Lillian M Hudspeth Memorial Hospital

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 51738 Based on observation, interview, and a review of facility documents, the facility failed to post signs in locations likely to be noticed when the only EMTALA signage at the facility was in the ambulance bay (not visible to the public) and in the hallway directly across from the ER. Findings were: Observations on the morning of 9/9/25 revealed that there were only two signs related to EMTALA, not in compliance with Federal Requirements or facility policies. These findings were verified by Staff #5 and #15 during the facility tour. A review of facility policy “EMTALA Guidelines For Emergency Department Services (EFFECTIVE: 12/19/2023)” reveals in part “1. The hospital posts signs in conspicuous area(s) of the Emergency Department, entrance, admitting areas, waiting room, treatment areas, etc., specifying the rights of the individual with respect to examination and treatment of medical conditions and women in labor ...””

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 51738 Based on a review of facility documents, medical record review, and interviews, the facility failed to maintain a central log on everyone who came to the Emergency Department. Findings were: A review of facility policy “Emergency Department [ED] Patient Log” (EFFECTIVE: 12/5/23) reveals in part “POLICY: A patient log shall be maintained on each individual who comes to the Emergency Department, as defined in Sec. 489.24(b), seeking assistance. The log shall contain the following information (at a minimum): Patient name, Chief complaint, Time of arrival, Mode of arrival.” A review of the patient census from 1/29/25, reveals that Patient #1 was not entered into the ED Log. A review of statements written by staff #1, #2, #3 who witnessed events related to Patient #1 on 1/29/25, reveal that patient #1 presented to the ED but was never triaged, assessed, or entered into the ED Log. In an interview on the afternoon of 9/10/25, staff #2 stated that she “forgot” to enter Patient #1 into the ED Log. In an interview on the afternoon of 9/9/25, while reviewing the ER and LWBS logs, Staff #5 and #15 verified that Patient #1 was not entered into the ED log. A review of the patient census from 6/7/25 reveals that when Patient #7 initially presented to the ED (at an unknown time), he was not entered into the ED Log but was entered into the Left Without Being Seen (LWBS) log. On 6/7/25 at 11:15 PM, the patient returned to the facility via EMS and was entered into the ED log, triaged, assessed, and transferred. Review of the EMS Patient Care Record on 1/7/25 for Patient #7 reveals a medic stated in part “Pt and pts family member stated he went to the ER POV [private vehicle] just before dark and that they did not have a bed for him, causing the patient to leave.” Review of the medical record for Patient #7 reveals ED physician note (Staff #6) dated 6/7/25 that stated in part, “He had been to the hospital earlier in the evening with the c/o [complaint of] some low back pain, but he was told he had to wait in the lobby to be seen since the ER was busy with several other patients from a MVA [motor vehicle accident] and a patient with respiratory distress. He did not want to wait in the lobby so he left and went home...””

