Hospital Is Not in Compliance - Situation Does Not Pose an

5460.4 - Hospital Is Not in Compliance - Situation Does Not Pose an Immediate Jeopardy to Patient Health and Safety (Rev. 243; Issued: 06-12-26; Effective: 06-12-26; Implementation: 06-12-26) If the CMS location determines that the hospital is not in compliance with the EMTALA requirements, but the violation does not pose an immediate jeopardy to patient’s health and safety, or the hospital took corrective action after the investigation to remove the immediate jeopardy, the CMS location follows a 90 calendar-day termination process. The termination procedures in §3012 are followed. The CMS location notifies the complainant that the complaint was substantiated. The CMS location informs the hospital, in writing, of the specific violations via a preliminary determination letter and sends the hospital a copy of Form CMS-2567. The SA receives a copy of the letter through ACTS. Examples of noncompliance that usually do not pose an immediate jeopardy: 1. A transfer which was appropriate, but not signed or dated by the physicians; 2. An appropriate, functioning, central log that on one particular day is not fully completed; and 3. A written hospital policy that is missing, but is nonetheless being implemented. The fact that the hospital has completed a POC should not be interpreted to mean that the hospital admits violating the EMTALA requirements. However, the hospital is included on the log of facilities with EMTALA violations, with the notation that an acceptable POC was received by CMS, and termination action was stopped.