Tag A-2401/C-2401
§489.20(m)

In the case of a hospital as defined in §489.24(b), to report to CMS or the State survey agency any time it has reason to believe it may have received an individual who has been transferred in an unstable emergency medical condition from another hospital in violation of the requirements of §489.24(e).

Interpretive Guidelines: §489.20 (m)

A hospital (recipient) that suspects it may have received an improperly transferred (transfer of an unstable individual with an emergency medical condition who was not provided an appropriate transfer according to §489.24(e)(2)), individual is required to promptly report the incident to CMS or the State Agency (SA) within 72 hours of the occurrence. If a recipient hospital fails to report an improper transfer, the hospital may be subject to termination of it’s provider agreement according to 42 CFR§489.53(a).

Surveyors are to look for evidence that the recipient hospital knew, or suspected the individual had been to a hospital prior to the recipient hospital, and had not been transferred in accordance with §489.24(e). Evidence may be obtained in the medical record or through interviews with the individual, family members or staff.

Review the emergency department log and medical records of patients received as transfers. Look for evidence that:

●    The hospital had agreed in advance to accept the transfers;

●    The hospital had received appropriate medical records;

●    All transfers had been effected through qualified personnel, transportation equipment and medically appropriate life support measures; and

●    The hospital had available space and qualified personnel to treat the patients.

Tags: Duty to report