Houston Behavioral Healthcare Hospital, LLC
HCO ID: 560331
2801 Gessner
Houston , TX, 77080
Activity as of:
10/12/2018
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Behavioral Health Care
Accredited
8/10/2018
2/16/2018
2/16/2018
 
Hospital
Accredited
4/24/2018
2/16/2018
10/4/2018
 
8/11/2018
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Behavioral Health Care
Accredited
8/10/2018
2/16/2018
2/16/2018
 
Hospital
Accredited
4/24/2018
2/16/2018
4/24/2018
 
7/13/2018
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Behavioral Health Care
Accredited
2/17/2018
2/16/2018
2/16/2018
 
Hospital
Accredited
4/24/2018
2/16/2018
4/24/2018
 
6/29/2018
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Behavioral Health Care
Accredited
2/17/2018
2/16/2018
2/16/2018
 
Hospital
Accredited
4/24/2018
2/16/2018
4/24/2018
 
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Behavioral Health Care
Accredited
2/17/2018
2/16/2018
2/16/2018
 
Hospital
Accredited
4/24/2018
2/16/2018
4/24/2018
 
4/6/2018
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Behavioral Health Care
Accredited
2/17/2018
2/16/2018
2/16/2018
 
Hospital
Preliminary Denial of Accreditation
2/17/2018
2/16/2018
3/29/2018
 

The following information provides a general description of the areas in which performance issues were found. Each of these areas typically has many specific requirements. The area is listed if one or more of the specific requirements were determined to require improvement.

  • A pharmacist reviews the appropriateness of all medication orders for medications to be dispensed in the hospital.
  • Identify patients at risk for suicide. Note: This requirement applies only to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.
  • Medical staff bylaws address self-governance and accountability to the governing body.
  • Policies and procedures for waived tests are established, current, approved, and readily available.
  • Staff and licensed independent practitioners are familiar with their roles and responsibilities relative to the environment of care.
  • Staff are competent to perform their responsibilities.
  • The hospital assesses and reassesses the patient and his or her condition according to defined time frames.
  • The hospital assesses the needs of patients who receive treatment for emotional and behavioral disorders.
  • The hospital conducts fire drills.
  • The hospital defines and verifies staff qualifications.
  • The hospital documents the patient’s discharge information.
  • The hospital effectively manages its programs, services, sites, or departments.
  • The hospital engages in planning activities prior to developing its written Emergency Operations Plan. Note: An emergency is an unexpected or sudden event that significantly disrupts the organization’s ability to provide care, or the environment of care itself, or that results in a sudden, significantly changed or increased demand for the organization's services. Emergencies can be either human-made or natural (such as an electrical system failure or a tornado), or a combination of both, and they exist on a continuum of severity. A disaster is a type of emergency that, due to its complexity, scope, or duration, threatens the organization’s capabilities and requires outside assistance to sustain patient care, safety, or security functions.
  • The hospital establishes and maintains a safe, functional environment. Note: The environment is constructed, arranged, and maintained to foster patient safety, provide facilities for diagnosis and treatment, and provide for special services appropriate to the needs of the community.
  • The hospital evaluates and reevaluates the patient who is restrained or secluded.
  • The hospital evaluates the effectiveness of its infection prevention and control plan.
  • The hospital implements its infection prevention and control plan.
  • The hospital initiates restraint or seclusion based on an individual order.
  • The hospital inspects, tests, and maintains emergency power systems. Note: This standard does not require hospitals to have the types of emergency power equipment discussed below. However, if these types of equipment exist within the building, then the following maintenance, testing, and inspection requirements apply.
  • The hospital inspects, tests, and maintains medical gas and vacuum systems. Note: This standard does not require hospitals to have the medical gas and vacuum systems discussed below. However, if a hospital has these types of systems, then the following inspection, testing, and maintenance requirements apply.
  • The hospital inspects, tests, and maintains utility systems. Note: At times, maintenance is performed by an external service. In these cases, hospitals are not required to possess maintenance documentation but must have access to such documentation during survey and as needed.
  • The hospital maintains complete and accurate medical records for each individual patient.
  • The hospital maintains fire safety equipment and fire safety building features. Note: This standard does not require hospitals to have the types of fire safety equipment and building features described below. However, if these types of equipment or features exist within the building, then the following maintenance, testing, and inspection requirements apply.
  • The hospital maintains the integrity of the means of egress.
  • The hospital manages medical equipment risks.
  • The hospital manages risks associated with its utility systems.
  • The hospital manages risks related to hazardous materials and waste.
  • The hospital plans the patient’s care.
  • The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.
  • The hospital provides and maintains systems for extinguishing fires.
  • The hospital provides patient education and training based on each patient’s needs and abilities.
  • The hospital respects the patient's right to receive information in a manner he or she understands.
  • The hospital uses restraint or seclusion safely.
3/21/2018
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Behavioral Health Care
Accredited
2/17/2018
2/16/2018
2/16/2018
 
