Off-Campus Departments: Extending the EMTALA Obligation to Remote Sites (42 CFR § 489.24(b))

EMTALA obligations extend beyond the physical walls of a hospital. Under 42 CFR 489.24(b), certain off-campus departments operating under the hospital’s license are treated as part of the hospital for EMTALA purposes, meaning a patient who arrives at these remote sites may trigger the requirement for an appropriate medical screening examination. Small practices, especially those functioning as provider-based clinics, imaging suites, or hospital-affiliated outpatient centers, must understand when EMTALA applies and how to respond. Failure to follow these rules can expose remote sites to federal penalties, survey findings, and significant patient safety risks. This article clarifies when EMTALA obligations extend to off-campus locations and provides practical tools to ensure compliance with minimal resources.

Hospitals increasingly operate remote facilities, urgent care extensions, imaging suites, outpatient surgery centers, and specialty clinics. Many small practices contract with hospitals or lease clinical space within hospital-affiliated buildings. Though these locations may be miles away from the main campus, EMTALA may still apply under 42 CFR 489.24(b) if they are designated as provider-based departments or commonly used to provide emergency services.

For small practices with tight budgets and limited staff, understanding EMTALA’s reach is vital. Misunderstanding when off-campus sites trigger EMTALA obligations can lead to improper routing, delayed evaluation, and federal findings. This article explains how EMTALA applies to off-campus departments and outlines practical steps for safe, compliant operations.

Understanding Legal Framework & Scope Under 42 CFR 489.24 b

1. Core Regulatory Requirements

Under 42 CFR 489.24(b), EMTALA protections apply whenever a patient “comes to”:

• A hospital’s dedicated emergency department, or

• Hospital property where emergency services are customarily provided, including certain off-campus provider-based departments operating under the hospital’s license.

For off-campus sites, EMTALA obligations activate when:

• The patient requests examination or treatment for a condition, or

• The patient exhibits symptoms suggesting an emergency medical condition that a reasonable person would recognize.

2. Provider-Based vs Independent Sites

Not all remote clinics are covered by EMTALA. Coverage depends on designation:

• Provider-based off-campus departments: Considered part of the hospital under CMS rules; EMTALA applies.

• Freestanding, non-affiliated clinics: Not subject to EMTALA unless they are owned and operated under the hospital license.

• Hospital-affiliated but independent practices: May not trigger EMTALA unless they act as hospital entry points.

Therefore, small practices must know their designation status to apply EMTALA correctly.

3. Scope Across Remote Sites

EMTALA may apply to:

• Off-campus urgent care sites using the hospital’s name

• Imaging or lab suites registered as provider-based

• Remote departments within 250 yards of hospital property

• Outpatient departments integrated under Medicare provider-based rules

4. Federal vs State Requirements

Federal EMTALA rules determine whether off-campus locations function as hospital entry points. State licensing may impose additional operational classifications but cannot reduce EMTALA obligations. Remote sites must apply EMTALA consistently across state and federal expectations.

5. Operational Significance

Understanding the legal framework reduces administrative conflict, prevents improper routing, and ensures timely evaluation of symptomatic walk-in patients. It also protects reimbursement pathways that depend on compliant emergency handling.

CMS enforces EMTALA rules across all hospital properties, including off-campus departments designated as part of the hospital. OIG handles civil monetary penalties for violations.

Common enforcement scenarios at off-campus locations include:

• A symptomatic patient turned away at a remote imaging suite.

• A hospital-affiliated outpatient center instructing a patient to “go to the main ED” without documenting the screening obligation.

• Staff not trained to recognize EMTALA triggers at off-campus clinics.

• Lack of documented screening steps when a patient presents with emergency symptoms.

Surveyors evaluate whether off-campus departments acted as hospital entry points and whether staff followed EMTALA screening and routing requirements.

These controls help off-campus departments comply with 42 CFR 489.24(b) while minimizing operational burden. Each action includes an implementation method, evidence to retain, and an affordable option for small practices.

1. Off-Campus EMTALA Trigger Screen

Because EMTALA applies when patients exhibit emergency symptoms, remote sites require a screening tool.

• Implementation: Add a simple three-point symptom screen addressing chest pain, altered mental status, or severe distress.

• Evidence: Completed screen attached to visit intake.

• Low-cost option: Laminated intake form used across all remote suites.

2. Designation Verification Protocol

Staff must know whether their location is EMTALA-covered.

• Implementation: Post a designation notice in staff workrooms describing the site’s provider-based status.

• Evidence: Internal memo or compliance note referencing 42 CFR 489.24(b).

• Low-cost option: One-page PDF stored in shared drives.

3. Immediate Clinical Assessment for Symptomatic Walk-Ins

If a patient presents with potential emergency symptoms, an initial clinical assessment must occur.

• Implementation: Train staff to obtain vitals and basic triage before any referral decision.

• Evidence: Timestamped vital signs in the chart.

