TIMBERLAWN DALLAS March 10,2015: ‘Ms. Ginger Odle, Manager ‘Enforcement Branch Centers for Medicare & Medicaid Services Dallas Regional Office 1301 Young Street, Room 827 Dallas, Texas. 75202 ATTN: Mr. Dedjie Guioa Re: CCN 454081 Intake #TX00207941 Dear Mz, Ole and Mr. Guios This ener and the anached document respond to your ster dated March 5, 2015, and the accompanying deficiency statement from the complaint survey concluded on February 25,2015, ‘We rust you wil find our plan of correction acceptable and authorize a resurvey. We recognize the seriousnes ofthe citations; hospital staff was devastated by what happened wih Patent #1.. We nevertheless ask for your reconsideration ofthe finding that an immediate Jeopardy existed a the time ofthe survey and the triggering of 8 23-day termination action. We have detailed in ou response the actions we initiated inimediately on December 3, 2014 to make the hospital environment safer, as well as additional actions implemented before the survey ended withthe exit conference on February 25,2015. Because of those timely actions, we request the acknowledgement that any immediate jeopardy had been removed by the time of the survey and the conversion ofthe 23day action to a 9-day action We appreciate your consideration of our plan of correcon and request. Please let me know if you have any questions or need addtional documentation Sincerely, Shek A. Adams Chief Exccutive Officer Enclosure Via Electronte MaltPraees:asesanis DDEPARTIAENT OF HEALTHAND MUMAN SERVICES on sPoeave \SENTERS FOR MEDICARE § MEDICAID SERVICES cn 9.085809 | mamoe tosn |sereacwaser reenact, mmneteetint crest {sorcery ee Feoeiaeeopects seh res ceemaemette cence, meaner comet | reenter ay |ecintemeteoees Sivan ne maming tae wan fepeseratves The pupae ana pee be | Sey wars exianad ond soppy ger ‘tomes ni copia urey woe corcetessexotag be ey poem Sue Operations Maru Casper 5 selon 5:09 sis hppesrh ad acorn 2 CFR 8ztbe Conshon ot Paopton or hes 102356 teophon ih hoon aero re ‘Saf Premier finge the sry ere sendoncon consent arene acy pode evans ccoretores wih 2 Ceo Re] ecurteeniemennet, ] wos wemomecritncion see S| ee, | eceeeeereee ‘20 rmacomuens Tce | ratn ofr agreement the Hs wth nea alg arte tonne tat xt Inbissatement of fierce. The spt hereon, nd the pont eareion focunens sion ake tosses the ced stance, RECENED wa 1.0205, owt REvieeee syne 10 208 pe “ (afis— ‘cernoopoa pasa onsen se mastectomy tes baa el aoe one(CENTERS FOR MEDICARE 8 MEDICAID SERVICES. Prue: uesa0ss © ‘000 canna Fem se 1 sound Non was proved te sys Sasadon races rvewenswiniews tes seteminad hat the decent prcices urd posed an medi jeoprey the hath and Ss of pate, ar esl aul ham 0 Patent, The hsp fe ens tat bates eve ein asa strain et Seda abana ware notrovdesapropie svt obconstan an ign at a cas weed by sued patents moe remeved. 110020791 was subsanined wih cetcences tm ftoning conto of ancpaton wee nat 22.CeR 48213 Pant ih 2ceR a2 21 GAM Anosptalmus ptctand promot each tis CONOTTION i not metas evened: Based cosets ranger rents Rosia naata ear a 938 entorrtnas proves br 2012 pens Jaset et ars Patet¥2). (Patent asted away tom hanging saifon ‘at Obeenaton coedcted he Hosa ‘eval econnued presence of eae a ‘cess peynatie patos orpoena I ans| pal leadership ane the cations, Implemented improvements systems, favcsted sat and established montorsto erly the efectvenescf changes, lace see eae responses to Alta Hospital ao requests reconsideration of hs fing hat there wa an brmedate Jopary athe time ofthe survey Pease see ead normation rowed under A 1