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)
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.