Every finding on record at Epeople Healthcare Inc.

Based on the findings of an unannounced, onsite Medicare recertification survey conducted March 9 through March 11, 2021, 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 conducted March 9 through March 11, 2021, eKidzcare was found not to be in compliance with the following requirements of 42CFR, Part 484, Subparts B & C, Conditions of Participation: Home Health Agencies.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on review of agency policies/procedures, documentation and clinical records, and based on interview with the alternate administrator and the administrator, the agency failed to ensure the patient rights forms included notification that the contact formation for administrator was provided in order for the administrator to receive complaints for two (2) of two (2) patients (clients)/responsible parties for whom the agency admission folder was available for review during a home visit. (Patients #2 and #5) Finding include: On March 11, 2021 at approximately 10:47 AM, review of the agency policy titled "Patient Rights & Responsibilities Policy" revealed the following: Policy: It is the policy...to provide the patient and/or their caregiver/family with written notice of their rights in advance of furnishing care to the patient. On March 9, 2021 at approximately 10:20 AM, review of the "Admission Booklet" revealed that the first page of the booklet included a section to document the administrator's name, telephone number and the local office address/telephone number but the "Comment/Complaint Form" information included instructions to forward the complaint form to a different office which is located in Sewickley, PA. There was no documentation on the "Patient Rights and Responsibilities" forms which provided evidence that the patient received notification that the contact formation for administrator was provided in order for the administrator to receive complaints. Patient #2: On March 9, 2021 at approximately 2:39 PM, review of the clinical record revealed the start of care date was 12/10/2020, the patient/client is 13 years old, the primary diagnosis is early onset cerebellar ataxia (neurological disorder which effects muscle coordination), and that skilled nursing services were to be provided as documented on the "Home Health Certification and Plan of Care" for the recertification period of 02/08/2021 through 04/08/2021. During a home visit conducted on 03/10/2021 at approximately 3:15 PM, review of the agency's admission folder revealed there was no documentation on the patient rights/consent forms which provided evidence that the contact formation for administrator was provided in order for the administrator to receive complaints. Patient #5: On March 11, 2021 at approximately 10:30 AM, review of the clinical record revealed the start of care date was 12/03/2020, the patient/client is 6 years old, the primary diagnosis is autistic disorder, and that home health aide services were be provided as documented on the "Home Health Certification and Plan of Care" for the recertification period of 02/01/2021 through 04/01/2021. During a home visit conducted on 03/10/2021 at approximately 2:45 PM, review of the agency's admission folder revealed there was no documentation on the patient rights/consent forms which provided evidence that the contact formation for administrator was provided in order for the administrator to receive complaints. During interview conducted on March 11, 2021 at approximately 12:25 PM, the alternate administrator and administrator confirmed there was no documentation which provided evidence that the above identified patients/responsible parties were provided with notification that the contact formation for administrator was provided in order for the administrator to receive complaints.

