be a discussion of the recently implemented maternal safety standards acute hospitals must meet.

Objectives

• Describe the requirement for emergency services in an acute hospital to be integrated into other services
• Recall the required14 emergency department written policies that must be present in a Critical Access Hospital
• Describe that CMS has a list of emergency drugs and equipment every CAH must have
• Recall that hospitals must also comply with EMTALA requirements in addition to emergency services requirements

Emergency Services – Acute Hospitals

• Need for P&P
• Qualified RN to assess patients
• Basic patient care requirements
  • Services must meet patient needs
  • Following standards of practice
  • Integrated into hospital PI
  • Qualified medical director
  • Policies required
  • Training required
• Maternal Safety Standards
• Urgent care clinics

Emergency Services – Critical Access Hospitals

• 14 Emergency department policies
• ED staffing
• Equipment, Supplies, and Medication
• Blood and Blood Products
• Staffing/Personnel
• Coordination with Emergency Response Systems
• Emergency medical services
• Maternal Safety Standards
• Emergency procedures

EMTALA Obligations

• Basic obligations
• Capacity and Capability
• Physician lists
• Central log
• Medical Screening examination
• Pregnant patients and stabilization
• Admit or transfer

Appendix and Resources

Who Should Attend?

 CEOs,
Chief Nursing Officer
Accreditation and regulation director
Nurse managers/supervisors
Quality managers
Risk managers
Nurses
Nurse educators
Patient safety officer
Emergency department directors
 

SPEAKER – Laura A. Dixon, BS, JD, RN, CPHRM
Laura A. Dixon recently served as the Regional Director of Risk Management and Patient Safety for Kaiser Permanente Colorado where she provided consultation and resources to clinical staff. Prior to joining Kaiser, she served as the Director, Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Such services included creation of and presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products.

Prior to joining COPIC, she served as the Director, Western Region, Patient Safety and Risk Management for The Doctors Company, Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the western United States. Ms. Dixon’s legal experience includes medical malpractice insurance defense and representation of nurses before the Colorado Board of Nursing.

Ms. Dixon has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management.

As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa. She is licensed to practice law in Colorado and California.