Every finding on record at C & E Home Health Services Inc

A recertification survey was conducted on 07/22/2025. The census was 29 (L&C), 0 (LHHS), and 0 (PAS). The agency was in compliance with no deficiency cited. Abbreviations used: L&C = Licensed and Certified LHHS = Licensed Home Health Services PAS = Personal Assistance Services

A recertification survey was conducted on 07/22/2025. The census was 29 (L&C), 0 (LHHS), and 0 (PAS). Abbreviations used: DON = Director of Nursing CMS = Centers for Medicare and Medicaid Services HHA = Home Health Agency 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 OASIS (group of standard data HHAs integrate into their comprehensive assessment, to collect and report quality data to the CMS) assessments within 30 days of completion date in 6 of 6 (January 2025 through June 2025) months of transmissions reviewed. 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. During pre-survey surveyor reviewed reports ran on 07/21/2025, titled “HHA ERROR Summary by Agency” for the following reporting periods reviewed: Period 10/21/24 to 07/21/25 revealed 240 assessments were processed with 97 (40.42%) of assessments with 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.” On 07/22/25 surveyor requested OASIS Validation Reports from Office manager and DON for 6-month period from 01/01/25- 06/30/25. Record review of OASIS validation reports for date range 01/07/25 to 06/22/25 revealed 148 assessments were processed with 46 (31.08%) of the assessments with error warning -3330. Reports for the OASIS Agency Final Validation report revealed submission date of 01/07/25 with 1 assessment submitted and showed 1 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 01/07/25 with 2 assessments submitted and showed 2 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 01/07/25 with 2 assessments submitted and showed 0 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 01/07/25 with 2 assessments submitted and showed 0 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 01/08/25 with 1 assessment submitted and showed 1 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 01/08/25 with 1 assessment submitted and showed 1 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 01/08/25 with 1 assessment submitted and showed 1 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 01/08/25 with 1 assessment submitted and showed 1 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 01/15/25 with 2 assessments submitted and showed 2 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 01/15/25 with 5 assessments submitted and showed 5 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 01/15/25 with 7 assessments submitted and showed 5 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 01/15/25 with 1 assessment submitted and showed 0 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 01/18/25 with 1 assessment submitted and showed 0 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 01/30/25 with 2 assessments submitted and showed 0 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 01/30/25 with 1 assessment submitted and showed 0 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 03/03/25 with 4 assessments submitted and showed 4 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 03/03/25 with 6 assessments submitted and showed 0 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 03/17/25 with 1 assessment submitted and showed assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 03/17/25 with 1 assessment submitted and showed 0 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 03/17/25 with 11 assessments submitted and showed 4 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 03/17/25 with 1 assessment submitted and showed 0 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 03/17/25 with 1 assessment submitted and showed 1 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 03/18/25 with 3 assessments submitted and showed 2 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 03/18/25 with 1 assessment submitted and showed 1 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 03/23/25 with 3 assessments submitted and showed 0 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 03/23/25 with 1 assessment submitted and showed 1 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 03/23/25 with 1 assessment submitted and showed 0 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 03/26/25 with 2 assessments submitted and showed 0 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 03/26/25 with 1 assessment submitted and showed 1 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 03/26/25 with 1 assessment submitted and showed 1 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 03/29/25 with 1 assessment submitted and showed 1 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 03/30/25 with 1 assessment submitted and showed 1 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 04/01/25 with 1 assessment submitted and showed 1 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 04/01/25 with 3 assessments submitted and showed 0 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 04/09/25 with 4 assessments submitted and showed 0 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 04/09/25 with 1 assessment submitted and showed 0 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 04/09/25 with 1 assessment submitted and showed 0 of the assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 04/10/25 with 2 assessments submitted and showed 0 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 05/01/25 with 1 assessment submitted and showed 0 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 05/01/25 with 2 assessments submitted and showed 0 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 