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)
A0353 MEDICAL STAFF BYLAWS
CFR(s): 482.22(c)

The medical staff must adopt and enforce bylaws to carry out its responsibilities. The bylaws must:


This STANDARD is not met as evidenced by:
Based on interview the facility failed to provide medical staff bylaws. An interview was conducted with staff #4 on 5/9/23. Staff #4 was asked 2 times on 5/8/23 to provide the surveyor with medical staff bylaws. On 5/9/23 staff #4 stated he did have medical staff by laws and would provide them for the surveyor. Staff #4 was unable to provide the bylaws. On 5/10/23 staff #4 was asked if the facility had medical staff bylaws and why would he not provide the bylaws. Staff #4 reassured the surveyor he would provide the bylaws. The facility failed to provide any medical staff bylaws after 5 requests.