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

Program Overview
Emergencies occur daily throughout hospitals—not only in the emergency department. No matter a facility’s size or setting, it is essential to have protocols in place for managing urgent patient care. This training session will cover the CMS Conditions of Participation applicable to both acute care and critical access hospitals.

Hospitals with designated emergency departments that receive Medicare or Medicaid funding must adhere to federal regulations, including CMS’s Interpretive Guidelines under the Emergency Medical Treatment and Labor Act (EMTALA).

Even hospitals without an emergency department must follow EMTALA regulations if they provide specialized services. This includes responsibilities related to obstetric and behavioral health patients.

This session will outline federal law and CMS requirements related to emergency care services and include key updates on newly introduced maternal safety protocols that acute hospitals must follow.

Learning Goals

• Understand how emergency services in acute care facilities must integrate with other hospital departments

• Identify the 14 mandated emergency department policies required in Critical Access Hospitals (CAHs)

• Recognize the CMS-prescribed emergency medications and equipment CAHs must maintain

• Comprehend that hospitals must meet both EMTALA and emergency services obligations

Agenda Highlights

Emergency Services – Acute Care Facilities

• Importance of policies and procedures

• Role of qualified RNs in patient assessment

• Core patient care expectations

• Compliance with clinical standards

• Integration with performance improvement plans

• Requirements for medical oversight and staff training

• Coordination with urgent care and other service areas

• Adequate staffing levels and supervision

Emergency Services – Critical Access Hospitals (CAHs)

• Required ED policies

• Staffing criteria

• Essential supplies, drugs, and equipment

• Access to blood products

• Personnel and resource management

• Emergency response coordination

• Maternal care protocols and emergency procedures

EMTALA Compliance

• Fundamental obligations under EMTALA

• Facility capability and capacity standards

• Maintaining physician rosters

• Use of central logs

• Medical screening process

• Stabilization of pregnant patients

• Admission and transfer procedures

Maternal Safety Requirements

• Organizational structure and staffing needs

• Service delivery expectations

• Mandatory equipment

• Protocol development

• Staff competency and training programs

Who Should Participate?

• Chief Executive Officers

• Chief Nursing Officers

• Regulatory and accreditation leaders

• Nurse supervisors and managers

• Quality and risk management personnel

• Frontline nurses and educators

• Patient safety officers

• Emergency department leadership