Please share this announcement with individuals in the following roles:

  • CEO, COO, CNO, Quality Director, Chief Medical Officer,
  • Quality Director,
  • Infection Control Coordinator, Emergency Preparedness Coordinator, Accreditation Coordinator

CMS QSO-20-15 EMTALA Requirements and Implications Related to COVID-19 (Revised 3/30/2020)

Key points:

This publication provides additional guidance for the establishment of drive-through testing sites, clarification of triage processes and the medical screening examination, and the use of EMTALA waivers. Links are provided throughout the QSO-20-15 memo to various resources from CDC and CMS related to COVID-19 and EMTALA.

CMS provides a question and answer document on page 11 of this QSO for organizations to reference for EMTALA obligations and Coronavirus.

Additional guidance in this memo for managing COVID-19 in relation to EMTALA includes:

  1. The receiving hospital may refuse the transfer of patients with suspected or confirmed COVID-19 if they do not have the capacity to provide necessary care and services. Transfer should not be solely based on the use of negative pressure rooms when, in most cases, a private room is appropriate for care.
  2. Patients may have medical screen exams (MSE) performed in the ED or at an alternate on-campus site. Patients can be redirected to the on-campus site for logging in and MSE, even if they arrive in the ED first. If the patient is redirected from the ED, the person redirecting the individual should be qualified, e.g. RN, to recognize an individual in need of immediate treatment in the ED.
  3. Guidance on screening at off-campus, hospital-controlled sites. An off-campus site can be used as screening center for respiratory or potential/presumed COVID-19 patients instead of the hospital. Guidance on who should be staffing this site.
  4. Guidance for communities or hospitals setting up testing stations at sites not under the control of a hospital. If patients are referred to this site from the ED, MSE must be provided by the ED prior to recommendation to determine there is no emergency medical condition. Protocols and processes must be in place to transport patients who arrive at the testing station in medical distress.
  5. Further guidance on EMTALA obligations when Screening Suggest Possible COVID-19, including posting signage directing individuals to testing locations, isolation of suspected COVID-19 individuals and stabilization of individual before transport
  6. Conditions of Participation must be maintained for EMTALA, infection control practices, and OSHA requirements.

Are any HFAP Standards affected? This is provided for information only. If your organization is surveyed during the COVID-19 pandemic, HFAP surveyors will survey the organization using the most up-to-date CMS requirements and 1135 waivers approved for the organization or state.

Effective date: March 30, 2020 (supersedes March 9, 2020 memo)

Read the entire memo.  

Questions? Email info@hfap.org.