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ASPIRE HOSPITAL

2006 SOUTH LOOP 336 WEST, SUITE 500

CONROE, TX 77304

RESPIRATORY CARE SERVICES POLICIES

Tag No.: A1160

Based on document review and interview the facility failed to have 2 (Policy #RP.001 and Policy #RP.004) of 2 respiratory care policies approved by the Medical Executive Committee (MEC) and Governing Body (GB).


Findings:


A review of the policies titled, "HHN (hand-held nebulizer) Policy #RP.001 with a revised date of 11/01/2023 and Oxygen Policy #RP.004 with a revised date of 11/01/2023 revealed the policies had not been submitted to the MEC or GB for approval.


During an interview with Staff #1 on 11/15/2023 at 2:15 PM, it was confirmed that Policy #RP.001 titled "HHN" and Policy #RP.004 titled "Oxygen" had not been submitted or approved through the MEC and GB.