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


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.

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.

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, Susan is experienced in conducting Centers for Medicare and Medicaid Services (CMS) and Joint Commission (TJC), Accreditation Association for Ambulatory Health Care (AAAHC) Healthcare Facilities Accreditation Program (HFAP) mock surveys and improving client hospitals’ accreditation survey preparedness through on-site education.

She has prepared organizations for continuous survey readiness by implementing ongoing teams to continue regulatory compliance after mock surveys and assists organizations with writing and implementing successful Plans of Corrections for EMTALA and other CMS and Joint Commission survey deficiencies. Susan 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.

Prior to becoming a consultant, Susan spent 19 years as Chief Nursing Officer at Florida rural hospital while working part-time for the parent company as a clinical consultant for their 200+ hospitals. In this role, she also had several other departments she was responsible for including Infection Prevention, Pharmacy Services, Nutritional Services and Quality.

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

Fred Fehlinger is an RN consultant for survey preparedness, on-site support and remediation for hospital, ambulatory healthcare, critical access hospital, long term care and addiction/substance use programs under The Joint Commission, CMS, DNV and specific Sate programs. 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. His responsibilities included but were not limited to: Oversite of all accreditation and federal inspections, survey readiness, and ensuring that responses to accreditation organizations are responded to properly.