Corporate Compliance

Tip: Learn how EMTALA violations can affect your accreditation

Compliance Monitor, April 14, 2004

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Hospitals that are not in compliance with EMTALA may not receive accreditation from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). During an accreditation survey, the JCAHO will verify that a hospital is in compliance with various specific standards applicable to the provision of urgent or emergency care.

JCAHO looks at the following during an accreditation survey for patients in need of emergency care and/or patients receiving emergent, urgent, or immediate care:

1. Assessment of patients-a licensed independent practitioner (LIP) determines the scope of assessment and care for patients

2. Continuum of care

  • an LIP is responsible for determining what assessments the patient requires to care for his/her needs
  • the hospital ensures coordination among health professionals and services or settings involved in a patient's care
  • the hospital provides for referral, transfer, or discharge of the patient to another level of care based on the patient's assessed needs and the hospital's capacity to provide the care
  • the discharge process provides for continuing care based upon the patient's assessed needs at the time of discharge
  • once a patient requests or presents for care, the hospital must provide care that is within its capacity, mission, and the applicable law and regulation

    3. Management of information

  • when care is provided, the time and means of arrival are documented in the medical record
  • if the patient has been treated previously at your facility, the records, dictations and important information, such as lab results, are made available
  • the medical record notes when a patient leaves against medical advice
  • the medical record notes the conclusions at termination of treatment, including final disposition, condition at discharge, and follow-up care.

    Editor's note: the following was adapted from A Practical Guide to EMTALA Compliance by Joseph Gatewood, Esq., Loren Johnson, MD, FACEP, and Ellen Arrington, RN, BSN. Copyright 2004 by HCPro. To learn more, click here.



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