Page 2 – HopeBridge Hospital · Tim Simmons, Manager HopeBridge Hospital 5556 Gasmer Drive...

April 20, 2017 Our Reference: CCN 670072 Tim Simmons, Manager HopeBridge Hospital 5556 Gasmer Drive Houston, TX 77035 Dear Mr. Simmons: On February 22, 2017, CMS extended a pending termination date for HopeBridge Hospital to June 1, 2017. Today’s notice of termination supersedes the pending action and HopeBridge Hospital’s provider agreement will terminate on May 5, 2017, for the reasons set forth in this letter. The Centers for Medicare & Medicaid Services (CMS) has determined that HopeBridge Hospital no longer meets the requirements for participation in the Medicare program because of deficiencies that represent an immediate jeopardy to patient health and safety. We have reviewed the State Agency's April 7, 2017, survey report and we are in agreement with the enclosed findings, which show that the following Medicare Conditions of Participation were out of compliance:

42 CFR 482.12 Governing Body 42 CFR 482.13 Patient Rights

Hospitals must meet all provisions of Section 1861(e) of the Social Security Act, be in compliance with each of the Medicare Conditions of Participation, and be free of hazard to patient health and safety in order to participate as providers of services in the Medicare program. The Medicare provider agreement of your hospital will be terminated on May 5, 2017. No payment for patients admitted on or after that date will be made by the Medicare program. For patients admitted prior to May 5, 2017, payment may continue to be made for up to 30 days of covered inpatient hospital services furnished on and after May 5, 2017. A list showing the names and health insurance claim numbers of the Medicare patients remaining in your hospital on May 5, 2017, must be forwarded immediately to the Centers for Medicare & Medicaid Services, Division of Survey and Certification, Attention: Ginger Odle, 1301 Young Street, Room 827, Dallas, TX 75202. We will publish notice of this termination in the Houston Chronicle. We will notify the appropriate State officials concerning termination of your provider agreement under Title XVIII because the requirements for participation in the Medicaid program are substantially the same as those for Medicare.

– HopeBridge Hospital If you believe this determination is not correct, you or your legal representative may request a hearing before an administrative law judge of the U.S. Department of Health and Human Services, Departmental Appeals Board. Procedures governing this process are set out in 42 CFR §498.40, et. seq. A request for a hearing should identify the specific issues, and the findings of fact and conclusions of law with which you disagree. It should also specify the basis for contending that the findings and conclusions are incorrect. You may have counsel to represent you at a hearing (at your own expense). You must file your hearing request electronically by using the Departmental Appeals Board's Electronic Filing System (DAB E-File) at https://dab.efile.hhs.gov no later than June 19, 2017. Requests for a hearing submitted by U.S. mail or commercial carrier are no longer accepted as of October 1, 2014, unless you do not have access to a computer or internet service. When using DAB e-File for the first time, you will need to create an account by a) clicking Register on the DAB E-File home page; b) entering the requested information on the Register New Account form; and c) clicking Register Account at the bottom of the form. Each representative authorized to represent you must register separately to use the DAB e-File on your behalf. The e-mail address and password given during registration must be entered on the login screen at: https:/dab.efile.hhs.gov/user_sessions/new to access DAB e-File. A registered user’s access to DAB e-File is restricted to the appeals for which he/she is a party or an authorized representative. You can file a new appeal by a) clicking the File New Appeal link on the Manage Existing Appeals screen; then b) clicking Civil Remedies Division on the File New Appeal screen; and c) entering and uploading the requested information and documents on the File New Appeal-Civil Remedies Division form. The Civil Remedies Division (CRD) requires all hearing requests to be signed and accompanied by the notice letter from CMS that addresses the action taken and your appeal rights. All submitted documents must be in Portable Document Format (PDF). Documents uploaded to DAB e-File on any day on or before 11:59 p.m. EST will be considered to have been received on that day. You will be expected to accept electronic service of any appeal-related documents filed by CMS or that the CRD issues on behalf of the Administrative Law Judge (ALJ) via DAB e-File. If you do not have access to a computer or internet service, you may call the Civil Remedies Division to request a waiver from e-filing and provide an explanation as to why you cannot file electronically or you may mail a written request for a waiver along with your written request for a hearing. A written request for a hearing must be filed no later than sixty (60) days after receiving this letter, by mailing to the following address: U.S. Department of Health and Human Services Departmental Appeals Board, MS 6132 Director, Civil Remedies Division 330 Independence Avenue, SW Cohen Building, Room G-644 Washington, D.C. 20201 Please contact the Civil Remedies Division at 202-565-9462 if you have questions regarding the DAB e-Filing System. If you experience technical issues with the DAB e-Filing System, please contact E-File System at [email protected] or call 202-565-0146 before 4:00 p.m. EST.

– HopeBridge Hospital In addition, please forward a copy of your request to: CMS Associate Regional Administrator Centers for Medicare & Medicaid Services Division of Survey and Certification ATTN: Ginger Odle 1301 Young Street; Room 827 Dallas, TX 75202 In accordance with the Medicare regulation 42 CFR 489.57, a new Medicare provider agreement will not be accepted until it has been determined that the reason for termination of the previous agreement has been removed and there is reasonable assurance that it will not recur. The terminated facility will have to operate for a period of time determined by CMS, during which the reasonable assurance requirement has been satisfied. During this period the facility must fulfill, or make satisfactory arrangements to fulfill, all of the statutory and regulatory responsibilities of the previous agreement. You may contact Dodjie Guioa at 214-767-6179 or by e-mail [email protected], if you have questions regarding this matter.

Sincerely,

Ginger Odle, Manager Enforcement Branch Enclosure: CMS-2567 cc: State Medicaid Agency, DSHS

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(X1) PROVIDER/SUPPLIER/CLIA

IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION

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PRINTED: 04/18/2017FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

670072 04/07/2017STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

5556 GASMER DRIVEHOPEBRIDGE HOSPITAL

HOUSTON, TX 77035

PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

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SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

A 000 INITIAL COMMENTS A 000

Note: The CMS 2567 is an official, legal

document. All information must remain

unchanged except for entering the plan of

correction, correction dates, and the signature

space. If information is inadvertently changed by

the provider, you should notify the state Survey

Agency. If information is inadvertently changed

by the provider, you should notify the state Survey

Agency. If the SA notices any discrepancy in the

information, the Regional Office will make a

referral of possible fraud to the Office of the

Inspector General (OIG).

