Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 670093 (X3) Date Survey Completed 09/05/2018
Name of Provider or Supplier Aspire Hospital Street Address, City, State 2006 South Loop 336 West, Suite 500, Conroe, TX
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
A0000 The CMS-2567 (Statement of Deficiencies) is an official, legal document. All information must remain unchanged except for entering the plan of correction, correction dates, and the signature space. Any discrepancy in the original deficiency citation(s) will be reported to the Dallas Regional Office (RO) for referral to the Office of the Inspector General (OIG) for possible fraud. If information is inadvertently changed by the provider/supplier, the State Survey Agency (SA) should be notified immediately. An entrance conference was held with the facility Director of Nursing and Director of Clinical Services on the morning of 9-4-18. The purpose and process of the complaint survey were discussed, and an opportunity given for questions. Complaint TX00294914 has been referred for physician review. An exit conference was held with the facility Director of Nursing, Director of Clinical Services, HR Coordinator, Director of Behavioral Health & Compliance and Director of Admissions & UR on the evening of 9-4-18.
A2400 COMPLIANCE WITH 489.24
CFR(s): 489.20(l)

[The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24.


This STANDARD is not met as evidenced by:
Based on a review of facility documentation and interviews with staff, the facility failed to comply with §489.24. Per the Centers for Medicare and Medicaid Services ("CMS"): "Under the provisions of §489.24, hospitals with an emergency department that participate in Medicare are required under EMTALA to do the following: o Provide an appropriate MSE to any individual who comes to the emergency department; o Obtain or attempt to obtain written and informed refusal of examination, treatment or an appropriate transfer in the case of an individual who refuses examination, treatment or transfer; and Further, any participating Medicare hospital is required to accept appropriate transfers of individuals with emergency medical conditions if the hospital has the specialized capabilities not available at the transferring hospital, and has the capacity to treat those individuals. Hospitals are required to adopt and enforce a policy to ensure compliance with the requirements of §489.24." Findings were: A review of the Facility Department Policy & Procedure Manual revealed no policies related to EMTALA or the completion of MOTs. Facility policy PC.028 titled "Emergency Medical Care" stated, in part: "Policy: It is the policy of Aspire Hospital to provide basic emergency care to the patient in accordance with hospital policy. As directed by the attending physician or hospital nursing supervisor, the patient will be transferred to a hospital medical-surgical unit or the Emergency Department for further evaluation and treatment." In an interview with staff #9 on 9-4-18, staff #9 stated that the policy pertained only to patients that had already been admitted to the facility (inpatient status). The above was confirmed in an interview with the DON and other administrative staff the evening of 9-4-18.
A2404 ON CALL PHYSICIANS
CFR(s): 489.20(r)(2) and 489.24(j)(1-2)

§489.20(r)(2) [The hospital (including both the transferring and receiving hospitals), must maintain] a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. §489.24(j)(1) Each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital's patients who are receiving services required under this section in accordance with the resources available to the hospital, including the availability of on-call physicians. §489.24(j)(2)(i) The hospital must have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician's control. §489.24(j)(2)(ii) The hospital must have written policies and procedures in place to provide that emergency services are available to meet the needs of patients with emergency medical conditions if it elects to permit on-call physicians to schedule elective surgery during the time that they are on call or to permit on-call physicians to have simultaneous on-call duties.


This STANDARD is not met as evidenced by:
Based on a review of facility documentation and an interview with staff, the facility failed to: §489.20(r)(2) Maintain a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. Findings were: A review of the physician schedule for March 2018 through August 2018 revealed on-call provider coverage (by either physicians or a mid-level provider) for 24-hour blocks of time. In an interview with staff #9 on 9-4-18, staff #9 stated that the providers listed on the schedule were on-call only for medical and psychiatric issues pertaining to individuals that had already been admitted to the facility (inpatient status). The above was confirmed in an interview with the DON and other administrative staff the evening of 9-4-18.
A2406 MEDICAL SCREENING EXAM
CFR(s): 489.24(a) & 489.24(c)

Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) "comes to the emergency department", as defined in paragraph (b) of this section, the hospital must (i) provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (b) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital's obligation under this section ends, as specified in paragraph (d)(2) of this section. (2) Nonapplicability of provisions of this section. Sanctions under this section for inappropriate transfer during a national emergency or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department located in an emergency area, as specified in section 1135(g)(1) of the Act. A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided for by section 1135(e)(1)(B) of the Act. (c) Use of Dedicated Emergency Department for Nonemergency Services If an individual comes to a hospital's dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition.


