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EMTALA: EMTALA: Getting Back to the BasicsGetting Back to the Basics

April 25, 2007 MorningApril 25, 2007 Morning Elizabeth (Lisa) Thomas, Esq.Elizabeth (Lisa) Thomas, Esq.

Dan Body, Esq.Dan Body, Esq. Ann M. Pfeiffer, RN, MSNAnn M. Pfeiffer, RN, MSN

Getting Back to the BasicsGetting Back to the BasicsA Brief Background and History A Brief Background and History Obligations Beyond PaperworkObligations Beyond Paperwork•• Posting of SignsPosting of Signs•• Medical recordsMedical records•• Central LogCentral LogOnOn--Call RequirementsCall Requirements•• ResponsibilitiesResponsibilities


A Brief Background and History of EMTALA: A Brief Background and History of EMTALA: Discussion of the Intent and Context of the "AntiDiscussion of the Intent and Context of the "Anti--

Dumping" StatuteDumping" Statute

EMTALA: The Background EMTALA: The Background Highly publicized incidentsHighly publicized incidentsEDsEDs failed to screen or transferfailed to screen or transferFinancial inadequacyFinancial inadequacy"Patient Dumping""Patient Dumping"Reports grew in 1980s:Reports grew in 1980s:•• Increase uninsured & underinsured Increase uninsured & underinsured •• Cost containment Cost containment

EMTALA: The HistoryEMTALA: The History19861986"COBRA""COBRA"Ensure public access to emergency Ensure public access to emergency servicesservicesRegardless of ability to payRegardless of ability to payMedicareMedicare--participating hospitals participating hospitals

EMTALA: A Brief OverviewEMTALA: A Brief OverviewEmergency Medical Treatment and Emergency Medical Treatment and Labor Act Labor Act Hospitals with Hospitals with EDsEDs§1866 and §1867 Social Security Act §1866 and §1867 Social Security Act 42 CFR §489.24 42 CFR §489.24 42 CFR §489.2042 CFR §489.20

EMTALA: A Brief OverviewEMTALA: A Brief OverviewAll individuals All individuals Not just Medicare beneficiaries Not just Medicare beneficiaries Screen any individual who comes to the Screen any individual who comes to the ED ED Prohibits refusing to examine or treat Prohibits refusing to examine or treat individuals with an emergency medical individuals with an emergency medical condition condition

Dedicated Emergency Department Dedicated Emergency Department Dedicated Emergency Department (DED)Dedicated Emergency Department (DED)(1) Licensed by the state as an ED(1) Licensed by the state as an ED(2) Held out to the public as providing treatment (2) Held out to the public as providing treatment

for for EMCsEMCs(3) One(3) One--third of the visits provided treatment for third of the visits provided treatment for

EMCsEMCs

EMTALA: EnforcementEMTALA: EnforcementComplaint driven processComplaint driven processHospitals may be terminated Hospitals may be terminated CMPsCMPs may be imposed against:may be imposed against:•• Hospitals and/or physiciansHospitals and/or physiciansCMS evaluates all complaints CMS evaluates all complaints Refers cases to the SA for investigation Refers cases to the SA for investigation


Obligations Beyond Paperwork: Obligations Beyond Paperwork: Posting of Signs, Maintaining Medical Posting of Signs, Maintaining Medical

Records and Central LogRecords and Central Log

EMTALA: Regulation OverviewEMTALA: Regulation Overview

Data Tags are cited for noncompliance Data Tags are cited for noncompliance Tags are correlated to specific regulationsTags are correlated to specific regulationsA400A400-- A411 Tags are the EMTALA A411 Tags are the EMTALA responsibilities responsibilities

A402: Posting of SignsA402: Posting of Signs42 CFR 489.20(q)42 CFR 489.20(q)

Post conspicuously Post conspicuously Rights of individuals with respect to:Rights of individuals with respect to:•• Examination Examination •• Treatment for Treatment for EMCsEMCs•• Women in labor Women in labor Participates in the Medicaid programParticipates in the Medicaid program

A402: Interpretive GuidelinesA402: Interpretive GuidelinesClear and simple termsClear and simple termsLanguages of population servedLanguages of population servedClearly readable Clearly readable A distance of at least 20 feet A distance of at least 20 feet

A403: Medical Records A403: Medical Records 42 §489.20(r)42 §489.20(r)

