Pediatric Home Nursing
Bringing NICU-level care home to Philadelphia families. RN-supervised skilled nursing for medically complex infants and children, with 24/7 on-call clinical support across every ZIP code in the city.
A safe discharge depends on what happens in the first 72 hours at home.
A medically complex infant goes home with equipment, a feeding regimen, a medication regimen, and parents who learned all of it just days ago.
Risk concentrates in the first weeks after discharge, not in the hospital.
What a discharge planner needs is not a brochure — it is a licensed clinician who answers the phone and shows up on the discharge date.
That is the only thing this program is built to do: deliver superior clinical care to the most vulnerable of our patients.
Who we are
A Philadelphia-based home health agency operating from Port Richmond. RN-supervised care with 24/7 on-call clinical support, now extended to pediatric referrals from birth through age 21.
2409 E Allegheny Ave, Philadelphia, PA 19134 — we staff every ZIP code in Philadelphia, with citywide coverage across all skilled home care populations. No excluded neighborhoods.
United Healthcare · UPMC · AmeriHealth Caritas / Keystone · PA Health & Wellness · Health Partners (coming soon)
Populations we serve
Referrals accepted from birth through age 21.
Premature infants
NICU graduates transitioning home
Congenital anomalies
Post-surgical monitoring
Oxygen-dependent
Titration and pulse oximetry
G-tube feeding
Bolus and pump regimens
Tracheostomy
Routine and emergency change
Ventilator-dependent
1:1 continuous coverage
Acuity matched to service model
NICU follow-up, oxygen management, feeding-tube teaching, post-surgical monitoring.
Visit-based under a physician plan of care
Pump-dependent feeding, apnea-monitored and high-monitoring infants.
Shifts of 8 to 12 hours
Tracheostomy and ventilator-dependent children.
1:1 licensed nursing, multiple shifts daily
Maternal acuity we accept
The mother is a patient in her own right — assessed, treated, and documented on her own plan of care.
Routine recovery, skilled teaching
- Routine C-section incision assessment
- Uncomplicated gestational hypertension follow-up
- Breastfeeding support requiring skilled nursing
- Medication teaching
Active monitoring and titration
- Persistent hypertension requiring medication titration
- Postpartum anemia requiring monitoring
- Uncomplicated diabetes requiring insulin teaching
- Wound checks with minor drainage
Complex wound and unstable disease
- Complex wound care — dehisced C-section, wound VAC
- Unstable diabetes
- Severe hypertension requiring frequent monitoring
- Postpartum infections and anticoagulation management
Medically complex after hospitalization
- Advanced therapies requiring intensive skilled home care after hospitalization
- Assessed case by case with the discharging team before we accept
What our nurses do at the bedside
Airway and respiratory
Tracheostomy care including routine and emergency change, suctioning, humidification, oxygen titration per orders, pulse oximetry, nebulizer therapy, ventilator circuit and alarm management, apnea and bradycardia response.
Nutrition and GI
G-tube and GJ-tube bolus and pump feeds, stoma site and granulation care, dislodgement protocol, pump troubleshooting, aspiration precautions, intake and weight trending.
Assessment and escalation
Head-to-toe pediatric assessment, vital signs and growth parameters, medication administration per orders, wound and post-surgical site care, seizure recognition and rescue protocol, defined escalation path to the Clinical Manager and ordering physician.
Building family capability
Caregiver teaching to demonstrated competency, written emergency action plan, equipment failure and power-loss planning, specialty appointment coordination.
Care team and supervision
The RN Clinical Manager is accountable for the plan of care and every delegated task. Pediatric-competent RNs and LPNs staff skilled visits and shift care. Home Health Aides provide personal care, assigned by and performed under RN supervision.
Aides never administer medication and never perform IV, sterile, or invasive procedures — a bright line written into our job descriptions. No-call/no-show is treated as client abandonment and is grounds for termination. Coverage is a written standard, not a hope.
