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Baylor St. Luke's Files Corrective Action Plan with CMS

By John Commins  
   May 17, 2019

The hospital made public a CMS on-site inspection that detailed unsanitary and dangerously inadequate disinfection efforts with patient rooms, and medical equipment.

Five months after a scathing report detailing substandard care and unsanitary conditions prompted the ouster of top executives at Baylor St. Luke's Medical Center, the new leadership at the beleaguered Houston hospital has provided an update on its corrective action plan.

"I promised to take all steps necessary to put the hospital back on the path to excellence and to earn the trust of our patients, their families and our community," St. Luke's President Doug Lawson said in an open letter posted Friday on the hospital's Website.

"In this short time, we have accomplished much – but clearly have much more to do," said Lawson, who took over in February.

"New hospital leadership began stepping into place in mid-January, and we immediately began to address a range of improvement areas across the hospital. We then participated in a full-scale review of every aspect of our operations by experts from the Centers for Medicare & Medicaid Services," Lawson said.

Lawson made public the findings of the 203-page CMS report, which details medication errors, bungled surgeries, unsanitary conditions in the hospital kitchens, dangerously inadequate disinfection of patients' rooms, and medical equipment that posed "immediate jeopardy" to patients that were observed by auditors inside the hospital in late March.

"The results point to remaining housekeeping, maintenance, and patient safety issues that in no way meet our standards, expectations or commitments to our community," Lawson said. "We are taking seriously every opportunity for improvement and we are addressing the findings with urgency. We are confident that the next review will reflect our commitments and accomplishments."

In his letter, Lawson said the alarming conditions detailed by CMS inspectors "did not occur overnight, nor were they the result of any single factor."

"CMS reviewers found deficiencies in the areas of hospital governance, infection control, and food services," Lawson said, adding that the hospital did not contest the CMS findings.

"We take the issues CMS identified seriously and we owe it our patients and their families to correct them immediately – and we have already started to do so through our internal quality program," he said.

The hospital this week filed a correction plan with CMS and Lawson pledged to "continue to work with our leaders, physicians and CMS to achieve full regulatory compliance."

"We are committed to adhering to safe practices and operations – it is foundational to our organization," he said.

“In this short time, we have accomplished much – but clearly have much more to do”

John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.


CMS inspectors visited the hospital in March and determined that dangerously inadequate disinfection of patients' rooms and medical equipment, lax prescription verification, and bungled surgeries posed 'immediate jeopardy' to patients.

St. Luke's Baylor officials say they have a lot of work remaining to improve conditions at the hospital, but have pledged to work with CMS 'to achieve full regulatory compliance.'

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