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Patient Dumping of Mentally Ill Individuals Needing Emergency Care

Chapter 1 - Introduction

1. Patient dumping refers to:

A. The act of hospitals denying individuals emergency medical screening and stabilization services once it is discovered that the patient is uninsured or has no means of paying for treatment.

B. The act of hospitals transferring patients to other hospitals once it is discovered that the patient is uninsured or has no means of paying for treatment.

C. A hospital’s denial of treatment for discriminatory reasons.

D. All of the above.


2. Although one motivation behind EMTALA was to protect indigent and uninsured individuals from being denied potentially life-saving medical treatment, the scope of the law protects all individuals seeking evaluation or treatment at hospital emergency departments participating in the Medicare program.

A. True

B. False


3. Which of the following is not one of the statutory rights of action created by Congress in drafting EMTALA?

A. That of a patient against a Medicare-participating hospital.

B. That of a medical facility that received an improperly transferred emergency patient or woman in labor against the transferring hospital.

C. That of a substitute for state law on medical malpractice.

D. All of the above are statutory rights of action.


4. Hospitals with specialized capabilities, regardless of whether they have a dedicated emergency department, are required to accept an appropriate transfer of an individual requiring such capabilities, if it has the capacity to treat the individual, fall under which statutory obligation?

A. Recipient Hospital

B. Appropriate Transfer

C. Stabilization

D. Medical Screening


5. EMTALA prohibits hospitals from delaying medical screening exams or providing stabilizing treatment in order to inquire about the patient’s method of payment or insurance status.

A. True

B. False


Chapter 2 - The Administrative Process to Enforce EMTALA

6. The goal of onsite inspections is to assess compliance with Medicare requirements, and in the case of long-term care and other facilities, Medicaid requirements as well.

A. True

B. False


7. In which of the following ways does the Office of Civil Rights enforce federal civil rights laws?

A. Investigating complaints.

B. Conducting compliance reviews.

C. Providing technical assistance for voluntary compliance.

D. All of the above.


8. When OCR initially identifies compliance concerns related to one of the laws it enforces, the first step is to:

A. Attempt to bring the entity into voluntary compliance.

B. Terminate federal financial assistance.

C. Refer the case to the Department of Justice.

D. All of the above.


9. Both CMS and OIG are responsible for enforcing EMTALA, but OIG has primary responsibility.

A. True

B. False


10. In addition to providing a medical screening examination, necessary stabilizing treatment, appropriate transfers, and acceptance of transfers under the statute, CMS requires that hospitals must also:

A. Post signs

B. Maintain a central log

C. Maintain an on-call roster

D. All of the above


11. Hospitals that believe they have received an inappropriate transfer of an individual with an un-stabilized emergency medical condition can, but are not required to, report such suspected EMTALA violations to CMS or the state survey agency.

A. True

B. False


12. Any physician who is responsible for the examination, treatment, or transfer of an individual in a participating hospital, including a physician on-call for the care of such an individual, and who negligently violates a requirement of EMTALA is subject to a civil money penalty.

A. True

B. False


13. By law, CMS must seek input of an appropriate, CMS-contracted QIO before it forwards a case to OIG if the EMTALA violation arises from a medical or clinical reason and OIG requires the opinion of a medical professional employed by a QIO to determine a hospital or physician’s liability.

A. True

B. False


14. OIG is required by federal regulation to take into account all of the following factors when determining the amount of a penalty for an EMTALA violation, except for:

A. Previous instances where the hospital or physician failed to meet EMTALA obligations.

B. The population mainly served by the hospital or physician.

C. The financial condition of the hospital or physician.

D. The nature and circumstances of the violation.


15. OIG considers whether an enforcement action would help educate a hospital or physician about obligations and responsibilities under EMTALA.

A. True

B. False


16. The Office for Civil Rights has EMTALA enforcement responsibilities.

A. True

B. False


17. The Office for Civil Rights has the authority to conduct compliance reviews where there is reason to believe an entity receiving federal financial assistance may be discriminating based on disability.

