Every finding on record at Epeople Health Care, Inc.

Based upon an unannounced, on-site home health state re-licensure and recertification survey conducted between December 9, 2024 and December 10, 2024, eKidzcare, was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies-Emergency Preparedness.

Based upon an unannounced, on-site home health state re-licensure and recertification survey conducted between December 9, 2024 and December 10, 2024, eKidzcare, was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B &; C, Conditions of Participation: Home Health Agencies.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on reviews of agency policy, clinical records (CRs), and interview with the agency administrator (EMP#1), it was determined the agency failed to ensure clinical staff followed frequency of hours as ordered on the plan of care for one (1) of seven (7) CRs reviews. (CR# 4) Findings included: Review of agency policy on December 10, 2024 at approximately 1:00 p.m. titled, 'Physician's Orders' section, 'Procedure' reads, "...5...It is the responsibility of the licensed nurse to communicate any necessary revisions to the plan of care to the RN (registered nurse) supervisor/RN Care Coordinator who oversees that particular patient's care based on an order received. These revisions consist of anything regarding the patient's plan of care at which includes any new, discontinued, or changed order/intervention and/or medication/treatment..." Review of CRs on December 10, 2024 between approximately 12:30 a.m. to 2:30 p.m. revealed the following: CR# 4, Start of Care (SOC), 4/15/2024: Plan of Care certification period reviewed: 10/11/2024-21/9/2024 with diagnosis: Spastic Quadriplegic Cerebral Palsy. Plan of Care Skilled Nursing Service Frequency orders include: "5-16 hours per day/night, 3-7 days/nights per week for mother's sleep and to accompany the child to school, including transportation and to cover the mother's work schedule and commute. SCHOOL: Approximately 4-9 hours /day , 3-5 days/week are utilized for school, SN to accompany child to school on the van. 17 hour shifts were provided on the following dates: 10/15/24, 10/16/24, 10/17/24, 10/18/24, 10/21/24, 10/22/24, 10/23/24, 10/24/24, 10/25,24, 10/28/24, 10/29/24, 10/30/24, 10/31/24, 11/1/24, 11/4/24, 11/5/24, 11/12/24, 11/13/24, 11/14/24, 11/15/24, 11/18/24, 11/19/24, 11/20/24 and 11/21/24. No documentation provided of obtaining physician orders for the increase in shift hours. Interview with EMP# 1 on December 10, 2024 at approximately 2:00 p.m. confirmed above findings.

Based on the findings of an unannounced onsite incident and complaint investigation survey conducted on August 17, 2023, and completed offsite on August 18, 2023, Ekidzcare, was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on review of policy/procedures, Clinical Record (CR) and interview with RN Care Coordinator Supervisor (EMP# 1), it was determined the agency failed to ensure skilled nurse followed physician orders including but not limited to monitoring for shunt malfunction signs and symptoms and ensuring the patient received the correct total volume amount of feeds for one (1) of one (1) clinical records (CRs) reviewed. (CR# 1) Findings include: Review of CR on 8/17/2023 at approximately 2:00 p.m. revealed the following: Review of 'Acceptance of Patients' policy on 8/17/2023 at approximately 1:15 p.m. reads, "Procedure:...The patient's care will follow a written plan of care established and periodically reviewed by a doctor of medicine, osteopathy, or podiatric medicine..." CR# 1: Patient’s SOC (Start of Care) was 3/23/2022 and She was in the current certification period of: 7/18/2023-9/15/2023. Patient was 9 years old; date of birth: 4/23/2014. Her primary diagnosis was tracheostomy status and other pertinent diagnoses included: paralysis of vocal cords and larynx, unilateral, unspecified convulsions, failure to thrive (child) and hydrocephalus, unspecified. Physician feeding orders included: “Nourish organic 50-80 mL/hr. (milliliters per hour) x 8 hours at night via feeding pump through GT (gastrostomy tube). CONTINUOUS FEEDS: Pump to be used: Infinity; Volume to be infused: 400-540 mL; Rate of Infusion: 50-80 mL/Hour; Frequency of feeds at night over 8 hours” Additional physician orders: “Monitor for S/S shunt malfunction and increased S/S ICP (increased intracranial pressure) (Malfunction: headaches, vomiting, lethargy, irritability, swelling or redness along the shunt tract, decreased cognitive performance, periods of confusion, seizures, etc. ICP/Increased Intracranial Pressure: headaches, blurred vision, decreased in alertness, changes in behavior, weakness, problems moving/talking, lack of energy, lethargy, mental confusion) Notify MD, Parent, Clinical Supervisor if client is showing any symptoms above that are not baseline AND/OR if there is redness/swelling/pain along the shunt track.” Flowsheet for shift: 7/19/2023 to 7/20/2023 documentation revealed: patient’s condition upon arrival was stable, no issues reported from mom upon arrival and prior to shift, no signs of symptoms of shunt malfunction, no GI (gastrointestinal) symptoms, active bowel sounds, last BM (bowel movement) 7/19/2023 and the feeding pump was in use and all the settings and rates were checked, verified and matched the MD order. - ‘Narrative Note r/t Initial Assessment’ stated, “Arrived at home for shift. Received report from mom. Zero concerns voiced. [Patient’s name] is awake on couch. To bedroom and bed. Infinity feed started as ordered via patient gtube. Tolerating well. Tracheotomy clean dry and intact. Zero seizures noted. Zero s/s (signs and symptoms) of discomfort noted. Productive loose/wet cough noted. Tracheotomy suctioned as ordered. Tolerated well. - The nurse documented at ‘12:00 AM’ the following: “[Patient’s name] is asleep in bed. Infinity feed continues to run as ordered. Tolerating well. Pull up dry. Zero seizures noted.” - The nurse documented at ‘2:00 AM’ the following: “[Patient’s name] remains asleep in bed. Tracheotomy suctioned as ordered for secretions. Tolerated well. Nourish added to feed bag. Infinity feed continues to run as ordered.” - The nurse documented at ‘4:00 AM’ the following: “[Patient’s name] awake in bed. Pull up and bed pad changed for lg (large) void. Perineal care complete. Pt encouraged to void in toilet. Pt back to sleep. Zero seizures. Zero s/s of discomfort noted.” - The nurse documented at ‘6:00 AM’ the following: “[Patient’s name] remains asleep in bed. Zero s/s of discomfort noted. Zero seizures noted. Infinity feed continues to run as ordered.” Section titled, ‘Total mL amount in FEEDS r/t (related to) feeding tube’ the nurse documented, “64.00”. No explanation provided/documented why the patient only received 64.00 ml of feeds during this shift. There was a black printed checkmark underneath the section titled, ‘Care Plan/Orders followed (throughout shift).’ Flowsheet for shift: 7/24/2023 to 7/25/2023 documentation revealed: patient’s condition upon arrival was stable, no issues reported from mom upon arrival and prior to shift, no signs of symptoms of shunt malfunction, no GI symptoms, active bowel sounds, last BM (bowel movement) 7/24/2023 and the feeding pump was in use and all the settings and rates were checked, verified and matched the MD order. - ‘Narrative Note r/t Initial Assessment’ stated, “Arrived for shift at home. received report from mom. Zero concerns voiced. [Patient’s name] is awake in bed. Assessment complete. Zero seizures noted. Zero s/s of discomfort noted. Zero cough noted. Infinity feed is running as ordered via patient tube. Pull up changed for small BM. Pt encouraged to void in toilet.” - The nurse documented at ‘12:00 AM’ the following:”[Patient’s name] is asleep in bed. Zero seizures noted. Zero s/s of discomfort [sic] noted. Zero cough noted. 0100-[Patient’s name] awake in bed coughing, dry heaving. Forced emesis noted. Tracheotomy suctioned as ordered. Pt repositioned in bed.” - Section titled, ‘Any change(s) in assessment from previous entry’ during the 2:00 AM assessment, the nurse documented, “No.” Nurse failed to document the onset of “forced emesis” that began at 0100 per nurse’s documentation within the previous entry at 12:00AM. - The nurse documented at ‘2:00 AM’ the following: “Infinity feed bag changed. Infinity feed continues to run as ordered. Suction canister changed. Laundry washed. Room cleaned up. Pt continues to cough off and on forcibly. Zero secretions noted.” - The nurse documented at ‘4:00 AM’ the following: “[Patient’s name] is sleeping in bed with periods of coughing. Tracheotomy suctioned. Zero secretions noted. Infinity feed continues to run as ordered.” - The nurse documented at ‘6:00 AM’ the following: “Pt sleeping in bed. Zero s/s of discomfort noted. Zero seizures noted.” - Section titled, ‘Total mL amount in FEEDS r/t (related to) feeding tube’ the nurse documented, “720.00”. No explanation provided/documented why the patient received more than 540 mL of feeds during shift. - Section titled, ‘Patient OUTPUT during shift hours’ the nurse documented, “Urine, Stool, Emesis.” - Section titled, ‘# of times patient had emesis’, the nurse documented, “4”. - Section titled, ‘MD notified during shift hours’, the nurse documented, “No/Not Applicable.” No documentation provided that the nurse followed physician orders and notified the physician, parent, and clinical supervisor of the shunt malfunction sign/symptom of vomiting experienced during this nightshift per plan of care. Flowsheet for shift: 7/26/2023 to 7/27/2023 documentation revealed: patient’s condition upon arrival was stable, mom reported that patient was forcing emesis all day, no signs of symptoms of shunt malfunction, GI symptoms included vomiting, active bowel sounds, last BM (bowel movement) 7/26/2023 and the feeding pump was in use and all the settings and rates were checked, verified and matched the MD order. Additional report from mom upon nurse arrival noted that patient has been forcing herself to vomit all day. Mother stated that she has given the patient Zofran, as ordered for nausea and patient was still trying to force herself to vomit. Forced emesis occurred at 10:30 pm, 10:40 pm and 11:00 pm. Patient denied feeling sick or having any stomach pains, patient encouraged not to make herself throw up and mom also strongly encouraged the patient to stop forcing herself to throw up. - Section titled, ‘Is patient experiencing any S/S Shunt Malfunction/Increased ICP’ the nurse documented, ‘No.” - Section titled, ‘GI Symptoms’ the nurse documented “Vomiting.” - Section titled, ‘Narrative Note r/t Initial Assessment’ stated, “Arrived at home for shift. Received report from mom. Per mom [patient’s name] has been forcing herself to vomit all day. Mother states she has given Zofran, as ordered for nausea and pt (patient) still tried to force herself to vomit. Assessment completed. Vitals wnl (within normal limits). Tracheotomy clear. Zero increase in sections noted. Zero cough noted. Pt is sitting in bed forcing herself to throw up. Pt encouraged to not make herself throw up. Pt became agitated and started swinging her arms in a punching fashion. Pt encouraged not to hit. 1030-forced emesis noted. Bed pad changed. 1040-forced emesis noted. Pt denies feeling sick or having any stomach pains. 1100-forced emesis noted. Pt encouraged not to make herself throw up. Pts mom-[mother’s name] strongly encouraged pt to stop forcing herself to throw up. - The nurse documented at ‘12:00 PM’ the following: “Pt awake sitting up in bed. Pt denies having any nausea or feeling sick. Zero cough noted. Zero increase in secretions. Emesis noted. HME changed. Bed pad changed for emesis on bed. 0100-forced emesis noted. Zero increase in secretions. Zero cough noted.” - The nurse documented at ‘2:00 AM’ the following, “Pt remains awake in bed. Pt denies having any nausea. Pt denies feeling sick. Pull up changed for small BM. Pt encouraged to void I [sic] toilet. Pt verbalized understanding. 