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 04/16/2019
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)
A0273 DATA COLLECTION & ANALYSIS
CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3)

(a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data, for example, information submitted to, or received from, the hospital's Quality Improvement Organization. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital's governing body.


This STANDARD is not met as evidenced by:
Based on record review and interviews, the facility failed to analyze restraint and seclusion data for 5 of 5 quarters (4 quarters in 2018 and the first quarter of 2019). Failure to measure, analyze, and track this high-risk, problem-prone area resulted in 37 of 37 incidents of restraint and seclusion not being analyzed for appropriateness, safety, and proper implementation. Findings: Record review at time of survey of the facility's QAPI minutes and supporting documentation showed that only raw data, solely comprised of the number of restraints and seclusions each month, was captured. There was no analysis of the data and/or any proposed improvement activities with regards to attempting to address and decrease the incidence of the facility's restraints and seclusions. Further review of the supporting documentation showed raw data for five quarters. The number next to the month represents the total number of restraints and seclusions for that month. 2018 first quarter: January-5, February-2 March-0 2018 second quarter: April-7 May-2 June-0 2018 third quarter: July-5 August-0 September-0 2018 fourth quarter: October-1 November-2 December-3 2019 first quarter: January-5 February-4 March-6 Record review of the Restraint and Seclusion log titled "2019 Q2 RESTRAINT/SECLUSION" and the QAPI data for 2019 first quarter showed a discrepancy in the two reports. 1.The Restraint and Seclusion log titled "2019 Q2 RESTRAINT/SECLUSION" showed three incidents of Restraint/Seclusion. 2. The QAPI data for the first quarter of 2019 showed six incidents of Restraint/Seclusion. Record review of the Restraint and Seclusion log titled "2019 Q2 RESTRAINT/SECLUSION" showed that Patient #1 was physically restrained for 17 minutes on 2/22/19 and given a "medication IM stat" (intramuscular injection of a medication given immediately). There was neither documentation of the rationale to hold the patient past 15 minutes nor identification of the medication administered. In an interview on 4/16/19 at 11:00 AM, Staff A, Quality Manager, he stated that restraints and seclusions had been reported to QAPI committee on a monthly basis. He also stated that the data was "just basic info - the number of restraints and seclusions," adding that the data was not analyzed for the quarterly QAPI meetings. He concluded by saying that there was no performance improvement plan to address restraints and seclusions and that this was true for the entire year of 2018 and 2019 year to date.