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)
A2404 ON CALL PHYSICIANS
CFR(s): 489.20(r)(2) and 489.24(j)(1-2)

§489.20(r)(2) [The hospital (including both the transferring and receiving hospitals), must maintain] a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. §489.24(j)(1) Each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital's patients who are receiving services required under this section in accordance with the resources available to the hospital, including the availability of on-call physicians. §489.24(j)(2)(i) The hospital must have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician's control. §489.24(j)(2)(ii) The hospital must have written policies and procedures in place to provide that emergency services are available to meet the needs of patients with emergency medical conditions if it elects to permit on-call physicians to schedule elective surgery during the time that they are on call or to permit on-call physicians to have simultaneous on-call duties.


This STANDARD is not met as evidenced by:
Based on a review of facility documentation and an interview with staff, the facility failed to: §489.20(r)(2) Maintain a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. Findings were: A review of the physician schedule for March 2018 through August 2018 revealed on-call provider coverage (by either physicians or a mid-level provider) for 24-hour blocks of time. In an interview with staff #9 on 9-4-18, staff #9 stated that the providers listed on the schedule were on-call only for medical and psychiatric issues pertaining to individuals 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.