HOUSTON (Dec. 13, 2019) — The Centers for Medicare and Medicaid Services (CMS) survey of Harris Health System was completed Sept. 27, 2019. Harris Health welcomed this review as an opportunity to improve our services, and takes the findings seriously. The entire Harris Health family believes we owe it to our patients, their families and our community to correct any deficiencies and improve our ability to sustain high-quality coordinated care across our entire system.
Surveyors from CMS and Texas Health and Human Services Commission (HHSC) inspected Harris Health Sept. 16-27, 2019, and found the system to be out of compliance with elements of the following eight (8) CMS Conditions of Participation:
• 482.12 Governing Body
• 482.13 Patient Rights
• 482.21 QAPI (Quality Assurance and Performance Improvement)
• 482.23 Nursing Services
• 482.27 Laboratory Services
• 482.43 Infection Control
• 482.51 Surgical Services
• 482.12 Rehabilitation Services
Surveyors also noted five (5) areas of Immediate Jeopardy (IJ) within these elements that impact the health and safety of patients under the Medicare Conditions of Participation, which included concerns related to a maternal death at LBJ Hospital on Sept. 12, 2019 (Note: Pgs. 19, and 51-80, CMS Statement of Deficiencies – Form CMS-2567). Acceptable Plans of Correction to abate all of the IJs were developed by Harris Health’s staff while the surveyors were on-site, resulting in the removal of the IJ designations by CMS.
On Nov. 18, 2019, Harris Health submitted its full Plan of Correction to CMS as well as HHSC. The plan is in response to a letter and report the system received Nov. 8, 2019, which detailed the system’s noncompliance with certain Conditions of Participation under the federal Medicare program.
Harris Health is sharing the comprehensive CMS report, Plan of Correction and Summary here:
Harris Health is confident that the follow-up survey, which we anticipate taking place within the coming month, will affirm that the corrective actions put in place fully meet the required Conditions of Participation and correct the deficiencies noted by CMS.
Reverse Timeline of Events:
Dec. 18, 2019 – Jan. 15, 2020
Anticipated return visit by CMS to validate implementation of Harris Health’s Plan of Correction.
Dec. 12, 2019
Harris Health releases comprehensive CMS report, Plan of Correction and Summary.
Nov. 18, 2019
Harris Health submits its Plan of Correction to Centers for Medicare and Medicaid Services (CMS) and Texas Health and Human Services Commission (HHSC).
Nov. 8, 2019
Harris Health received Statement of Deficiencies Report (Form CMS-2567) from comprehensive survey.
Sept. 16-27, 2019
CMS conducts a comprehensive survey of Harris Health System. Harris Health self-reports maternal death case and presents preliminary root cause analysis of case to surveyors.
Sept. 12, 2019
Maternal death occurs at LBJ Hospital.
July 19, 2019
Harris Health reports second patient death to HHSC.
July 16, 2019
A second patient death occurs in the Emergency Department at Ben Taub Hospital.
July 1, 2019
Harris Health submits its Plan of Correction to HHSC.
July 9, 2019
Harris Health engages consultants Alvarez & Marsal to assist with quality assessments and meeting CMS Conditions of Participation.
June 18, 2019
Harris Health receives Statement of Deficiencies Report from HHSC.
June 4-5, 2019
HHSC completes inspection of Harris Health related to patient safety complaint.
April 12, 2019
Patient death occurs in the Emergency Department at Ben Taub Hospital, prompting a complaint with HHSC.