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 01/24/2023
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 FEDERAL 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 survey for Complaint # TX00429904 was conducted on site. An entrance conference was held the morning of 01/24/2023 with hospital administrative representatives. It was explained to them that the complaint survey would be conducted to determine the facility's compliance per Chapter 5 of the SOM, Appendix A, and applicable sections of CFR 482 - Federal Regulations for Acute Care. An exit conference was held the afternoon of the same day with hospital administrative representatives at which time the findings of the survey were explained. The administrative representatives were given an opportunity to provide evidence of compliance with those requirements of which non-compliance had been found. None was provided. Instructions were provided on writing plans of correction with instructions to return the plans of correction to the Arlington zone office within 10 days. This report was electronically sent to the facility. Complaint # TX00429904 was substantiated with deficiencies cited.