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 05/11/2023
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)
A0119 PATIENT RIGHTS: REVIEW OF GRIEVANCES
CFR(s): 482.13(a)(2)

[The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.] The hospital's governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee.


This STANDARD is not met as evidenced by:
Based on review and interview the facility failed to review, analyze, and report to the Governing Body (GB) complaints and grievances through the Quality Assessment Performance Improvement (QAPI) process, failed to have a clear understanding of the complaint vs grievance process, failed to ensure the patient's complaint or grievance was effectively handled in a timely manner, and failed to inform the patients of any resolutions to their complaints and grievances. During the survey process, the administrative staff was asked 4 different times to provide the surveyor with GB bylaws and GB meeting minutes. The administrative staff could not provide the information requested. A review of the policy and procedure "Patient and Family Grievance Guidelines" stated, "Oversight and Reporting The patient grievance process is approved by the governing board. The governing board is responsible for the effective operation of the grievance process. The governing board - by approval of this policy - officially has delegated the oversight and responsibility for implementing this grievance process to Quality Assessment/Performance Improvement Committee (QA/PI) .Complaints or grievances involving the members of the medical staff are forwarded to the DON for review, investigation and follow-up. The data collected regarding patient grievances, as well as other complaints that are not defined as grievances will be reported through the Quality Assessment/Performance Improvement Committee (QA/PI)." An interview was conducted with staff #2 on 5/8/23. Staff #2 stated that she just started at the facility. Staff #2 stated she was aware that QAPI information and meeting minutes were conducted monthly but were not able to speak to any previous meeting minutes and was not able to provide the surveyor with any previous meeting minutes. Staff #2 stated that she would be having a meeting sometime in June 2023. Staff #2 provided the surveyor with a Complaint Tracking Log, only three complaints were documented. The dates were 4/13/23 and 4/15/23. There were no other logs provided. Staff #2 stated that was all she had. The complaints on 4-15-23 were requests to have a label on the complaint box. The complaint was not resolved until 4/18/23. The complaint was not handled in a timely manner. The next complaint on 4/15/23 was patient(s) not having any "outside time". There was no resolution documented. The final complaint written on 4/13/23 revealed an outcry of abuse and staff retaliation. The complainant stated the staff refused to give patient #1 snacks when there was extra left over. When the patient (patient #1) got upset a tech gave him a snack, the second tech took it away from the patient with no explanation. Patient #1 received chemical restraints for emergency behavior on 4/10/23 prior to this incident. The complainant stated, "The night shifts attitude are horrible. I have to get a nurse to go with me just to ask a question because the tech's dispositions are horrible. I'm here to get my meds adjusted. I am a human being and completely coherent. They roll their eyes when we ask questions but smile if someone higher up is near. A kindness training or something needs to happen. I will be following up with higher ups myself thank you. ... I'm writing on a blank piece of paper because the nurse stated there were no complaint forms. Ms. ____ (RN) and ___ (RN) are amazing they are welcoming if they weren't here I would be afraid to go to sleep because the techs ____ (tech)and ___(tech) are so nasty. The sad part is that Ms. ___ (RN) agrees that they have horrible attitudes she could barely write down crayon names for me because when they came back there she stopped writing and just franticly said, "Here take this" (politely). No one including myself asks (the techs) for them to do anything because of their horrible attitudes. They don't hand things to you, they avoid eye contact, and say here!..." A review of the complaint log revealed a comment that stated, "Will forward to ____ ( Staff #1) to have an in-service training with ____ (tech) and ___ (tech) over patient care. There was no other documentation of interviews with staff or the patient. The complaint was not addressed as a grievance and possible staff abuse was not addressed. Staff #2 could not provide the surveyor with any grievances or outcomes. Staff #2 stated that she did not have anything else to provide. Staff #2 was not aware that patient #1, who was refused a snack, was patient #1 and had been given chemical restraints on 4/10/23. The facility failed to ensure this patient was not being singled out or any retaliation was placed upon the patient due to prior behaviors.