Alpine Home Health Agency

“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 interview and record review the home health agency (HHA) failed to ensure the plan of care (POC) for two of 7 sampled patients (Patient 2 and Patient 7) were signed by the physician within 30 days of the start of care (SOC). This failure had the potential for Patient 2 and Patient 7 to receive treatments not approved by the physician. 1a. A review of Patient 2’s Home Health Certification and POC for certification period 1/23/26 through 3/23/26 indicated Patient 2 had diagnoses including cerebral palsy (a disorder caused by an injury or abnormal development in the brain before, during, or shortly after birth) and epilepsy (brain disorder causing sudden bursts of abnormal activity). Patient 2’s POC was signed by the physician on 3/19/26. During a concurrent interview and record review on 6/30/26 at 4:29 p.m. with the Administrator/Director of Patient Care Services (ADM/DPCS), Patient 2’s POC was reviewed. The ADM/DPCS stated Patient 2’s POC for certification period 1/23/26 through 3/23/26 was signed by the physician on 3/19/26, over 30 days. The ADM/DPCS further stated the importance of having the POC signed by the physician is to ensure the agency has the active POC for treatment. 1b. A review of Patient 7’s Home Health Certification and POC for certification period 3/23/26 through 5/21/26 indicated Patient 7 had diagnoses including mucopolysaccharidosis type II (a genetic disorder where the body cannot properly break down and recycle complex sugar molecules) and hydrocephalus (abnormal buildup of spinal fluid that can damage or alter brain function). Patient 7’s POC was signed by the physician on 4/29/26. During a concurrent interview and record review on 7/1/26 at 1:38 p.m. with the Registered Nurse Supervisor (RNS), Patient 7’s POC was reviewed. The RNS stated the HHA had 30 days for the physician to sign the POC. The RNS further stated if the physician signed Patient 7’s POC on 4/29/26, “then it’s late”. The RNS added Patient 7’s POC was sent to the physician on 4/2/26 and the physician signed the POC on 4/29/26. A review of the HHA’s undated policy and procedure titled, “PHYSICIAN PARTICIPATION IN PLAN OF CARE” indicated, “...The attending physician....will certify that medical, skilled...services provided by the organization are medically necessary...The care will be provided in compliance with the therapeutic...orders and accepted standards of practice...The attending physician...will sign the plan of care/treatment within 30 days of the start of care.””

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to maintain accurate Medication Profiles for two of seven sampled patients (Patient 6 and Patient 1) when: 1.Patient 6’s Medication Profile did not accurately reflect Patient 6’s medications given in the home, and 2.Patient 1’s Medication Profile was not complete and not accurate. These failures had the potential for Patient 6 and Patient 1 to experience adverse effects or ineffective results of medications not given per physician’s orders. 2. A review of the clinical record indicated the HHA agency originally admitted Patient 1 in May of 2025 and re-admitted on 9/5/25. Patient 1’s diagnoses included cerebral palsy and neuromuscular scoliosis (a curve of the spine in the middle back due to muscles and nerves that normally support the spine not working properly). A review of Patient 1’s current medication profile (MP) for care period 5/8/26 to 7/6/26 contained multiple medications and treatment orders. The MP was signed by Registered Nurse Case Manager (RNCM) on 5/6/26 and acknowledged that all Patient 1’s listed medications were reviewed for “potential adverse effects, drug reactions...significant side effects...drug interactions, duplicate drug therapy, and noncompliance with drug therapy...” A further review of Patient 1’s clinical record contained OASIS (Outcome and Assessment Information Set, a standardized assessment to evaluate patients’ health and care needs) for the new recertification period 5/8/26 to 7/6/26, conducted on 5/6/26 indicated, “RNCM completed full medication reconciliation with parent/PCG [Patient Caregiver] and no medication issues were identified. During a Home Visit observation on 7/1/26 commencing at 2:20 p.m., accompanied by RNCM, Patient 1’s active medications were provided by the patient’s caregiver and were compared to the medication profile provided by the agency. The medication profile included in Patient 1’s records was not accurate and did not match the medications that were provided by patient’s caregiver. The following medications were observed in Patient 1’s supply and not