Every finding on record at Rn4kids, Inc.

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 01/14/2026. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

A partial extended survey for Medicare recertification for the home health provider was completed on 01/14/2026. The provider had 39 current patients.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure the registered nurse (RN) completed the initial assessment within 48 hours of the patient's referral or return home in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider's undated policy titled, "Initial Visit," showed the initial visit will be done within 24-48 hours upon receiving the referral unless specific [doctors] orders state otherwise. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 11/18/2025 with a primary diagnosis of premature infant of 26 weeks gestation (process of developing - born before full term gestation; 39 weeks, 0 days, through 40 weeks, 6 days) and a secondary diagnosis of bronchopulmonary dysplasia (is a chronic lung disease that primarily affects premature babies with underdeveloped lungs, causing inflammation and damage from prolonged oxygen therapy and mechanical ventilation). The patient was an infant and resided at home with his/her parents. Review of the clinical record showed the following: - A referral dated 11/11/2025; and - The patient was discharged from the hospital on 11/12/2025. Review of the initial assessment showed a start of care date of 11/18/2025, six days after the patient's discharge to home. During an interview on 01/13/2026 at 2:45 PM, the home health administrator stated that he/she would expect the physician to be notified of the reason for the late start of care.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health provider failed to ensure that the physician orders were signed in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 11/18/2025 with a primary diagnosis of premature infant of 26 weeks' gestation (process of developing - born before full term gestation; 39 weeks, 0 days, through 40 weeks, 6 days) and a secondary diagnosis of bronchopulmonary dysplasia (is a chronic lung disease that primarily affects premature babies with underdeveloped lungs, causing inflammation and damage from prolonged oxygen therapy and mechanical ventilation). The patient was an infant and resided at home with his/her parents. Review of the clinical record showed the patient was discharged from the hospital on 11/12/2025. Review of the clinical record showed a document titled, "Unable to Contact Patient or Late Start of Care," dated 11/13/2025. The document showed the clinician was unable to contact the patient and would have to reschedule the start of care visit. The document failed to contain a physician's signature. During an interview on 01/13/2026 at 2:45 PM, the home health administrator stated that he/she would expect the order to be faxed to the physician to be signed on the day of the order. He/she then stated that they would expect the order to be returned signed no later than 30 days after the order date.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on review of the provider's admission folder, record review, home visit observation, and interview, the provider failed to ensure the name and contact information for the clinical manager was provided to the patient's family in two of three home visit observations conducted (Records/Patients #1 and #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider's admission folder showed the name and contact information for the clinical manager was not included in the folder. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 12/22/2025 with a primary diagnosis of 33 weeks gestation (process of developing - born before full term gestation; 39 weeks, 0 days, through 40 weeks, 6 days). The patient was an infant and resided at home with his/her parents. Observation on 01/13/2026 at 8:45 AM, showed the admission folder, in the patient's home, failed to contain the name and contact information for the clinical manager. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 12/22/2025 with a primary diagnosis of 33-week preemie (premature - an infant born before 37 weeks gestation). The patient was an infant and resided at home with his/her parents. Observation on 01/13/2026 at 9:00 AM, showed the admission folder, in the patient's home, failed to contain the name and contact information for the clinical manager. During an interview on 01/14/2026 at 8:45 AM, the home health administrator stated that the home health admission folder failed to contain the name and contact information for the clinical manager.

A partial extended survey for Medicare recertification for the home health provider was completed on 01/19/2023. The agency had 147 current patients. The COVID-19 Health Care Staff Vaccination regulation was reviewed as part of the Medicare recertification survey. During the survey it was determined the agency was in compliance with the regulation. The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 01/19/2023. One standard level deficiency was identified.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on policy review, employee file review, and interview the agency failed to maintain documentation of emergency preparedness training at orientation in three (Employees #1, #2, and #3) of three employee files reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s undated policy titled, Emergency Operations Plan Training Program,” showed the agency would provide initial training in emergency preparedness policies and procedures to all new and existing staff and maintain documentation of the training. EMPLOYEE #1: - Date of hire: 12/04/2018; and - No evidence of emergency preparedness training at orientation. EMPLOYEE #2: - Date of hire: 06/03/2022; and - No evidence of emergency preparedness training at orientation. EMPLOYEE #3: -Date of hire: 02/24/2020; and - No evidence of emergency preparedness training at orientation. During an interview on 01/19/2023 at 9:45 AM, the administrator stated that he/she does provide emergency preparedness training at orientation, but he/she was unable to find the documentation.