TEXAS DEPARTMENT OF STATE HEALTH SERVICES

P.O. Box 149347
Austin, Texas 78714-9347
1-888-963-7111
TTY: 1-800-735-2989
www.dshs.state.tx.us

DAVID L. LAKEY, M.D.
COMMISSIONER
December 10, 2014
Certified Mail Number: 7011 2970 0004 0212 0985
and First Class Mail Service
C T Corporation System, Registered Agent
Baylor Regional Medical Center at Plano
1999 Bryan St Ste 900
Dallas, TX 75201
Certified Mail Number: 7011 0470 0003 0321 1233
and First Class Mail Services
Jerri Garison, President
Baylor Regional Medical Center at Plano
4700 Alliance Blvd
Plano, TX 75093
Re:

Notice of Violation (Notice), Baylor Regional Medical Center at Plano, General Hospital,
License #008140, Case #1068144773; Docket No. 23711-505-2015

The Department of State Health Services (Department) has reviewed documents and evidence related
to an on-site complaint investigation of Baylor Regional Medical Center at Plano (Facility or
Respondent) conducted on or about April 1 – 2, 2014.
As a result of that review, the Department proposes to impose an administrative penalty in the amount
of $100,000 against the Facility 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).
The proposed action is 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 ensure the Facility reported the results and/or circumstances
for a professional review and/or investigation of a physician to the Texas Medical Board, to
wit:
A review of records and interview revealed the Governing Body failed to ensure the Facility
reported the results and/or circumstances for a peer review for Personnel #7 to the Texas

An Equal Opportunity Employer and Provider

 Notice of Violation
Baylor Regional Medical Center at Plano
Page 2

Medical Board. Personnel #12 advised that the Facility was made aware that Personnel #7’s
license was revoked when it reported to the Texas Medical Board (TMB) by another unrelated
facility. Personnel #7 caused injury and/or death to 2 patients. Personnel #12 stated the medical
executive committee left the filing of the Texas Medical Board report to legal counsel. This
conduct is in violation of 25 TAC §133.41(f)(4)(G) and (H), which state that (G) the governing
body shall ensure the hospital complies with the requirements for reporting to the Texas
Medical Board the results and circumstances of any professional review action in accordance
with the Medical Practice Act, Occupations Code, §160.002 and §160.003, and (H) the
governing body shall ensure that any policies and procedures it adopts to implement the
requirements of the rules shall be implemented and enforced .
An administrative penalty in the amount of $100,000 ($1,000 x 100 days during which the Facility
failed to report the peer review action to the TMB) is proposed for this rule violation. Although the
conduct continued for a period longer than 100 days, the Department believes this minimum
estimate conforms to the evidence and results in an appropriate penalty.
In accordance with Health and Safety Code Section 241.059, you have the right 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) Accept the Department’s determination to impose an Administrative Penalty in the amount of
$100,000. Remit the recommended penalty amount of $100,000 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.
YOU MUST RESPOND TO THIS NOTICE WITHIN 20 CALENDER 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 WILL 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).

 Notice of Violation
Baylor Regional Medical Center at Plano
Page 3

If you have any questions regarding this proposal, please contact me at (512) 834-6665, ext. 3320.
Sincerely,

Dianne Estrada, MBA
Program Specialist
Enforcement Unit
Division for Regulatory Services
Enclosure

 RESPONSE TO NOTICE OF VIOLATION (NOTICE)
I, Baylor Regional Medical Center at Plano, Hospital, (Respondent), have received a Notice from the
Department of State Health Services (Department), in which I was notified that the Department is
proposing an Administrative Penalty of $ 100,000 for License #008140, Case #1068144773.
________________________________________________________________________
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

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 hereby remits an administrative penalty in the amount of
$100,000 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 787149347.

OPTION 2

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

OPTION 3

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: Dianne Estrada, P.O.
Box 149347, Austin, TX 78714-9347 or fax it to: 512-834-6625.

SIGNATURE
Respondent’s Printed Name and Title of
Representative signing for Respondent

DATE
008140
License Number