An unannounced visit was made to conduct a

follow-up and complaint survey per Sections

5040, 5130 and 5210F of the State Operations

Manual (SOM). Appendix A-Survey Protocol,

Regulations and Interpretive Guidelines for

Hospitals was utilized to determined hospital's

compliance with 42 CFR 482 Conditions of

Participation (CoP) for Hospitals. An entrance

conference was held on the morning of 04-04-17

with key administrative personnel. The purpose,

scope and process of the survey was explained

and an opportunity for questions and discussion

was provided.

An exit conference was held on the afternoon of

04-07-17 with key administrative personnel. The

preliminary findings of the survey were discussed

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that

other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete 8CUR11Event ID: Facility ID: 810854 If continuation sheet Page 1 of 29

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A 000 Continued From page 1 A 000

and again, an opportunity for questions and

discussion was provided. The facility Chief

Executive Officer and the owner were informed

on 04-07-17 at 3:00 p.m. that the Immediate

Jeopardy could not be removed due to the

current findings. The following Conditions of

Participation were determined to remain out of

compliance:

42 CFR 482.12 Governing Body

42 CFR 482.13 Patient Rights

A 043 482.12 GOVERNING BODY

There must be an effective governing body that is

legally responsible for the conduct of the hospital.

If a hospital does not have an organized

governing body, the persons legally responsible

for the conduct of the hospital must carry out the

functions specified in this part that pertain to the

governing body ...

This CONDITION is not met as evidenced by:

A 043

Based on observation, interview, and record

review, on April 4-7, 2017, the governing body

failed to provide effective oversight to ensure that

patients recieved care in a safe environment.

1.The facility did not ensure that each patient

receive treatment in a safe setting as evidenced

by the presence of multiple ligature risks. These

identical ligature risks were previously cited on

March 8, 2017 and had not been removed.

2. The facility was not constructed and


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maintained to guarantee the safety and well-being

of each patient as evidenced by the presence of

multiple ligature risks. The identified practices

continue to present a likelihood of Immediate

Jeopardy to the 32 current patients and all

potential patients with behavioral problems on the

adult and adolescent units.


review, the facility failed to ensure the rights of

each patient to receive treatment in a safe setting

as evidenced by all patients placed on units with

known multiple ligature risks present that were

easily accessible for self-harm.

This deficient practice posed a likelihood of

serious harm or death for current and potential

patients with suicidal ideation on the adult and

adolescent units.

Refer to 482.13(c)(2) - [A-0144]

A 115 482.13 PATIENT RIGHTS

A hospital must protect and promote each

patient's rights.

This CONDITION is not met as evidenced by:

A 115


review, on April 4-7, 2017, the facility failed to

ensure the rights of each patient to receive

treatment in a safe setting. Eleven (11) of 33

patients (Patients #1, #2, #3, #10, #11, #15, #16,

#18, #28, #32, #33) were placed in rooms with

known multiple ligature risks present and easily

accessible for use to harm self or others. These


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eleven (11) patients were on suicide precautions.

This deficient practice posed a likelihood of

serious harm or death for current and potential

patients with suicidal ideation on the adult and

adolescent units.

Refer to 482.13(c)(2) - [A-0144]

A 144 482.13(c)(2) PATIENT RIGHTS: CARE IN SAFE

SETTING

The patient has the right to receive care in a safe

setting.

This STANDARD is not met as evidenced by:

A 144


review, the facility failed to ensure the rights of

each patient to receive care in a safe setting on 2

of 2 patient care units (Unit 1-adult and Unit

2-child/adolescent). The facility failed to:

(1) remove multiple known ligature risks that

jeopardized the safety of 11 patients on Suicide

Precautions (SP) that included bathroom faucets,

push/pull door handles, and architechtural grade

butt door hinges potentially usable for ligature

during self-harm,

(2) ensure that a patient diagnosed with

Disorganized Schizophrenia on suicide

precautions was prevented access to a glass light

bulb and electrical wiring,


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(3) ensure unoccupied patient bedrooms were

locked when unoccupied,

(4) ensure that a personal hygiene item requiring

poison control intervention in case of ingestion

was inaccessible to patients,

(5) ensure that a piece of plastic that can be used

for self-harm was not accessible to patients,

(6) implement an effective system to prevent

patients on SP from accessing cutlery pthat can

be used for to harm self or others,

(7) make certain newly admitted patient on SP did

not have personal clothing item potentially that

can be used for self-harm.

Findings included:

(1) Ligature Risks:

Observation on 04-04 17 at 2: 30 p.m. revealed

the following:

Unit 1 (adults) :

Observation of all 19 occupied patient rooms

revealed the following ligature risks in each room:


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bathroom faucets, push/pull door handles, and

architechtural grade butt hinges [the identical

risks were previously cited on 03-08-17 survey].

Record review of facility "Patient Census," dated

04-04-17 revealed the Unit 1 census was 28

patients; two(2) were on Suicide Precautions

(Patient # 15, #16).

Patient # 15:

Record review of the medical record of Patient #

15 revealed he was admitted on 04-02-17 with a

diagnosis of "Schizophrenia superimposed on a

mildly intellectually disabled state". Physician

order, dated 04/04/17 read : "... suicide

precautions..." Patient # 15 was admitted to room

123-B where there are ligature risks easily

accessible for self harm.

Patient # 16:


16 revealed she was admitted on 04-02-17 with

diagnoses of bipolar disorder and polysubstance

abuse. Admission orders dated 04-04-17, read:

...suicide precautions.." Patient # 16 was admitted

to room 108-B where there are ligature risks

easily accessible for self harm.

Observation on 04-04 17 at 2: 30 p.m. revealed

the following:


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Unit 2 ( adolescents/children) :




architechtural grade butt door hinges [the

identical risks were previously cited on 03-08-17

survey].

Record review of facility "Patient Census", dated


patients; three (3) were on Suicide Precautions

(Patient # 1, # 2, # 10).

Patient # 1:


1 revealed she was admitted on 04-03-17 with a

diagnosis of major depressive disorder with

suicidal ideation. Physician order, dated 04/04/17

read : "... suicide precautions..." Patient # 1 was

admitted to room 204-A where there are ligature

risks easily accessible for self harm.