Every clinician has cleared our screening
- Licensure and aide competency verification per 42 CFR 484.80 and PA Code 611.55
- In-person CPR certification — online certification is not accepted
- Annual TB screening with a 30-day advance reminder; removed from the schedule immediately if it lapses
- Hepatitis B vaccine offered at no cost, with documented acceptance or declination
- State criminal history for all staff; federal check plus a PA Department of Aging letter where required
- A 26-topic orientation and a 13-item observed competency checklist before any unsupervised care
- 12 hours of in-service annually, plus device-specific competency sign-off
- Signed HIPAA and PHI protection agreements; PHI transported in a protected travel chart
No nurse is alone with a child until skills are verified three times
Completed as a self-assessment by every new nurse, then reviewed line by line with the Clinical Manager.
Performed in front of our nurse trainer and signed off before the nurse is deployed into the field.
The nurse trainer accompanies the nurse on the first visit in the home for in-field verification.
Our Clinical Director, Lenore Sears-Gay, brings 30 years of pediatric experience and personally serves as nurse trainer for the program.
Quality, safety, compliance
ACHC accredited
Surveyed against national home health standards.
Corporate compliance
Zero tolerance for fraud, false claims, and misconduct, with whistleblower protection.
EVV management
Every visit time-stamped and reconciled weekly.
Incident reporting
Documented occurrence reporting, including medical device hazard reporting.
Infection control
Exposure control plan and a full PPE kit issued to every field clinician.
Emergency preparedness
A disaster and power-loss plan on file for every active case.
From referral to first shift
- 1Referral received
Through Repisodic.
- 2Insurance verified, prior authorization initiated
We prepare and submit the shift-care or PDN request.
- 3RN assessment
In-hospital before discharge where the unit permits, otherwise in the home within 24 to 48 hours.
- 4Staffing match
Caregiver competency confirmed for the child and mother specific clinical needs and devices.
- 5Start of care
Coordinated to the discharge date.
- Face sheet
- Discharge summary
- Signed physician orders and plan of care
- Equipment and DME list
- Current medication list
- Insurance card
- Caregiver contact
Payers and authorization
Medical Assistance / HealthChoices Southeast, CHIP, and commercial plans.
Pediatric shift care and private duty nursing for members under 21 are EPSDT benefits and require prior authorization. We assemble and submit the medical-necessity packet and track it to decision. For out-of-network cases we will pursue a single-case agreement.
Family partnership
Caregiver training to competency
We teach with demonstration and teach-back before we step back.
A written emergency action plan
Posted in the home, covering device failure and power loss.
Respite coverage so parents sleep
Scheduled relief hours built into the plan of care.
Family caregiver program
Eligible relatives can be trained, employed, and paid for covered hours.
Mental and behavioral health is part of the plan of care
Perinatal mood disorders and substance use are the leading drivers of postpartum harm — and the most commonly referred out. These are approved services on our license.
Perinatal mood screening
Validated depression and anxiety screening at defined visit windows, documented and returned to the OB and pediatrician.
Counseling for mothers
Licensed behavioral health clinicians deliver counseling in the home, on the same schedule as the nursing visits.
Substance use disorder treatment
Treatment support and recovery coordination, including medication-assisted treatment adherence and relapse prevention.
Care for the substance-exposed newborn
Withdrawal scoring, feeding and soothing support, weight trending, and caregiver coaching.
Behavior therapy and BCBA
Behavior therapy for the child, overseen by a Board Certified Behavior Analyst, alongside PT, OT, and speech.
Medical social work
Benefits, housing, food, and transportation barriers addressed directly, with a warm handoff when a case escalates.
The arithmetic of prevention
Average cost of a 30-day readmission across 3.8M adult readmissions
All-cause 30-day readmission rate — more than $50B a year system-wide
Adjusted Medicaid postpartum readmission risk vs. privately insured births
What avoided readmissions return to the unit each year
A skilled nurse in the home in the first 72 hours is what catches the dehisced incision, the climbing blood pressure, the feeding intolerance — while it is still a phone call to the OB and not an admission.
Sources: AHRQ HCUP Statistical Brief #278 (2018 Nationwide Readmissions Database); Reddy et al., AJOG MFM 2022, postpartum readmission by payer. Annualized figures are illustrative arithmetic on the national average cost, not a hospital-specific projection.
Send us the referral.
We will tell you within one business day whether we can take the case — and we will not say yes to a case we cannot staff.
Philadelphia, PA 19134