EMTALA citation rates climbed from 4% of inspections in 2019 to 6.9% in 2024, concentrated in three categories: medical screening exams, appropriate transfers, and general EMTALA requirements. A July 2026 CMS proposed rule would add accreditor review of EMTALA administrative requirements to routine surveys — shifting the enforcement trigger from complaint to calendar, if finalized.
EMTALA concerns often reach CMS through complaints and state-agency investigations, and substantiated violations can lead to corrective action, Medicare-participation consequences, or referral to OIG for potential civil monetary penalties. Not every EMTALA survey deficiency begins with a complaint, and not every finding is referred to OIG. The compliance posture in most emergency departments reflects the traditional complaint-and-investigation pathway — EMTALA lives in the binder, not in the shift-change huddle.
That may be changing, in a specific and practical way.
According to a secondary analysis of CMS data, the proportion of inspections with at least one EMTALA citation rose from 4% in 2019 to 6.9% in 2024. The rate eased to 6.6% in 2025. The pattern of the last five years represents a sustained shift in enforcement posture, not a transient spike.
The violations are not concentrated in the places where most compliance programs invest their effort — complex transfer agreements, specialist on-call policies, or the legal definitions of stabilization. The shortcomings most frequently cited by inspectors fall into three categories: compliance with general EMTALA requirements (Tag A-2400), medical screening examinations (Tag A-2406), and appropriate transfers (Tag A-2409). Medical-screening and transfer deficiencies can involve substantive clinical and operational failures, not merely paperwork.
EMTALA violations can expose hospitals and responsible physicians to civil monetary penalties and other enforcement consequences. The applicable maximum penalty is adjusted for inflation and varies by provider type and enforcement period; use current OIG penalty guidance rather than a static dollar figure.
In the CY2027 Hospital Outpatient Prospective Payment System proposed rule, CMS-1850-P, released July 2 and published July 7, 2026, CMS proposed to permit approved accrediting organizations with Medicare deeming authority to assess the EMTALA administrative requirements at 42 CFR §§489.20(l), (m), (q), and (r) as part of accreditation and reaccreditation surveys.
Those provisions address, respectively: reporting suspected inappropriate transfers (§489.20(l)); required EMTALA/Medicaid-participation signage (§489.20(m)); maintenance of medical-record and transfer-related requirements, including a central log and retention of transfer records (§489.20(q)); and maintenance of an on-call list of physicians available to provide stabilizing treatment (§489.20(r)).
CMS would retain responsibility for the core clinical EMTALA duties under §489.24, including appropriate medical screening, stabilization, and transfer determinations. If an accrediting organization observes potential noncompliance with those substantive requirements, the proposal contemplates referral to CMS for further review and possible state-agency investigation.
This is a proposed, not final, change. If finalized and implemented through CMS-approved accrediting organizations' survey processes, the proposal would allow these defined administrative requirements to be assessed during accreditation and reaccreditation activity rather than only through the traditional complaint-and-investigation pathway. It would not convert every medical-screening or transfer dispute into an accreditor citation, and it would not eliminate CMS or OIG's existing enforcement roles.
If finalized, the proposal would make the administrative layer of EMTALA more likely to appear in a scheduled survey cycle. A pre-survey audit is sensible now. Here is what needs to be ready.
The medical screening exam. EMTALA requires an appropriate medical screening examination for an individual who comes to the emergency department and requests examination or treatment for a medical condition. Registration and insurance questions may occur, but they cannot delay the screening examination or be used to discourage the person from seeking care. The record should show timely clinical assessment and a workflow that does not condition care on payment information. Note: triage is not automatically an EMTALA-compliant medical screening examination; whether it is depends on the hospital's policies, the person performing it, the scope of the assessment, and the clinical facts.
Appropriate transfers. An appropriate transfer under EMTALA includes multiple elements: the transferring hospital provides medical treatment within its capability that minimizes risks; the receiving facility has available space and qualified personnel and has agreed to accept the transfer; the transferring hospital sends relevant medical records; the transfer occurs through qualified personnel and transportation equipment, including necessary life support; and the transfer is made with written physician certification that the medical benefits reasonably expected from transfer outweigh the increased risks. Sample transfer cases for accepting-facility agreement, risk/benefit certification where required, records sent, stabilization efforts, and appropriate transport — not artificial timestamp sequencing.
General EMTALA requirements. Verify that required EMTALA and Medicaid-participation signage is conspicuously posted in required locations. Validate that the ED central log captures each person who comes to the dedicated emergency department seeking care and records disposition. Confirm transfer records are retained and readily retrievable for the required period.
The on-call list. Audit whether the hospital maintains a current on-call list that identifies the physicians available to provide stabilizing treatment, reflects the hospital's approved coverage arrangements, and can be promptly accessed by ED staff. Hospitals have flexibility in structuring coverage, including permissible backup and on-call arrangements, and must maintain the list in accordance with EMTALA requirements.
The proposed rule's comment period closed August 31, 2026. A final rule is expected, but not certain. Whether and when CMS-approved accrediting organizations would actually conduct the review would depend on the final rule, CMS approval processes, accreditor program changes, survey protocols, and effective date.
The window between now and a final implementation is your pre-survey audit window regardless. Start with the on-call log. Run the last 90 days and ask: Is the log current and accurate, reflecting the hospital's approved coverage arrangements? Is it being maintained in real time or reconstructed after the fact? And is it accessible to the charge nurse on duty? The answers will tell you whether you are ready for a surveyor or whether you have a process problem to fix before the calendar brings one to your door.
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