Patient # 2

Record review of medical record of Patient # 2

revealed he was admitted on 03-17-17 with

diagnoses of bipolar disorder and suicidal

ideation. Observation on 04-04-17 of unit

"bedboard" [whiteboard] and record review of

"Precaution Sheets", dated 04-04-17 revealed

Patient # 2 was on suicide precautions. Patient #

2 was admitted to room 205 where there are

ligature risks easily accessible for self harm.


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Patient # 10:


10 revealed he was admitted on 04-03-17 with a

diagnosis of mood disorder/mood swings

depressive disorder with suicidal ideation.

Admission physician order, dated 04/04/17 read :

"... suicide precautions..." Patient # 10 was

admitted to room 221-B where there are ligature

risks easily accessible for self harm.

Multiple observations were done on 04-05-17 &

04-06-17 between 8:00 a.m. and 2:00 p.m. on

Unit 1 and Unit 2 revealed the following:

04-05-17:

Unit 1: three (3) patients were on suicide

precautions ( Patients # 11, #15, 16)

Unit 2: four(4) patients were on suicide

precautions ( Patients # 1, #2,# 3)

04-06-17:

Unit 1: two(2) patients were on suicide

precautions ( Patients # 28, # 18)

Unit 2: five(5) patients were on suicide


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precautions ( Patients # 1, #2, #3,# # 32, #33)

Record review of the medical records for Patients

1, 2, 3, 11,15,16,18,28,32,33 revealed physician

orders for suicide precautions on April 5 & 6,

2017.

Observation on 04-07-17 between 9 a.m. and 11

a.m. revealed the following:

Unit 1 (adults) :




architechtural grade butt door hinges [the same


Record review of facility "Patient Census," dated


patients; two(2) were on Suicide Precautions

(Patient # 15, #28). Record review of medical

records for both patients revealed current

physician orders for suicide precautions.

Unit 2 (adolescents/children) :





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architechtural grade butt door hinges [the same


Record review of facility "Patient Census", dated


patients; two(2) whom were currently on Suicide

Precautions (Patient # 2, #33). Record review of

medical records for both patients revealed current

physician orders for suicide precautions.

During the interview on 04-07-17 at 11:10 a.m.

with Chief Executive Officer (CEO) #1, he

provided the following information in regards to

the ligature risks (previously cited on 03-08-17

survey) :

Faucets: waiting for a "prefab faucet shroud" to

be developed. "This was supposed to be ready

on 04-03-17 but the machine broke; should be

ready by 04-10-17. We will test this to make sure

it works before we order it. After it is ordered, it

will be 4 to 5 weeks to be delivered and 1 week to

install in all the patient rooms." CEO # 1 went on

to say "the back up plan" was to order all new

sinks which would be a 3 to 6 week delivery time;

2 to 3 week installation.

Door hinges: ordered on 03-24-17; delivery

expected in 2 to 3 weeks; 2 week installation

time.

Door handles: ordered on 03-23-17; up to 4 week

delivery time; less than 1 week to install.


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When asked how facility verified in-room checks

(of patient's on SP) on the night shift, CEO # 1

went on to say the facility did not presently have

closed circuit TV video (CCTV) surveillance

cameras. He said the CCTV cameras were

placed in the coming year's capital budget. No

other measures were put in place in the interim.

During the interview on 04-06-17 at 1:45 p.m. with

Chief Nursing Officer (CNO) # 2, she stated in

addition to the staff training , Registered Nurse

(RN) rounds were increased from every 3 hours

to every hour. She went on to say these rounds

included RN verification that SP was correctly

documented on unit bedboard, nursing notes,

observation sheets, and treatment plans. CNO #

1 did not include actual patient observation by the

RNs during the rounds. CNO #1 went on to say

that RNs reviewed the patients for need for 1:1

monitoring, especially for those at high risk.

Record review of facility "Precaution Sheets",

dated April 4, 5, 6, 7, 2017 failed to reveal any

patients had been monitored 1:1 on any shift at

any time. This was verified by interviews with

charge nurses on both units on same dates.

During an interview on 4/5/2017 at 7:45 am on

the Adult Psychiatric Unit with Staff # 16 Charge

Nurse, he stated when there are patients in their

rooms the doors are kept opened and there was

staff assigned to the hall to monitor the patients in


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their rooms. He stated, the staff is always on the

hallway to ensure they are aware of the patients'

locations. When the patients are not in their

rooms the doors were locked with keys kept by

staff.

According to Staff (# 16), patients were

"eyeballed" every fifteen (15) minutes and the

observation was documented on the rounding

sheet. Staff (#16) stated patients on Suicide

Precaution are monitored more closely.

However, Staff (#16) was not able to describe

what "more closely" meant or show where the

"more closely" monitoring was documented for

patients on suicide precautions.

( 2) Light fixture risk:

Observations in Room 123 on 04/05/17 at

approximately 11:30 a.m. reflected a loose light

fixture above the sink.

Employee #5 acknowledged the potential for

hiding contraband and access by patients to a

light bulb and electric wiring at that time.

The Patient Census dated 04/05/17 reflected

Patient #15 was assigned to Room 123.

Patient #15's Psychiatric Evaluation dated

04/01/17 at 2354 reflected Patient #15 had a

history of Schizophrenia. The patient was


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intellectually disabled. He was admitted with

increasingly bizarre behavior, was noted to be

hallucinating and stated he "would rather die."

Patient #15's Psychiatric Admission Orders dated

04/02/17 reflected the patient was on suicide

precautions and on fifteen-minute observational

checks.

Employees #2 and #17 were interviewed

regarding the loose fixture on 04/05/17 at

approximately 12:05 p.m. Employee #17 stated, "I

would not be surprised if the patient did it."

(3) Unlocked patient rooms with identified ligature

risks : [120, 126, 204, 210, 222, & soiled utility

room]

Observation on 4/4/17 at 3:25 p.m. of facility's

child and adolescent unit hallways, accompanied

by Registered Nurse (RN)#5, revealed an empty

patient's room, #204. The door was closed but

unlocked, allowing anyone to enter. RN #5 stated

the room door should have been locked.

Observation on 04/04/17 at 12:30 p.m. of facility's

child and adolescent hallways, accompanied by

RN#5, revealed an empty patient's room, # 210.

The door was closed but unlocked, allowing

anyone to enter. RN #5 stated that the room door

should have been locked.


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Observation on 4/7/17 at 9:50 a.m. of facility child

and adolescent unit hallways, accompanied by

RN # 4, revealed an empty patient's room, # 222.

The door was closed but unlocked, allowing

anyone to enter. RN #4 stated that the room door

should have been locked.

