Guideline text:
(Rev. 37, Issued:  10-17-08; Effective/Implementation Date:  10-17-08)

§482.12(f)(3) If emergency services are provided at the hospital but are not provided at one or more off-campus departments of the hospital, the governing body of the hospital must assure that the medical staff has written policies and procedures in effect with respect to the off-campus department(s) for appraisal of emergencies and referral when appropriate.

Interpretive Guidelines §482.12(f)(3)

This requirement applies to any off-campus hospital department/location that does not qualify as a dedicated emergency department in accordance with 42 CFR 489.24(b) and is part of a hospital that provides emergency services.  Such departments/locations must have and must implement medical staff policies and procedures for the appraisal of emergencies and referral when appropriate.

- Appraisal of Persons with Emergencies: A hospital must have medical staff policies and procedures for conducting appraisals of persons with emergencies at off-campus departments/locations that are not dedicated emergency departments.  The policies and procedures must ensure that clinical personnel -- who are qualified, through a combination of education, licensure, and training, to conduct an assessment that enables them to recognize the fact that a person has a need for emergency care -- are  available during all hours of operation at the off-campus department/location.
- Referral when Appropriate: A hospital must have medical staff policies and procedures to address situations in which a person's emergency needs may exceed the capabilities of the off-campus departments/locations that are not dedicated emergency departments.  The policies and procedures should be designed to enable staff members at such locations to:  (a) recognize when a person requires a referral or transfer, and (b) assure appropriate handling of the transfer.  This includes arrangement for appropriate transport of the patient along with the transfer of the patient's medical information so that the receiving hospital may treat the medical emergency more efficiently.
- Initial Treatment: Although there is no specific regulatory requirement for such offcampus departments or locations to provide initial treatment of emergencies, nevertheless they are expected to provide treatment and stabilization consistent with the complexity of services, the type and qualifications of clinical staff, and the resources available at that location.  This expectation is based on the requirements of the Outpatient Services CoP that hospital outpatient services meet the needs of the patients in accordance with acceptable standards of practice, outpatient services must be appropriately organized and integrated with inpatient services, and outpatient services must have appropriate professional and nonprofessional personnel available.  For example, an off-campus cardiac rehabilitation clinic would be expected to have the appropriate qualified staff, equipment (such as a crash cart), and policies and procedures in place to appropriately provide appraisal, initial interventions, and referral of a patient who experiences a cardiac emergency.
- A hospital policy or practice that relies on calling 9-1-1 in order for EMS to substitute its emergency response capabilities for those the hospital is required to maintain at its off-campus departments/locations, as described above, is not consistent with the Medicare CoPs.  However, given the more limited emergency capabilities that may be present in some off-campus departments or locations, calling 9-1-1 to respond to an emergency might be appropriate.

See the hospital emergency services CoP (42 CFR 482.55) for the emergency requirements for the hospital's locations that provide emergency services.

## Survey Procedures §482.12(f)(3)

- Review emergency care policies and procedures.  Determine if they address emergency procedures for all off-campus locations.
- Interview off-campus hospital department staff.  Can they state their duties and what they are to do if an individual seeks emergency care?

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance"], "logic_config": {"required_artifact": "Medical staff policies and procedures for appraisal of emergencies and appropriate referral at off-campus departments, ensuring qualified clinical personnel availability and appropriate transfer protocols.", "trigger_assertion": "Hospital provides emergency services, but specific off-campus department(s) do not provide dedicated emergency services."}, "rule_type": "conditional_existence", "scope_tags": ["clinical", "facility", "legal"]}