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview the agency failed to ensure a registered nurse or applicable rehabilitation skilled professional conducted an initial assessment visit within 48 hours of referral, within 48 hours of the patient’s return home, or on the physician ordered start of care date in three (Records/Patients #2, #3 and #4) of five full records reviewed. This deficient practice has the potential to affect the immediate care needs of all patients served by the agency. Findings included: Review of the agency’s undated policy titled, “Referal (Referral) Process,” showed in part: - When getting a new referral, the patient is to be contacted or seen within 48 hours to introduce the agency and arrange for the initial visit to be set up; - The registered nurse (RN) will confirm they have seen the referral and will contact the parent/caregiver to arrange the visit within 48 hours of discharge or at a time the mom requests; and - If the patient is not seen within 48 hours, the RN will complete a late start of care form and that will be faxed to the doctor on file to assure they are aware the patient will start care at a different time. RECORD/PATIENT #2: Review of the document titled, “Ambulatory Referral to Home Health," showed, in part: - The patient was a premature twin born at 29 to 30 weeks of gestation (the period of development inside the womb); - The referral for home health was dated 01/09/2023; - The anticipated discharge date was 01/10/2023; and - The requested start of care date was within 24 to 48 hours of the referral. Review of the hospital discharge summary cover page, dated 01/10/2023, showed, under the heading “memo,” the patient was discharged on 01/10/2023. Review of the initial visit assessment, dated 01/13/2023, showed: - The primary diagnosis was bronchopulmonary dysplasia (a chronic lung disease that most often affects newborns born prematurely where the lungs and airways are damaged, causing tissue destruction in the tiny air sacs of the lung); and - The start of care (SOC) date was 01/13/2023. Review of the plan of care (POC) showed the SOC date was 01/13/2023. During an interview on 01/18/2023 at 6:50 PM, the administrator stated that the agency usually tries to see the patients within 24 to 48 hours and, if the patient’s family cannot see them in that time frame, a late start of care form gets filled out and faxed over to the physician but it does not usually get signed within the first 48 hours of the referral or hospital discharge. The administrator stated that this form serves as the order for the start of care but it would be almost impossible to get a signed order within the 48 hour time frame. RECORD/PATIENT #3: Review of the document titled, “Ambulatory Referral to Home Health," showed in part: - The patient was a premature twin born at 29 to 30 weeks of gestation; - The referral for home health was dated 01/09/2023; - The anticipated discharge date was 01/10/2023; and - The requested start of care date was within 24 to 48 hours of the referral. Review of the hospital discharge summary cover page, dated 01/10/2023, showed, under the heading “memo,” the patient was discharged on 01/10/2023. Review of the initial visit assessment, dated 01/13/2023, showed: - The primary diagnosis was bronchopulmonary dysplasia; and - The SOC date was 01/13/2023. Review of the POC showed the SOC date was 01/13/2023. During an interview on 01/18/2023 at 6:50 PM, the administrator stated that the agency usually tries to see the patients within 24 to 48 hours and, if the patient’s family cannot see them in that time frame, a late start of care form gets filled out and faxed over to the physician but it does not usually get signed within the first 48 hours of the referral or hospital discharge. The administrator stated that this form serves as the order for the start of care but it would be almost impossible to get a signed order within the 48 hour time frame. RECORD/PATIENT #4: Review of the hospital ambulatory referral to home health dated 12/29/2022, showed: - Anticipated discharge 01/01/2023; - Discipline requested - Skilled Nurse (SN); - Home Health Services – Evaluate; - Requested start of care date – Within two to three days; and - SN visits two times a week for two weeks then reassess. Review of the hospital discharge summary showed the date of discharge was 01/01/2023. Review of a Home State Health (managed Medicaid insurance provider) letter dated 01/05/2023, showed authorization for four visits. Review of an agency form dated 01/08/2023 showed this was to inform the physician the SN was unable to contact parent, several messages left on voicemail, no return call. This form had no fax date and no physician signature. Review of the record showed the SN initial assessment was dated 01/11/2023 (13 days after referral and 11 days after discharge). Review of the record showed no physician order/contact within 48 hours of the referral date or discharge to obtain a physician ordered start of care date. During an interview on 01/18/2023 beginning at 6:30 PM, the administrator stated that they try to see the patients within 24 to 48 hours of the referral. If they were unable to see in that time, the nurse does a late start of care order. The SN does not call the physician to get an order during that time. The administrator stated that he/she typically notified the home state health within 48 hours of the referral to obtain authorization.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview the agency failed to ensure the plans of care (POC) included all required information in three (Records/Patients #2, #3, and #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s policy titled, “Plan of Care (Skilled Services/Physician Ordered Services) (undated) showed: - An individualized POC will be developed for each patient requiring skilled or physician-ordered services and admitted to the agency and reviewed/revised as needed to meet the patient's needs; - The POC is written by the RN in collaboration with the physician and patient/family, and based on the initial assessment forms; and - The POC includes complete diagnosis, including dates of onset and medications, including route, dosage, and frequency. RECORD/PATIENT #5: Review of the initial medication list dated 12/18/2022, showed medications that included: - Tylenol (per instruction) by mouth every four hours as needed; - Mylicon drops (per instruction, used to relieve gas in infants) by mouth every four