Maintain record for 5 yearsMaintain record for 5 yearsTransferring and receiving hospitalsTransferring and receiving hospitalsOriginal or legally reproduced form Original or legally reproduced form •• Hard copy, microfilm, microfiche, optical Hard copy, microfilm, microfiche, optical

disks, computer disks, or computer disks, computer disks, or computer memorymemory

A405: Central LogA405: Central Log42 §489.20(r)(3)42 §489.20(r)(3)

Individuals who present seeking Individuals who present seeking assistance:assistance:

•• Whether he or she refused treatment Whether he or she refused treatment •• Was refused treatmentWas refused treatment•• Whether he or she was transferredWhether he or she was transferred•• Admitted and treatedAdmitted and treated•• Stabilized and transferredStabilized and transferred•• DischargedDischarged

A405: Interpretative GuidelinesA405: Interpretative GuidelinesForm that meets the needs of the hospitalForm that meets the needs of the hospitalPatient logs from other areas that may be Patient logs from other areas that may be considered considered DEDsDEDsMay keep in an electronic formatMay keep in an electronic formatNo gaps in entries or missing infoNo gaps in entries or missing info

A408A408: : Delay in ExaminationDelay in Examination42 §489.24(d)(4) and (5)42 §489.24(d)(4) and (5)

No delay in exam or treatment to inquire:No delay in exam or treatment to inquire:•• Method of payment Method of payment •• Insurance statusInsurance status•• Authorization from insurance companyAuthorization from insurance companyReasonable registration processesReasonable registration processesTransferring and receiving hospitalsTransferring and receiving hospitals

"Little Tags" Cause Big Problems"Little Tags" Cause Big ProblemsPhysician onPhysician on--call lists for the past 6 call lists for the past 6 monthsmonthsDED logs for the past 6DED logs for the past 6--12 months12 months•• Gaps or nonGaps or non--sequential entries sequential entries •• Refusals of examination, treatment or Refusals of examination, treatment or

transfertransfer•• Leaving AMA or left without being seen Leaving AMA or left without being seen •• Returning within 48 hoursReturning within 48 hours

EMTALA: NonEMTALA: Non--Immediate Jeopardy Immediate Jeopardy

These Tags could follow a 90 day trackThese Tags could follow a 90 day trackWould not in themselves involve referral Would not in themselves involve referral to OIG for to OIG for CMPsCMPs"Red flag" to surveyors"Red flag" to surveyorsProvide a road map to a vulnerabilityProvide a road map to a vulnerability

EMTALA: Case ExamplesEMTALA: Case Examples

"Circular filing" of those patients that "Circular filing" of those patients that did not get past registrationdid not get past registrationLWBS or AMALWBS or AMATransfer forms Transfer forms Return within 48 hoursReturn within 48 hours


OnOn--Call Requirements: Call Requirements: No Easy Answers No Easy Answers Responsibilities and CMS GuidanceResponsibilities and CMS Guidance

A404: On CallA404: On Call42 CFR §489.24(j) 42 CFR §489.24(j)

42 CFR 489.20(r)(2)42 CFR 489.20(r)(2)

List of physicians who are on call to List of physicians who are on call to provide necessary stabilizing treatment provide necessary stabilizing treatment ED is prospectively aware ED is prospectively aware

A404: Interpretative GuidelinesA404: Interpretative GuidelinesNo requirements on frequencyNo requirements on frequencyNo ratio for days of call: staff physicians No ratio for days of call: staff physicians ""Manner that best meets the needs of Manner that best meets the needs of

the patients who are receiving services the patients who are receiving services under EMTALA according to resources under EMTALA according to resources availableavailable""Decision left to hospital and physiciansDecision left to hospital and physicians

A404: Interpretative GuidelinesA404: Interpretative GuidelinesIndividual MDs names are to be identifiedIndividual MDs names are to be identifiedNo physician is required to be onNo physician is required to be on--call at call at all times all times ED capability includes onED capability includes on--call servicescall services

A404: Interpretative GuidelinesA404: Interpretative GuidelinesTreating MD determines whether onTreating MD determines whether on--call call MD must physically assess the patientMD must physically assess the patientMD must arrive within the response timeMD must arrive within the response timeStated in minutesStated in minutesNonNon--physician practitioner may respondphysician practitioner may respondSelective on call is prohibitedSelective on call is prohibited