Observation on 4/5/17 at 11:00 a.m. of facility

child and adolescent unit hallways , accompanied

by Mental Health Tech (MHT) Staff # 8, revealed

an unlocked door to the "Soiled Utility Room",

allowing anyone to enter. Inside this Soiled Utility

room the following items were observed: a sharp

metal dust pan, a broom, two (2) large

approximately 25 gallon sinks, two (2) large

plastic bag trash can liners, a sprinkler head,

regular door hinges, large air vents protruding

down from ceiling, and a wheelchair with

removable leg rests. MHT Staff #8 stated that this

door should have been locked.

Observations on 04/07/17 at 9:31 a.m. revealed

that Rooms 126 and 120 were unlocked. No

patient was observed in the room at that time.

Personnel #8 acknowledged at that time that he

should have locked Room #126. Room 126 was

observed unlocked again approximately three

hours later, on 04/04/17 at 12:20 p.m. without a

patient's presence in the room.

Observation on 04-07-17 at 9:58 a.m. of Unit 2

patient "bedboard" [posted white board] revealed

Patient # 18 was currently placed in room # 126

and was on Suicide Precautions. Record review


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of Patient # 18's physician order, dated 04-07-17

revealed SP had been in the room at that time.

Personnel #8 acknowledged at that time that he

should have locked Room #126. Room

discontinued at 2:00 a.m. The white board had

not been updated.

Record review of facility's policy titled "Locks on

Patient Room Doors", dated 4/2017, read:

"Purpose: to help in establishing a safe

environment for patients and to mitigate ligature

risks in patient rooms...Procedure:...Vacant

unoccupied rooms will be locked...occupied

patient rooms will be locked when the patients

are in scheduled activities or not in their rooms.."

(4) Hazardous items

Observations on 04/04/17 at 2:40 p.m. on the

hospital's adult unit Room 125, Bed A, had a

bottle with lotion that stated to keep the content

"out of reach of children." Bed B's night stand had

a bottle labeled as antiperspirant that noted to

"call poison control in case of ingestion."

Review of facility policy titled:" Search and

Contraband", undated , read: "...Prohibited

items-possessions that may create a safety risk

for self or others:...toxic or hazardous liquids,

materials, or aerosols..."

(5) Hazardous item

A piece of black plastic material potentially


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dangerous when ingested or inhaled was

observed in the bathroom of Room 126 on

04/04/17 at approximately 2:25 p.m. Personnel

#13 acknowledged the item and removed it.

Record review of a blank facility "Environmental

Services Daily Routine Quality Checklist" read:

"...TASK: Clean shower stall..remove ...all

debris.."

(6) Accessibility of cutlery

During the interview in the facility kitchen on

04-06-17 at 10:45 a.m. with Assistant Dietary

Director # 37, she stated the facility used

Styrofoam and plastic products because they

have "many patients at risk to harm themselves".

She went on to say patients on Suicide

Precautions (SP) were not given any cutlery, salt,

or ice.

Dietary Director # 37 said, 'Nursing gives us the

Diet Logs every day and it will indicate if a patient

is on suicide precautions. We prepare the patient

tray based on that".

Review of the "Adult Diet Sheet"; "Adolescent

Diet Log"; and the Children Unit Diet Log" , all 3

dated 04-06-17 failed to indicate any patient on

any unit was on SP. Assistant Dietary Director #

37 said "according to the logs, no patients are on

SP today."


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Observation on 04-06-17 at 11:15 a.m. on the

Children's hall activity room revealed six (6)

patients eating lunch. Further observation

revealed after the children finished eating, they

disposed of the trash from their trays into a large

paper bag located on the floor by the wall. Patient

# 32 was observed disposing of his trash which

included plastic cutlery. At the time Patient # 32

placed his trash into the paper bag, Mental Health

Tech (MT) # 7 had his back to this patient. No

other staff was observing this patient.

Further observation revealed Patient # 32 could

have easily hidden the cutlery on his person with

no staff noticing.

Record review of facility "Precaution Sheet, Unit

2: Children", dated 04-06-17 ( 7A-7P) revealed

Patient #32 was on Suicide Precautions.

(7) Personal clothing: ligature risk

Observation of room # 206 on 04-07-17 9:30 a.m.

revealed a plastic basket that contained clothing.

Within the basket a girl's tank-top style shirt with

thin "spagetti straps" was observed . RN # 6

stated Patient # 33 had been newly-admitted to

this room. She went on to say this patient was on

Suicide precautions (SP). RN # 6 said the patient

should not have a shirt with straps like this as

they posed a risk. She removed the shirt from the

room.

Review of facility policy titled "Organization


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Ethics and Compliance", revised 5-18-16, read:

"...Treatment of Patients:...The well-being and

safety of patients should be the focus of all

employees...Safe Patient Care: Safe environment

safe care is essential to the well-being and

recovery of psychiatric patients.....the hospital will

promote a safety culture based on appropriate

policies, systems,and equipment..."

A 395 482.23(b)(3) RN SUPERVISION OF NURSING

CARE

A registered nurse must supervise and evaluate

the nursing care for each patient.


A 395

Based on record review, observation, and

interview, the hospital's nursing staff failed to

supervise and evaluate the nursing care for two

of two patients (Patients #15, #20) according to

the patients' needs.

1)Although Patient #15 had a 50 pound reported

weight loss during the two months prior to his

hospital admission, nursing failed to verify the

patient's reported weight on admission and to

obtain a dietary consult for the patient who was

under-weight and refused at least three meals at

the time of survey,

2)Although Patient #20 had been noted to be

losing weight during his partial hospitalization

treatment, nursing did not weigh the patient for

two and one half months.

Findings included:


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1) On 04/05/17 at 11:15 a.m., Patient #15 was

observed in the adult unit's dining room. Patient

#15 was very slender. He refused his lunch meal.

Personnel #12 reported the patient did not eat

breakfast.

On 04/05/17 at 1635, Patient #15 was observed

eating only his dinner roll and refused to eat the

rest of the meal.

Hospital Intake Assessment dated 04/01/17 at 11:

24 a.m. reflected Patient #15 had lost 50 pounds

during the two months prior to his admission.

Vital Signs Flow Sheet dated 04/06/17 reflected

the patient weighed 131 pounds.

Personnel #20 was interviewed by telephone on

04/06/17 at 9: 11 a.m. and denied that the Patient

#15 was weighed during the hospital intake

process because the patient was "non-

responsive."

