On April 26, 2007, the Centers for Medicare and Medicaid Services ("CMS") issued guidance in the form of a Survey and Certification Letter ("Letter") for Medicare certified hospitals that provide emergency services. Effective immediately, all hospitals, notably even those without emergency departments, must be able to evaluate persons with emergencies, provide initial treatment, and refer or transfer individuals with emergencies, as appropriate. The guidance applies to specialty hospitals but does not apply to Critical Access Hospitals, as they are subject to separate regulation.
In the Letter, CMS set forth three key requirements for all hospitals regarding emergency services, including the following:
(1) Capability of 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 for appraisal should provide that the physician (on-site or on-call) would directly provide appraisals of emergencies or provide medical direction for on-site staff conducting appraisals. The policies and procedures must take into consideration all other applicable Medicare Conditions of Participation ("COP"), as well as, ensure that:
- A RN is immediately available, as needed, to provide bedside care to any patient; and
- Among such RN(s) who are immediately available at all times, there must be at least one RN who is qualified, through a combination of education, licensure, and training, to conduct an assessment that enables the RN to recognize the fact that a person has a need for emergency care.
(2) Provide initial treatment: A hospital must have medical staff policies and procedures for providing the initial treatment needed by persons with emergency conditions. 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 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 policies and procedures that would enable it to provide safe and adequate initial treatment.
(3) 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. 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.
CMS also clarified that the COP do not permit a hospital policy or practice to rely on calling 911 in order for emergency medical services to substitute for the hospital’s emergency response capabilities. For example, a hospital may not rely on 911 to provide appraisal and initial treatment of medical emergencies that occur at the hospital; however, a hospital may arrange transportation of the referred patient by several methods, including using the hospital’s own ambulance service or calling 911 in order to obtain transport.
The Letter also addressed a proposed rule issued on April 13, 2007, that would increase transparency and public disclosure concerning emergency services. The proposed rule for the 2008 hospital inpatient perspective payment system ("IPPS") would require a hospital to notify all patients, in writing, if a physician is not present in the hospital 24 hours a day, 7 days per week. This rule would require hospitals to disclose how they would meet the medical needs of a patient who develops an emergency condition when a physician is not on site. CMS also invited comments on whether current requirements for emergency service capabilities in hospitals without emergency departments should be strengthened in certain areas, such as the type of clinical personnel that should be present at all times and their competencies; the type of emergency response equipment that should be available; and whether hospital emergency departments should be required to operate 24 hours per day, 7 days per week.
In addition, the Letter discussed CMS’s implementation efforts to date as required by the Strategic and Implementing Plan for Specialty Hospitals that CMS reported to Congress in August 2006, in accordance with the provisions of section 5006 of the Deficit Reduction Act of 2005.
Survey and certification letters are used by state surveyors to provide guidance as to whether or not a hospital meets the COPs; they are not regulations in and of themselves. This Letter reaffirms CMS’s position that all Medicare-participating hospitals have policies and procedures in place to handle patients presenting with emergency conditions. While applicable to all Medicare-participating hospitals, the Letter has special applicability to specialty hospitals that do not have established emergency departments. To ensure continued compliance with the COPs, such hospitals should evaluate their policies and procedures to ensure they comply with the guidance provided in the Letter.