Hospital
Preliminary Denial of Accreditation
2/17/2018
2/16/2018
2/16/2018
 

The following information provides a general description of the areas in which performance issues were found. Each of these areas typically has many specific requirements. The area is listed if one or more of the specific requirements were determined to require improvement.

  • A pharmacist reviews the appropriateness of all medication orders for medications to be dispensed in the hospital.
  • Identify patients at risk for suicide. Note: This requirement applies only to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.
  • Medical staff bylaws address self-governance and accountability to the governing body.
  • Policies and procedures for waived tests are established, current, approved, and readily available.
  • Staff and licensed independent practitioners are familiar with their roles and responsibilities relative to the environment of care.
  • Staff are competent to perform their responsibilities.
  • The hospital assesses and reassesses the patient and his or her condition according to defined time frames.
  • The hospital assesses the needs of patients who receive treatment for emotional and behavioral disorders.
  • The hospital conducts fire drills.
  • The hospital defines and verifies staff qualifications.
  • The hospital documents the patient’s discharge information.
  • The hospital effectively manages its programs, services, sites, or departments.
  • The hospital engages in planning activities prior to developing its written Emergency Operations Plan. Note: An emergency is an unexpected or sudden event that significantly disrupts the organization’s ability to provide care, or the environment of care itself, or that results in a sudden, significantly changed or increased demand for the organization's services. Emergencies can be either human-made or natural (such as an electrical system failure or a tornado), or a combination of both, and they exist on a continuum of severity. A disaster is a type of emergency that, due to its complexity, scope, or duration, threatens the organization’s capabilities and requires outside assistance to sustain patient care, safety, or security functions.
  • The hospital establishes and maintains a safe, functional environment. Note: The environment is constructed, arranged, and maintained to foster patient safety, provide facilities for diagnosis and treatment, and provide for special services appropriate to the needs of the community.
  • The hospital evaluates and reevaluates the patient who is restrained or secluded.
  • The hospital evaluates the effectiveness of its infection prevention and control plan.
  • The hospital implements its infection prevention and control plan.
  • The hospital initiates restraint or seclusion based on an individual order.
  • The hospital inspects, tests, and maintains emergency power systems. Note: This standard does not require hospitals to have the types of emergency power equipment discussed below. However, if these types of equipment exist within the building, then the following maintenance, testing, and inspection requirements apply.
  • The hospital inspects, tests, and maintains medical gas and vacuum systems. Note: This standard does not require hospitals to have the medical gas and vacuum systems discussed below. However, if a hospital has these types of systems, then the following inspection, testing, and maintenance requirements apply.
  • The hospital inspects, tests, and maintains utility systems. Note: At times, maintenance is performed by an external service. In these cases, hospitals are not required to possess maintenance documentation but must have access to such documentation during survey and as needed.
  • The hospital maintains complete and accurate medical records for each individual patient.
  • The hospital maintains fire safety equipment and fire safety building features. Note: This standard does not require hospitals to have the types of fire safety equipment and building features described below. However, if these types of equipment or features exist within the building, then the following maintenance, testing, and inspection requirements apply.
  • The hospital maintains the integrity of the means of egress.
  • The hospital manages medical equipment risks.
  • The hospital manages risks associated with its utility systems.
  • The hospital manages risks related to hazardous materials and waste.
  • The hospital plans the patient’s care.
  • The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.
  • The hospital provides and maintains systems for extinguishing fires.
  • The hospital provides patient education and training based on each patient’s needs and abilities.
  • The hospital respects the patient's right to receive information in a manner he or she understands.
  • The hospital uses restraint or seclusion safely.
2/28/2018
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Preliminary Denial of Accreditation
2/17/2018
2/16/2018
2/16/2018
 

The following information provides a general description of the areas in which performance issues were found. Each of these areas typically has many specific requirements. The area is listed if one or more of the specific requirements were determined to require improvement.