On 04/06/17 at 4:00 p.m. Personnel #5 stated a

dietary consult was ordered at that time.

Personnel #2 acknowledged that Patient #15's

reported weight on admission had not been

verified through hospital personnel.


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According to the National Institute of Health,

Patient #15 had a body mass index of 17.8 and

was under-weight.

(https://www.nhlbi.nih.gov/health/educational/lose

_wt/BMI/bmicalc.htm)

2) Patient #20's Psychiatric Progress Notes dated

04/05/17 reflected that nursing reported the

patient's "ongoing weight loss."

During an interview on 04/06/17 at 11:55 a.m.,

Personnel #24 stated the physician saw Patient

#20 the day prior to the interview and noted the

patient's weight loss. Personnel #24 denied

weighing the patient at that time and stated the

last time that the patient was weighed was on

01/18/17.

A 396 482.23(b)(4) NURSING CARE PLAN

The hospital must ensure that the nursing staff

develops, and keeps current, a nursing care plan

for each patient. The nursing care plan may be

part of an interdisciplinary care plan


A 396

Based on record review, observation, and

interview, the hospital failed to keep current a

nursing care plan according to hospital policy for

one of one patient (Patient #15) whose fear of

receiving poison in his hospital food was not

addressed by the treatment team.

Findings included:


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Patient #15's Psychiatric Evaluation dated

04/01/17 at 11:54 p.m. , unsigned as of 04/05/17

at 3:15 p.m., reflected the patient's admitting

diagnoses that included Disorganized

Schizophrenia and Mild Intellectual Disability.

Prior to his hospital admission, Patient #15 had

decreased his food intake and lost 50 pounds.

On 04/05/17 at 11:15 a.m. Patient #15 was

observed in the adult unit's dining room. He

refused his lunch meal. On 04/05/17 at 4:35 p.m.,

Patient #15 was observed eating only his plastic

wrapped dinner roll and refused to eat the rest of

the meal.

On 04/07/17 at 1:45 p.m., Patient #15 stated

through an interpreter that he thought his food

was "poisoned" and staff put medicine in his food.

Patient #15 stated he would "die soon."

Patient #15's Multidisciplinary Treatment Plan

dated 04/05/17 did not address the patient's

statements regarding hos food had 'poison" or

staff adding medicine to it.

Personnel #5 denied on 04/06/17 at 2:00 p.m.

that Patient #15's treatment plan addressed the

patient's fear.

Clinical Services Policy # 608, undated, reflected

the hospital policy to "provide documentation ...of

the care and treatment ...that is planned and

provided ..."


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A 724 482.41(c)(2) FACILITIES, SUPPLIES,

EQUIPMENT MAINTENANCE

Facilities, supplies, and equipment must be

maintained to ensure an acceptable level of

safety and quality.


A 724

Based on observation and interview, the hospital

failed to ensure that the facility and equipment

were maintained to ensure an acceptable level of

safety and quality.

Findings included:

Observation on 04/04/17 at 2:20 p.m. revealed a

fist-sized hole in the wall of the hallway leading

from the main entrance to the adult patient unit.

A small cove in the hallway identified by

Personnel #13 as space formerly occupied by

washer and dryer was observed on 04/04/17 at

2:20 p.m. with water dripping from the space

above the missing ceiling tile. Wet towels covered

the floor.

Observations on 04/07/17 at 9:26 a.m. revealed

water dripping again through the ceiling into a

trash barrel. Two wet towels were on the floor at

that time.

Observation on the hospital's adult unit

Quiet/Activity Room on 04/04/17 at 2:55 p.m.

revealed the paint on at least two walls was

scraped off. Personnel #3 and/or Personnel #13

acknowledged the findings at that time.


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Two stained ceiling tiles were observed in the

hospital's clean utility room and in the hallway in

front of Room 123 on 04/05/17 at 11:40 a.m.

Observations in the hospital's Partial

Hospitalization Program on 04/06/17 at 12:25

p.m. revealed a central supply room with multiple

brown spots, trash, and two bugs on the floor. A

floor tile was missing. Personnel #23 stated on

04/06/17 at 12:30 p.m. that the room had not

been checked.

Observations in the hospital's Central Supply

room on 04/06/17 at 2:20 p.m. revealed a rough

cement floor without covering. Two light bulbs

were burnt out. A rectangle hole sized

approximately 15 centimeter times 10 centimeter

was cut out of the wall's sheet rock and gave view

onto the wood frame. Three walkers identified by

Personnel #5 as "used" were leaning against two

pair of wrapped crutches. Personnel #5 stated,

the crutches were new and acknowledged that

used and clean equipment were in close

proximity. Three large ceiling tiles were missing

and gave view to pipes in the floor above. A large

piece of plastic was dangling down from the

ceiling.

Observation on 04-06-17 at 11:30 a.m. on the of

children's unit revealed three large holes in the

hall's walls in-between patient rooms on the

children's unit. There was one hole next to patient

room 205 approximately 6" x 3" with a 3"-5'' depth

(6 inches x 3 inches with approximately 3-5 inch

depth). Further observation revealed another hole


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in the wall of approximately the same dimensions

as the first aforementioned hole. This second

hole was located between patient rooms 205 and

206. A third smaller hole also in the corridor

hallway walls, approximately 2" x 4" with

approximately a 2"-3" depth (2 inches by 4 inches

with approximately a 2-3 inch depth) was also

located between patient rooms 205 and 205.

Observation on the adult unit on 4/5/2017 at 9:15

am in the bath room shared by rooms 121 and

122 revealed an area of peeling ceiling plaster

over the hand sink low enough for a patient to

reach up and pull the peelings off. This material

could be ingested by a patient. The rooms were

occupied by patients.

Observation in the facility kitchen on 04-06-17 at

10:30 a.m. revealed a large six(6) burner

industrial gas stove top. The stove top was

approximately 3 feet in height from the floor. The

pilot lights on all six burners were lit and

appeared to be approximately 3 inches in height.

Heat was felt coming off the appliance as

surveyor walked by the stove top.

When asked at the time of observation, Dietary

Director # 37 said she did consider this a safety

hazard. She said "I was reaching over on the

stove top one day and caught my shirt on fire."

Dietary Director # 37 went on to say she had

brought this to the attention to the contracted

company she worked for "but this is the way they

like it."