hours as needed; - Desitin (for diaper rash) topical for diaper rash with diaper change; - A&D (for diaper rash) topical for diaper rash with diaper change; and -The Tylenol and Mylicon orders failed to include the dosage order. Review of the POC dated 12/18/2022, failed to include the above medications. During an interview on 01/18/2023, beginning at 6:30 PM, the administrator stated that the medications should have been included on the POC. The nurse should have put on the POC to see page 2 or to see the medication kardex. The medication orders should include the dosage. RECORD/PATIENT #2: Review of the document titled, “Ambulatory Referral to Home Health,” dated 01/09/2023, showed the patient had the following diagnoses at the time of referral: - Neonate (a newborn infant) with risk factor for hearing loss; - Anemia (a condition in which the blood does not have enough healthy red blood cells) of prematurity; - Neonatal jaundice (yellowing of the skin that occurs when the liver can’t efficiently process red blood cells as they break down); - Central neonatal apnea (temporary cessation of breathing) of newborn; - Preterm twin newborn delivered by cesarean section during current hospitalization, birth weight 1500 to 1749 grams, with 29 to 30 completed weeks of gestation (the period of development within the womb), with live newborn mate; and - Bronchopulmonary dysplasia (a chronic lung disease that most often affects newborns born prematurely where the lungs and airways are damaged, causing tissue destruction in the tiny air sacs of the lung). Review of the plan of care (POC), dated 01/13/2023 to 03/13/2023, showed the following diagnoses: - 30 weeks gestational age; and - Bronchopulmonary dysplasia. During an interview on 01/18/2023 at 7:20 PM, the administrator stated that he/she did not know they had to list all of the pertinent diagnoses on the POC. He/she thought they only needed to list the reason the agency was seeing the patient but he/she could see that it would be important to know the patient’s other diagnoses so the nurse would know to assess for potentially related issues. RECORD/PATIENT #3: Review of the document titled, “Ambulatory Referral to Home Health,” dated 01/09/2023, showed the patient had the following diagnoses at the time of referral: - Neonate with risk factor for hearing loss; - Bronchopulmonary dysplasia; - Premature infant of 30 weeks gestation; - Twin delivered by cesarean section with live born mate, 1,000 to 1249 grams birth weight, 29 to 30 completed weeks of gestation; - Feeding difficulty in an infant; and - Anemia of prematurity. Review of the POC, dated 01/13/2023 to 03/13/2023, showed the following diagnoses: - 30 weeks gestational age; and - Bronchopulmonary dysplasia. During an interview on 01/18/2023 at 7:20 PM, the administrator stated that he/she did not know they had to list all of the pertinent diagnoses on the POC. He/she thought they only needed to list the reason the agency was seeing the patient but he/she could see that it would be important to know the patient’s other diagnoses so the nurse would know to assess for potentially related issues.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on policy review, home visit observation, and interview the agency failed to follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases in two (Records/Patients #1 and #7) of two home visit observations. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s undated policy titled, “Infection Control,” showed: - The registered nurse (RN) is to use a barrier between the scale and on the scale prior to placing the patient on the scale: - After using the scale, the RN is to clean down the scale with bleach products prior to exiting the patient’s home; - The RN is to wipe down the stethoscope, head measuring tape, and thermometer; and - Any items that have left the bag in the home are to be cleaned, placed back into the clean space, and all dirty items are to stay out of the bag and be discarded in the home if possible. RECORD/PATIENT #1: Observation on 01/18/2023 at 9:00 AM, during the patient’s home visit, showed the RN: - Placed his/her clipboard and the case containing vital signs equipment on the patient’s sofa without placing a barrier; - Placed a packet of disinfectant wipes on the patient’s sofa without using a barrier; - Weighed the patient and cleaned the scale surface with the disinfectant wipes; - Placed the pack of wipes and the vital signs case from the patient’s sofa back into his/her equipment bag without cleaning the outer surfaces of the containers; and - Placed the clipboard from the patient’s sofa onto the disinfected surface of the scale. During an interview on 1/18/2023 at 12:45 PM, the administrator stated that she did not think about laying the clipboard and vitals case on the patient’s sofa. They focus so much on keeping the vitals equipment inside the case clean, but he/she sees how items like clipboards and containers could take germs from home to home and that the nurse should have used a barrier between the items and the patient’s sofa. RECORD/PATIENT #7: Observation on 01/18/2023 at 12:00 PM, during the patient’s home visit, showed the RN: - Placed his/her clipboard and the case containing vital signs equipment on the patient’s sofa without placing a barrier; - Weighed the patient and cleaned the scale surface with disinfectant wipes; - Measured the patient’s temperature and head circumference; - Cleaned the thermometer and measuring tape and then laid them on the patient’s sofa without placing a barrier; - Placed the vital signs case from the patient’s sofa back into his/her equipment bag without cleaning the outer surface of the container; and - Placed the clipboard, thermometer, and measuring tape from the patient’s sofa onto the disinfected surface of the scale. During an interview on 1/18/2023 at 12:45 PM, the administrator stated that the nurse should have laid the cleaned thermometer and tape measure onto a barrier after cleaning them. He/she did not think about laying the clipboard and vitals case on the patient’s sofa. They focus so much on keeping the vitals equipment inside the case clean, but he/she sees how items like clipboards and containers could take germs from home to home and that the nurse should have used a barrier between the items and the patient’s sofa.