“GOVERNING BODY OR RESPONSIBLE INDIVIDUAL CFR(s): The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing and monitoring policies governing the CAH’S total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment. This Standard is not met as evidenced by: 30250 Based on a review of documentation and interview, the facility governing body failed to implement policies governing the CAH’S total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment, as the facility failed to maintain current privileging delineation forms for medical staff members. Findings included: Facility bylaws stated in part, “DEFINITIONS The following definitions apply to the provisions of these Medical Staff Bylaws, the Medical Staff Rules and Regulations, and any related policies... 6. “Clinical Privileges” or “Privileges” means the permission granted by the Board of Directors to a Practitioner to provide those diagnostic, therapeutic, medical, or surgical services specifically delineated to the Practitioner. 7. “Complete Application” means an application that contains all necessary documentation to verify the applicant’s qualifications for Medical Staff membership and/or clinical privileges. In general, this requires that (a) each question on the application has been answered; (b) all verifying information has been received; (c) the applicant has signed the forms; and (d) the applicant has provided all requested information regarding current valid license to practice in the State of Texas, DEA controlled substance registrations, and proof of liability insurance... 4.4 Reappointment Process... 4.4.2 Reappointment Application. 1. The Hospital shall send the Member an application for reappointment approximately six (6) months prior to the expiration of the term of appointment. The Member shall submit the signed reappointment application which shall include: (a) complete information and all documents necessary to provide current information listed in Medical Staff policies; (b) documentation of continuing education external to the Hospital since the last reappointment; ( c) new clinical privileges list; and ( d) any requests for changes in Staff category... ARTICLE VII CLINICAL PRIVILEGES 7.1 Privileges... 7 .1.2 Every initial application and reapplication for staff appointment and reappointment contain a request for the specific clinical privileges desired by the applicant. The evaluation of such requests shall be based upon the Applicant’s education, training, experience, demonstrated competence, references, and other relevant information including an appraisal by the service in which such privileges are sought. The Applicant shall have the burden of establishing his/her qualifications and competency in the clinical privileges requested.” Review of the facility credentialing files, revealed 2 of 2 physicians (#16 and 17) did not have current delineation of privilege forms in their files: * Physician #16 was re-appointed to the medical staff in February 2024. The last “Delineation of Medical Privileges Desired” form was completed on 01/27/07. * Physician #17 was re-appointed to the medical staff in February 2024. The last “Delineation of Medical Privileges Desired” form was completed on 07/09/18. * Neither physician had sedation approved on their “Delineation of Medical Privileges Desired”. * Both physicians had reappointment letters in their file stating, “Please accept this letter as my request for reappointment to Lillian M. Hudspeth Memorial Hospital and the Sutton County Hospital District. There have been no changes to my health status or my medical privileges. I am up to date on my CM E’s and all other required certifications. I am requesting to maintain my privileges as originally requested.” Review of the facility credentialing files, revealed 2 of 2 Advanced Practitioners (staff member # 18 Physician Assistant and staff member # 19 Nurse Practitioner) had issues with delineation of privileges: * Physician #18 was re-appointed to the medical staff in February 2024. The last “Delineation of Medical Privileges Desired” form was completed on 01/27/07. This Advanced Practitioner also did not have had sedation approved on their “Delineation of Medical Privileges Desired”. * Physician #19 (Nurse Practitioner) did not have any delineation of privileges in their credentialing file. * Advanced Practitioner #18 had a reappointment letters in their file stating, “Please accept this letter as my request for reappointment to Lillian M. Hudspeth Memorial Hospital and the Sutton County Hospital District. There have been no changes to my health status or my medical privileges. I am up to date on my CM E’s and all other required certifications. I am requesting to maintain my privileges as originally requested.” In interview on 07/22/25 with staff member #3 (who manages credentialing at the facility) was not aware of the privileging form required for reappointment or the lapse in obtaining an updated form with the reappointment of medical staff members. The above findings were verified on 07/23/25, with staff members #1 and 2.”

“A life safety code (LSC) survey was conducted on site on 07/23/2025. An entrance conference was held for the plant manager and the CEO on 07/23/2025 to discuss the purpose of the LSC survey, and the survey process was explained. Instructions were provided on writing plans of correction. An opportunity was provided for questions and discussion. The LSC survey was conducted under the authority of Chapter 2 of the State Operations Manual, Appendix A, Acute Care Hospitals, 42CFR482 to determine the Hospital’s compliance. An LSC exit conference was conducted on 07/23/2025 in the hospital. In attendance were the plant manager and the CEO. The preliminary findings of the survey and the next steps in the survey process were explained. An opportunity was provided for questions and discussion. Note: The CMS-2567 (Statement of Deficiencies) is an official, legal document. All information must remain unchanged except for entering the plan of correction, correction dates, and the signature space. Any discrepancy in the original deficiency citation(s) will be reported to the Dallas Regional Office (RO) for referral to the Office of the Inspector General (OIG) for possible fraud. If information is inadvertently changed by the provider/supplier, the State Survey Agency (SA) should be notified immediately.”

“Protection - Other CFR(s): NFPA 101 Protection - Other List in the REMARKS section any LSC Section 18.3 and 19.3 Protection requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. This Standard is not met as evidenced by: 35320 The inspector observed, while accompanied by the facilities manager during the hours of the inspection from 1:00 pm to 4:00 pm on 07/22/2025 that 18 inches clearance between the sprinkler head and stored items in the kitchen storage room and between the sprinkler head and hanging pots was not being maintained. The inspector observed, while accompanied by the facilities manager during the hours of the inspection from 1:00 pm to 4:00 pm on 07/22/2025 that fire walls need additional fire protection at the following locations: - Near Radiology: Above double doors: The top edge of the wall needs to be sealed. And around the steel beam where it penetrates the fire wall. - Near Lobby: Above double doors: Around wiring penetrations need to be sealed. - Near room 111: Above double doors: There is a large penetration that needs to be sealed. - Hospital’s firewall separating it from adjacent facility. Above double doors. There is overlapping gypsum boards where the edge of the gypsum board needs to be sealed. “Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device.” - NFPA 101, 8.3.5.1.”

