The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on policy review and staff interviews the facility through it's administrator failed to comply with a request by the Texas Department Of State Health Services to update and return the Medicare Database Worksheet as requested.

The findings include:

Review of facility policy titled "Governing Body Bylaws" states, in part, "Committees shall be charged with the responsibilities to act upon any reports and/or recommendations from authorized agencies, as appropriate." "The Chief Executive Officer shall appoint, with the final approval of the Governing Body, an Administrator that is responsible for the facilities day to day operations. The authority and duties of the Administrator shall include the following: To be responsible for the management of the hospital concerned with the operation of the hospital. To comply with Federal and State statutes and regulations....."

Interview with the Administrator the morning of 5/6/14 revealed the corporate compliance officer took care of this information and the completed form had been sent to the compliance office for review a couple weeks ago. He further stated he had a message on his desk that he got yesterday and he should have called back.

Interview with the Associate Corporate Compliance Officer the afternoon of 5/6/14 revealed initially she stated she had completed one and sent to the office in Austin in January of this year. When asked to produce confirmation of this she stated "I did not do one for that site. I thought you meant Lufkin. I never received one for that location."

Interview with the Administrator in training the afternoon of 5/6/14 revealed he had received an email from the Austin zone office on 3/25/14 with the database worksheet attached and he had forwarded it to the Administrator on 3/26/14. He stated he did not follow up on the form since he forwarded it to the Administrator and he was going on vacation.

Further interview with the Administrator the afternoon of 5/6/14 revealed he had found the database worksheet in his email and even though it said return within 10 days that he had until May 8th since that is when their accreditation ends.

No evidence of compliance was provided as to the completion and return of the database worksheet at the time of the complaint survey investigation.