0230- Forced emesis noted. Zero cough noted. Zero increase in secretions. Pt encouraged to stop making herself throw up. Pt swinging arms and hands at nurse striking her. Pt encourage not to hit. 0245—forced emesis noted. Zero cough noted. Zero increase in sections. Pull up dry. 0300-forced emesis noted. Pt denies having nausea. Pt denies feeling sick.” - The nurse documented at ‘4:00 AM’ the following: “Pt sitting up in bed. Forced emesis noted. Pt told via this nurse I am going to get her mom if she continues to force herself to vomit. Pt became alert and stopped dry heaving. 0422-Forced emesis noted. Pt encouraged not to do so. Pt became angry swinging her arms and hands saying, “shut up”. Pt encouraged not to do so. 0440-forced emesis noted. Pt encouraged to stop forcing emesis. Pt denies feeling sick. It [sic] denies having nausea or feeling like she is going to throw up. 0500-forced emesis noted. Zero cough noted. Zero increase in secretions.” - The nurse documented at ‘6:00 AM’ the following: “Pt remains awake in bed. Pt trying to force herself to throw up but is unsuccessful. Dry heaving noted. Zero emesis noted. Pull up dry.” - Section titled, ‘Patient OUTPUT during shift hours’ the nurse documented, “Urine, Stool, Emesis.” - Section titled, ‘# of times patient had emesis’ the nurse documented, “12”. - Section titled, ‘MD notified during shift hours’ the nurse documented, “No/Not Applicable”. No documentation provided that the nurse followed physician orders and notified the physician, parent, and clinical supervisor of the shunt malfunction sign/symptom of vomiting experienced during the daytime per mom’s report. No documentation provided that the nurse followed physician orders and notified the physician, parent, and clinical supervisor of the shunt malfunction signs/symptoms of vomiting, irritability and changes in behavior experienced during the nightshift per plan of care. Flowsheet for shift: 7/27/2023 to 7/28/2023 documentation revealed: patient’s condition upon arrival was stable, mom reported to nurse that patient has been seen forcing herself to vomit during the day, nurse performed an assessment and patient was covered in emesis, patient denied feeling nauseated or sick, no signs of symptoms of shunt malfunction, GI symptoms included vomiting, active bowel sounds, last BM (bowel movement) 7/27/2023 and the feeding pump was in use and all the settings and rates were checked, verified and matched the MD order. - Section titled, ‘Is patient experiencing any S/S Shunt Malfunction/Increased ICP’ the nurse documented, ‘No.” - Section titled, ‘GI Symptoms’ the nurse documented “Vomiting.” - Section titled, ‘Narrative Note r/t Initial Assessment’ stated, “Arrived at home for shift. Received report from mom. Mom states [Patient’s name] has been seen forcing herself to vomit during the day. Assessment complete. [Patient’s name] is covered in emesis. Bed linens changed. Pt wiped clean. Pt back to bed. Pt denies feeling nauseated or sick. Zero cough noted. Zero increase in secreations [sic]. HME changed. 2300-pt is sleeping in bed. Zero s/s of discomfort noted. - The nurse documented at ‘12:00 AM’ the following: “[Patient’s name] is awake in bed laying down. Pt is sticking tongue out forcing herself to dry heave. Emesis noted. Bed linens changed. Pt wiped clean. Pt encouraged to vomit in a garbage can and not her bed. Pt verbalized understanding. Pt denies having any nausea or any s/s of being sick. HME changed. Tracheotomy suctioned as ordered. 0100- [Patient’s name] is awake in bed. Pt is sticking tongue out forcing herself to gag. Zero cough noted. Emesis noted. Tracheotomy suctioned as ordered. HME changed.” - The nurse documented at ‘2:00 AM’ the following: “[Patient’s name] is awake in bed. Pt denies feeling sick. Pull up dry. Zero seizures noted. Zero s/s of discomfort noted. Pt is dry heaving. Zero emesis noted.” - The nurse documented at ‘400 AM’ the following: “[Patient’s name] is awake in bed. Pt is sticking tongue out trying to make herself gag/vomit. Pt encouraged not to do so. Pt denies feeling sick or having nausea. 0425-emesis noted. 0500-emesis noted.” - The nurse documented at ‘6:00 AM’ the following: “Pt is sleeping in bed. Pull up dry. Zero s/s of discomfort noted. Zero seizures. - Section titled, ‘Total mL amount in FEEDS r/t (related to) feeding tube’ the nurse documented, “560.00”. No explanation provided/documented why the patient received more than 540 mL of feeds during shift. - Section titled, ‘Patient OUTPUT during shift hours’ the nurse documented, “Emesis.” - Section titled, ‘# of times patient had emesis’ the nurse documented, “8”. - Section titled, ‘MD notified during shift hours’ the nurse documented, “No/Not Applicable”. No documentation provided that EMP# 2 followed physician orders and notified the physician, parent, and clinical supervisor of the shunt malfunction sign/symptom of vomiting experienced during the daytime per mom’s report. No documentation provided that EMP# 2 followed physician orders and notified the physician, parent, and clinical supervisor of the shunt malfunction signs/symptoms of vomiting and changes in behavior experienced during the nightshift per plan of care. Interview with EMP # 1 on 8/17/2023 at approximately 3:00 p.m. confirmed the findings above.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on review of policy/procedures, clinical record (CR) and interview with RN Care Coordinator Supervisor (EMP# 1), it was determined the agency failed to ensure home health care agency personnel promptly alerted relevant physician of changes for one (1) of one (1) CR reviewed. (CR# 1) Findings include: Review of CR on 8/18/2023 at approximately 9:00 a.m. revealed the following: Review of 'Nursing Assessment and Plan of Care' policy on 8/17/2023 at approximately 12:30 p.m. reads, "Procedure: PLAN OF CARE...f. The plan of care will be reviewed and updated at least every 60 days or as often as the severity of the patient's condition requires...i. The physician will promptly be notified to any changes that suggest a need to alter the plan of care..." CR# 1: Patient’s SOC (Start of Care) was 3/23/2022 and She was in the current certification period of: 7/18/2023-9/15/2023. Patient was 9 years old; date of birth: 