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 670072 (X3) Date Survey Completed 04/07/2017
Name of Provider or Supplier Hopebridge Hospital Street Address, City, State 5556 Gasmer Drive, Houston, 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)
A0043 GOVERNING BODY
CFR(s): 482.12

There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ...


This CONDITION is not met as evidenced by:
Based on observation, interview, and record review, on April 4-7, 2017, the governing body failed to provide effective oversight to ensure that patients recieved care in a safe environment. 1.The facility did not ensure that each patient receive treatment in a safe setting as evidenced by the presence of multiple ligature risks. These identical ligature risks were previously cited on March 8, 2017 and had not been removed. 2. The facility was not constructed and maintained to guarantee the safety and well-being of each patient as evidenced by the presence of multiple ligature risks. The identified practices continue to present a likelihood of Immediate Jeopardy to the 32 current patients and all potential patients with behavioral problems on the adult and adolescent units. Based on observation, interview, and record review, the facility failed to ensure the rights of each patient to receive treatment in a safe setting as evidenced by all patients placed on units with known multiple ligature risks present that were easily accessible for self-harm. This deficient practice posed a likelihood of serious harm or death for current and potential patients with suicidal ideation on the adult and adolescent units. Refer to 482.13(c)(2) - [A-0144]