listed on medication profile: a. Children’s Loratadine Oral Solution 5milligram/5milliliter (dose of measurement) to be administered as needed for allergies, dated 4/2/26; b. Fluticasone Propionate 50 mcg [mcg-microgram, unit of measurements] nasal spray for allergies; and c. A bottle of D-Vite (liquid Vitamin D) drops 2.5 ml every day for supplement. In a concurrent observation and interview with Caregiver on 7/1/26 at 2:20 p.m., the Caregiver explained that Loratadine solution, Fluticasone nasal spray, and Vitamin D drops had been prescribed by Patient 1’s physician about 2-3 months ago and she had been administering these medications to Patient 1 since then. The medication profile listed Cetirizine HCL 10mg oral tablet for allergies and Senna 8.8 mg/5ml oral syrup (laxative) to be administered nightly for constipation as active medications. When asked about Cetirizine HCL, the Caregiver reported that Patient 1 have not been using the medications since April of 2026 when the physician prescribed Loratadine and Fluticasone for allergies. The Caregiver showed an empty bottle of Senna oral syrup and added that Patient 1 had not been taking the medication for a while. A further review of medication profile indicated that respiratory vest (a wearable medical device that helps clear mucus from the lungs) was listed as active treatment used daily for 15 minutes as one of the respiratory interventions. According to the Caregiver, Patient 1 have not been using the vest for over two years. During an interview with RNCM on 7/1/26 at 3:05 p.m., the RNCM validated that Patient 1’s medication profile was not completed accurately and Patient 1 was taking three medications that were not documented on patient’s medication list. The RNCM stated that during recertification (reassessment) visit completed on 5/8/26 Patient 1’s medication profile should have been updated to reflect Loratadine, Fluticasone, and Vitamin D as active medications. The RNCM acknowledged that Cetirizine, Senna syrup, and the treatment with respiratory vest should not have been listed on Medication profile as active medications and treatment, because Patient 1 was not using them. During an interview on 7/2/26 at 10:50 a.m., Patient 1’s inaccuracies with medication profile were discussed with the DPCS. The DPCS stated the clinicians relied on Patient 1’s Caregiver informing the agency about the changes in the medication profile. The DPCS stated that it was an expectation that RNCM conducted a full medication reconciliation during the recertification visit on 5/8/26. The DPCS added that RNCM should ask the Caregiver if there were new medications ordered or if any of the medications were discontinued and then update the medication profile. A review of undated policy and procedure (P&P) provided by the agency indicated, “Patient receiving medications...will have a current, accurate medication profile in the clinical record...Medications profiles will be updated for each change to reflect current medications, new, and/or discontinued medications...A drug regimen will be performed at the time of admission, when updates to the comprehensive (OASIS) assessments are performed...and with addition of a new medication.” The P&P indicated that the medication profile will be used as a care planning and teaching guide and as a communication tool for other clinicians involved in the patient’s care. 1.A review of Patient 6’s “Home Health Certification and Plan of Care (POC),” for certification period 5/30/26 to 7/28/26, indicated Patient 6 had a Start of Care (SOC) with the Home Health Agency on 4/10/24 for diagnoses including cerebral palsy (abnormal brain development or damage to the brain affecting movement, balance, and posture) and hydrocephalus (abnormal buildup of cerebrospinal fluid in the brain causing pressure that can damage brain tissue). Further review of Patient 6’s POC indicated orders for Registered Nurse Case Manager (RNCM) services 2 hours per month, Licensed Vocational Nurse (LVN) services 1 to 60 hours per month, and Certified Home Health Aide (CHHA) services for 75 to 310 hours per month. A review of Patient 6’s current “Medication Profile” indicated “...Drug Regimen Review Acknowledgement: I have reviewed all listed medications for potential adverse effects, drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy...” signed by clinician on 5/28/26. During a home visit on 7/1/26 at 2:25 p.m. with Patient 6’s caregiver and the Administrator/ Director of Patient Care Services (ADM/DPCS) a review of Patient 6’s “Medication Profile” was conducted. Review of Patient 6’s “Medication Profile” indicated “Erythromycin [medication to stimulate stomach