4/23/2014. Her primary diagnosis was tracheostomy status and other pertinent diagnoses included: paralysis of vocal cords and larynx, unilateral, unspecified convulsions, failure to thrive (child) and hydrocephalus, unspecified. Physician feeding orders included: “Nourish organic 50-80 mL/hr. (milliliters per hour) x 8 hours at night via feeding pump through GT (gastrostomy tube). CONTINUOUS FEEDS: Pump to be used: Infinity; Volume to be infused: 400-540 mL; Rate of Infusion: 50-80 mL/Hour; Frequency of feeds at night over 8 hours” Additional physician orders: “Monitor for S/S shunt malfunction and increased S/S ICP (increased intracranial pressure) (Malfunction: headaches, vomiting, lethargy, irritability, swelling or redness along the shunt tract, decreased cognitive performance, periods of confusion, seizures, etc. ICP/Increased Intracranial Pressure: headaches, blurred vision, decreased in alertness, changes in behavior, weakness, problems moving/talking, lack of energy, lethargy, mental confusion) Notify MD, Parent, Clinical Supervisor if client is showing any symptoms above that are not baseline AND/OR if there is redness/swelling/pain along the shunt track.” Flowsheet for shift: 7/24/2023 to 7/25/2023: The nurse documented at ‘12:00 AM’ the following:”[Patient’s name] is asleep in bed. Zero seizures noted. Zero s/s of discomfort [sic] noted. Zero cough noted. 0100-[Patient’s name] awake in bed coughing, dry heaving. Forced emesis noted. Tracheotomy suctioned as ordered. Pt repositioned in bed.” - Section titled, ‘Any change(s) in assessment from previous entry’ during the 2:00 AM assessment, the nurse documented, “No.” Nurse failed to document the onset of “forced emesis” that began at 0100 per nurse’s documentation within the previous entry at 12:00AM. - The nurse documented at ‘2:00 AM’ the following: “Infinity feed bag changed. Infinity feed continues to run as ordered. Suction canister changed. Laundry washed. Room cleaned up. Pt continues to cough off and on forcibly. Zero secretions noted.” - The nurse documented at ‘4:00 AM’ the following: “[Patient’s name] is sleeping in bed with periods of coughing. Tracheotomy suctioned. Zero secretions noted. Infinity feed continues to run as ordered.” - The nurse documented at ‘6:00 AM’ the following: “Pt sleeping in bed. Zero s/s of discomfort noted. Zero seizures noted.” - Section titled, ‘Patient OUTPUT during shift hours’ the nurse documented, “Urine, Stool, Emesis.” - Section titled, ‘# of times patient had emesis’, the nurse documented, “4”. - Section titled, ‘MD notified during shift hours’, the nurse documented, “No/Not Applicable.” Flowsheet for shift: 7/26/2023 to 7/27/2023 documentation revealed: patient’s condition upon arrival was stable, mom reported that patient was forcing emesis all day, no signs of symptoms of shunt malfunction, GI symptoms included vomiting, active bowel sounds, last BM (bowel movement) 7/26/2023 and the feeding pump was in use and all the settings and rates were checked, verified and matched the MD order. Additional report from mom upon nurse arrival noted that patient has been forcing herself to vomit all day. Mother stated that she has given the patient Zofran, as ordered for nausea and patient was still trying to force herself to vomit. Forced emesis occurred at 10:30 pm, 10:40 pm and 11:00 pm. Patient denied feeling sick or having any stomach pains, patient encouraged not to make herself throw up and mom also strongly encouraged the patient to stop forcing herself to throw up. - Section titled, ‘Is patient experiencing any S/S Shunt Malfunction/Increased ICP’ the nurse documented, ‘No.” - Section titled, ‘GI Symptoms’ the nurse documented “Vomiting.” - Section titled, ‘Narrative Note r/t Initial Assessment’ stated, “Arrived at home for shift. Received report from mom. Per mom [patient’s name] has been forcing herself to vomit all day. Mother states she has given Zofran, as ordered for nausea and pt (patient) still tried to force herself to vomit. Assessment completed. Vitals wnl (within normal limits). Tracheotomy clear. Zero increase in sections noted. Zero cough noted. Pt is sitting in bed forcing herself to throw up. Pt encouraged to not make herself throw up. Pt became agitated and started swinging her arms in a punching fashion. Pt encouraged not to hit. 1030-forced emesis noted. Bed pad changed. 1040-forced emesis noted. Pt denies feeling sick or having any stomach pains. 1100-forced emesis noted. Pt encouraged not to make herself throw up. Pts mom-[mother’s name] strongly encouraged pt to stop forcing herself to throw up. - The nurse documented at ‘12:00 PM’ the following: “Pt awake sitting up in bed. Pt denies having any nausea or feeling sick. Zero cough noted. Zero increase in secretions. Emesis noted. HME changed. Bed pad changed for emesis on bed. 0100-forced emesis noted. Zero increase in secretions. Zero cough noted.” - The nurse documented at ‘2:00 AM’ the following, “Pt remains awake in bed. Pt denies having any nausea. Pt denies feeling sick. Pull up changed for small BM. Pt encouraged to void I [sic] toilet. Pt verbalized understanding. 0230- Forced emesis noted. Zero cough noted. Zero increase in secretions. Pt encouraged to stop making herself throw up. Pt swinging arms and hands at nurse striking her. Pt encourage not to hit. 0245—forced emesis noted. Zero cough noted. Zero increase in sections. Pull up dry. 0300-forced emesis noted. Pt denies having nausea. Pt denies feeling sick.” - The nurse documented at ‘4:00 AM’ the following: “Pt sitting up in bed. Forced emesis noted. Pt told via this nurse I am going to get her mom if she continues to force herself to vomit. Pt became alert and stopped dry heaving. 