“Draperies, Curtains, and Loosely Hanging Fabr CFR(s): NFPA 101 Draperies, Curtains, and Loosely Hanging Fabrics Draperies, curtains including cubicle curtains and loosely hanging fabric or films shall be in accordance with 10.3.1. Excluding curtains and draperies: at showers and baths; on windows in patient sleeping room located in sprinklered compartments; and in non-patient sleeping rooms in sprinklered compartments where individual drapery or curtain panels do not exceed 48 square feet or total area does not exceed 20 percent of the wall. 18.7.5.1, 18.3.5.11, 19.7.5.1, 19.3.5.11, 10.3.1 This Standard is not met as evidenced by: 35320 The inspector observed, while accompanied by the facilities manager during the hours of the inspection from 1:00 pm to 4:00 pm on 07/22/2025 that the shower curtains in the patient room bathrooms did not have tags indicating that they meet NFPA 701 flame spread and smoke development requirements. Verification that they meet NFPA 701 must be provided, or verification that replacement curtains have been installed that meet NFPA 701.”

“Fundamentals - Building System Categories CFR(s): NFPA 101 Fundamentals - Building System Categories Building systems are designed to meet Category 1 through 4 requirements as detailed in NFPA 99. Categories are determined by a formal and documented risk assessment procedure performed by qualified personnel. Chapter 4 (NFPA 99) This Standard is not met as evidenced by: 35320 The inspector observed, while accompanied by the facilities manager, during the hours of the inspection from 1:00 pm to 4:00 pm on 07/22/2025 that risk assessment documentation was available for review. However, the risk assignments of 1 to 4 per NFPA 99 - A4.1, A4.2 were not being used.”

“Gas and Vacuum Piped Systems - Other CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Other List in the REMARKS section any NFPA 99 Chapter 5 Gas and Vacuum Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 5 (NFPA 99) This Standard is not met as evidenced by: 35320 The inspector observed, while accompanied by the facilities manager during the hours of the inspection from 1:00 pm to 4:00 pm on 07/22/2025 that in the medical gas cylinder storage room there was a light switch that was lower that the five-foot requirement per the following. Locations for central supply systems and the storage of medical gases shall meet the following requirements: (5) Be compliant with NFPA 70, National Electrical Code, for ordinary locations, with electrical devices located at or above 5 feet above finished floor to avoid physical damage - NFPA 99, 5.1.3.3.2(5).”

“Gas and Vacuum Piped Systems - Maintenance Pr CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Maintenance Program Medical gas, vacuum, WAGD, or support gas systems have documented maintenance programs. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040. 5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99) This Standard is not met as evidenced by: 35320 The inspector observed, while accompanied by the facilities manager during the hours of the inspection from 1:00 pm to 4:00 pm on 07/22/2025 that risk assessment documentation for medical gases were not available for review.”

“Electrical Systems - Other CFR(s): NFPA 101 Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 6 (NFPA 99) This Standard is not met as evidenced by: 35320 The inspector observed, while accompanied by the facilities manager during the hours of the inspection from 1:00 pm to 4:00 pm on 07/22/2025 that items were being stored within six feet of electrical panel boxes. This is not allowed per “Dedicated Equipment Space: All switchboards, panelboards, distribution boards, and motor control centers shall be located in dedicated spaces and protected from damage.” - NFPA 70, 2012, 110.26(E) The inspector observed, while accompanied by the facilities manager during the hours of the inspection from 1:00 pm to 4:00 pm on 07/22/2025 that two different electrical room’s panel boxes were not labeled per the following requirement. “Emergency panels shall be distinctively marked so that they are readily identifiable as a component of the essential electrical system.” - NFPA 70: 110-22 and 700-9(a). They shall be labeled “LIFE SAFETY”, “CRITICAL”, or “EQUIPMENT” as applicable. The inspector observed, while accompanied by the facilities manager during the hours of the inspection from 1:00 pm to 4:00 pm on 07/22/2025 that an emergency electrical generator was less than 10 feet from an electrical transformer. In lieu of moving them further apart, a one-hour fire barrier may be constructed between them. This barrier must be designed by a structural engineer.”