muscles to improve gastric motility] 200 mg [milligrams]/5 ml [milliliters] oral liquid Three times daily feeding tube (FT) Give 1.5mL via G-tube [gastrostomy tube inserted directly into the stomach to deliver food, hydration, and medication] ...” Observed Patient 6’s medication bottle labeled “Erythromycin 200 mg/5 ml susp [suspension] Give 1.5 mL via g tube 2 times a day...” During an interview with Patient 6’s caregiver, the caregiver stated she was giving the medication two times a day. Review of Patient 6’s “Medication Profile” indicated “Lansoprazole [medication to reduce stomach acid] 3 mg/ml oral suspension Twice/day feeding tube (FT) give 5 ml twice daily via feeding tube...” Observed Patient 6’s medication bottle labeled “Lansoprazole DR [Delayed Release] 15 mg capsule...Administer 1 capsule (15 mg total) by feeding tube route...” During an interview with Patient 6’s caregiver, the caregiver stated the pharmacy provided capsules instead of the liquid. Review of Patient 6’s “Medication Profile” indicated “Polyethylene Glycol [laxative medication] 3350 Daily feeding tube (FT) Mix 1 capful...in 8oz [ounces] of water...” Observed Patient 6’s medication bottle labeled “Polyethylene Glycol 3350 Powd [powder]...Mix 1 capful in liquid and give by mouth once daily” During an interview with Patient 6’s caregiver, the caregiver stated the medication is given as needed, a couple of times per week, not daily. During an interview on 7/1/26 at 3:52 p.m. with the ADM/DPCS, the ADM/DPCS acknowledged Patient 6’s medication profile did not accurately reflect medications given in the home. The ADM/ DPCS stated the order for Erythromycin needed to be adjusted to two times a day, order for Lansoprazole needed to be changed to reflect capsules given instead of liquid, and the Polyethylene Glycol order needed to be changed to as needed instead of daily. The ADM/DPCS stated the medication profile is updated at the time of recertification. The ADM/ DPCS stated clinicians will ask during visits, including supervisory visits, if there are any medication changes. The ADM/ DPCS stated the accuracy of the medication profile is reliant on being informed by caregivers of changes. The ADM/DPCS stated a consequence of the medication profile not being accurate is that a nurse may give meds differently from what was being given by the caregiver. A review of the HHA’s Policy and Procedure (P&P) titled “Medication Profile & Review,” not dated, indicated “...Patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications...A drug regimen review will be performed at the time of admission, when updates to the comprehensive (Oasis) assessments are performed, when care is resumes after a patient has been placed on hold, and with the addition of a new medication...During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver as well as other clinicians understand the medication regimen. This includes. ...Using the medication profile to evaluate the use of medications in the home setting. The medication profile includes...all current medications, date prescribed, name of medication, dose, frequency, drug classification, date discontinued, and drug and/or food allergies... Using the medication profile as a communication tool for other clinicians involved in the care...Deviations from taking medications as ordered will be documented in clinical notes, and the physician...will be notified...””

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure the Plan of Care (POC) developed in consultation with the agency staff included all patient care orders for one of 7 sampled patients (Patient 1). This failure had the potential for Patient 1 to receive inaccurate care. A review of clinical record indicated the HHA agency originally admitted Patient 1 in May of 2025 and re-admitted on 9/5/25 with multiple diagnoses which included cerebral palsy (a lifelong condition in which the brain has trouble controlling the muscles making it difficult for a person to walk, move their arms or legs, or perform everyday activities) and neuromuscular scoliosis (a curve of the spine in the middle back due to muscles and nerves that normally support the spine not working properly). A review of Patient 1’s plan of care from 3/9/26 to 5/7/26 included orders for Registered Nurse Case Manager (RNCM) services 2 hours per month, Licensed Vocational Nurse (LVN) services 1 to 60 hours per month, and Certified Home Health Aide (CHHA) services for 75 to 248 hours per month. A review of the clinical records included a skilled nursing (SN) visit note dated 4/22/26 which contained an assessment and skilled observation for Patient 1. The nurse documented that Patient 1 had