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)
A0396 NURSING CARE PLAN
CFR(s): 482.23(b)(4)

The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient's goals and the nursing care to be provided to meet the patient's needs. The nursing care plan may be part of an interdisciplinary care plan.


This STANDARD is not met as evidenced by:
Based on review the facility failed to provide a interdisciplinary treatment plan for 2 (Patient #26 and 29) out of 3(patient #1, #26 and #29) charts reviewed. A review of patient #29's chart revealed the patient was admitted to the facility on 4/14/23 and was still in the facility as of 5/10/23. Patient #29 had no treatment plan on the chart. The facility was unable to provide a treatment plan after 3 requests. A review of patient #26's chart revealed the patient was admitted to the facility on 4/26/23. Patient #26 had no treatment plan on the chart. The facility was unable to provide a treatment plan after 2 requests. A review of the policy and procedure Interdisciplinary Treatment Plan stated: "POLICY Each patient admitted to Aspire Hospital shall have a written, individualized, comprehensive, outcome-oriented interdisciplinary treatment plan of care. Based on assessments of clinical needs (as well as reassessments and results of diagnostic testing) and the patient's goals (and the time frames, settings, and services required to meet those goals), the plan for the patient's care, treatment, and services shall describe patient strengths and limitations; short and long term goals of treatment; clinical interventions prescribed; patient progress in meeting treatment goals; criteria for discharge from treatment; and provisions for aftercare. Treatment shall be planned, reviewed, and evaluated at regular intervals by the Interdisciplinary Treatment Team. This team shall consist of the physician and representatives of each clinical discipline involved in the treatment as appropriate .