A404: Interpretative GuidelinesA404: Interpretative GuidelinesReferral of Emergency Cases to Referral of Emergency Cases to Physician Office:Physician Office:•• Part of a hospitalPart of a hospital--owned facility owned facility •• On the hospital campus On the hospital campus •• All persons are moved in such All persons are moved in such

circumstancescircumstances•• Bona fide medical reason Bona fide medical reason •• Appropriate medical personnel Appropriate medical personnel

A404: OnA404: On--CallCallP&P for situations:P&P for situations:•• Specialty is not available Specialty is not available •• On call cannot or does not respondOn call cannot or does not respondProvide emergency services to meet the Provide emergency services to meet the needs of patients with needs of patients with EMCsEMCs if:if:

•• OnOn--call physicians schedule elective surgery call physicians schedule elective surgery •• Physicians have simultaneous onPhysicians have simultaneous on--call dutiescall duties

EMTALA: Questions and EMTALA: Questions and ConcernsConcerns

On morning topics:On morning topics:BackgroundBackgroundObligations Beyond PaperworkObligations Beyond PaperworkOnOn--Call RequirementsCall Requirements

EMTALA:EMTALA: Getting Back to the BasicsGetting Back to the Basics

April 25, 2007 AfternoonApril 25, 2007 Afternoon

Elizabeth (Lisa) Thomas, Esq.Elizabeth (Lisa) Thomas, Esq. Dan Body, Esq.Dan Body, Esq.

Ann M. Pfeiffer, RN, MSNAnn M. Pfeiffer, RN, MSN

EMTALA: The BasicsEMTALA: The BasicsMedical Screening ExaminationMedical Screening Examination•• Requirements and Interpretative GuidelinesRequirements and Interpretative Guidelines

Stabilizing TreatmentStabilizing Treatment•• "Stable?""Stable?"•• Capability and CapacityCapability and Capacity

EMTALA TransferEMTALA Transfer•• Written Certification and four criteriaWritten Certification and four criteria

Recipient Hospital ResponsibilityRecipient Hospital Responsibility•• When you must acceptWhen you must accept


Medical Screening Examination: Medical Screening Examination: Definition, Requirements, Interpretative Definition, Requirements, Interpretative

GuidelinesGuidelines

A406:A406: Appropriate Medical Appropriate Medical Screening Examination (MSE)Screening Examination (MSE)

42 §489.24(a)42 §489.24(a)

Determine whether or not an emergency Determine whether or not an emergency medical condition (EMC) exists medical condition (EMC) exists Within the capability of the hospital’s EDWithin the capability of the hospital’s EDAncillary services routinely available Ancillary services routinely available Beyond initial triaging Beyond initial triaging

When is EMTALA Triggered?When is EMTALA Triggered?Request made for examination or Request made for examination or treatment:treatment:

•• By the individual By the individual •• On the individual’s behalfOn the individual’s behalf•• Prudent layperson observer Prudent layperson observer DED: aDED: a medical conditionmedical conditionElsewhere: an Elsewhere: an emergencyemergency medical medical conditioncondition

A406:A406: Appropriate Medical Appropriate Medical Screening Examination (MSE)Screening Examination (MSE)

Qualified Medical Person (QMP)Qualified Medical Person (QMP)•• Governing body approval Governing body approval •• Hospital byHospital by--laws laws •• Rules and regulations Rules and regulations Informal appointments are not acceptableInformal appointments are not acceptableDetermination of false laborDetermination of false labor

EMC is defined as:EMC is defined as:EMC defined as a medical condition EMC defined as a medical condition Acute symptoms of sufficient severityAcute symptoms of sufficient severity•• Severe pain Severe pain •• Psychiatric disturbances Psychiatric disturbances •• Symptoms of substance abuseSymptoms of substance abuse

EMC definition continued:EMC definition continued:Absence of immediate attention could Absence of immediate attention could result in:result in:•• Health in serious jeopardyHealth in serious jeopardy•• Serious impairment Serious impairment •• Serious dysfunctionSerious dysfunctionWomen having contractions:Women having contractions:•• Inadequate time to transfer before delivery Inadequate time to transfer before delivery •• Transfer may pose a threatTransfer may pose a threat

A406: Interpretative GuidelinesA406: Interpretative GuidelinesRegistered outpatient yet to begin careRegistered outpatient yet to begin careMovement to another department:Movement to another department:•• OnOn--campuscampus•• All persons with the same medical condition All persons with the same medical condition

are moved in such circumstancesare moved in such circumstances•• Bona fide medical reason Bona fide medical reason •• Appropriate personnel accompany individual Appropriate personnel accompany individual