05/01/25 with 4 assessments submitted and showed 0 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 05/01/25 with 1 assessment submitted and showed 0 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 05/01/25 with 1 assessment submitted and showed 0 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 05/01/25 with 1 assessment submitted and showed 0 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 05/04/25 with 1 assessment submitted and showed 1 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 05/08/25 with 5 assessments submitted and showed 0 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 05/08/25 with 4 assessments submitted and showed 0 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 05/12/25 with 1 assessment submitted and showed 0 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 05/12/25 with 1 assessment submitted and showed 0 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 05/12/25 with 1 assessment submitted and showed 0 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 05/12/25 with 3 assessments submitted and showed 0 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 05/12/25 with 3 assessments submitted and showed 0 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 05/15/25 with 1 assessment submitted and showed 0 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 05/18/25 with 2 assessments submitted and showed 0 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 05/26/25 with 1 assessment submitted and showed 0 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 06/03/25 with 5 assessments submitted and showed 1 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 06/03/25 with 1 assessment submitted and showed 1 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 06/12/25 with 1 assessment submitted and showed 1 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 06/12/25 with 1 assessment submitted and showed 1 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 06/12/25 with 2 assessments submitted and showed 1 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 06/12/25 with 1 assessment submitted and showed 1 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 06/13/25 with 3 assessments submitted and showed 1 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 06/13/25 with 6 assessments submitted and showed 0 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 06/13/25 with 2 assessments submitted and showed 0 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 06/13/25 with 1 assessment submitted and showed 0 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 06/22/25 with 1 assessment submitted and showed 0 assessment had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 06/22/25 with 5 assessments submitted and showed 0 of the assessments had -3330 warning code. Reports for the OASIS Agency Final Validation report revealed submission date of 06/22/25 with 4 assessments submitted and showed 0 of the assessments had -3330 warning code. During an interview with DON conducted on 07/22/25 at 4:00 p.m. the surveyor asked the DON who did the OASIS submissions for the HHA. The DON said the Office manager did the OASIS submissions for the agency. When the surveyor asked the DON if anyone else at the HHA helped with the OASIS submissions, the DON said no but DON was responsible for overseeing OASIS transmissions. During interview with Office manager conducted on 07/22/25 at 04:05 p.m., when the surveyor asked if the Office manager did the OASIS assessment submissions for the HHA the Office manager said yes. The surveyor asked the Office manager how often did the Office manager do OASIS submissions, the Office manager said she did the assessment submissions immediately when she received the assessments from the nurses. During a continued interview with DON, also alternate administrator for HHA, conducted on 07/24/25 at 10:45 a.m., the surveyor asked the DON how often OASIS assessment was submitted for HHA. The DON said every time an assessment was ready to be submitted when the nurse finished. The surveyor asked when did the OASIS assessment have to be submitted according to CMS. The DON said no later than 30 days. The surveyor asked what process did the HHA have in place for submitting OASIS assessments. The DON said once the nurse completed the assessment it was transmitted. Once transmitted if the assessment was rejected then it was given back to the nurse for corrections. The DON said when the assessment was given back to the nurse, the nurse would not do corrections immediately and it resulted in the transmissions being done late. The DON acknowledged that the HHA had problems doing transmissions on time but said the HHA was working on it with the nurses. The DON said she was responsible for the OASIS transmissions and making sure that they were transmitted on time before the 3O days are up. When the surveyor asked the DON what problems or harm could transmitting OASIS assessments late impose on patients, the DON said she did not know. The surveyor asked why are OASIS assessments transmitted. The DON said for the data to show how good or bad of care was being provided to patients by the HHA and what areas the HHA could improve on. Review of HHA’s policy titled “OASIS: Data Collection, Encoding and Transmittal,” not dated, read in part, “Procedure: Encoding OASIS Data: 5. All collected and corrected data shall be locked in by seventh (7th) day from the date assessment is completed (MO090). 6. All licked data… shall be transmitted to the state database daily or at least within 30 days in compliance with the state. Transmittal of OASIS Data: Patient data collected, encoded and locked in a one-month period will be transmitted using the State approved method.”