A 749 482.42(a)(1) INFECTION CONTROL PROGRAM A 749


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The infection control officer or officers must

develop a system for identifying, reporting,

investigating, and controlling infections and

communicable diseases of patients and

personnel.



review, the hospital failed to develop an effective

system for identifying and controlling potential

infections.

Patient accessible furniture and equipment were

in need of repair and cleaning,

Patient belongings / clothing were stored directly

on the floor,

Washing machine was not cleaned after each

use,

Clean linen was not stored in a manner to prevent

contamination,

Staff failed to sanitize their hands prior to donning

gloves.

Findings included:

Observation on the hospital's adult unit's

Quiet/Activity Room identified by Personnel #13


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on 04/04/17 at 2:55 p.m. as patient care area

reflected two chairs with ripped padding which

would make it difficult to adequately clean and

sanitize. The paint on at least two walls was

scraped off. The wood veneer table top was

broken in two places leaving it difficult to clean.

A large black bug was observed in Room 120 on

04/05/17 at 12:10 p.m. across the room.

Personnel #17 stated it was a spider and

removed it.

Observations on 04/05/17 at 11:40 a.m. in the

hospital's adult unit clean utility room reflected

one oversized and one regular sized wheel-chair

covered with plastic. Employee #5 stated those

wheel-chairs were clean. Both wheel-chairs were

observed with dusty and grimy wheels. Employee

#5 acknowledged the observations at that time

and stated they needed to be cleaned.

Review of undated Hospital Policy titled "Hospital

Equipment Cleaning" reflected that "equipment

used routinely during the day shall be cleansed

after each use per national healthcare regulatory

standards ...examples of these are wheel-chairs."

Observation during initial tour on 04-04-17

between 2:30 p.m. and 3:30 p.m. revealed the

following infection control issues on Unit 2

(adolescent and children's hallways):

Patient belongings room:


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a. Floor was dirty with multiple areas of dark

grime and stains,

b. (3) large 30 gallon plastic bags overflowing

with clothing were placed directly on the floor,

c. Two (2) wire shelving units that contained

various patient items: no plastic/impermeable

barrier noted on the bottom shelf of either

shelving unit.

Interview with Chief Nursing Officer (CNO) # 2 at

the time of observation, she stated the floor

should be cleaned and the clothing bags should

all be labeled and not be stored on the floor. CNO

went on to say she thought all the wire shelving

units had plastic barriers on the bottom; "these

must have been missed."

Patient laundry room:

Observation of the washing machine revealed a

thick film that covered most of the inside of the

washer. Interview with CNO # 2 at the time of

observation, she said the washer was used to

wash the patients' clothing and it should be

cleaned after every use by the techs.

Record review of facility policy titled" Cleaning of

Patient Washers and Dryers, undated, read: "...3.

The hospital staff will spray the drum with

disinfectant solution and allow to air dry following

each use...Housekeeping will disinfect the

machine daily.."


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Clean linen storage room:

Observation of a large wire cart that contained

stacks of linen revealed a wadded up towel and

a plastic "golf club" mixed in with the "clean

linen". Further observation revealed no

plastic/impermeable barrier noted on the bottom

shelf of the storage cart.

Interview with CNO # 2 at the time of observation,

she stated the bottom shelf should have a plastic

barrier on the bottom. She acknowledged the

linen could become contaminated when the floor

was mopped.

Review of facility policy titled" Handling of Clean

and Soiled Linen", undated , read: "Clean Linen

shall be handled, transported and stored by

methods that prevents contamination and

ensures cleanliness.."

Hand Hygiene:

Observation on 04-06-17 at 11: 00 a.m. revealed

Mental Health Techs(MHT) # 8 and MHT# 9

preparing to serve lunch trays on the children's

hallway. Both MHTs failed to sanitize their hands

prior to donning gloves and serving lunch to the

patients.

Interview on 04-07-17 at 1:00 p.m. with

Registered Nurse (RN) # 4, she stated hand


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hygiene should be performed before and after

donning gloves.

Record review of facility policy titled " Hand

Hygiene",undated, read: "...Indication For Hand

Washing and Hand Antisepis: Hands should be

sanitized using the hospital approved waterless

antiseptic agent in the following situations:...upon

entering the work area...before eating or handling

food..."


TEXAS Health and Human Services

Texas Department of State Health Services

Certified Mail Number: 7011 0470 0003 0321 1967 and First Class Mail Service

B. John Lange III, Registered Agent HopeBridge Hospital Houston, LLC dba HopeBridge Hospital 6363 Woodway Dr., Suite 1000 Houston, TX 77057

Certified Mail Number: 7011 0470 0003 0321 1974 and First Class Mail Service

Timothy Simmons, CEO HopeBridge Hospital 5556 Gasmer Drive Houston, TX 77035

John Heflmtttdt. M.O. <:omm&iooer

Re: Notice of Violation (Notice), HopeBridge Hospital Houston, LLC dba HopeBridge Hospital, General Hospital, License No. 100323, Case Nos. 1068170853 and 1068173695, Docket No. A26670-510-2017.

Dear Mr. B. John Lange III:

The Department of State Health Services (Department) has reviewed documents and evidence related to on-site complaint surveys at HopeBridge Hospital Houston, LLC dba HopeBridge Hospital (Respondent) located at 5556 Gasmer Drive, Houston, Texas, 77035 (Facility). The Department conducted complaint surveys on or about August 10 - 11, 2016 and January 19 - 20, 2017. As a result of those surveys, the Department proposes to revoke the Respondent's license #100323 and assess an administrative penalty of $455,000.00 pursuant to its authority under Chapter 241 of the Texas Health and Safety Code (HSC) and Title 25 of the Texas Administrative Code (TAC) Chapter 133 (Rules).

P.O. Box 149347 • Aus~in, Texas 78714-9347 • Phone: 888-963-7111 •TTY: 800-735-2889 • www.dshs.texas.gov

Notice of Violation HopeBridge Hospital Houston, LLC Page2

The proposed actions are based upon the following allegations (names of persons identified by initials or numbers will be provided upon request if permitted by law):

1. The Governing Body failed to appropriately oversee the organization, management, control, and operation of the Facility, to wit:

Specifically, the Governing Body failed to ensure patients received care in a safe setting, free from mistreatment or abuse, pertaining to the complaints investigated in August 2016 and in January 2017. This conduct is in violation of 25 TAC §133.41(f)(1) and (1)(3)(B), which states:

133.41 Hospital Functions and Services

(f) Governing body.

