The CMS Investigation Process: What to Expect During an EMTALA Survey (42 CFR § 489.24(g))

A CMS EMTALA survey can occur at any time and often begins with no prior warning. Under 42 CFR 489.24(g), CMS investigates potential violations by reviewing medical records, conducting interviews, observing operations, and assessing compliance with screening, stabilization, and transfer obligations. For small practices connected to hospitals through call panels, provider-based departments, or stabilization roles, understanding the investigation process is critical. This article explains what CMS looks for, how surveys proceed, and how small practices can prepare evidence that protects the organization.

EMTALA enforcement begins when CMS receives a complaint, transfer concern, or hospital self-report. Surveyors then conduct a detailed review under 42 CFR 489.24(g) to determine whether the hospital, and by extension, its affiliated clinical partners, complied with federal emergency care requirements. For small practices, the CMS investigation process may feel distant, but any clinician contributing to emergency screening, stabilization, or transfer decisions can be swept into an EMTALA review.

Understanding the structure of a CMS EMTALA survey reduces disruption, prevents panic during unannounced visits, and ensures that small practices supporting emergency care maintain proper documentation and readiness.

Understanding Legal Framework & Scope Under 42 CFR 489.24 g

1. Scope of a CMS EMTALA Investigation

42 CFR 489.24(g) authorizes CMS to:

• Investigate any complaint alleging EMTALA noncompliance.

• Conduct comprehensive on-site surveys.

• Review patient records, logs, and transfer documentation.

• Interview staff and clinicians.

• Examine hospital operations at any department involved in emergency care.

Although the regulation refers to hospitals, any affiliated clinic or contracted practice may contribute records or be interviewed.

2. Trigger Events for CMS Surveys

CMS initiates surveys for:

• Patient complaints

• Concerns reported by receiving hospitals

• Patterns of problematic transfers

• Abnormal ED logs

• Self-reported incidents

• Information obtained from state agencies

3. Evidence Required Under the Regulation

Surveyors review:

• Medical screening documentation

• Stabilization notes

• Transfer forms

• Acceptance and communication logs

• On-call schedules

• Routing and triage records

The regulation places heavy weight on evidence, meaning verbal explanations cannot replace written documentation.

4. What CMS Must Determine

CMS assesses whether:

• The medical screening examination was performed appropriately.

• Stabilization obligations were met.

• Transfers complied with requirements.

• On-call physicians responded promptly.

• Documentation demonstrates compliance.

5. Federal vs State Authority

States may add requirements, but federal EMTALA determinations under 42 CFR 489.24(g) supersede state processes in emergency care investigations.

CMS conducts EMTALA investigations, but OIG issues penalties. Survey outcomes can lead to:

• Immediate jeopardy findings

• Termination of Medicare participation (rare but possible)

• Mandatory corrective action plans

• Civil monetary penalties

Common Surveyor Triggers at Small Practices

• Call panel gaps

• Inconsistent charting on emergency cases

• Conflicting versions of patient contact events

• Routing decisions unsupported by documentation

• Missing acceptance or communication entries

Surveyors contact small-practice clinicians when their documentation or involvement contributed to the EMTALA event under review.

These controls help small practices prepare for CMS EMTALA surveys. Each action aligns with 42 CFR 489.24(g) and supports defensible evidence.

1. EMTALA Readiness Binder

Surveyors frequently ask for documents immediately.

• Implementation: Create a binder (physical or digital) containing policies, on-call schedules, transfer forms, logs, and workflow diagrams.

• Evidence: Binder with updated materials available to surveyors.

• Low-cost option: Cloud folder labeled “EMTALA Readiness.”

2. Real-Time Documentation Standard

Because surveys focus on records, the documentation must be immediate and complete.

• Implementation: Require clinicians to complete notes before shift end.

• Evidence: Time-stamped entries for screening, stabilization, and transfers.

• Low-cost option: EHR auto-timestamp features.

3. Staff Interview Preparation

Surveyors interview staff to verify consistent understanding of EMTALA obligations.

• Implementation: Provide simple, accurate, role-specific scripts.

• Evidence: Staff attestations that they reviewed EMTALA expectations.