This STANDARD is not met as evidenced by:
Based on a review of documentation, the hospital failed to provide an appropriate medical screening exam for 5 of 5 patients in order to determine whether or not an emergency medical condition existed. None of the individuals providing screening exams had been deemed qualified to do so by hospital bylaws (or rules and regulations). Findings were: * Patient #1 presented to the facility on 5-1-18 after being referred to the facility by her primary care physician. A copy of her driver's license was attached. Her chief complaint was listed as "panic attacks". The section titled "Precipitating Event: (events of past 24-72 hours that resulted in request for assessment)" stated "Panic Attacks, anxiety, depression, SI [suicidal ideation] on Sunday [2 days prior to assessment], hitting self". Also stated was the fact that patient #1 had cut her wrists 2 days prior and that her boyfriend had taken the knife away from her. The patient's disposition stated "Pt [patient] denies current SI or HI - pt able to contract for safety - pt refusing tx at this time - referrals given". The screening was performed by staff #8 (social worker). * Patient #2 presented to the facility on 6-13-18. No information other than the patient demographics, a copy of the patient's insurance card and a copy of the patient's identification card was present. A statement at the bottom of the page read "Pt refused assessment and left abruptly". The screening was performed by staff #8 (social worker). * Patient #3 presented to the facility on 6-13-18. Copies of his driver's license and insurance card were attached. His chief complaint was listed as "manic". The section titled "Precipitating Event: (events of past 24-72 hours that resulted in request for assessment)" stated "b/c [because] wife & son think I'm too happy; client is rambling on abt [about] family problems; appears delusional". The disposition area of the screening was blank but a note at the bottom of the front page read "no criteria". The screening was performed by staff #5 (an unlicensed, mental health technician). * Patient #4 presented to the facility on 7-12-18. A copy of her insurance card was attached. Her chief complaint was listed as "homicidal". The section titled "Precipitating Event: (events of past 24-72 hours that resulted in request for assessment)" stated "thoughts of hurting others x [for] 2 months; increased depression, increased anxiety". The patient's disposition stated "Pt able to contract for safety; obsessive thoughts but no intent, no previous assaultive behavior, referred to outpt [outpatient] psychiatrist, referrals x 3 given". The screening was performed by staff #8 (social worker). * Patient #5 presented to the facility on 8-29-18. Copies of his driver's license and insurance card were attached. His chief complaint was listed as "meth[amphetamine] use". The section titled "Precipitating Event: (events of past 24-72 hours that resulted in request for assessment)" stated "used crystal meth last Friday; lost time [un]til 3pm Sat[urday], feeling antsy, remorse, depression, poor sleep, restless.". The patient's disposition stated "Refer to PCP [primary care physician] for anxiety". The screening was performed by staff #8 (social worker). A review of the facility Bylaws, Rules & Regulations for the Medical Staff revealed no reference to or mention of EMTALA or MSEs. No staff members were designated individuals that were qualified to perform medical screening exams. In an interview with staff #14, staff #14 confirmed that the facility Bylaws, Rules & Regulations for the Medical Staff revealed no reference to or mention of EMTALA or MSEs and that no staff members were designated individuals that were qualified to perform medical screening exams. A review of personnel files for staff #5, #6, #8, #9, #10, #11, #12 and #13 (all of whom worked as admissions intake personnel) revealed no documentation that the individuals had been designated as qualified to perform medical screening exams by the Medical Staff. Staff #5 held no degree in a medically-related field. Staff #5's education consisted of an Associate's Degree in Computer Science and the staff member's employment experience consisted of a computer-related job and direct, unlicensed, patient care in 2 other healthcare facilities. A review of the staffing schedule for the intake/admissions department (for January 2018 through the date of the survey) revealed that the full-time intake staff consisted of a social worker and three unlicensed, direct-care personnel. The above was confirmed in an interview with the DON and other administrative staff the evening of 9-4-18.