  • A pharmacist reviews the appropriateness of all medication orders for medications to be dispensed in the hospital.
  • Identify patients at risk for suicide. Note: This requirement applies only to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.
  • Medical staff bylaws address self-governance and accountability to the governing body.
  • Policies and procedures for waived tests are established, current, approved, and readily available.
  • Staff and licensed independent practitioners are familiar with their roles and responsibilities relative to the environment of care.
  • Staff are competent to perform their responsibilities.
  • The hospital assesses and reassesses the patient and his or her condition according to defined time frames.
  • The hospital assesses the needs of patients who receive treatment for emotional and behavioral disorders.
  • The hospital conducts fire drills.
  • The hospital defines and verifies staff qualifications.
  • The hospital documents the patient’s discharge information.
  • The hospital effectively manages its programs, services, sites, or departments.
  • The hospital engages in planning activities prior to developing its written Emergency Operations Plan. Note: An emergency is an unexpected or sudden event that significantly disrupts the organization’s ability to provide care, or the environment of care itself, or that results in a sudden, significantly changed or increased demand for the organization's services. Emergencies can be either human-made or natural (such as an electrical system failure or a tornado), or a combination of both, and they exist on a continuum of severity. A disaster is a type of emergency that, due to its complexity, scope, or duration, threatens the organization’s capabilities and requires outside assistance to sustain patient care, safety, or security functions.
  • The hospital establishes and maintains a safe, functional environment. Note: The environment is constructed, arranged, and maintained to foster patient safety, provide facilities for diagnosis and treatment, and provide for special services appropriate to the needs of the community.
  • The hospital evaluates and reevaluates the patient who is restrained or secluded.
  • The hospital evaluates the effectiveness of its infection prevention and control plan.
  • The hospital implements its infection prevention and control plan.
  • The hospital initiates restraint or seclusion based on an individual order.
  • The hospital inspects, tests, and maintains emergency power systems. Note: This standard does not require hospitals to have the types of emergency power equipment discussed below. However, if these types of equipment exist within the building, then the following maintenance, testing, and inspection requirements apply.
  • The hospital inspects, tests, and maintains medical gas and vacuum systems. Note: This standard does not require hospitals to have the medical gas and vacuum systems discussed below. However, if a hospital has these types of systems, then the following inspection, testing, and maintenance requirements apply.
  • The hospital inspects, tests, and maintains utility systems. Note: At times, maintenance is performed by an external service. In these cases, hospitals are not required to possess maintenance documentation but must have access to such documentation during survey and as needed.
  • The hospital maintains complete and accurate medical records for each individual patient.
  • The hospital maintains fire safety equipment and fire safety building features. Note: This standard does not require hospitals to have the types of fire safety equipment and building features described below. However, if these types of equipment or features exist within the building, then the following maintenance, testing, and inspection requirements apply.
  • The hospital maintains the integrity of the means of egress.
  • The hospital manages medical equipment risks.
  • The hospital manages risks associated with its utility systems.
  • The hospital manages risks related to hazardous materials and waste.
  • The hospital plans the patient’s care.
  • The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.
  • The hospital provides and maintains systems for extinguishing fires.
  • The hospital provides patient education and training based on each patient’s needs and abilities.
  • The hospital respects the patient's right to receive information in a manner he or she understands.
  • The hospital uses restraint or seclusion safely.
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Accredited
3/25/2015
2/20/2015
11/29/2017
 
11/30/2017
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Accredited
3/25/2015
2/20/2015
11/29/2017
 
10/26/2017
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Accredited
3/25/2015
2/20/2015
10/17/2017
 
7/30/2015
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Accredited
3/25/2015
2/20/2015
2/20/2015