Access to auxiliary aids and language service CFR(s): 484.50(c)(12) Be informed of the right to access auxiliary aids and language services as described in paragraph (f) of this section, and how to access these services. This ELEMENT is not met as evidenced by: Based on review of agency policies/procedures, documentation and clinical records, and based on interview with the alternate administrator and the administrator, the administrator failed to ensure written information/instructions regarding the patient's right to access auxiliary aids (accessible web sites, assistive aids identified in the American's with Disabilities Act) and language services, and the means/processes to access those services were provided to for two (2) of two (2) patients (clients)/responsible parties for whom the agency admission folder was available for review during a home visit. (Patients #2 and #5) Finding include: On March 11, 2021 at approximately 10:47 AM, review of the agency policy titled "Patient Rights & Responsibilities Policy" revealed the following: Policy: It is the policy...to provide the patient and/or their caregiver/family with written notice of their rights in advance of furnishing care to the patient. On March 9, 2021 at approximately 10:20 AM, review of the "Admission Booklet" revealed that there was no documentation on the "Patient Rights and Responsibilities" forms which provided evidence that written information/instructions had been included on the forms regarding the patient's right to access auxiliary aids and language services, and the means/processes to access those services. Patient #2: On March 9, 2021 at approximately 2:39 PM, review of the clinical record revealed the start of care date was 12/10/2020, the patient/client is 13 years old, the primary diagnosis is early onset cerebellar ataxia (neurological disorder which effects muscle coordination), and that skilled nursing services were to be provided as documented on the "Home Health Certification and Plan of Care" for the recertification period of 02/08/2021 through 04/08/2021. During a home visit conducted on 03/10/2021 at approximately 3:15 PM, review of the agency's admission folder revealed there was no documentation on the patient rights/consent forms which provided evidence that patient/responsible party received written information/instructions regarding the patient's right to access auxiliary aids and language services, and the means/processes to access those services. Patient #5: On March 11, 2021 at approximately 10:30 AM, review of the clinical record revealed the start of care date was 12/03/2020, the patient/client is 6 years old, the primary diagnosis is autistic disorder, and that home health aide services were be provided as documented on the "Home Health Certification and Plan of Care" for the recertification period of 02/01/2021 through 04/01/2021. During a home visit conducted on 03/10/2021 at approximately 2:45 PM, review of the agency's admission folder revealed there was no documentation on the patient rights/consent forms which provided evidence that patient/responsible party received written information/instructions regarding the patient's right to access auxiliary aids and language services, and the means/processes to access those services. During interview conducted on March 11, 2021 at approximately 12:25 PM, the alternate administrator and administrator confirmed there was no documentation on the patient rights/consent forms which provided evidence that the above identified patients/responsible parties were provided with written information/instructions regarding the patient's right to access auxiliary aids and language services, and the means/processes to access those services.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on review of agency policies/procedures, documentation, clinical records and personnel files, and based on interview with the alternate administrator and the administrator, the agency failed to ensure documentation was maintained in the personnel file which provided evidence that one (1) of two (2) registered nurses (RN) completed an annual tracheostomy (surgically created airway in the front of the neck) hands-on skills demonstration. (Employee #3) Findings include: On March 11, 2021 at approximately 11:34 AM, review of the agency policy titled "Hiring Policy and Procedure" revealed the following: Procedure...9. All nursing...staff competencies will be verified...annually with their anniversary date... On March 11, 2021 at approximately 11:56 AM, review of the agency policy titled "Performance Evaluations Policy" revealed the following: Policy...The immediate supervisor of the employee will observe job effectiveness... On March 11, 2021 at approximately 10:48 AM, review of the "Employee Personnel File Audit" form revealed the "Nursing Competency Checklist" was to be completed annually. Patient #3: On March 10, 2021 at approximately 12:10 PM, review of the clinical record revealed the start of care date was 06/06/2020, the patient/client is 4 years old, the primary diagnosis is neurofibromatosis (genetic disorder of the nervous system), and that skilled nursing services was to provide tracheostomy care as documented on the "Home Health Certification and Plan of Care" for the recertification period of 02/11/2021 through 04/11/2021. Review of "Pediatric Assessment" documentation revealed the RN (employee #3) assessed the tracheostomy status and determined that a 4.0/41 length (size) Bivona uncuffed tracheostomy was in place, that a replacement tracheostomy of 3.5/40 length could be utilized and that the tracheostomy was to be suctioned was using a #8 French (size) suction catheter to a depth of 9 centimeters during the start of care visit performed on 06/16/2020. Between March 9, 2021 at approximately 12:50 PM and March 11, 2021 at approximately 9:59 AM, review of personnel file documentation revealed the following: The nursing competency checklist included columns to document the date verbal competency was determined and the date skills demonstration was performed for tracheostomy care, suctioning and tracheostomy change. Employee #3: The date of hire of the RN/alternate clinical supervisor was 09/14/2018. Review of nursing competency checklist documentation revealed verbal competency for tracheostomy care, suctioning and tracheostomy change was completed on 11/05/2019 but there was no documentation on the nursing competency checklist which provided evidence that a skills demonstration to determine competency for tracheostomy care, suctioning and tracheostomy change had been performed in 2019 nor 2020. During interview conducted on March 11, 2021 at approximately 12:25 PM, the alternate administrator and administrator confirmed there was no documentation in the nursing competency checklist which provided evidence that the RN (employee #3) had completed tracheostomy hands-on skills demonstration in 2019 nor 2020.

