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 670068 (X3) Date Survey Completed 12/23/2020
Name of Provider or Supplier Texas Health Presbyterian Hospital Flower Mound Street Address, City, State 4400 Long Prairie Road, Flower Mound, 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 (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 unannounced complaint survey was conducted on site. An entrance conference was held with the hospital representative on the morning of 12/23/2020. The hospital representative was informed that the survey would be conducted according to 42 CFR 489.24 and 42 CFR 489.20 (1), (m), (q), and (r) of the Emergency Medical Treatment and Labor Act (EMTALA), and Section 5400, Appendix V of the State Operations Manual. An exit conference was conducted the afternoon of 12/23/2020 with the hospital representatives. The hospital representatives were informed that CMS would make the final determination of the hospital's compliance with EMTALA regulations for Complaint TX00368732.