A. True

B. False


18. The Office for Civil Rights has the power to enforce which of the following federal provisions related to mental health disabilities?

A. Section 504 of the Rehabilitation Act of 1973, which prohibits disability discrimination by recipients of federal assistance.

B. Title II of the Americans with Disabilities Act, which covers state and local government agencies’ health and social services programs, and prohibits the denial of care to an individual with a psychiatric disability, or the transfer, relocation, or discharge of such a patient by a facility that otherwise has the ability to provide appropriate services.

C. The Hill-Burton Act passed in 1946, which requires certain community service assurances by facilities in order to receive federal financial assistance and prohibits discrimination.

D. All of the above.


Chapter 3 - Current Regulations and EMTALA Enforcement Mechanisms

19. Which of the following may file a civil rights complaint with OCR on behalf of a victim?

A. Hospital staff member

B. Friend

C. Family member

D. All of the above


20. EMTALA was written with chronic psychiatric conditions in mind.

A. True

B. False


21. Congress passed EMTALA to assure access to emergency medical care in emergency departments and to establish a federal standard of care.

A. True

B. False


22. Hospitals are often worried they will not be reimbursed for psychiatric emergencies, so there is a need for:

A. More emergency department diversion programs such as crisis intervention or social work assistance.

B. An increase in beds for psychiatric institutions or the expansion of psychiatric wings in acute care hospitals.

C. Both (A) and (B).

D. None of the above.


23. Allowing individuals with mental health conditions to choose their treatment is a concern because of potentially diminished mental capacity.

A. True

B. False


24. The criminalization of the mentally ill is a result of improper medical treatment and the desire of some police to clean the streets of homeless individuals, some of whom are mentally disturbed.

A. True

B. False


25. Hospitals with specialized capabilities, such as psychiatric units, are required to accept appropriate transfers from other hospitals only if the accepting institution has an emergency department.

A. True

B. False


26. Many first responders, ambulance drivers, emergency department physicians, and hospital staff are not properly trained to identify the medical root causes of mental illness in patients who enter an emergency facility.

A. True

B. False


27. By modifying EMTALA and CMS regulations to include written protocols through evidence-based best practices, there could be greater equality of care across institutions.

A. True

B. False


28. EMTALA applies to all EMS, even if the ambulance is not owned and operated by a hospital receiving Medicare dollars.

A. True

B. False


Chapter 4 - Findings and Recommendations

29. CMS has the discretion to refer an EMTALA case to OCR if there is a claim of discrimination on the basis of all of the following, except for:

A. National origin

B. Socioeconomic status

C. Sex

D. Disability


30. Linking the budgets of community-based mental health programs with local area hospitals does each of the following, except:

A. Allows for community centers to recover some costs for providing treatment.

B. Allows for best practice guidelines and written protocols to be used when treating patients.

C. Reduces the number of patients in hospital emergency departments.

D. Allows financial reimbursement for services.


31. Patients with a psychiatric disability only fall under EMTALA if they present a psychiatric emergency medical condition by expressing homicidal or suicidal thoughts and gestures and being a threat to self or others.

A. True

B. False


32. The legislative definition of stabilization, as outlined in EMTALA, follows the medical definition of stabilization and a hospital's EMTALA obligation does not end when the hospital changes a patient’s status from emergency to in-patient.

A. True

B. False


33. States do not provide adequate community mental health services and many states seek federal reimbursement under Medicare/Medicaid to supplant the states’ original obligation to pay for this care, even though it was a state responsibility prior to EMTALA.

A. True

B. False


34. If an individual is suffering a mental health emergency, and the emergency is not accompanied by a physical health emergency, HHS/CMS should encourage EMS professionals to divert patients to Medicare-participating facilities that specialize in mental health issues, instead of requiring the individual be cared for at a traditional emergency department.

