CMS SOM App. A, Tag A-0093

assure that the medical staff has written policies and procedures for appraisal of emergencies,

initial treatment, and referral when appropriate.

Interpretive Guidelines §482.12(f)(2)

This requirement applies hospital-wide (all on-campus and off-campus locations) to hospitals that do not

provide emergency services.

Hospitals without emergency departments must have appropriate policies and procedures in place for

addressing individuals’ emergency care needs 24 hours per day and 7 days per week, including the

following:

• Appraisal of Persons with Emergencies: A hospital must have medical staff policies and

procedures for conducting appraisals of persons with emergencies. The policies and procedures

must ensure that:

o As required by 42 CFR 482.23(b), an RN is immediately available, as needed, to provide

bedside care to any patient and that,

o Among such RN(s) who are immediately available at all times, there must be an RN(s) who

is/are qualified, through a combination of education, licensure, and training, to conduct an

assessment that enables them to recognize the fact that a person has a need for emergency

care.

The policies and procedures for appraisal should provide that the MD/DO (on-site or on-call)

would directly provide appraisals of emergencies or provide medical direction of on-site staff

conducting appraisals.

• Initial Treatment: A hospital must have medical staff policies and procedures for providing the

initial treatment needed by persons with emergency conditions. Among the RN(s) who must be

available at all times in a hospital as required by 42 CFR 482.23(b), there must be RN(s) who are

qualified, through a combination of education, licensure, and training, to provide initial treatment

to a person experiencing a medical emergency. The on-site or on-call physician could provide

initial treatment directly or provide medical oversight and direction to other staff. This

requirement, taken together with other hospital regulatory requirements, suggests that a prudent

hospital would evaluate the patient population the hospital routinely cares for in order to

anticipate potential emergency care scenarios and develop the policies, procedures, and staffing

that would enable it to provide safe and adequate initial treatment of an emergency.

• Referral when Appropriate: A hospital must have medical staff policies and procedures to

address situations in which a person’s emergency needs may exceed the hospital’s capabilities.

The policies and procedures should be designed to enable hospital staff members who respond to

emergencies to: (a) recognize when a person requires a referral or transfer, and (b) assure

appropriate handling of the transfer. This includes arrangement for appropriate transport of the

patient. Further, in accordance with the Discharge Planning CoP at 42 CFR 482.43(d), the

hospital must transfer patients to appropriate facilities, i.e., those with the appropriate capabilities

to handle the patient’s condition. The regulation also requires that necessary medical

information be sent along with the patient being transferred. This enables the receiving hospital

to treat the medical emergency more efficiently.

• Patient Transportation and Emergency Medical Services (EMS)

A hospital may arrange transportation of the referred patient by several methods, including using

the hospital’s own ambulance service, the receiving hospital’s ambulance service, a contracted

ambulance service, or, in extraordinary circumstances, alerting EMS via calling 9-1-1. There is

no specific Medicare prohibition on a hospital with or without an emergency department calling

9-1-1 in order to obtain transport of a patient to another hospital. Use of 9-1-1 to obtain transport

does not, however, relieve the hospital of its obligation to arrange for the patient’s transfer to an

appropriate facility and to provide the necessary medical information along with the patient.

A hospital policy or practice that relies on calling 9-1-1 in order for EMS to substitute its

emergency response capabilities for those the hospital is required to maintain, as described

above, is not consistent with the Medicare CoPs. For example, a hospital may not rely upon 9-

1-1 to provide appraisal and initial treatment of medical emergencies that occur at the

hospital. Such policy or practice should be considered as condition-level non-compliance with

the applicable CoP, 42 CFR 482.55 or 42 CFR 482.12(f).

Survey Procedures §482.12(f)(2)

• Verify that the medical staff has adopted written policies and procedures for the management of

medical emergencies.

• Review emergency care policies and procedures. Are they consistent with the expectations

articulated above for appraisal, initial treatment, and referral? Do they address emergency

procedures for all on-campus and off-campus locations?

• Interview hospital staff at various locations. Can they state their duties and what they are to do if

an individual seeks or needs emergency care at their location?