A406: Interpretative GuidelinesA406: Interpretative GuidelinesNot applicable to offNot applicable to off--campus and noncampus and non--DED DED Depends on presenting symptomsDepends on presenting symptomsRange from simple to complex process Range from simple to complex process Ongoing processOngoing processLike MSE for like symptomsLike MSE for like symptomsNot outcome basedNot outcome based

A406: Interpretative GuidelinesA406: Interpretative GuidelinesDo not delay MSE of minor for consentDo not delay MSE of minor for consentHospital owned and operated ambulance Hospital owned and operated ambulance is "hospital property"is "hospital property"HelipadHelipadCommunity or State Plans do not Community or State Plans do not supersede EMTALA obligationssupersede EMTALA obligations

A406: Interpretative GuidelinesA406: Interpretative GuidelinesCMS guidelines in national emergency CMS guidelines in national emergency Hospitals responsible for providing a Hospitals responsible for providing a MSEMSETransfer or referral in accordance with Transfer or referral in accordance with community plan community plan Would not result in sanctions Would not result in sanctions

Documentation of MSEDocumentation of MSEMedical records should contain:Medical records should contain:•• History and physical examinationHistory and physical examination•• Medically indicated screenings Medically indicated screenings •• Laboratory and other tests resultsLaboratory and other tests results•• Mental status evaluation Mental status evaluation •• Impressions Impressions •• Diagnoses Diagnoses

Documentation of MSEDocumentation of MSEFor pregnant women: For pregnant women: •• Fetal heart tones Fetal heart tones •• Uterine contractions Uterine contractions •• Fetal position and station Fetal position and station •• Cervical dilationCervical dilation•• Status of membranesStatus of membranes

Documentation of MSEDocumentation of MSEFor individuals with psychiatric For individuals with psychiatric symptoms:symptoms:•• Suicide or homicide attempt Suicide or homicide attempt •• Suicide or homicide risk Suicide or homicide risk •• OrientationOrientation•• AssaultiveAssaultive behavior that indicates behavior that indicates

danger to self or othersdanger to self or others

““Appropriate” Appropriate” Does not mean “correct”Does not mean “correct”Not required to correctly diagnose Not required to correctly diagnose Negligence is not necessarily a violationNegligence is not necessarily a violationMeans suitable for symptoms presented Means suitable for symptoms presented Conducted in a nonConducted in a non--disparate fashion disparate fashion

DED for NonDED for Non--emergency Servicesemergency Services42 §489.24(c)42 §489.24(c)

Request is clear it is not an emergency Request is clear it is not an emergency Screening same Screening same Determine there is not an EMCDetermine there is not an EMCPharmaceutical servicesPharmaceutical servicesPreventative care servicesPreventative care servicesGathering of evidence for criminal lawGathering of evidence for criminal law


Stabilizing Treatment: Stabilizing Treatment: What Does "Stable" Really Mean?What Does "Stable" Really Mean?Capability and Capacity IssuesCapability and Capacity Issues

A407: Stabilizing TreatmentA407: Stabilizing Treatment42 §489.24(d)42 §489.24(d)

If an EMC exists: If an EMC exists: •• Provide further medical examination Provide further medical examination •• Any necessary stabilizing treatmentAny necessary stabilizing treatmentWithin the capabilities of the staff Within the capabilities of the staff Facilities available at the hospitalFacilities available at the hospitalRegardless if hospital will be paid Regardless if hospital will be paid

Stabilization is defined as:Stabilization is defined as:Medical treatment of the condition Medical treatment of the condition necessary to assure:necessary to assure:•• Within reasonable medical probability Within reasonable medical probability •• No material deterioration of condition is No material deterioration of condition is

likely to result from or occur during the likely to result from or occur during the transfer or discharge transfer or discharge

•• Woman has delivered child and Woman has delivered child and placentaplacenta

Documentation of StabilizationDocumentation of StabilizationDoes not apply to inpatientsDoes not apply to inpatientsMedical record reflects:Medical record reflects:•• Medically indicated treatment necessaryMedically indicated treatment necessary•• MedicationsMedications•• SurgeriesSurgeries•• ServicesServices•• Effect of treatment on the EMCEffect of treatment on the EMC•• Labor and condition of unborn childLabor and condition of unborn child

