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 670031 (X3) Date Survey Completed 02/02/2017
Name of Provider or Supplier St Luke's Patients Medical Center Street Address, City, State 4600 East Sam Houston Parkway South, Pasadena, 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 Note: The CMS-2567 is an official, legal document. All information must remain unchanged except for entering the plan of correction, correction dates, and the signature space. If information is inadvertently changed by the provider, you should notify the state Survey Agency. If the SA notices any discrepancy in the information related to scope and severity assigned or the deficiency citation(s), the SA will report this occurrence to the Dallas Regional Office. The Regional Office will make a referral of possible fraud to the Office of the Inspector General (OIG). An unannounced visit was made on the morning of 2/1/2017 at the above named hospital to conduct a complaint survey TX00252790 regarding a possible Emergency Medical Treatment and Labor Act (EMTALA) violation. The survey was conducted per Sections 5300-5370 of the State Operations Manual (SOM). In addition, Appendix V - "Interpretive Guidelines-Responsibilities of Medicare Participating Hospitals in Emergency Cases" was utilized to determine the hospital's compliance with 42 CFR 489.24 and the related requirements at 489.20 (l), (m), (q), and (r). An entrance conference was held on the morning of 2/1/2017 with the facility's key administrative personnel to explain the nature of the allegation, the purpose of the survey, and the requirements against which the complaint would be surveyed. An exit conference was conducted on the afternoon of 2/2/2017 with key administrative personnel. The facility was informed of the findings of the survey and was given an opportunity for discussion and to provide additional information. The hospital's administrative staff were informed the Centers for Medicare & Medicaid Services (CMS) would determine whether or not an EMTALA violation occurred and inform them in writing.