0422-Forced emesis noted. Pt encouraged not to do so. Pt became angry swinging her arms and hands saying, “shut up”. Pt encouraged not to do so. 0440-forced emesis noted. Pt encouraged to stop forcing emesis. Pt denies feeling sick. It [sic] denies having nausea or feeling like she is going to throw up. 0500-forced emesis noted. Zero cough noted. Zero increase in secretions.” - The nurse documented at ‘6:00 AM’ the following: “Pt remains awake in bed. Pt trying to force herself to throw up but is unsuccessful. Dry heaving noted. Zero emesis noted. Pull up dry.” - Section titled, ‘Patient OUTPUT during shift hours’ the nurse documented, “Urine, Stool, Emesis.” - Section titled, ‘# of times patient had emesis’ the nurse documented, “12”. - Section titled, ‘MD notified during shift hours’ the nurse documented, “No/Not Applicable”. Flowsheet for shift: 7/27/2023 to 7/28/2023 documentation revealed: patient’s condition upon arrival was stable, mom reported to nurse that patient has been seen forcing herself to vomit during the day, nurse performed an assessment and patient was covered in emesis, patient denied feeling nauseated or sick, no signs of symptoms of shunt malfunction, GI symptoms included vomiting, active bowel sounds, last BM (bowel movement) 7/27/2023 and the feeding pump was in use and all the settings and rates were checked, verified and matched the MD order. - Section titled, ‘Is patient experiencing any S/S Shunt Malfunction/Increased ICP’ the nurse documented, ‘No.” - Section titled, ‘GI Symptoms’ the nurse documented “Vomiting.” - Section titled, ‘Narrative Note r/t Initial Assessment’ stated, “Arrived at home for shift. Received report from mom. Mom states [Patient’s name] has been seen forcing herself to vomit during the day. Assessment complete. [Patient’s name] is covered in emesis. Bed linens changed. Pt wiped clean. Pt back to bed. Pt denies feeling nauseated or sick. Zero cough noted. Zero increase in secreations [sic]. HME changed. 2300-pt is sleeping in bed. Zero s/s of discomfort noted. - The nurse documented at ‘12:00 AM’ the following: “[Patient’s name] is awake in bed laying down. Pt is sticking tongue out forcing herself to dry heave. Emesis noted. Bed linens changed. Pt wiped clean. Pt encouraged to vomit in a garbage can and not her bed. Pt verbalized understanding. Pt denies having any nausea or any s/s of being sick. HME changed. Tracheotomy suctioned as ordered. 0100- [Patient’s name] is awake in bed. Pt is sticking tongue out forcing herself to gag. Zero cough noted. Emesis noted. Tracheotomy suctioned as ordered. HME changed.” - The nurse documented at ‘2:00 AM’ the following: “[Patient’s name] is awake in bed. Pt denies feeling sick. Pull up dry. Zero seizures noted. Zero s/s of discomfort noted. Pt is dry heaving. Zero emesis noted.” - The nurse documented at ‘400 AM’ the following: “[Patient’s name] is awake in bed. Pt is sticking tongue out trying to make herself gag/vomit. Pt encouraged not to do so. Pt denies feeling sick or having nausea. 0425-emesis noted. 0500-emesis noted.” - The nurse documented at ‘6:00 AM’ the following: “Pt is sleeping in bed. Pull up dry. Zero s/s of discomfort noted. Zero seizures. - Section titled, ‘Patient OUTPUT during shift hours’ the nurse documented, “Emesis.” - Section titled, ‘# of times patient had emesis’ the nurse documented, “8”. - Section titled, ‘MD notified during shift hours’ the nurse documented, “No/Not Applicable”. No documentation provided to show the plan of care was reviewed and updated due to the changes in the patient's condition. No documentation provided to show the physician being promptly notified to any of the changes and no suggestions made for a need to alter the plan of care based on the patient's observed symptoms/behaviors. Interview with EMP # 1 on 8/17/2023 at approximately 3:00 p.m. confirmed the findings above.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on review of policy/procedures, Clinical Record (CR) and interview with RN Care Coordinator Supervisor (EMP# 1), it was determined the agency failed to ensure clinical notes were written and incorporated into the clinical record (1) of one (1) clinical records (CRs) reviewed. (CR# 1) Findings include: Review of 'Patient's Home Health Medical Care record' policy on 8/17/2023 at approximately 12:00 p.m. reads, "Procedure:...A. eKidzcare utilizes electronic medical record (EMR) software to collect daily care documentation. a. Documentation is required to be completed the day services are rendered...1. All forms of paper documentation will be filed in the patient's medical record/chart in the respective eKidzcare office within seven days of the service being provided..." Review of CR on 8/17/2023 at approximately 2:00 p.m. revealed the following: CR# 1: Flowsheets for shifts: 7/20/2023 to 7/21/2023 and 7/25/2023 to 7/26/2023 were not provided to surveyor. Interview with EMP # 1 on 8/17/2023 at approximately 3:00 p.m. confirmed the findings above.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on review of agency policy/procedure, 'RN Care Coordinator Supervisor' job description, Clinical Record (CR) documentation and interview with RN Care Coordinator Supervisor (EMP# 1), it was determined the agency failed to ensure registered nurse followed duties and responsibilities for one (1) of (1) CR reviewed. (CR# 1) Based on review of agency policy/procedure, 'RN Care Coordinator Supervisor' job description, Clinical Record (CR) documentation and interview with RN Care Coordinator Supervisor (EMP# 1), it was determined the agency failed to ensure registered nurse followed duties and responsibilities for one (1) of (1) CR reviewed. (CR# 1) Findings include: Review of 'RN Care Coordinator Supervisor' job description on 8/17/2023 at approximately 2:00 p.m. reads, "Duties and responsibilities...Evaluating and documenting whether HHA services are being delivered in an acceptable manner, consistent with policies/procedures and all regulations that dictate this level of care…ensuring that all direct care staff are performing their job duties appropriate to their job descriptions and EPeople Health Care Standards…Performing or supervising all clinical care and services that are provided to patients and families admitted to EPeople Health Care…Initiating, developing, implementing, evaluating and updating as necessary all patient plans of care…informing the physician and all involved employees of changes in the patient’s conditions and needs…performing