EMTALA Update 2022 – August 3, 10 and 17, 2022


Important Registration Information: Please register using the PDF form or contact the THA Service Center at 512/465-1057 or servicecenter@tha.org to register. Our online registration system is currently unavailable as we update the website.

EMTALA is a hot topic and should be on the radar screen for every hospital. There have been a recent increased number of deficiencies and increased CMS and OIG activity. It is important for hospitals to be prepared should a CMS surveyor walked into your hospital today to investigate an EMTALA complaint.

This 3-part webinar series will include the regulations and interpretive guidelines. It will include all 12 sections and an expanded section for on-call physicians and the shared and community care plan process. The federal EMTALA law and the accompanying regulations are complex. This program is structured to make the requirements understandable with the liberal use of examples.

Part 1

  • Recognize EMTALA as a frequently cited deficiency for hospitals
  • Recall that CMS has a manual on EMTALA that all hospitals that accept Medicare must follow

Part 2

  • Describe that the hospital must maintain a central log
  • Discuss the hospital’s requirement to maintain a list of the specific names of physicians who are on call to evaluate emergency department patients
  • Describe the CMS requirements on what must be in the EMTALA sign

Part 3

  • Describe the hospital’s requirements regarding a minor who is brought to the ED by the babysitter for a medical screening exam
  • Discuss when the hospital must complete a certification of false labor

Target Audience

CEOs, chief operations officers, chief nursing officers, chief legal officers, nurses and medical staff, quality Emergency department managers, medical director, ED physicians and nurses and ED education staff; OB managers and nurses; behavioral health director and staff; CNO, nursing supervisors, nurse educators and staff nurses; outpatient directors; compliance officers, legal counsel, and risk manager; directors of hospital-based ambulance services; director of registration and staff; on-call physicians, chief medical officer, chief financial officer, patient safety officer and Joint Commission coordinator.


Susan Seeley, MSN, RN, NEA-BC, Senior Consultant, Nash Healthcare Consulting

Susan Seeley has over 40 years of experience in the healthcare industry both as a nurse leader and as a clinical consultant with a focus on patient care services and regulatory compliance. As a consultant, she is experienced in conducting CMS and Joint Commission mock surveys and improving client hospitals’ accreditation survey preparedness through on-site education.

Sue has prepared organizations for continuous survey readiness by implementing ongoing teams to continue regulatory compliance after mock surveys. She also assists organizations with writing and implementing successful Plans of Corrections for EMTALA and other CMS and Joint Commission survey deficiencies. She has also performed assessments of quality programs and reviews of clinical operations, the structure and function of medical staff committees and implementation of peer review quality plans.

Fred Fehlinger, BSN, RN, PHRN, EMTP, Consultant, Accreditation and Regulatory Survey Readiness, Nash Healthcare Consulting

Fred Fehlinger is a nurse consultant for survey preparedness, on-site support and remediation for programs under The Joint Commission, CMS, DNV and specific Sate programs. These areas include hospital, ambulatory healthcare, critical access hospital, long term care and addiction/substance use. He also has years of expertise in quality, patient safety, infection control, case management, environment of care, emergency preparedness, medical staff, provision of care, patient’s rights, organizational leadership, and process improvement.

Fred’s background includes experience resolving and responding to OSHA complaints and survey findings, condition level deficiency findings, EMTAL violations and immediate threat/immediate jeopardy deficiencies. In his previous hospital positions, he worked in senior leadership positions as a quality Officer, Market Chief Quality Officer, Regional Director of Survey Readiness/Quality, and Director of Quality and Risk Management for Community Health Systems.

Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by AXIS Medical Education and Texas Hospital Association. AXIS Medical Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Credit Designation for Nursing
AXIS Medical Education designates this continuing nursing education activity for 2.0 contact hours each.

Learners are advised that accredited status does not imply endorsement by the provider or ANCC of any commercial products displayed in conjunction with an activity.

AXIS Contact Information 
For information about the accreditation of this program please contact AXIS at info@axismeded.org.

Disclosure of Conflicts of Interest
AXIS Medical Education requires faculty, instructors, authors, planners, directors, managers, reviewers and other individuals who are in a position to control the content of this activity to disclose all real or apparent conflicts of interest they may have with ineligible companies. An ineligible entity is any organization whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. All relevant conflicts of interest are identified and mitigated prior to initiation of the planning phase for an activity.

AXIS has mitigated and disclosed to learners all relevant conflicts of interest disclosed by staff, planners, faculty/authors, peer reviewers, or others in control of content for this activity. Disclosure of a relationship is not intended to suggest or condone bias in any presentation but is made to provide participants with information that might be of potential importance to their evaluation of a presentation or activity. Disclosure information for faculty, authors, course directors, planners, peer reviewers, and/or relevant staff is provided with this activity.

The faculty, Susan Seeley and Fred Fehlinger, reported no relevant financial relationships or relationships she has with ineligible companies of any amount during the past 24 months.

The directors, planners, managers and reviewers reported the following financial relationships they have with any ineligible company of any amount during the past 24 months:

Name of Planner/ManagerReported Financial Relationship
Shirley LaVergne, CMPNothing to disclose
Lindsay ThompsonNothing to disclose
Holly M. Hampe, D.Sc., RN, MHA, MRMNothing to disclose
Dee Morgillo, MEd, MT (ASCP), CHCPNothing to disclose

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed in this activity should not be used by clinicians without evaluation of patient conditions and possible contraindications on dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

Requirements for credit:

  • Attend/participate in the educational activity and review all course materials.
  • Complete the CE Declaration form online by 11:59 pm ET September 17, 2022. Instructions will be provided at the conclusion of each Webinar. If you do not enter the online portal by the above date, you will not be able to retrieve your statement of participation. 
  • Upon successful completion of the online form, your statement of completion will be presented to you to print.