(1) Legal responsibility. There shall be a governing body responsible for the organization, management, control, and operation of the hospital, including appointment of the medical staff. For hospitals owned and operated by an individual or by partners, the individual or partners shall be considered the governing body.

(I) Mental health services.

(3) Compliance. A hospital providing mental health services shall comply with the following rules administered by the department. The rules are:

(B) Chapter 404, Subchapter E of this title (relating to Rights of Persons Receiving Mental Health Services);

See 25 TAC §404.154, Rights of All Persons Receiving Mental Health Services.

Persons receiving mental health services from department facilities, community centers, and psychiatric hospitals have the following rights.

(3) The right to a humane treatment environment that ensures protection from harm, provides privacy to as great a degree as possible with regard to personal needs, and promotes respect and dignity for each individual.

(24) The right to be free from mistreatment, abuse, neglect, and exploitation ...

P.O. Box 149347 • Austin, Texas 78714-9347 • Phone: 888-963-7111 • TTY: 800-735-2889 • www.dshs.texas.gov

Notice of Violation HopeBridge Hospital Houston, LLC Page 3

(26) The right not to be secluded or have physical restraint applied to the individual unless it has been prescribed by a physician, except in emergency situations. If physical restraint or seclusion is utilized, the reason for the medical order, the length of time restraint or seclusion has been ordered, and the behaviors necessary for the individual to be removed from restraint or seclusion shall be explained to the individual, and the restraint or seclusion shall be discontinued as soon as possible ...

Revocation and an administrative penalty in the amount of $50,000.00 is proposed for this rule violation.

2. The Facility failed to ensure patients received care in a safe setting, free from mistreatment or abuse. Further, the Facility failed to ensure patients' right to safe implementation of restraint, to wit:

An untrained staff member inappropriately inserted herself into a behavioral intervention for Patient #7. Patient #7 stated staff choked her, leaving scratches and bruises. Also, the Facility failed to ensure protection from harm by not adequately investigating allegations of physical abuse for eight patients. This conduct is in violation of 25 TAC §§133.41(1)(3)(B) and 25 TAC §404.154(3), (24) and (26), which state:

133.41 Hospital Functions and Services




25 TAC §404.154, Rights of All Persons Receiving Mental Health Services.



P.O. Box 149347 • Austin, Texas 78714-9347 • Phone: 888-963·7111 •TTY: 800-735-2889 • www.dsh:uexos.gov

Notice of Violation HopeBridge Hospital Houston, LLC Page4


(26) The right not to be secluded or have physical restraint applied to the individual unless it has been prescribed by a physician, except in emergency situations. If physical restraint or seclusion is utilized, the reason for the medical order, the length of time restraint or seclusion has been ordered, and the behaviors necessary for the individual to be removed from restraint or seclusion shall be explained to the individual, and the restraint or seclusion shall be discontinued as soon as possible ...

An administrative penalty in the amount of $25,000.00 is proposed for this rule violation.

3. The Facility failed to comply with the rules relating to the rights of persons receiving mental health services, to wit:

Specifically, the Facility failed to ensure protection from harm by allowing patients to elope from the facility eighteen times, including one incident in which a patient alleged she was sexually assaulted while absent from the facility. This conduct is in violation of 25 TAC § 133.41(1)(3)(8), which states:

133.41 Hospital Functions and Services.




See 25 TAC§ 404.154, Rights of All Persons Receiving Mental Health Services:




P.O. Sox 149347 • Austin, Texa$ 78714-9347 • Phone: SSS..963-7111 • TTY: 800-735-2889 • www.dshs.texos.gov


An administrative penalty in the amount of $280,000.00 (17 elopements x $15,000 and 1 elopement x $25,000) is proposed for this rule violation.

4. The Facility failed to ensure an adequate nurse staffing plan, to wit:

The Facility failed to assign staff to monitor an exit which patients used to elope from the facility. The Facility failed to ensure this exit was monitored even after the nurse staffing committee knew (or should have known) patients could exploit this exit for elopement. This conduct is in violation of 25 TAC §133.4l(o)(2)(F)(iv), which states:


(o) Nursing services. The hospital shall have an organized nursing service that provides 24-hour nursing services as needed.

(2) Staffing and delivery of care.

(F) The hospital shall establish a nurse staffing committee as a standing committee of the hospital. The committee shall be established in accordance with Health and Safety Code (HSC), §§161.031 - 161.033, to be responsible for soliciting and receiving input from nurses on the development, ongoing monitoring, and evaluation of the staffing plan. As provided by HSC, §161.032, the hospital's records and review relating to evaluation of these outcomes and indicators are confidential and not subject to disclosure under Government Code, Chapter 552 and not subject to disclosure, discovery, subpoena or other means of legal compulsion for their release. As used in this subsection, "committee" or "staffing committee" means a nurse staffing committee established under this subparagraph.

(iv) The responsibilities of the committee shall be to:

(I) develop and recommend to the hospital's governing body a nurse staffing plan that meets the requirements of subparagraph (G) of this paragraph;

(II) review, assess and respond to staffing concerns expressed to the committee;

(Ill) identify the nurse-sensitive outcome measures the committee will use to evaluate the effectiveness of the official nurse services staffing plan;

P.O. Box 149347 • Austin, Texas 78714-9347 • Phone: 888-963-7111 • TTY: 800-735-2889 • www.dshs.texos.gov


(IV) evaluate, at least semiannually, the effectiveness of the official nurse services staffing plan and variations between the plan and the actual staffing; and

(V) submit to the hospital's governing body, at least semiannually, a report on nurse staffing and patient care outcomes, including the committee's evaluation of the effectiveness of the official nurse services staffing plan and aggregate variations between the staffing plan and actual staffing.


5. The Facility failed to implement an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement (QAPI) program, to wit:

Specifically, the Facility failed to track adverse events, including reports of physical abuse. This conduct is in violation of 25 TAC §133.41(r)(l)(E), which states:


(r) Quality assessment and performance improvement. The governing body shall ensure that there is an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement (QAPI) program to evaluate the provision of patient care.

(1) Program scope. The hospital-wide QAPI program shall reflect the complexity of the hospital's organization and services and have a written plan of implementation. The program must include an ongoing program that shows measurable improvements in the indicators for which there is evidence that they will improve health outcomes, and identify and reduce medical errors.