and supervising all care and services to patients per physician orders within specified timeframes per state regulations…maintain accurate and complete patient, employee, and company records, assuring compliance with federal state, local and company policies and procedures as they pertain to the delivery of patient care and services…” Review of 'Physician's Orders' policy on 8/17/2023 at approximately 12:35 p.m. reads, "Procedure:..6. The RN Supervisor/RN Care Coordinator will make sure any necessary changes are made to the patient's POC (plan of care) and all staff responsible for providing that care are informed of the changes..." Review of CR on 8/17/2023 at approximately 2:00 p.m. revealed the following: CR# 1: Patient’s SOC (Start of Care) was 3/23/2022 and She was in the current certification period of: 7/18/2023-9/15/2023. Patient was 9 years old; date of birth: 4/23/2014. Her primary diagnosis was tracheostomy status and other pertinent diagnoses included: paralysis of vocal cords and larynx, unilateral, unspecified convulsions, failure to thrive (child) and hydrocephalus, unspecified. Physician feeding orders included: “Nourish organic 50-80 mL/hr. (milliliters per hour) x 8 hours at night via feeding pump through GT (gastrostomy tube). CONTINUOUS FEEDS: Pump to be used: Infinity; Volume to be infused: 400-540 mL; Rate of Infusion: 50-80 mL/Hour; Frequency of feeds at night over 8 hours” Additional physician orders: “Monitor for S/S shunt malfunction and increased S/S ICP (increased intracranial pressure) (Malfunction: headaches, vomiting, lethargy, irritability, swelling or redness along the shunt tract, decreased cognitive performance, periods of confusion, seizures, etc. ICP/Increased Intracranial Pressure: headaches, blurred vision, decreased in alertness, changes in behavior, weakness, problems moving/talking, lack of energy, lethargy, mental confusion) Notify MD, Parent, Clinical Supervisor if client is showing any symptoms above that are not baseline AND/OR if there is redness/swelling/pain along the shunt track.” Flowsheet for shift: 7/19/2023 to 7/20/2023 documentation revealed: Section titled, ‘Total mL amount in FEEDS r/t (related to) feeding tube’ the nurse documented, “64.00”. No explanation provided/documented why the patient only received 64.00 ml of feeds during this shift. Flowsheet for shift: 7/24/2023 to 7/25/2023 documentation revealed: The nurse documented at ‘12:00 AM’ the following:”[Patient’s name] is asleep in bed. Zero seizures noted. Zero s/s of discomfort [sic] noted. Zero cough noted. 0100-[Patient’s name] awake in bed coughing, dry heaving. Forced emesis noted. Tracheotomy suctioned as ordered. Pt repositioned in bed.” - Section titled, ‘Any change(s) in assessment from previous entry’ during the 2:00 AM assessment, the nurse documented, “No.” Nurse failed to document the onset of “forced emesis” that began at 0100 per nurse’s documentation within the previous entry at 12:00AM. The nurse documented at ‘2:00 AM’ the following: “Infinity feed bag changed. Infinity feed continues to run as ordered. Suction canister changed. Laundry washed. Room cleaned up. Pt continues to cough off and on forcibly. Zero secretions noted.” Section titled, ‘Total mL amount in FEEDS r/t (related to) feeding tube’ the nurse documented, “720.00”. No explanation provided/documented why the patient received more than 540 mL of feeds during shift. - Section titled, ‘Patient OUTPUT during shift hours’ the nurse documented, “Urine, Stool, Emesis.” - Section titled, ‘# of times patient had emesis’, the nurse documented, “4”. - Section titled, ‘MD notified during shift hours’, the nurse documented, “No/Not Applicable.” Flowsheet for shift: 7/26/2023 to 7/27/2023 documentation revealed: patient’s condition upon arrival was stable, mom reported that patient was forcing emesis all day, no signs of symptoms of shunt malfunction, GI symptoms included vomiting, active bowel sounds, last BM (bowel movement) 7/26/2023 and the feeding pump was in use and all the settings and rates were checked, verified and matched the MD order. Additional report from mom upon nurse arrival noted that patient has been forcing herself to vomit all day. Mother stated that she has given the patient Zofran, as ordered for nausea and patient was still trying to force herself to vomit. Forced emesis occurred at 10:30 pm, 10:40 pm and 11:00 pm. Patient denied feeling sick or having any stomach pains, patient encouraged not to make herself throw up and mom also strongly encouraged the patient to stop forcing herself to throw up. - Section titled, ‘Is patient experiencing any S/S Shunt Malfunction/Increased ICP’ the nurse documented, ‘No.” - Section titled, ‘GI Symptoms’ the nurse documented “Vomiting.” - Section titled, ‘Narrative Note r/t Initial Assessment’ stated, “Arrived at home for shift. Received report from mom. Per mom [patient’s name] has been forcing herself to vomit all day. Mother states she has given Zofran, as ordered for nausea and pt (patient) still tried to force herself to vomit. Assessment completed. Vitals wnl (within normal limits). Tracheotomy clear. Zero increase in sections noted. Zero cough noted. Pt is sitting in bed forcing herself to throw up. Pt encouraged to not make herself throw up. Pt became agitated and started swinging her arms in a punching fashion. Pt encouraged not to hit. 1030-forced emesis noted. Bed pad changed. 1040-forced emesis noted. Pt denies feeling sick or having any stomach pains. 1100-forced emesis noted. Pt encouraged not to make herself throw up. Pts mom-[mother’s name] strongly encouraged pt to stop forcing herself to throw up. - The nurse documented at ‘12:00 PM’ the following: “Pt awake sitting up in bed. Pt denies having any nausea or feeling sick. Zero cough noted. Zero increase in secretions. Emesis noted. HME changed. Bed pad changed for emesis on bed. 0100-forced emesis noted. Zero increase in secretions. Zero cough noted.” - The nurse documented at ‘2:00 AM’ the following, “Pt remains awake in bed. Pt denies having any nausea. Pt denies feeling sick. Pull up changed for small BM. Pt encouraged to void I [sic] toilet. Pt verbalized understanding. 