Administrator CFR(s): 484.115(a) Standard: Administrator, home health agency. (1) For individuals that began employment with the HHA prior to January 13, 2018, a person who: (i) Is a licensed physician; (ii) Is a registered nurse; or (iii) Has training and experience in health service administration and at least 1 year of supervisory administrative experience in home health care or a related health care program. (2) For individuals that begin employment with an HHA on or after January 13, 2018, a person who: (i) Is a licensed physician, a registered nurse, or holds an undergraduate degree; and (ii) Has experience in health service administration, with at least 1 year of supervisory or administrative experience in home health care or a related health care program. This STANDARD is not met as evidenced by: Based on review of Pennsylvania Department of Health state licensure regulations, agency policies/procedures, documentation, and personnel files, and based on interview with the administrator (employee #1) and the alternate administrator, the agency failed to ensure one (1) of one (1) employees met the qualifications for administrator under Pennsylvania state licensure regulations. (Employee #1) Findings include: On March 10, 2021 at approximately 12:41 PM, review of Pennsylvania state licensure regulations revealed the following under 601.6. Definitions. The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise: Administrator-A person who performs the functions as outlined in § 601.21(d) (relating to organization, services and administration) and is one of the following: (i) A licensed physician. (ii) A registered nurse. (iii) Has training and experience in health service administration and at least 1 year of supervisory or administrative experience in home health care or related health programs. On March 9, 2021 at approximately 3:40 PM, review of the "Administrator" job description revealed the following: Job Purpose...The administrator is a qualified employee appointed by the Governing Body... Qualifications...Minimum Requirements... Must meet initial ongoing educational requirements as stipulated by the state... On March 11, 2021 at approximately 10:46 AM, review of the agency policy titled "Governing Body Policy" revealed the following: Procedure: The Governing Body's responsibilities include: 1. Appointing a qualified administrator... Between March 10, 2021 at approximately 4:38 PM and March 11, 2021 at approximately 8:28 AM, review of the agency-based administrative/health services administration orientation/training program revealed the following subject areas were included under the administrative orientation process: -Medicare Conditions of Participation, State and Federal regulations -Agency Policies and Procedures -Compliance Review and Monitoring (QAPI--Quality Assessment/Performance Improvement) -Human Resource Process -Customer Service: Internal and External -Recruiting -Operational Reporting -Department of Health Survey & Investigations -Marketing and Developing Relationships -Emergency Preparedness -Licensure Renewal, Annual Program Evaluation and Professional Advisory Committee -Budget Development -Unemployment, Safety, and Workman ' s Compensation -Long Term/Short Term Customer Service During interview conducted on March 11, 2021 at approximately 10:02 AM, the administrator (employee #1) reported that the administrator's date of hire was 11/03/2020. Between March 9, 2021 at approximately 12:50 PM and March 11, 2021 at approximately 9:59 AM, review of personnel file documentation revealed the following: Employee #1: Professional resume documentation revealed the administrator attained a bachelor's degree in nutrition and dietetics but there was no documentation that the administrator had completed training in health services administration. During interview conducted on March 11, 2021 at approximately 9:50 AM, the alternate administrator reported that the administrator (employee #1) was scheduled to begin the agency-based health services administration orientation/training program in March 2021 but confirmed that the administrator had not completed the training program prior to appointment as administrator. During interview conducted on March 11, 2021 at approximately 12:25 PM, the administrator and alternate administrator confirmed that the administrator did not meet the qualifications for an administrator under the Pennsylvania state licensure requirements since the administrator had not completed the agency-based health services administration orientation/training program prior to appointment as administrator.