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)
A0343 COMPOSITION OF THE MEDICAL STAFF
CFR(s): 482.22(a)(4)

When telemedicine services are furnished to the hospital's patients through an agreement with a distant-site telemedicine entity, the governing body of the hospital whose patients are receiving the telemedicine services may choose, in lieu of the requirements in paragraphs (a)(1) and (a)(2) of this section, to have its medical staff rely upon the credentialing and privileging decisions made by the distant- site telemedicine entity when making recommendations on privileges for the individual distant-site physicians and practitioners providing such services, if the hospital's governing body ensures, through its written agreement with the distant-site telemedicine entity, that the distant-site telemedicine entity furnishes services that, in accordance with §482.12(e), permit the hospital to comply with all applicable conditions of participation for the contracted services. The hospital's governing body must also ensure, through its written agreement with the distant-site telemedicine entity, that all of the following provisions are met: (i) The distant-site telemedicine entity's medical staff credentialing and privileging process and standards at least meet the standards at §482.12(a)(1) through (a)(7) and §482.22(a)(1) through (a)(2). (ii) The individual distant-site physician or practitioner is privileged at the distant-site telemedicine entity providing the telemedicine services, which provides the hospital with a current list of the distant-site physician's or practitioner's privileges at the distant-site telemedicine entity. (iii) The individual distant-site physician or practitioner holds a license issued or recognized by the State in which the hospital whose patients are receiving such telemedicine services is located. (iv) With respect to a distant-site physician or practitioner, who holds current privileges at the hospital whose patients are receiving the telemedicine services, the hospital has evidence of an internal review of the distant-site physician's or practitioner's performance of these privileges and sends the distant-site telemedicine entity such performance information for use in the periodic appraisal of the distant-site physician or practitioner. At a minimum, this information must include all adverse events that result from the telemedicine services provided by the distant-site physician or practitioner to the hospital's patients, and all complaints the hospital has received about the distant-site physician or practitioner.


This STANDARD is not met as evidenced by:
Based on review and interview the facility failed to provide credentialing, privileges, and a current list of telemedicine physicians. The facility presented a practitioner list by specialty. The list did not identify by name or specialty any of the telehealth physicians performing current psychiatric evaluations and care. The facility was not able to provide the surveyor with Governing Board bylaws after 5 requests. The surveyor was unable to determine if the GB allowed the contracted service to credential its staff or if the facility chose to credential all physicians through the hospital process. A review of the contract for Physician Credentialing and Privileging Agreement dated 2/28/2014 stated, " Each such credentialed Redi answer physician providing telemedicine physician services to the hospital has been appropriately credentialed and privileged by Redi answer...The hospital may accept Redi answer and comply as necessary with the standards set forth in that regulation." The distant-site telemedicine entity failed to provide a list to the hospital of all physicians and practitioners covered by the agreement, including their privileges at the distant-site telemedicine entity, current privileges, and pertinent licensure information. There was no evidence that the hospital reviews the services provided by the telemedicine physicians and practitioners, including any adverse events and complaints, and provides written feedback to the distant-site telemedicine entity. An interview was conducted with staff #16 on 5/9/23. Staff #16 confirmed that the provider list given to the surveyor had no telemedicine physicians listed and confirmed the physicians had not been credentialed for the facility. Staff #16 confirmed that he was unsure who was credentialed and stated many of the providers on the list were no longer with the organization.