0230- Forced emesis noted. Zero cough noted. Zero increase in secretions. Pt encouraged to stop making herself throw up. Pt swinging arms and hands at nurse striking her. Pt encourage not to hit. 0245—forced emesis noted. Zero cough noted. Zero increase in sections. Pull up dry. 0300-forced emesis noted. Pt denies having nausea. Pt denies feeling sick.” - The nurse documented at ‘4:00 AM’ the following: “Pt sitting up in bed. Forced emesis noted. Pt told via this nurse I am going to get her mom if she continues to force herself to vomit. Pt became alert and stopped dry heaving. 0422-Forced emesis noted. Pt encouraged not to do so. Pt became angry swinging her arms and hands saying, “shut up”. Pt encouraged not to do so. 0440-forced emesis noted. Pt encouraged to stop forcing emesis. Pt denies feeling sick. It [sic] denies having nausea or feeling like she is going to throw up. 0500-forced emesis noted. Zero cough noted. Zero increase in secretions.” - The nurse documented at ‘6:00 AM’ the following: “Pt remains awake in bed. Pt trying to force herself to throw up but is unsuccessful. Dry heaving noted. Zero emesis noted. Pull up dry.” - Section titled, ‘Patient OUTPUT during shift hours’ the nurse documented, “Urine, Stool, Emesis.” - Section titled, ‘# of times patient had emesis’ the nurse documented, “12”. - Section titled, ‘MD notified during shift hours’ the nurse documented, “No/Not Applicable”. Flowsheet for shift: 7/27/2023 to 7/28/2023 documentation revealed: patient’s condition upon arrival was stable, mom reported to nurse that patient has been seen forcing herself to vomit during the day, nurse performed an assessment and patient was covered in emesis, patient denied feeling nauseated or sick, no signs of symptoms of shunt malfunction, GI symptoms included vomiting, active bowel sounds, last BM (bowel movement) 7/27/2023 and the feeding pump was in use and all the settings and rates were checked, verified and matched the MD order. - Section titled, ‘Is patient experiencing any S/S Shunt Malfunction/Increased ICP’ the nurse documented, ‘No.” - Section titled, ‘GI Symptoms’ the nurse documented “Vomiting.” - Section titled, ‘Narrative Note r/t Initial Assessment’ stated, “Arrived at home for shift. Received report from mom. Mom states [Patient’s name] has been seen forcing herself to vomit during the day. Assessment complete. [Patient’s name] is covered in emesis. Bed linens changed. Pt wiped clean. Pt back to bed. Pt denies feeling nauseated or sick. Zero cough noted. Zero increase in secreations [sic]. HME changed. 2300-pt is sleeping in bed. Zero s/s of discomfort noted. - The nurse documented at ‘12:00 AM’ the following: “[Patient’s name] is awake in bed laying down. Pt is sticking tongue out forcing herself to dry heave. Emesis noted. Bed linens changed. Pt wiped clean. Pt encouraged to vomit in a garbage can and not her bed. Pt verbalized understanding. Pt denies having any nausea or any s/s of being sick. HME changed. Tracheotomy suctioned as ordered. 0100- [Patient’s name] is awake in bed. Pt is sticking tongue out forcing herself to gag. Zero cough noted. Emesis noted. Tracheotomy suctioned as ordered. HME changed.” - The nurse documented at ‘2:00 AM’ the following: “[Patient’s name] is awake in bed. Pt denies feeling sick. Pull up dry. Zero seizures noted. Zero s/s of discomfort noted. Pt is dry heaving. Zero emesis noted.” - The nurse documented at ‘400 AM’ the following: “[Patient’s name] is awake in bed. Pt is sticking tongue out trying to make herself gag/vomit. Pt encouraged not to do so. Pt denies feeling sick or having nausea. 0425-emesis noted. 0500-emesis noted.” - The nurse documented at ‘6:00 AM’ the following: “Pt is sleeping in bed. Pull up dry. Zero s/s of discomfort noted. Zero seizures. - Section titled, ‘Total mL amount in FEEDS r/t (related to) feeding tube’ the nurse documented, “560.00”. No explanation provided/documented why the patient received more than 540 mL of feeds during shift. - Section titled, ‘Patient OUTPUT during shift hours’ the nurse documented, “Emesis.” - Section titled, ‘# of times patient had emesis’ the nurse documented, “8”. - Section titled, ‘MD notified during shift hours’ the nurse documented, “No/Not Applicable”. EMP# 1 failed to ensure services are being delivered in an acceptable manner, consistent with policies/procedures and all regulations that dictate this level of care; failed to ensure that all direct care staff are performing their job duties appropriate to their job descriptions and EPeople Health Care Standard; failed to evaluate and update the plan of care as necessary; failed to supervise all care and services to patients per physician orders; failed to ensure accurate patient records; and failed to ensure company policies and procedures were followed as they pertain to the delivery of a patient care and services. Interview with EMP # 1 on 8/17/2023 at approximately 3:00 p.m. confirmed the findings above.

Based on an unannounced, on-site Medicare recertification and state re-licensure survey conducted between December 6, 2021 through December 8, 2021, Ekidzcare, was found not to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies-Emergency Preparedness.

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 review of agency policy, emergency preparedness binder and interview with agency Nurse Supervisor (EMP# 1) and Branch Manager (EMP# 2), it was determined the agency failed to complete an annual Hazard vulnerability analysis per agency policy for one (1) of one (1) Hazard Vulnerability Analysis (HVA) forms reviewed. (HVA #1) Review of policy, 'Emergency Preparedness Communication Plan' on December 8, 2021 at approximately 1:24 p.m. states, "A. Emergency Preparedness Communication Plan will be reviewed and updated by the Governing Body; at least annually..." HVA # 1: No Hazard Vulnerability Analysis assessment completed for year of 2020. Interview with EMP# 1 and EMP# 2 conducted on December 8, 2021 at approximately 2:30 p.m. confirmed the above findings.

