Hospital accreditors may survey EMTALA administrative requirements (signage, central log, 5-year transfer records, on-call list) during accreditation surveys
Published November 8, 2026 · Coverage November 1–7, 2026, Pacific · Lower priority
CMS finalized, as proposed with clarifications, a new 42 CFR 488.5(a)(23) under which hospital accrediting organizations (AOs) with deeming authority review compliance with the EMTALA administrative requirements at 42 CFR 489.20(l), (m), (q) and (r) during initial accreditation and reaccreditation surveys: posting EMTALA signage, keeping a central log of individuals who present to the emergency department, retaining transfer records for 5 years and maintaining an on-call physician list. AOs cite deficiencies through their own procedures, including corrective action; findings that suggest violations of the substantive screening, stabilization and transfer rules at 489.24 stay with CMS and State Survey Agencies. Before surveying these elements, each AO must have an updated program approved by CMS, and AOs must show, as a condition of approval, that surveyors assigned to EMTALA administrative reviews have completed CMS-approved EMTALA training before conducting these assessments. CMS reported 1,071 EMTALA citations in calendar year 2025, 521 of them under 489.20.
Background
The Emergency Medical Treatment and Labor Act (EMTALA), enacted in 1986, applies to hospitals that participate in Medicare and operate emergency departments, including critical access hospitals (CAHs) and rural emergency hospitals (REHs). Its enforcement has historically occurred through complaint investigations by State Survey Agencies under CMS direction, while CMS deems a hospital to meet Medicare requirements if it is accredited by an accrediting organization with a hospital accreditation program approved by CMS.
Who this affects
Hospitals, critical access hospitals (CAHs) and rural emergency hospitals (REHs) accredited by CMS-approved accrediting organizations with deeming authority (the rule notes no REHs currently use a CMS-approved accreditation program); the accrediting organizations themselves.
Why it matters
Inference: EMTALA signage, logs, transfer-record retention and on-call lists will be checked at routine accreditation surveys, not only in complaint investigations. The underlying hospital duties are not new.
Required actions
- Accrediting organizations with CMS-approved hospital, CAH or REH programs: describe in the application the policies and procedures used to assess compliance with the EMTALA-related provider agreement requirements, and show that surveyors assigned to EMTALA administrative reviews completed CMS-approved EMTALA training before conducting those assessments, as a condition of approval (42 CFR 488.5(a)(23) and the preamble). The rule states no new duty for hospitals beyond the existing EMTALA requirements.
Recommended action
- Run a mock-survey check of the four 489.20 elements before the next accreditation survey
- Watch for the accreditor's updated standards and CMS interpretive guidance
Scope and timing
- Authority status
- Final
- Responsible owner
- Compliance / Accreditation (primary); Emergency Department leadership
- Publication date
- 2026-11-06
- Effective date
- 2027-01-01
- Implementation date
- Not fixed: each accrediting organization must first submit, and CMS approve, an updated accreditation program before surveying these elements
Not established
The rule's summary says AOs 'may assess' these requirements, while section XVIII says the amendment 'would formally require' AOs to include them, and the regulatory text requires each AO application to describe its assessment procedures. Which California-relevant AOs have filed program updates is unknown.
Sources
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