recent laboratory blood tests completed and the results for Vitamin D (essential nutrient to keep strong bones and teeth) showed that it was low. The SN documented that Patient 1’s primary care physician prescribed Vitamin D supplement for daily administration. The SN noted that the order was reviewed with Patient 1’s mother. A further review of the clinical records included POC’s from 3/9/26 to 5/7/26 and from 5/8/26 to 7/6/26 and contained list of medications and treatment orders for Patient 1 but did not include the order for Vitamin D supplement. A review of the agency’s undated policy and procedure (P&P) titled, “CARE PLANNING PROCESS” indicated that the purpose of the care planning was to provide clinical direction to the clinicians. The P&P indicated, “Based on the assessment and conclusions, the plan of care will include, but will not be limited to...Specific... treatments to be provided...All medications...All patient care orders, including verbal.” During a concurrent interview and record review on 7/1/26 at 10:29 a.m., with Director of Patient Care Services (DPCS), the DPCS reviewed Patient 1’s SN visit note dated 4/22/26 and confirmed that per nursing documentation, Patient 1 was prescribed Vitamin D supplement by his primary care physician. The DPCS searched Patient 1’s clinical record and did not find the physician order for Vitamin D supplement was included in Patient 1’s POC’s. The DPCS explained, “The communication note should also indicate information addressing the order [for Vitamin D supplement] and there is nothing to show there was any communication with RNCM.” The DPCS stated that during the recertification visit on 5/8/26 the RNCM should have updated the POC with Vitamin D order, but it was not done. The DPCS added, “If mom opted not give it [Vitamin D], there should be documentation in the chart and notification of MD [physician], but I don’t see any documentation.” A review of the agency’s undated Policy & Procedure titled, “Verification of Physician Orders,” indicated, “To ensure that accurate physician (or other authorized independent practitioner) orders are obtained in accordance with applicable law and regulation...An order or prescription will be verified...when the order is communicated by someone other than the physician or his/her agent.””

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure there was a coordination of care between the HHA staff and the physician for one of seven sampled patients (Patient 7). This failure increased the potential for Patient 7’s physician not being aware of the care and services not being provided. A review of Patient 7’s clinical records indicated Patient 7 had two (2) Home Health Certification and Plan of Care (POC) certification periods 3/23/26 through 5/21/26 and certification period 5/22/26 through 7/20/26. Patient 7 had diagnoses including mucopolysaccharidosis type II (a genetic disorder where the body cannot properly break down and recycle complex sugar molecules) and hydrocephalus (abnormal buildup of spinal fluid that can damage or alter brain function). The POC for both certification periods indicated Patient 7 had orders for Licensed Vocational Nurse (LVN) for 1-60 hours/month and Certified Home Health Aide (CHHA) for 60-248 hours/month. During a concurrent interview and record review on 7/1/26 at 3:45 p.m. with the Registered Nurse Supervisor (RNS), Patient 7’s POC for the two certification periods was reviewed. The RNS stated Patient 7’s POC for both certification periods indicated orders for LVN and CHHA. The RNS further stated Patient 7 had no skilled nursing and home health aide notes. During an interview and record review on 7/2/26 starting at 9:02 a.m. with the Administrator/Director of Patient Care Services (ADM/DPCS), Patient 7’s authorization to treat was reviewed. The ADM/DPCS stated Patient 7’s authorization was received on 5/19/26. The ADM/DPCS further stated Patient 7 did not have LVN visits since 5/19/26. The ADM/DPCS stated Patient 7’s mother was HHA certified and was in the process of onboarding. During a follow up interview on 7/2/26 at 11:57 a.m. with the ADM/DPCS, she stated the physician was not notified of Patient 7 not receiving LVN visits since 5/19/26. A review of the HHA’s undated policy and procedure titled, “CARE PLANNING PROCESS” indicated, “To provide clinical direction to the clinicians providing direct patient care...The care planning process will be documented on the plan of care, individualized discipline...clinical notes...Clinicians will inform the patient’s physician (or other authorized licensed independent practitioner) of any changes that suggest a need to alter the plan of care.””