• Low-cost option: One-page Q&A sheets in break rooms.

4. On-Call Accountability Evidence

Surveyors examine call patterns and clinician responsiveness.

• Implementation: Maintain a call log noting contact times, responses, and delays.

• Evidence: Log demonstrating compliance with on-call obligations.

• Low-cost option: Spreadsheet shared via secure cloud service.

5. Transfer Compliance Records

CMS reviews all transfer decisions for legal compliance.

• Implementation: Use a standard checklist including medical necessity, receiving facility acceptance, risks, benefits, and mode of transport.

• Evidence: Completed checklist stored with the encounter.

• Low-cost option: Paper form with checkboxes for ease of use.

6. Incident Reconstruction Protocol

When a complaint triggers a survey, the ability to reconstruct events is essential.

• Implementation: Assemble all encounter-related records immediately and ensure consistency.

• Evidence: Timeline created from existing records.

• Low-cost option: Free timeline template in spreadsheet format.

7. Minimum Evidence Preservation Standards

Under 42 CFR 489.24(g), CMS expects preserved records for all relevant encounters.

• Implementation: Designate responsible staff to collect logs, screening forms, vitals, transfer documents, and call records.

• Evidence: Secure, organized evidence repository.

• Low-cost option: Shared drive with date-labeled folders.

Case Study

A 67-year-old patient arrived at a hospital-affiliated imaging suite reporting severe back pain and inability to walk. Staff documented only that the patient “needed ED evaluation” and arranged a transfer, but no medical screening examination details or vitals were recorded.

CMS initiated a survey under 42 CFR 489.24(g) after the receiving hospital filed a concern.

Survey Findings

• No documented screening examination

• No proof of receiving facility acceptance

• Inconsistent staff recollections

• No logs detailing contact with on-call providers

• No written rationale for transfer urgency

Even though staff insisted the patient appeared unstable and needed ED-level care, CMS found noncompliance because required evidence was missing.

Consequences

• CMS issued a violation finding.

• The system was required to submit a corrective action plan.

• Staff underwent mandatory retraining.

• The clinic’s relationship with the hospital was reviewed.

How the Operational Playbook Would Have Prevented This

With the Readiness Binder, complete checklists, and real-time documentation standards in place, the clinic would have produced evidence demonstrating legally compliant screening, routing, and communication, even if the ultimate transfer outcome remained the same.

Common Audit Pitfalls to Avoid Under 42 CFR 489.24 g

CMS surveys consistently reveal avoidable deficiencies.

• Missing or incomplete medical screening documentation, forcing CMS to assume noncompliance.

• Inconsistent staff statements, suggesting lack of training or reliable workflow.

• No record of receiving facility acceptance, violating transfer requirements.

• Gaps in on-call logs, obscuring physician responsiveness.

• Delayed or retrospective documentation, undermining credibility.

• Failure to preserve records, preventing CMS from reconstructing events.

Proper documentation and readiness significantly reduce compliance risks during CMS EMTALA surveys.

Survey readiness is a continuous operational expectation, not a last-minute task. Leadership should assign clear ownership for EMTALA readiness, maintain updated policies, and track completion of documentation audits. Clinics should implement brief, recurring training emphasizing accurate documentation, interview readiness, and understanding of emergency workflows. Regular monitoring of screening completeness, transfer documentation accuracy, and call logs ensures that organizations remain prepared for unannounced CMS visits.

CMS EMTALA surveys evaluate evidence, not intentions. Under 42 CFR 489.24(g), surveyors assess records, interview staff, and analyze operations to determine compliance. Small practices must ensure that their documentation, communication logs, and transfer processes are always ready for review. With simple, standardized tools and workflows, clinics can meet federal expectations without large budgets or additional staff.

Next Steps

1. Build and maintain an EMTALA Readiness Binder.

2. Implement real-time documentation standards.

3. Conduct quarterly staff interview preparation sessions.

4. Use transfer checklists for every applicable event.

5. Maintain updated on-call logs and evidence repositories.

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
  

• CMS State Operations Manual, Appendix V – EMTALA Guidelines
  

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

• Federal Register EMTALA Interpretive Guidance
  

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