CMS SOM App. A, Tag A-0094

more off-campus departments of the hospital, the governing body of the hospital must assure that

the medical staff has written policies and procedures in effect with respect to the off-campus

department(s) for appraisal of emergencies and referral when appropriate.

Interpretive Guidelines §482.12(f)(3)

This requirement applies to any off-campus hospital department/location that does not qualify as a

dedicated emergency department in accordance with 42 CFR 489.24(b) and is part of a hospital that

provides emergency services. Such departments/locations must have and must implement medical staff

policies and procedures for the appraisal of emergencies and referral when appropriate.

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

procedures for conducting appraisals of persons with emergencies at off-campus

departments/locations that are not dedicated emergency departments. The policies and procedures

must ensure that clinical personnel -- who 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 -- are available during all hours of operation at the off-campus

department/location.

• 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 capabilities of the off-campus

departments/locations that are not dedicated emergency departments. The policies and procedures

should be designed to enable staff members at such locations 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 along with the transfer of the patient’s medical

information so that the receiving hospital may treat the medical emergency more efficiently.

• Initial Treatment: Although there is no specific regulatory requirement for such off-campus

departments or locations to provide initial treatment of emergencies, nevertheless they are expected

to provide treatment and stabilization consistent with the complexity of services, the type and

qualifications of clinical staff, and the resources available at that location. This expectation is based

on the requirements of the Outpatient Services CoP that hospital outpatient services meet the needs

of the patients in accordance with acceptable standards of practice, outpatient services must be

appropriately organized and integrated with inpatient services, and outpatient services must have

appropriate professional and nonprofessional personnel available. For example, an off-campus

cardiac rehabilitation clinic would be expected to have the appropriate qualified staff, equipment

(such as a crash cart), and policies and procedures in place to appropriately provide appraisal, initial

interventions, and referral of a patient who experiences a cardiac emergency.

• 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 at its off-campus

departments/locations, as described above, is not consistent with the Medicare CoPs. However,

given the more limited emergency capabilities that may be present in some off-campus departments

or locations, calling 9-1-1 to respond to an emergency might be appropriate.

See the hospital emergency services CoP (42 CFR 482.55) for the emergency requirements for the

hospital’s locations that provide emergency services.

Survey Procedures §482.12(f)(3)

• Review emergency care policies and procedures. Determine if they address emergency

procedures for all off-campus locations.

• Interview off-campus hospital department staff. Can they state their duties and what they are to

do if an individual seeks emergency care?