Capability is defined as:Capability is defined as:Physical spacePhysical spaceEquipment Equipment SuppliesSuppliesSpecialized services Specialized services •• Surgery, psychiatry, obstetrics, intensive care, Surgery, psychiatry, obstetrics, intensive care,

pediatrics, trauma carepediatrics, trauma care

Level of care personnel can Level of care personnel can provide provide OnOn--call rostercall roster

Capacity is defined as:Capacity is defined as:Census: occupancy of a specialized unitCensus: occupancy of a specialized unitNumber of staff on dutyNumber of staff on dutyEquipment on premises Equipment on premises Whatever customarily does to Whatever customarily does to accommodate patients in excess of accommodate patients in excess of occupancy limits occupancy limits

Refusal to consent to treatmentRefusal to consent to treatmentOffer further examination and treatment Offer further examination and treatment Written informed refusal indicates:Written informed refusal indicates:•• Risks of refusingRisks of refusing•• Benefits of consentingBenefits of consentingRecord contains description of what was Record contains description of what was

refused refused Take all reasonable steps to secure Take all reasonable steps to secure

EMTALA Obligation Ends EMTALA Obligation Ends (1) No EMC(1) No EMC(2) EMC exists: (2) EMC exists: •• AdmittedAdmitted•• Appropriately transferredAppropriately transferred


EMTALA Transfer: EMTALA Transfer: When is it Appropriate?When is it Appropriate?Written Certification and Four PreWritten Certification and Four Pre--requisitesrequisites

A409: Appropriate TransferA409: Appropriate Transfer42 42 §§489.24(e)489.24(e)

May not transfer with an EMC unless:May not transfer with an EMC unless:•• (1) appropriate transfer(1) appropriate transfer•• (2) request for transfer(2) request for transfer

Must be in writingMust be in writingIndicate the reasons for request Indicate the reasons for request Aware of the hospital's obligation, as well as risks Aware of the hospital's obligation, as well as risks and benefits of the transferand benefits of the transfer

Transfer is defined as:Transfer is defined as:Movement of an individual outside a Movement of an individual outside a hospital’s facilities hospital’s facilities Includes discharge Includes discharge At the direction of employee of the At the direction of employee of the hospitalhospitalDoes not include individuals:Does not include individuals:•• Declared dead Declared dead •• Who leave voluntarily Who leave voluntarily

Physician CertificationPhysician CertificationInformation available at time of transfer Information available at time of transfer Medical benefits expected of treatment Medical benefits expected of treatment Outweigh increased risks from being Outweigh increased risks from being transferred transferred Contains reason (s) for transferContains reason (s) for transferSummary of the risks and benefits Summary of the risks and benefits

Physician CertificationPhysician CertificationWhen a physician is not physically present When a physician is not physically present in ED:in ED:•• QMP signs certification QMP signs certification •• In consultation with physician who In consultation with physician who

agrees with certification agrees with certification •• Subsequently countersigns certificationSubsequently countersigns certification

A409: Four Requirements A409: Four Requirements (1)(1) Transferring hospital provides treatment within Transferring hospital provides treatment within

its capacityits capacity(2)(2) Receiving hospital has available space and Receiving hospital has available space and

personnel and has agreed to acceptpersonnel and has agreed to accept(3)(3) Medical records available at time of transfer Medical records available at time of transfer

sent to receiving hospital and includes the sent to receiving hospital and includes the name and address of any onname and address of any on--call MDcall MD

(4)(4) Transfer conducted through qualified Transfer conducted through qualified personnel and transportation equipmentpersonnel and transportation equipment

A409: First Requirement A409: First Requirement The hospital provides medical treatmentThe hospital provides medical treatmentWithin its capacity Within its capacity Minimizes risks:Minimizes risks:•• To the individual’s healthTo the individual’s health•• In the case of a woman in labor, the In the case of a woman in labor, the

health of the unborn childhealth of the unborn child

A409: Second Requirement A409: Second Requirement Recipient hospital:Recipient hospital:•• Available space Available space •• Qualified personnel for treatment of the Qualified personnel for treatment of the

individualindividual•• Agreed to accept transfer of the Agreed to accept transfer of the

individual individual •• Agreed to provide appropriate medical Agreed to provide appropriate medical

treatmenttreatment

A409: Third Requirement A409: Third Requirement Send all records available at time Send all records available at time Records related to the EMC:Records related to the EMC:•• HistoryHistory•• Observations of signs or symptoms Observations of signs or symptoms •• Treatment providedTreatment provided•• Preliminary diagnosisPreliminary diagnosis•• Results (telephone reports) of tests and Results (telephone reports) of tests and

diagnostic studiesdiagnostic studies•• Informed written consent or certification Informed written consent or certification Any onAny on--call physician who refused or call physician who refused or failed to appear failed to appear