(E) The program must measure, analyze and track quality indicators, including adverse patients' events, and other aspects of performance that assess processes of care, hospital services and operations.


P.O. Box 149347 • Austin, Texas 78714-9347 • Phone: 888-963-711 l • TTY: S00-735-2889 • www.dshs.texos.gov


6. The Facility failed to report abuse of two patients, to wit:

Specifically, the Facility found evidence of two instances of patient abuse, but no report of these incidents was made to the state health care regulatory agency. This conduct is in violation of 25 TAC §133.47(c)(3)(A) which states:

133.47 Abuse and Neglect Issues.

(c) Abuse and neglect of individuals with mental illness, and illegal, unethical, and unprofessional conduct. The requirements of this subsection are in addition to the requirements of subsection (b) of this section.

(3) Reporting responsibility.

(A) Reporting abuse and neglect. A person, including an employee, volunteer, or other person associated with the facility who reasonably believes or who knows of information that would reasonably cause a person to believe that the physical or mental health or welfare of a patient of the facility who is receiving mental health or chemical dependency services has been, is, or will be adversely affected by abuse or neglect (as those terms are defined in this subsection) by any person shall as soon as possible report the information supporting the belief to the department or to the appropriate state health care regulatory agency in accordance with HSC, §161.132(a).


7. The Facility failed to report suspected abuse of a patient, to wit:

The Facility failed to report the elopement and alleged sexual assault of a patient to the Department. This conduct is in violation of 25 TAC § 133.47(c)(3)(A), which states:

133.47 Abuse and Neglect Issues.

(c) Abuse and neglect of individuals with mental illness, and illegal, unethical, and unprofessional conduct. The requirements of this subsection are in addition to the requirements of subsection (b) of this section.

(3) Reporting responsibility.

P.O. Box 149347 • Austin. Texas 78714-9347 • Phone: BSEMi>63-7 l 11 • TTY: B00-735-2889 • www.dshs.texas.gov


(A) Reporting abuse and neglect. A person, including an employee, volunteer, or other person associated with the facility who reasonably believes or who knows of information that would reasonably cause a person to believe that the physical or mental health or welfare of a patient of the facility who is receiving mental health or chemical dependency services has been, is, or will be adversely affected by abuse or neglect (as those terms are defined in this subsection) by any person shall as soon as possible report the information supporting the belief to the department or to the appropriate state health care regulatory agency in accordance with HSC, §161.132(a).


In accordance with Government Code Section 2001.054(c), you have the right to show compliance with all requirements of law prior to final action by the Department. Within 20 calendar days following the day you receive this notice, you may:

1) Admit the allegations and accept the Department's determination to revoke the Facility's license #100323 and assess an administrative penalty in the amount of $455,000.00. Mail the license #100323 to the Department of State Health Services, Regulatory Licensing Unit - Facility Licensing Group, Mail Code 2003, P.O. Box 149347, Austin, TX 78714. Remit the recommended penalty amount of $455,000.00 by cashier's check, money order, or company check made payable to the Department of State Health Services, with a notation of: Deposit in Budget #ZZ156, Fund #152, and return the enclosed Response to Notice form, with the first box checked. Please be sure to sign and date the form; or

2) Submit a written request for an informal conference and a hearing (if necessary), regarding the occurrence of the alleged violations, the amount of the penalties, or both; or,

3) Submit a written request for a contested case hearing to be held at the State Office of Administrative Hearings regarding the occurrence of the alleged violations, the amount of the penalty, or both.

Please use the attached RESPONSE TO NOTICE form to notify the Department of which option you have selected.

P.O. Box 149347 • Austin, Texas 78714-9347 • Phone: SSS-963-7111 •TTY: 800-735-2889 • www.dshs.texos.gov


YOU MUST RESPOND TO THIS NOTICE WITHIN 20 CALENDAR DAYS AFTER THE DATE YOU RECEIVE THIS NOTICE. IF YOU DO NOT RESPOND TO THIS NOTICE BY THE DEADLINE: YOUR OPPORTUNITY TO REQUEST A CONFERENCE SHALL BE DEEMED WAIVED; AND THE DEPARTMENT WILL SET THIS CASE FOR HEARING BEFORE THE STATE OFFICE OF ADMINISTRATIVE HEARINGS PURSUANT TO HSC §241.059(h).

If you have any questions regarding this proposal, please contact me at (512) 834-6665, ext. 2092.

Sincerely,

Charles Burkhalter Program Specialist Enforcement Unit Division for Regulatory Services

Enclosure

P.O. Box 149347 • Austin, Texas 78714-9347 • Phone: 888-963-7111 • TTY: 800-735-2889 • www.dshs.rexos.gov

RESPONSE TO NOTICE OF VIOLATION CNOTICEl

HopeBridge Hospital Houston, LLC dba HopeBridge Hospital, General Hospital, (Respondent), has received a Notice from the Department of State Health Services (Department), in which the Respondent was notified that the Department is proposing to assess an administrative penalty of $455,000.00 and to revoke Respondent's License #100323, Case #1068170853 and 1068173695, Docket # A26670-510-2017.

Please select an option by checking the applicable box. Sign in the space provided below, and return this page not later than the 20th calendar day after you receive this notice.

OPTION 1 D Respondent admits the allegations and accepts the proposed action in the Department's Notice. Respondent waives the right to an administrative hearing or an appeal. Respondent accepts the Department's issuance of an Order for revocation and hereby remits an administrative penalty in the amount of $455,000.00 by cashier's check, money order, or company check, made payable to the Department of State Health Services, with a notation of: Deposit in Budget #ZZ156, Fund #152. Mail the penalty with this form to: Texas Department of State Health Services, Cash Receipts Branch MC-2003, PO Box 149347, Austin, Texas 78714-9347.

OPTION 2 D Respondent does not accept the proposed action in the Department's Notice and requests an informal conference and, if necessary, a hearing.

OPTION 3 D Respondent does not accept the proposed action in the Department's Notice and requests a hearing before the State Office of Administrative Hearings.

If you are not including a payment with your response, please mail your response to: Texas Department of State Health Services, Enforcement Unit - MC 7927, Attn: Charles Burkhalter, P.O. Box 149347, Austin, TX 78714-9347 or fax it to: 512-834-6625.

SIGNATURE OF RESPONDENT'S AUTHORIZED REPRESENTATIVE

PRINTED NAME AND TITLE OF SIGNATORY

DATE

100323 LICENSE NUMBER

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