A. True

B. False


35. EMTALA requires the posting of a patient’s EMTALA rights in a conspicuous place within the emergency room, however, this posting may not be adequate since:

A. Not all patients are literate at the level needed to understand the EMTALA rights.

B. EMTALA rights may not be posted in the patient’s primary language.

C. Emergency room patients are in distress upon admission and may not be totally lucid and focused upon discharge.

D. All of the above.


36. Medical and Social discharge plans should contain which of the following?

A. Information on the type of follow-up care and treatment necessary for recovery.

B. Where follow-up care can be obtained.

C. Information on obtaining relevant government benefits that may include Supplemental Security Income Social Security Disability, Section 8, Supplemental Nutritional Assistance, and housing that may be obtained.

D. All of the above.


Commissioner Statements and Rebuttals

37. The victims of patient dumping fall into all of the following distinct categories, except for:

A. The mentally disabled

B. The homeless

C. The elderly

D. The undocumented immigrant


38. The Emergency Medical Treatment and Active Labor Act protects persons from patient dumping regardless of their citizenship or immigration.

A. True

B. False


39. The medical definition of stability does not consider whether the average person could care for himself or herself outside the hospital environment, however, the EMTALA definition takes this into account.

A. True

B. False


40. The problem of injustice in treatment of mentally disabled patients negatively affects other types of service delivery in emergency departments in which way?

A. Emergency rooms are losing the ability to deal with imminent physical emergencies because they are crowded with people suffering mental emergencies.

B. Because mentally disabled patients require a different type of treatment, their presence in the emergency department frequently leads to longer wait times for individuals who present at the emergency room in need of acute medical care.

C. The influx in mentally disabled patients means true emergencies are being delayed in care.

D. All of the above.


41. EMTALA’s definition of emergency does not acknowledge the nuance of emergencies caused by, or resulting from, mental disability, but instead treats these emergencies the same as physical emergencies.

A. True

B. False


42. Where both physical and mental emergencies exist, medical professionals should:

A. Handle physical emergencies first.

B. Handle mental emergencies first.

C. Handle physical and mental emergencies simultaneously.

D. Handle the physical emergency and transfer the patient to another hospital for the mental emergency.


43. A person should not be declared completely stable until they are strong enough to function without medical supervision or until the hospital accounts for the type of care necessary to keep that person stable outside the hospital.

A. True

B. False


44. Giving EMS and other first responders the ability to choose alternatives to the emergency room works to solve the problem of patient dumping in which way?

A. It gets mentally disabled people exactly the kind of help they need.

B. It reduces the problem of overcrowding by diverting them from traditional emergency departments, which decreases wait times for individuals who are experiencing emergencies that can only be handled in emergency rooms.

C. Medical facilities could use the funds saved from providing less expensive, appropriate care to assist in aftercare or respite care for people with mental illness.

D. All of the above.


45. Existing systems allow for more thorough data collection methods, however, medical professionals leave many of the fields blank.

A. True

B. False


46. The victims of EMTALA violations are being discriminated against on the account of their:

A. Disability

B. Age

C. Inability to pay for their medical care

D. Race


47. A decision that affects a disabled person is not the same thing as a decision that discriminates against a disabled person.

A. True

B. False


48. The population that EMTALA primarily benefits is:

A. The indigent.

B. The ones that are a little too well off to qualify for Medicaid and too young and healthy for Medicare.

C. The disabled.

D. The elderly.


49. One of the easiest and most profitable ways for a hospital to discharge its responsibility under EMTALA is to close its emergency room, since only hospitals with emergency rooms are required to accept all comers.

A. True

B. False


50. Which of the following reasons are consistent with the conclusion that EMTALA has contributed substantially to the problem of emergency room closure, perhaps even being the predominant factor?

A. Hospitals that provide a much higher than average level of medical care to uninsured, Medicaid, and other vulnerable patients were more likely to close their emergency rooms than those that did not.

B. Hospitals with lower than average profit margins were more likely to close their emergency rooms.

C. For-profit status, as opposed to not-for-profit or government status, was positively correlated with emergency room closure.

D. All of the above.


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