Earlier this year, the Centers for Medicare & Medicaid Services (CMS) conducted an unannounced survey at Salem Hospital related to EMTALA complaints. CMS is the federal agency responsible for enforcing hospital participation in Medicare and Medicaid, and the outcome of this survey is serious.
The survey began in March with an initial focus on urgent care and continued with investigation of additional complaints, with findings formally issued in late November. A plan of correction was submitted, and CMS requested a revision late last week. CMS will return to resurvey between Jan. 5 and Feb. 3, 2026. Although the citations are specific to the Salem Hospital campus, the education, workflows and expectations to address the deficiencies apply to all staff and medical staff at both Salem Hospital and West Valley Hospital.
The deficiencies identified related to documentation of medical screening examinations, clarity around who is qualified to perform mental health evaluations, documentation for patients who leave without being seen or against medical advice and interfacility transfer documentation. In response, systemwide improvements have been implemented, including updated Medical Staff Rules and Regulations, clarified Behavioral Health Clinician roles, improved Epic workflows, revised EMTALA policies, a rebuilt interfacility transfer process and new campus emergency response infrastructure. Some of these updates were previously shared in the Nov. 25 urgent edition of Common Ground.
A critical requirement for CMS approval is clear evidence that all medical staff understand, follow and consistently apply the elements of the plan of correction. Mandatory education will be required through a second computer-based training (CBT) in addition to the CBT previously assigned in November. You will receive an urgent Common Ground email in the coming days when the new CBT in HealthStream is live and available for completion.
CMS allows zero margin for error, and failure is not an option. We will be working closely with medical staff leadership and section chiefs to ensure 100% completion of this training, and we sincerely thank you for prioritizing this education and for your partnership in this critically important work. If you have any questions, please reach out to Chief Medical Officer Matt Boles, MD, at matthew.boles@salemhealth.org.