Every finding on record at Epeople Health Care, Inc. D/B/A Ekidzcare

Based on the findings of an unannounced onsite Medicare recertification survey completed March 10, 2022, 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 on the findings of an unannounced onsite Medicare recertification survey completed March 10, 2022, 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.

Standard: Initial assessment visit. CFR(s): 484.55(a) Standard: Initial assessment visit. This STANDARD is not met as evidenced by: Based on a review of agency policy, review of clinical records, and an interview with the agency Administrator, the agency failed to complete the initial assessment visit within 48 hours of referral, or within 48 hours of the patients return home, or on the physician-ordered start of care date, for five (5) of nine (9) clinical records (CR#1, CR#4, CR#5, CR#7, CR#8). Findings: A review of agency Policy/Procedure was conducted on March 8, 2022 at approximately 10:00 a.m. 'Nursing Assessment and Plan of Care' 'Procedure' 'Nursing Assessment' (A) Initial assessment (assessment visit) is completed during any of the following: (a) Within 48 hours of a referral. (b) Within 48 hours of the patients return home (post hospital). (c) On the physician-ordered start of care date. 'Admission Policy and Procedure' 'Procedure' (1) "After accepting a referral, an RN will conduct an initial assessment visit to determine the immediate care and support needs of the patient. ...... (b) The initial assessment will be completed either within 48 hours after acceptance of the referral, or within 48 hours of the patients return home, or on the physician ordered start of care date." (Note: This policy/procedure is not compliant with regulation). A review of clinical records conducted on March 8, 2022 between approximately 10:00 a.m. and 2:00 p.m. revealed the following: CR#1 SOC 09/09/19: Referral (per agency form, "Inquiry Date") from ("self") for skilled nursing services on 08/05/19. No patients return home specified nor physician ordered start of care date specified. Documentation of initial assessment visit by registered nurse visit on 09/09/19. CR#4 SOC 01/21/22: No documentation provided of a referral for this patient. Documentation of initial assessment visit by registered nurse visit on 01/21/22. CR#5 SOC 02/28/22: No documentation provided of a referral for this patient. Documentation of initial assessment visit by registered nurse visit on 02/28/22. CR#7 SOC 10/05/20: Referral (per agency form, "Inquiry Date") from ("insurance company") for skilled nursing services on 09/21/20. No patients return home specified nor physician ordered start of care date specified. Documentation of initial assessment visit by registered nurse visit on 10/04/20. CR#8 SOC 05/04/20: Referral (per agency form, "Inquiry Date") from ("insurance company") for skilled nursing services on 11/12/19. No patients return home specified nor physician ordered start of care date specified. Documentation of initial assessment visit by registered nurse visit on 05/04/20. An interview conducted with the agency Administrator on March 9, 2022 at approximately 9:45 a.m. confirmed the above findings.

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 a review of agency policy, review of clinical records, and an interview with the agency Administrator, the agency failed to provide home health aide services, in accordance with the written orders of the physician, for one (1) of nine (9) clinical records (CR) reviewed (CR#9). Findings: A review of agency Policy/Procedure was conducted on March 8, 2022 at approximately 10:00 a.m. ''Acceptance of Patients' 'Procedure' (3)"The patients care will follow a written plan of care established and periodically reviewed by a doctor of medicine, osteopathy, or podiatric medicine ........" A review of clinical records conducted on March 8, 2022 between approximately 10:00 a.m. and 2:00 p.m. revealed the following: CR#9 SOC 04/17/18: The patient was discharged from the agency on 11/23/21. Recertification period 09/27/21-11/25/21 reviewed. 'Orders for Discipline and Treatments' list "(Agency) to provide HHA (home health aide), Skilled Nursing services x 60 days as follows: (a) HHA 2-4 hours/day, 2-4 days/week, Tuesday through Friday on school days. (b) HHA 4-8 hours/day, 1-7 days/week Tuesday-Friday on school days. (c) SN (skilled nursing) 4-9 hours/day, 2-4 days/week Tuesday-Friday on school days to accompany the child on the school bus during transportation to and from school and while attending school, currently on hold." ("Skilled nursing for school hours only.") No documentation provided of home health aide hours being provided, as ordered by the physician, from 09/27/21-11/23/21. No documentation provided of the physician being made aware of missed home health aide visits. An interview conducted with the agency Administrator on March 9, 2022 at approximately 9:45 a.m. confirmed the above findings.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on observations and an interview with the agency Administrator, the agency failed to ensure that everyone entering the health care facility is screened and triaged for COVID-19 for one (1) of one (1) observations (Observation #1). Findings: CMS-QSO-20-18-HHA (03/10/2020) 'Guidance for Infection Control and Prevention Concerning Coronavirus Disease 2019 (COVID-19) in Home Health Agencies (HHAs)' 'Guidance' states "...... Also, HHAs should be monitoring the health status of everyone (patients/residents/visitors/staff/etc.) in the homecare setting for signs or symptoms of COVID-19". "How should HHAs monitor or restrict home visits for health care staff? Health care providers (HCP) who have signs and symptoms of a respiratory infection should not report to work". A review of agency Policy/Procedure was conducted on March 10, 2022 at approximately 8:00 a.m. 'Covid-19 Screening Log' 'For internal staff: (2) ALL persons entering the branch office MUST complete this log. (3) "You may store the completed sheets in your COVID-19 Binder, as DOH may ask to see this during survey." Observation #1: On March 9, 2022 at approximately 9:00 a.m. the state surveyor entered the agency to conduct the survey. The surveyor was screened for COVID-19 and documented on the 'COVID-19 Screening Tool' at the entry of the agency. No entries observed on the 'COVID-19 Screening Log' on 03/01/22-03/04/22 nor on 03/07/22 for the agency Branch Manager (EF#8), who was present at the office on 03/07/22. No other documentation provided of EF#8 self screening prior to reporting to the agency office. An interview conducted with the agency Administrator on March 9, 2022 at approximately 9:45 a.m. confirmed the above findings.

Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient's home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This STANDARD is not met as evidenced by: Based on an interview with the agency Administrator, the agency failed to meet the definition of a home health agency, by being staffed and equipped to provide skilled nursing and at least one other therapeutic service for one (1) of one (1) interviews conducted (Interview #1). Findings: Interview #1: An interview was conducted with the agency Administrator on March 7, 2022 at approximately 9:15 a.m. The Administrator was asked what services were being provided by the agency. The Administrator stated "Skilled nursing and home health aides." A review of the employee list on 03/07/22 at approximately 9:15 a.m. does not show home health aides listed as employees. The employee list that was provided listed twelve (12) employees; eleven (11) nurses, and one (1) manager. Per the Administrator, "We currently do not have any home health aides on services. The last home health aide case was for (clinical record #9) last July." No documentation provided of an arrangement with another agency or organization to provide home health aide services. A pre-survey review of the agency's listed offered services was conducted on 02/08/22, prior to the onsite survey. Services offered by the agency were listed as Home Health Aide-Facility Staff and Nursing Services-Facility Staff. An interview conducted with the agency Administrator on March 9, 2022 at approximately 9:45 a.m. confirmed the above findings.