Based on an unannounced, on-site Medicare recertification and state re-licensure survey conducted between December 6, 2021 through December 8, 2021, Ekidzcare, was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on review of agency policy, home visit observations, clinical records (CRs), and interviews with agency nurse supervisor (EMP# 1), branch manager (EMP# 2) and licensed practical nurse (EMP# 12), it was determined agency failed to ensure Plan of Care, physician orders and communication policies were followed for one (1) of three (3) home visits conducted and two (2) of seven (7) CRs reviewed. (Home Visit # 1, CR# 3 and CR# 7) Review of policy, 'Physician's Orders' on December 7, 2021 at approximately 1:15 p.m. states, "Procedure:...4. It is the responsibility of the licensed nurse to communicate revisions to the plan of care to the RN Supervisor who oversees that particular patient's care based on an order received. 5. The RN Supervisor will make sure any necessary changes are made to the patient's POC and all staff responsible for providing that care are informed of the changes." Policies regarding following plan of care, communication with the physician and shift orders were requested by surveyor. Policies requested were not provided to the surveyor. Home Visits conducted on December 7, 2021 between approximately 8:00 p.m. and 12:00 p.m. and on December 8, 2021 between approximately 8:00 a.m. to 9:00 a.m. revealed the following: Home Visit # 1: Patient Start of Care (SOC), 5/24/2017. During Home visit # 1, on December 7, 2021 at approximately 8:33 a.m. surveyor observed licensed practical nurse (LPN) # 12, enter the Nutren Jr. with fiber flow rate of 210 mL/hr. The surveyor reviewed the plan of care and questioned the LPN # 12 regarding the current orders. Surveyor asked LPN# 12 if an updated order was entered and received for the increase of the Nutren Jr. flow rate. LPN# 12 replied, "No, mom just told me what the doctor increased it to from the last appointment." Recertification period reviewed:10/24/2021-12/22/2021. Primary Care Diagnosis: Hypoxic Ischemic Encephalopathy. Medication list ordered on the Plan of Care included: "Nutren Jr with Fiber (or Whole Foods Pureed) 333 mL (milliliters) (185 mL/hr), TID (three times daily). Incorrect Flow Rate of Nutren Jr. was documented given on the nursing clinical note on the following dates: - Flow rate of "208/hr = 335 mL TID" documented on nurse note on 10/27/2021. - Flow rate of "210/hr = 335 mL TID" documented on nurse note on 10/28/2021. - Flow rate of "210/hr = 335 mL TID" documented on nurse note on 10/29/2021. - Flow rate of "210/hr = 335 mL TID" documented on nurse note on 11/1/2021. - Flow rate of "210/hr = 335 mL TID" documented on nurse note on 11/24/2021. - Flow rate of "210/hr = 335 mL TID" documented on nurse note on 11/29/2021. - Flow rate of "210/hr = 335 mL TID" documented on nurse note on 11/30/2021. - Flow rate of "210/hr = 335 mL TID" documented on nurse note on 12/1/2021. - Flow rate of "210/hr = 335 mL TID" documented on nurse note on 12/2/2021. - Flow rate of "210/hr = 335 mL TID" documented on nurse note on 12/3/2021. Clinical record reviews conducted on December 7, 2021 between approximately 12:00 p.m. and 3:00 p.m. and on December 8, 2021 between approximately 10:00 a.m. to 2:00 p.m. revealed the following: CR# 1, Start of Care (SOC): 1/28/2021. Certification period reviewed: 9/26/2021-11/24/2021. Primary diagnosis: unspecified hereditary retinal dystrophy. Skilled Nursing (SN) services frequency orders included, "Client is receiving Skill Nursing Services for 5-9.5 hours, 2-5 days per week and 6-8 hours per night 5-7 night per week for parent's sleep x 60 days. [Other health agency name] is co-vending with eKidz. but we are the primary agency. [Other health agency name] fills staffing for 3-5 nights/week. Ekidzcare may pick up any additional hours not covered by [Other health agency name] ." - Agency caregiver was injured during shift on 10/23/2021. No further shifts provided by primary agency after caregiver injury from dates of: 10/24/2021 to 11/24/2021. Agency faxed 'MD Order-Addendum/General Order' on 11/30/2021 to physician stating, "SN Services for Ekidz care to be placed on current HOLD due to illness of Ekidz caregiver EFFECTIVE 11/24/2021...Skilled nursing services will be resumed if/when an alternate caregiver can be found or his nurse returns to work following work-related injury." 'MD Order/Addendum/General Order' signed by physician on 11/30/2021. - Agency failed to notify the responsible physician of the missed shifts within a week as required. Agency has not provided services to the patient since 10/24/2021. Agency also put the patient on hold status solely based on the lack of availability of home health agency staffing. CR# 7, SOC: 3/26/2020. Certification period reviewed: 5/25/2020-7/23/2020. Primary diagnosis: Tracheostomy Status. SN services frequency orders included, "SN to provide care 6-8 hr/night x 2-4 nights/wk to cover parents sleep. Case is covended with [Other health agency name] who is the primary provides who provides additional SN services. If [Other health agency name] is unable to staff shifts, eKiedzCare may staff additional shifts." - Certification period began on 5/25/2021. No skilled nursing shifts were provided during the entire certification period of 5/25/2020-7/23/2020. Agency faxed 'Physician Order changer' on 6/19/2020 to physician stating, "Dear [Physician Name], SN services are being placed on hold at this time due to lack of adequate staffing. Child will continue to receive SN services via agency [Other health agency name] which is the primary SN services provider at this time. eKidzcare will continue to recruit for additional SN staff as a back up option to the primary agency. If no adequate staffing is found by the end of the current certification period, eKidzcare will discharge from services at that time." 'Physician order change' form was signed by physician on 6/26/2020. - Agency failed to notify the responsible physician of the missed shifts within a week as required. Agency has not provided services to the patient for entire certification period. Agency also put the patient on hold status solely based on the lack of availability of home health agency staffing. Interview with EMP# 1 and EMP# 2 conducted on December 8, 2021 at approximately 2:30 p.m. confirmed the above findings.