In 2011, the Centers for Medicare & Medicaid Services (CMS) determined that Spring Mountain Treatment Center violated two conditions of Medicare participation and risked termination of its Medicare provider agreement. One of the conditions specifies that health care facilities must protect and promote patient rights. CMS determined that Spring Mountain Treatment Center was non-compliant with this condition by not ensuring that three of its patients received care in a safe setting. In one incident, lapses in patient monitoring and implementing patient safety precautions (such as the removal of unsafe items/self-harm risks) resulted in a patient’s attempted suicide. The patient was found hanging from the shower by a bed sheet and was sent to the ER of an acute care facility, where a consultation report stated she was in cardiac arrest upon arrival, sustained a possible “permanent anoxic brain injury,” and that her “prognosis appears quite poor…” Spring Mountain Treatment Center also violated the condition of Medicare participation that requires facilities to provide outpatient services that met the needs of patients in accordance with acceptable standards of practice. In one case, facility staff psychologists and therapists failed to adequately assess and treat a partial hospitalization patient’s suicide risk. They failed to recognize that the teen patient’s suicidal statements were a “red flag” and she later committed suicide by hanging. CMS determined that Spring Mountain’s deficiencies “substantially limit the hospital’s capacity to render adequate care to patients or are of such character as to adversely affect patient health and safety…” As a result, the facility was required to submit a plan of correction to address its cited deficiencies and deficient policies and procedures.