• Low-cost option: Low-tech triage chair kit with BP cuff and pulse oximeter.

4. Safe Routing to Higher-Level Care

Off-campus sites must safely hand off symptomatic patients to the main hospital or ED.

• Implementation: Establish routing criteria and specify when to call 911 versus transferring internally.

• Evidence: Routing logs showing acceptance, departure time, and destination.

• Low-cost option: Shared spreadsheet or free forms platform.

5. EMTALA-Compliant Communication Script

Staff must avoid telling patients, “We can’t see you here,” without documenting the EMTALA process.

• Implementation: Standard script: “We will evaluate you now and arrange immediate care consistent with 42 CFR 489.24(b).”

• Evidence: Documentation in the visit note.

• Low-cost option: Pocket card for front-desk and clinical staff.

6. Ongoing Monitoring Until Handoff

A symptomatic patient cannot be left unattended before routing.

• Implementation: Assign a staff member to continuous observation until transfer or stabilization.

• Evidence: Serial monitoring notes.

• Low-cost option: Observation sheet on a clipboard.

7. Coordination with Main Campus ED

Remote departments must confirm that the main ED or a higher-level department is ready.

• Implementation: Call the ED, document acceptance, and verify care availability.

• Evidence: Acceptance documentation with name, time, and receiving clinician.

• Low-cost option: Pre-formatted note template.

These controls ensure EMTALA compliance across all off-campus environments while preventing duplication with risk sections.

Case Study

A hospital-owned off-campus imaging suite operated 12 miles from the main hospital. A 72-year-old man arrived for an outpatient CT scan but reported severe dizziness and chest pressure at check-in. The receptionist instructed him to “go to the emergency department” without triggering any EMTALA process. He collapsed in the parking lot, and EMS transported him to a competing hospital, which later reported the event to CMS.

Surveyors determined:

• The imaging suite was a provider-based off-campus department.

• The patient requested evaluation on hospital property.

• EMTALA was triggered under 42 CFR 489.24(b).

• No screening or routing documentation was created.

• Staff had no training on EMTALA obligations at remote sites.

Consequences

• CMS findings against the hospital for failure to screen at a remote department.

• OIG monetary penalty for EMTALA violations.

• Mandatory corrective action plan requiring retraining and new protocols.

• Reputational harm and increased scrutiny on all remote sites.

How the Operational Playbook Would Have Prevented This

If the staff used the EMTALA Trigger Screen, conducted basic vitals, documented acceptance by main ED, and observed the patient until transfer, the event would have demonstrated full compliance and prevented the collapse.

Common Audit Pitfalls to Avoid Under 42 CFR 489.24 b

Remote sites often make predictable EMTALA mistakes.

• Assuming the site is exempt from EMTALA, resulting in missed screening duties.

• Redirecting symptomatic patients without assessing them, violating the obligation to evaluate emergency symptoms.

• Failure to document safe routing, leaving no evidence of compliance.

• Leaving patients unattended, increasing deterioration risk while on hospital property.

• Not confirming main ED acceptance, causing delays or gaps in care.

• Staff unaware of EMTALA obligations, a common cause of survey deficiencies.

Addressing these pitfalls ensures consistent compliance and reduces exposure to penalties under 42 CFR 489.24(b).

Off-campus departments need coordinated leadership with clear EMTALA ownership. Compliance leads should maintain designation records, update EMTALA posters and scripts, and conduct annual training tailored to remote workflows. Managers should monitor metrics such as symptomatic walk-ins, routing times, and documentation completeness. Effective governance ensures remote locations perform as safe extensions of the hospital and handle emergency symptoms with competence and accountability.

Off-campus departments functioning as part of the hospital play a critical role in EMTALA compliance. Under 42 CFR 489.24(b), symptomatic patients at remote sites require prompt evaluation, safe routing, and clear documentation. With streamlined tools and consistent processes, even lean remote practices can meet EMTALA standards and protect patient safety.

Next Steps

1. Post EMTALA Trigger Maps in all remote suites.

2. Train staff annually on identifying emergency symptoms.

3. Implement a basic vitals-first protocol for symptomatic walk-ins.

4. Create routing documentation templates to ensure safe handoffs.

5. Audit remote sites quarterly for EMTALA readiness.

Recommended compliance tool

A shared “Medicare Plan Interaction” log and policy folder on your existing network or EHR, used to store scripts, training records, and any sponsor correspondence about beneficiary communications. 

Advice:

Before the next open enrollment, walk through your clinic as an auditor would and remove or rewrite anything that could be interpreted as recommending one Part D plan over another.

• EMTALA Regulations – 42 CFR 489.24
  

• Emergency Medical Treatment and Labor Act (42 USC 1395dd)
  

• CMS State Operations Manual, Appendix V – EMTALA Guidelines
  

• Federal Register EMTALA Interpretive Guidance
  

• HHS Office of Inspector General – Civil Monetary Penalties Law Guidance