CMS Proposes Expanding EMTALA Oversight
Through Accreditation Organizations

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CMS has published a proposed rule that would formally integrate EMTALA administrative compliance into the accreditation survey process conducted by organizations such as The Joint Commission. If finalized, accredited hospitals would face EMTALA scrutiny not only through complaint-driven CMS investigations but as a routine component of the surveys that determine their Medicare participation status. For hospital leadership, this is a meaningful expansion of the contexts in which EMTALA compliance will be evaluated.

The proposal arrives against the backdrop of a sharp rise in enforcement activity. In calendar year 2025, CMS issued 1,071 EMTALA citations, a figure that represents a dramatic increase over historical norms. For context, the annual average over the decade from 2005 to 2014 was roughly 200 to 250 citations per year. The enforcement environment has changed materially, and this proposed rule signals that the trajectory is not reversing.

What the Proposed Rule Would Do

EMTALA's regulatory requirements fall into two distinct categories. The substantive obligations at 42 CFR §489.24 govern the core protections: medical screening examinations, stabilizing treatment, appropriate transfers, and receiving hospital responsibilities. These are the provisions most associated with EMTALA enforcement and patient protection. The administrative obligations at §489.20(l), (m), (q), and (r) are more procedural in nature, requiring hospitals to post EMTALA signage, maintain a central ED log, retain transfer records for five years, and keep a current on-call physician list.

Currently, both sets of obligations are enforced through complaint-driven investigations conducted by State Survey Agencies under CMS direction. The proposed rule would change that for the administrative requirements only. Under the proposal, accrediting organizations (AOs) with CMS-approved programs, including The Joint Commission, DNV Healthcare, and others, would be required to assess §489.20 compliance as part of their routine accreditation and reaccreditation surveys. More than 90 percent of Medicare-participating hospitals are accredited by a CMS-approved AO, meaning the reach of this change would be broad.

The substantive §489.24 requirements would remain exclusively under CMS and OIG enforcement authority. If an accrediting organization identifies a potential §489.24 deficiency during a survey, it would be required to refer the matter to CMS for further review and possible State Agency investigation rather than acting on it directly.

The Two-Track Consequence Structure

Under the proposal, the consequences of an AO finding depend on which regulation is implicated. For §489.20 administrative deficiencies, the AO would cite the finding and require the hospital to submit a Plan of Correction through its established accreditation procedures. If the Plan of Correction is accepted and the hospital returns to compliance, no further enforcement action would be taken. If the Plan of Correction is rejected, the AO would refer the matter to CMS.

For §489.24 substantive deficiencies identified during an AO survey, the referral to CMS is mandatory and immediate. That referral triggers the existing complaint investigation process, with its attendant risk of citation, physician review, Plan of Correction requirements, OIG referral, and potential CMP or termination of the Medicare provider agreement.

What This Means For Your Hospital

The practical implications for accredited hospitals are significant in two ways.

More frequent and broader EMTALA review. Hospitals currently face EMTALA scrutiny primarily when a complaint is filed. Under the proposed rule, every accreditation and reaccreditation survey, which for Joint Commission-accredited hospitals occurs on a triennial cycle with unannounced visits, would include EMTALA administrative review. The odds of an EMTALA deficiency being identified increase simply because the number of occasions on which it is looked for increases.

Administrative deficiencies can trigger substantive scrutiny. CMS has signaled clearly that it views §489.20 compliance as a window into overall EMTALA posture. A gap in the on-call log or a missing transfer record is not merely an administrative finding under this framework. It is a flag that invites deeper examination. If an AO survey finds §489.20 deficiencies and, in the course of reviewing records, also identifies what appears to be a §489.24 problem, the mandatory referral pathway is activated.

The proposed rule also shifts the timing of EMTALA scrutiny. The complaint-driven process is reactive. A hospital faces investigation only after something has gone wrong and someone has complained. The accreditation-integrated process is prospective: it identifies gaps before a complaint is filed. For hospitals with latent compliance vulnerabilities, that is a meaningful change in exposure.

The Broader Enforcement Context

The 1,071 citations in 2025 are the most direct evidence of where EMTALA enforcement stands. The split between administrative and substantive citations is nearly even, 521 under §489.20 and 530 under §489.24, which reinforces CMS's explicit position that administrative compliance is not a secondary concern. Hospitals that have treated signage, logging, and records retention as low-priority administrative housekeeping are operating on assumptions the enforcement data no longer supports.

The proposed rule is not yet final and remains open to public comment. But the direction of travel is unmistakable. CMS is building a more comprehensive, more frequent, and more structurally embedded EMTALA oversight framework. The complaint-driven model is being supplemented, not replaced.

What Hospitals Should Be Doing Now

Whether or not the proposed rule is finalized in its current form, the combination of record citation volume and a proposed expansion of review mechanisms points to a clear operational conclusion: EMTALA compliance requires proactive, systematic attention, not reactive remediation after a complaint is filed.

Specifically, hospitals should:

• Conduct a structured audit of §489.20 administrative compliance, including on-call logs, ED central log completeness, transfer record retention, and signage, treating these as substantive compliance matters rather than administrative formalities
• Review §489.24 policies and procedures against current CMS Appendix V standards, with particular attention to MSE documentation, transfer certification practices, and stabilization standards
• Assess high-risk case categories, including psychiatric emergencies, obstetric presentations, and complex transfers, where §489.24 citations are disproportionately concentrated
• Ensure medical staff and nursing leadership understand the EMTALA standards that will apply if an accreditation survey or complaint investigation occurs, particularly around what constitutes an appropriate MSE and when stabilization obligations are satisfied

The window to identify and address vulnerabilities before they become findings is exactly what proactive compliance advisory is designed to use. A gap found internally and corrected is categorically different from a gap found by a surveyor.