Every finding on record at Evening Star Healthcare Inc

A recertification entrance conference was conducted on 04/07/2026. Census was 0 (L&C), 0 (LHHS) and 8 (PAS). The agency was in compliance and no deficiencies were cited. Abbreviations: L&C- Licensed and Certified LHHS -Licensed Home Health Services PAS -Personal Assistance Services

A recertification entrance conference was conducted on 04/07/2026. Census was 0 (L&C), 0 (LHHS) and 8 (PAS). Abbreviations: Admin -Administrator Alt Admin- Alternate Administrator CMS- Centers for Medicare and Medicaid Services DON- Director of Nursing HHA- Home Health Agency iQies- internet Quality Improvement Evaluation System L&C- Licensed and Certified LHHS -Licensed Home Health Services OASIS- Outcome Assessment Information Set PAS -Personal Assistance 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 Outcome Assessment Information Set (OASIS), group of standard data HHAs integrate into their comprehensive assessment, to collect and report quality data to the CMS assessments to the Centers for Medicare and Medicaid Services (CMS) system within 30 days of completing the OASIS assessment from 03/01/2025 to 4/7/2026. This failure prevented the patients’ data from being made available to CMS for analysis to identify agency performance levels in the provision of patient care. Findings include: During pre-survey, surveyor reviewed report ran on 04/06/26, titled "HHA Error Summary by Agency," for the following reporting periods: 04/06/25 to 4/06/26 revealed 9 assessments of 15 (60%) were processed with the error warning -3330 with error description that read, “Record Submitted late: The submission date was more than 30 days after M0090 (assessment) on this new record.” Period 01/01/26 to 04/06/26 revealed 1 of 3 assessments (33.3%) were processed with error warning -3330. On 04/07/26, surveyor requested OASIS Validation Reports from CM for 12-month period from 03/01/25 to 04/07/26. Record review of OASIS validation reports for date range 03/31/25 to 03/31/26 revealed 16 assessments were processed with 9 assessments (56%) with error warning -3330. Reports for the OASIS Agency Final Validation report revealed submission date of 04/29/25 with 2 assessments submitted and the 1 assessment had the -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 05/31/25 with 1 assessment submitted and the 1 assessment had the -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 06/30/25 with 1 assessment submitted and the 1 assessment had the -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 07/31/25 with 1 assessment submitted and the 1 assessment had the -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 08/29/25 with 1 assessment submitted and the 1 assessment had the -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 09/30/25 with 2 assessment submitted and the 2 assessment had the -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 10/22/25 with 1 assessment submitted and the 1 assessment had the -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 02/28/26 with 1 assessment submitted and the 1 assessment had the -3330 warning code. During an interview with the Alt Admin/DON on 04/07/2026 at 11:13am, the Surveyor asked the Alt Admin/DON who was responsible for OASIS submissions and she replied, “I am responsible for OASIS submissions. I did the last submission on 3/31/26.” The Alt Admin/DON was asked if anyone else helped with the OASIS submissions and she answered “No.” The Alt Admin/DON was asked how often she did the OASIS submissions and she said it was done every month. The Alt Admin/DON was asked when the OASIS should be submitted by and she said, “every 30 days.” The Alt Admin/DON was asked the reason for late submissions and she said, “I submitted the OASIS to CMS every month. I did not know I had late submissions.” The Alt Admin/DON was asked what was the process to prevent late submissions and she said, “to submit assessments before 30 days.” When asked how submitting the OASIS assessments after 30 days could harm the patients she stated “the late submissions do not put patients in any harm. The sole purpose of OASIS submissions is for data collection.” During an interview with the Admin conducted on 04/09/2026 at 10:41a.m., the Surveyor asked the Admin how often the agency submitted OASIS assessments and he stated, “the DON takes care of that, so I don’t know.” The Surveyor asked when did the OASIS assessment have to be submitted, according to CMS. The Admin said, “no later than 30 days.” The Surveyor asked what process did the HHA have in place for submitting OASIS assessments. The Admin said the Alt Admin/DON oversees the process. The Surveyor asked why the OASIS assessments were being submitted greater than 30 days. The Admin stated he did not know the assessments were submitted late. The Admin was asked how late OASIS submissions could harm patients, and he stated he does not believe there is any harm. When the surveyor asked about the purpose of submitting OASIS assessments, the Admin stated that it was used to collect patient information and compare outcomes with other agencies. Review of the agency’s policy titled, OASIS Transmission”, dated 04/2008, read in part, …Evening Star Healthcare, Inc. must electronically report all OASIS data collected on each client no later than 30 days following the completion of each assessment.” Review of agency’s policy titled, “OASIS-Accuracy of Encoded Data, OASIS, Transmittal, Release of identifiable OASIS Information”, dated 04/2008, read in part, …will transmit OASIS information no later than on the 30th calendar day…”