Every finding on record at Dallas Lending Source LLC

Purpose of Visit: Recertification survey Entrance Date: 08/19/2021 An entrance conference was conducted with the agency Adm at 10:52 a.m. The Adm was informed that the purpose of the survey was for a 36-month recertification survey. L&C Census: 0 Exit Date: 08/20/2021 An exit conference was conducted at 4:45 p.m. with the Adm. The preliminary findings were discussed. The agency was given an opportunity to ask questions and provide additional documentation. Additional documentation was not provided. The agency was informed that if deficiencies were cited, the agency would receive the Statement of Deficiencies within 10 business days post exit. Written instructions were provided for how to submit an acceptable plan of correction, within 10 days of receipt of the Statement of deficiencies. Abbreviations: ADM - Administrator Alt Adm - Alternate Administrator L & C- Licensed and Certified EP-Emergency Preparedness COVID-19- Novel Coronavirus Disease 2019

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to have a written emergency preparedness and response plan that was based on and included a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. The risk assessment was not updated to include the Novel Coronavirus of 2019 pandemic and did not include strategies for addressing emergency events related to the pandemic. The failure could result in the agency being unable to properly prepare for an outbreak of COVID-19 among its clients or staff. The failure could also place clients' health and safety at risk. FINDINGS INCLUDED: During the entrance conference at 10:52 a.m. on 08/19/2021, the Adm self-identified as the disaster coordinator. The Adm identified the Alt Adm as the alternate disaster coordinator. Review of the agency's EP binder revealed the following: A risk assessment dated 08/02/2017. The binder did not include any other risk assessments. The binder did not contain any further documents that showed the agency had updated the EP plan and risk assessment, utilizing an all-hazards approach, to include the COVID-19 pandemic in its EP and response plan. In an interview on 08/20/2021 at 4:20 p.m., with the Adm the surveyor discussed the above findings of why the agency's risk assessment and agency EP and response plan was not updated to include the COVID-19 pandemic. The Adm replied, "That's when we started the process to sell, so things probably did slack off."

Purpose of Visit: Recertification survey Entrance Date: 08/19/2021 An entrance conference was conducted with the agency Adm at 10:52 a.m. The Adm was informed that the purpose of the survey was for a 36-month recertification survey. L&C Census: 0 Exit Date: 08/20/2021 An exit conference was conducted at 4:45 p.m. with the Adm. The preliminary findings were discussed. The agency was given an opportunity to ask questions and provide additional documentation. Additional documentation was not provided. The agency was informed that if deficiencies were cited, the agency would receive the Statement of Deficiencies within 10 business days post exit. Written instructions were provided for how to submit an acceptable plan of correction, within 10 days of receipt of the Statement of deficiencies. Met conditions of participation. Abbreviations: ADM - Administrator Alt Adm - Alternate Administrator L & C- Licensed and Certified QAPI-Quality Assessment Performance Improvement OASIS -outcome and assessment information set Moo90-Date OASIS Assessment is completed. CMS- Center for Medicare and Medicaid Services

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to transmit completed OASIS assessments to CMS OASIS contractor, within 30 days of completing the OASIS assessment of the beneficiary (patient) in: 1. Three (Patients # 11, 12 and 13) of Three randomly selected OASIS assessments submitted in 2020. 2. Four (Patients # 14, 15, 16 and 17) of Four randomly selected OASIS assessments submitted in 2019. 3. Five ( Patients # 18, 19, 20, 21 and 22) of six randomly selected OASIS assessments submitted in 2018. The failure could have prevented the agency's patient data from being made available to CMS for analysis in order to identify agency performance levels in the provision of patient care. FINDINGS INCLUDED: On 08/19/2021 the surveyor reviewed the "OASIS Agency Final Validation Report[s]" for the years 2018, 2019 and 2020. The reports revealed that the agency had not submitted the completed OASIS assessments to CMS OASIS contractor within 30 days of completing the assessment. The following OASIS Final Validation reports showed that the agency had not submitted the OASIS assessments within 30 days: 1. 2020 OASIS assessments, Patient # 11, submission date 01/08/2020; Patient # 12, submission date 01/08/2020 and Patient # 13, submission date 01/08/2020, had the message "WARNING Record Submitted Late: The submission date is more than 30 days after Moo90 on this new record." 2. 2019 OASIS assessments, Patient # 14, submission date 07/22/2019; Patient # 15, submission date 07/01/2019; Patient # 16, submission date 07/01/2019; and Patient # 17, submission date 07/01/2019, had the message "WARNING Record Submitted Late: The submission date is more than 30 days after Moo90 on this new record." 3. 2018 OASIS assessments, Patient # 18, submission date 11/16/2018; Patient # 19, submission date 11/16/2018; Patient # 20, submission date 11/16/2018; Patient # 21, submission date 06/07/2018 and Patient # 22, submission date 06/07/2018, had the message "WARNING Record Submitted Late: The submission date is more than 30 days after Moo90 on this new record." During an interview with the Adm on 08/20/2021 at approximately 4:15 p.m., the surveyor discussed the above findings of why the agency had not transmitted the completed OASIS assessments to CMS OASIS contractor, within 30 days of completing the OASIS assessment of the beneficiary (patient). The Adm stated that the OASIS(s) were transmitted late because in 2018 the agency began the process of selling the agency and there were multiple family deaths and a staff member death during that time period.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interviews, the agency's governing body failed to ensure that, in one of one QAPI program, an ongoing program for quality improvement and patient safety was implemented and maintained. The governing body failed to address priorities for improved quality of care and patient safety and ensure that: all improvement actions were evaluated for effectiveness; clear expectations for patient safety were established, implemented, and maintained for the years 2019 and 2020. The failure could have placed the agency's Patients at risk of substandard care from unidentified and uncorrected problems and/or weaknesses with patient care. FINDINGS INCLUDED: During the entrance conference on 08/19/2021 at approximately 10:52 a.m. the surveyor requested all agency QAPI/documents/reports/binders. Review of the QAPI binders revealed that the last QAPI activity was implemented for the last quarter of 2018 and dated 01/17/2019. The binder did not contain any other reports, reviews or documentation that indicated the agency had maintained a QAPI program that included the federal regulatory requirements, for the years 2019 and 2020. The binders did not indicate that the agency had conducted any QAPI activity for the years 2019 and 2020. During an interview on 08/20/2021 at approximately 4:00 p.m., the surveyor discussed the above findings of why the agency had not ensured that the agency's QAPI program was implemented and maintained for the years 2019 and 2020 per federal regulatory requirements. The Adm stated that the agency began the process of selling the agency in 2018, "so things probably did slack off."