A409: Fourth Requirement A409: Fourth Requirement Transfer is effected through:Transfer is effected through:Qualified personnel Qualified personnel Transportation equipmentTransportation equipment•• Use of necessary and medically Use of necessary and medically

appropriate life support measures appropriate life support measures

Women in LaborWomen in LaborTransferred only if she requests the Transferred only if she requests the transfertransferPhysician signs certification that Physician signs certification that benefits outweigh the risks: benefits outweigh the risks:

•• If obstetrical services are not providedIf obstetrical services are not provided•• Transfer agreements for handling highTransfer agreements for handling high--risk risk

deliveries or highdeliveries or high--risk infants risk infants Screening, treatment and transfer Screening, treatment and transfer requirements applyrequirements apply

A409: Interpretative GuidelinesA409: Interpretative GuidelinesMoved for diagnostics at another facility, Moved for diagnostics at another facility, appropriate transfer requirements applyappropriate transfer requirements applyImplementing an appropriate transfer Implementing an appropriate transfer back is not necessaryback is not necessaryVerified by surveyors through transferring Verified by surveyors through transferring

hospital’s information at the receiving hospital’s information at the receiving hospital and any EMS recordshospital and any EMS records


Recipient Hospital Responsibilities: Recipient Hospital Responsibilities: When you must accept and when it is ok to refuseWhen you must accept and when it is ok to refuse

A411: Recipient Hospital A411: Recipient Hospital ResponsibilitiesResponsibilities

42 §489.24(f)42 §489.24(f)Participating hospital that has specialized Participating hospital that has specialized capabilities including, but not limited to:capabilities including, but not limited to:•• burn units, shockburn units, shock--trauma units, neonatal trauma units, neonatal

intensive care units or regional referral intensive care units or regional referral centerscenters

Must accept from a U.S. referring hospital Must accept from a U.S. referring hospital Appropriate transfer requiring capabilities Appropriate transfer requiring capabilities If has the capacity to treat the individualIf has the capacity to treat the individual

A411: Interpretative GuidelinesA411: Interpretative GuidelinesResponsible if individual presents at the Responsible if individual presents at the receiving hospitalreceiving hospitalLateral transfers are not sanctionedLateral transfers are not sanctionedIndividual would likely benefit if the Individual would likely benefit if the transferring hospital lacks capacitytransferring hospital lacks capacity

EMTALA: Case Study #8EMTALA: Case Study #8

RecommendationsRecommendationsP&P for emergency medical services are:P&P for emergency medical services are:•• EstablishedEstablished•• EvaluatedEvaluated•• Updated on an ongoing basis. Updated on an ongoing basis.

Procedures assure integration with other Procedures assure integration with other hospital services, e.g.:hospital services, e.g.:•• Laboratory Laboratory •• RadiologyRadiology•• ICU and OR ICU and OR

Internal ReviewInternal ReviewMedical records from all facilities involvedMedical records from all facilities involved•• TransferringTransferring•• ReceivingReceivingEMS reportsEMS reportsRecords of delivery Records of delivery Records of neonateRecords of neonateInterviewsInterviews

TrainingTrainingRegularly scheduledRegularly scheduledDifferent modalitiesDifferent modalitiesApplicability to real life practiceApplicability to real life practiceCase studiesCase studies

Statistics for Region IV: Southeast Statistics for Region IV: Southeast

FY 2004FY 2004342 authorized, 71 in violation 342 authorized, 71 in violation

FY 2005FY 2005300 authorized, 79 in violation300 authorized, 79 in violation

FY 2006FY 2006273 authorized, > 70 in violation 273 authorized, > 70 in violation

some presome pre--decisionaldecisional

EMTALA: Question and ConcernsEMTALA: Question and ConcernsThank you.Thank you.

www.nelsonmullins.comwww.nelsonmullins.com

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