Southern Assured Home Health LLC

“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 (Outcome and Assessment Information Set) assessments within 30 days of completions in August of 2025 for 1 of 1 completed assessments. This failure prevented the patient’s data from being made available to Center for Medicare and Medicaid (CMS) for analysis to identify agency performance levels in the provision of patient care. Findings included: During an interview on 01/12/2026 at 1:46 p.m. with the Administrator the above findings were reviewed and discussed. He stated that he had one patient that was admitted to the agency in August of 2025 and was discharged ‘a couple of weeks ago.” He further stated that an OASIS Assessment was not submitted to CMS because he forgot about it until the surveyor mentioned it. During an interview on 01/12/2026 at 1:50 p.m. with the Alternate Administrator the above findings were reviewed and discussed. She stated that an OASIS Assessment was completed but “I guess it wasn’t submitted.” Record review of IQIES “Home Health Error Summary by Agency” report generated from the CMS national data system during presurvey preparation on 01/11/2026 revealed Agency had submitted and processed 0 assessments.”

“Participate in the HHA’s QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA’s QAPI program; and This Element is not met as evidenced by: Based on record review and interview, the agency failed to establish a QAPI (Quality Assessment and Performance Improvement) Committee that included the required membership. The committee did not include a representative from the scope of services the agency provided, in that, the committee did not include representatives from the agency’s nurses or therapy services (OT, PT, ST) which were being offered by the agency for two out of two years (2023 and 2024) of QAPI committee meetings that were reviewed. The failure of the agency to have appropriate representation on the QAPI committee placed the agency’s clients at risk of not having their problems and/or concerns regarding nursing or therapy (OT, PT, ST) services addressed which placed the agency’s clients at risk of receiving inadequate care and services. The Findings Included: Review of a QAPI meeting reports for 2023 and 2024 titled “Quality Assessment/Performance Improvement Report” revealed no documented evidence that individuals representing nursing and therapy services (OT, PT, ST) attended the meetings. The signature page only included the signature of the Administrator. During an interview on 01/13/2026 at 3:17 p.m. with the Administrator the above findings were reviewed and discussed. He confirmed that there was no documented evidence that individuals representing nursing and therapy (OT, PT, ST) attended the meetings because he was the only one reviewing the information and signing the committee meeting notes He stated it was an oversight on his part. He further stated that it was his responsibility as the Administrator and stated it could have a negative impact on client care if everyone is not involved. Review of the agency’s policy titled, “Quality Assessment Performance Improvement Program”, with a review date of 041423, revealed in part, “…The governing body will ensure that the QAPI program: B. Involves all agency services, and any branch offices, if applicable (including those services provided under contract or arrangement) …” Review of the agency’s policy titled, “Quality Assessment Performance Improvement Program-Addendum”, with a review date of 041423, revealed in part, “…B. The QAPI committee will consist of, at a minimum, the Administrator, supervising nurse for therapist, and individuals representing the scope of services provided by the agency…” Review of the agency’s policy titled, “Responsibilities of the Administrator”, with a review date of 050124, revealed in part, “…The Agency Administrator will assume overall responsibility and authority for the day-to-day operations of the Agency…D. Ensuring the Agency, including any branches, is in compliance with all applicable federal, state, and local laws and regulatory agencies…G. Ensuring completion, maintenance, and submission of required reports…””