DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Dallas Regional Office
1301 Young Street, Suite 900
Dallas, Texas 75202
DIVISION OF SURVEY AND CERTIFICATION, REGION VI

June 3, 2019
Our Reference: CCN 450076, Complaint Intake #TX00311802
Peter Pisters, M.D., CEO
The University of Texas M D Anderson Cancer Center
1515 Holcombe Blvd
Houston, TX 77030
Dear Dr. Pisters:
Section 1865 of the Social Security Act (the Act) provides that a provider entity accredited by a
nationally recognized accrediting organization will be "deemed" to meet all the applicable Medicare
Conditions of Participation with the exception of utilization review, and the special requirements for
hospital providers of long term care services (swing-bed).
Section 1864 of the Act requires the Secretary of Health and Human Services to conduct a survey at
an accredited/deemed provider entity if the Secretary finds that a survey is appropriate because of
substantial allegations of a significant deficiency or deficiencies which would adversely affect health
and safety of patients if found to be present. If a provider entity is found to have significant
deficiencies with respect to compliance with the applicable Medicare Conditions of Participation in
the course of such a survey, we are required to remove the "deemed" status of your hospital and keep
it under State Survey Agency’s jurisdiction until the provider entity is substantially in compliance
with all the applicable Medicare Conditions of Participation.
We have reviewed the May 17, 2019, report of the deficiencies found by the Texas Health and
Human Services Commission (HHSC) during its recent substantial allegation survey of your hospital.
Based on this report, we find that The University of Texas M D Anderson Cancer Center does not
comply with all the applicable Medicare Conditions of Participation for hospitals.
The following Medicare Conditions of Participation were out of compliance:
42 CFR 482.12
42 CFR 482.13
42 CFR 482.21
42 CFR 482.23
42 CFR 482.27

Governing Body
Patient Rights
QAPI
Nursing Services
Laboratory Services

The deemed status of your hospital was removed on June 3, 2019, as a result of the findings of
substantial noncompliance from the May 17, 2019, survey and survey jurisdiction has been
transferred to the HHSC.

 Page 2 – The University of Texas M D Anderson Cancer Center
A complete listing of all deficiencies found by the HHSC is enclosed. These deficiencies have been
determined to be of such a serious nature as to substantially limit your hospital's capacity to render
adequate care and prevent it from being in compliance with all the applicable Medicare Conditions of
Participation. A plan of corrective action is not required at this time. However, it is to your
advantage to initiate corrective action on the identified deficient practices in order to bring your
hospital in compliance with the regulations.
If you decide to submit a plan of correction, please submit the Form CMS-2567, dated and signed
by your hospital's authorized representative to Jeannette Ray, HHSC, via email at
Jeannette.Ray@hhsc.state.tx.us.
In accordance with section 1865(b) of the Social Security Act, the HHSC will conduct a complete
Medicare survey of your facility to assess compliance with all the applicable Medicare Conditions of
Participation.
Please contact Dodjie Guioa at 214-767-6179 or by email at dodjie.guioa@cms.hhs.gov if you have
any questions.
Sincerely,

Karen Hillman, Manager
Enforcement Branch
Enclosure: CMS-2567
cc: Accrediting Organization, HHSC