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency failed to provide Certified Home Health Aide (CHHA) supervisory visits every 14 days for two of seven sampled patients (Patient 6 and Patient 1). This failure had the potential for Patient 6’s and Patient 1’s CHHA service needs to be unmet resulting in Patient 6 and Patient 1 experiencing decreased quality of life. 2.A review of clinical record indicated the HHA agency originally admitted Patient 1 in May of 2025 and re-admitted on 9/2025 with multiple diagnoses which included cerebral palsy and neuromuscular scoliosis (a curve of the spine in the middle back due to muscles and nerves that normally support the spine not working properly). A review of Patient 1’s plan of care from 7/5/25 to 9/2/25, 11/9/25 to 1/7/26, and 3/9/26 to 5/7/26 indicated that Patient 1 received skilled nursing (SN) and Certified Home Health Aide (CHHA) services. A review of Patient 1’s clinical record indicated Patient 1 had a CHHA supervisory visit on 8/4/25 and on 8/29/25, which was 11 days later. A review of Patient 1’s clinical record indicated Patient 1 had a CHHA supervisory visit on 12/17/25 and on 1/7/26, 21 days later. A review of Patient 1’s clinical record indicated Patient 1 had a CHHA supervisory visit on 4/15/26 and on 5/6/26, 21 days later. A review of the undated policy and procedures (P&P) titled, “Home Health Aide Supervisory Visit Policy,” indicated that the purpose of the policy was to ensure that home health aide and personal care services were supervised as required by federal and state regulations, and as documented on the patient’s individualized plan of care. The P&P indicated, “The agency is committed to timely supervision, patient safety, aide competency, and continuity of care...The agency shall provide supervisory visits for home health aide/personal care services based on the type of services the patient is receiving. For patients receiving skilled nursing...services in conjunction with home health aide services, the agency shall complete a supervisory assessment no less frequently than every 14 days/two weeks, as required by applicable regulation.” During an interview on 7/1/26 at 10:50 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated that CHHA supervisory visits were conducted two times a month. The DPCS acknowledged that the agency’s HHA supervision policy indicated that supervisory visits were completed every 14 days. Discussed with DPCS that CHHA supervisory visits for Patient 1 were conducted longer than 14 days between visits, with 8/29/25 supervisory visit conducted 11 days later, and 1/7/26 and 5/6/26 visits conducted 21 days later than they were supposed to be. 1.A review of Patient 6’s “Home Health Certification and Plan of Care (POC),” for certification periods 6/4/25 to 8/2/25 and 5/30/26 to 7/28/26, indicated Patient 6 had a Start of Care (SOC) with the Home Health Agency on 4/10/24 for diagnoses including cerebral palsy (abnormal brain development or damage to the brain affecting movement, balance, and posture) and hydrocephalus (abnormal buildup of cerebrospinal fluid in the brain causing pressure that can damage brain tissue). Further review of Patient 6’s POCs indicated orders for Registered Nurse Case Manager (RNCM) services 2 hours per month, Licensed Vocational Nurse (LVN) services 1 to 60 hours per month, and CHHA services for 75 to 310 hours per month. A review of Patient 6’s clinical record indicated Patient 6 had a HHA supervisory visit on 7/11/25 and 19 days later on 7/30/25. A review of Patient 6’s clinical record indicated Patient 6 had a HHA supervisory visit on 2/23/26 and 17 days later on 3/12/26. A review of Patient 6’s clinical record indicated Patient 6 had a HHA supervisory visit on 5/7/26 and 21 days later on 5/28/26. During an interview on 6/30/26 at 3:08 p.m. with RNCM, the RNCM stated HHA supervisory visits are done two times a month by the RNCM or LVN supervisor. During an interview on 7/1/26 at 11:44 a.m. with the Administrator/ Director of Clinical Services (ADM/DPCS), the ADM/DPCS stated HHA supervisory visits are done two times a month. The ADM/DPCS stated the agency tries to have one HHA supervisory visit done at beginning of the month and one towards the end of the month. Reviewed with the ADM/ DPCS HHA supervisory visits longer than 14 days between visits including 7/11/25 and 7/30/25, 2/23/26 and 3/12/26, and 5/7/26 and 5/28/26. The ADM/DPCS stated HH supervisory visits were done two times a month but not every 14 days. A review of the Home Health Agency’s Policy and Procedure (P&P) titled “Home Health Aide Supervisory Visit Policy,” dated 2009, indicated “...The purpose of this policy is to ensure that home health aide and personal care services are supervised in accordance with applicable federal Conditions of Participation, California Title 22 requirements, payer requirements, and the patient’s individualized plan of care. The agency is committed to timely supervision, patient safety, aide competency, and continuity of care...The agency shall provide supervisory visits for home health aide/personal care services based on the type of services the patient is receiving. For patients receiving skilled nursing, physical therapy, occupational therapy, or speech-language pathology services in conjunction with home health aide services, the agency shall complete a supervisory assessment no less frequently than every 14 days/two weeks, as required by applicable regulation...””