Every finding on record at Immaculate Home Health, Inc

An investigation was conducted on 04/09/26 for Complaint # 29711981 / 262494. The Agency was not in compliance with the Conditions of Participation at: 42 CFR 484.1 Basic and Scope 42 CFR 484.100 Compliance with Federal, State, and local laws and regulations related to health and safety of patients 42 CFR 484.105 Organization and administration of services 42 CFR 484.110 Clinical Records Therefore, the Agency is precluded from conducting aide training and/or competency evaluations for 24 months effective 04/09/2026 until 4/8/2028.This applies even if the agency is not currently conducting aide training and/or competency evaluations. 42 CFR 484.80(f)(3): Eligible training and competency evaluations organizations. Abbreviations: HHA = Home Health Agency SN = Skilled Nurse PT = Physical Therapy OT = Occupational Therapy ST = Speech Therapy MSW = Medical Social Worker POC/PsOC = Plan of Care/Plans of Care SOC = Start of Care

Basis and Scope CFR(s): §484.1 Basis and Scope (a) Basis. This part is based on: (1) Sections 1861(o) and 1891 of the Act, which establish the conditions that an HHA must meet in order to participate in the Medicare program and which, along with the additional requirements set forth in this part, are considered necessary to ensure the health and safety of patients; and (2) Section 1861(z) of the Act, which specifies the institutional planning standards that HHAs must meet. (b) Scope. The provisions of this part serve as the basis for survey activities for the purpose of determining whether an agency meets the requirements for participation in the Medicare program. This CONDITION is not met as evidenced by: Based on observations and staff interview the Agency failed to meet the operational requirements, institutional planning and allow survey activities to determine if the Agency meets the requirements to participate in the Medicare program. Findings include: 1. Upon arrival to Agency office location, it was observed that the office had no furniture, no computers, no telephone service system. The office was empty. A phone call was made to the Agency phone number on file with the Department. An answering service answered and stated it was answering phones for a different home health agency, but was able to provide phone number for biller/Owner #3 of Immaculate. During a phone interview at 9:30 AM with Owner #3 the office location was confirmed. Owner #3 stated the office location was shared with another home health agency. 2. During interviews on 04/09/26 at 11:30 AM and 1:45 PM with Owner #1, Owner #2 and the Administrator, a request was made to view employee personnel files and information and documents of Agency's ownership and management information sent to Department for approval. Owner #1 stated Agency could not provide personnel files for review or any other Agency documents due to Agency does not have documents in the Office. It was also stated they did not submit change of ownership documents or change in management documents to the Department. The above findings were confimed during the interview at 1:45 PM. The Agency did not have office space to conduct Medicare survey and was unable to provide all neccessary documents to conduct Medicare survey. The Agency failed to meet operation requirements or provide evidence of institutional planning.

Compliance with Federal, State, Local Law CFR(s): 484.100 Condition of participation: Compliance with Federal, State, and local laws and regulations related to the health and safety of patients. The HHA and its staff must operate and furnish services in compliance with all applicable federal, state, and local laws and regulations related to the health and safety of patients. If state or local law provides licensing of HHAs, the HHA must be licensed. This CONDITION is not met as evidenced by: Based on observation and staff interview, the Agency failed to operate and furnish services in compliance with federal and state regulations. Findings include: 1. The Agency failed to disclosure ownership and management information to the Departement. (G0850) 2. The Agency failed to ensure all persons furnishing services to patients were licensed or certified in accordance with the state licensing. (G0860) The cumulative effect of these practices have the potential to affect all services and care provided to patients.

Disclosure of ownership and management info. CFR(s): 484.100(a) The HHA must comply with the requirements of part 420 subpart C, of this chapter. The HHA also must disclose the following information to the state survey agency at the time of the HHA's initial request for certification, for each survey, and at the time of any change in ownership or management: (1) The names and addresses of all persons with an ownership or controlling interest in the HHA as defined in §420.201, §420.202, and §420.206 of this chapter. (2) The name and address of each person who is an officer, a director, an agent, or a managing employee of the HHA as defined in §420.20l, §420.202, and §420.206 of this chapter. (3) The name and business address of the corporation, association, or other company that is responsible for the management of the HHA, and the names and addresses of the chief executive officer and the chairperson of the board of directors of that corporation, association, or other company responsible for the management of the HHA. This STANDARD is not met as evidenced by: Based on staff interview and document request, the Agency failed to notify the Department of the Agency's change of Ownership and change in Management. Findings include: 1. During the entrance interview on 04/09/26 at 11:30 AM, Owner #2 stated that the Agency had a change in Ownership in December 2025. 2. During the same entrance interview the Administrator and Director of Nursing stated they have been in their positions since March 2026. 3.. During an interview with Owner # 2 on 04/09/26 at 11:30 AM a request was made for documentation of the Agency's new owner disclosure notification and change in management sent to the Department. Owner # 2 stated and confirmed that the Agency has not sent documentation to Department regarding change of Ownership or change in management.

Licensing CFR(s): 484.100(b) (b) Standard: Licensing. The HHA, its branches, and all persons furnishing services to patients must be licensed, certified, or registered, as applicable, in accordance with the state licensing authority as meeting those requirements. This STANDARD is not met as evidenced by: Based on observation and staff interview, the Agency failed to verify licenses and certifications for staff providing care. This has the potential to affect all patients being served. Findings include: 1. During the entrance interview on 04/09/26 at 9:00 AM it was observed Agency office had no office equipment, files or computers. The office was empty. 2. During the entrance interview on 04/09/26 at 11:30 AM, Agency Owner #2 stated the Agency provides SN, PT, OT, ST MSW and Aide services. SN and Aide services are provided by Agency staff and PT, OT, ST and MSW are contracted services. 3. During an interview on 04/09/26 at 1:45 PM. A request was made to the Administrator and Owner #1 for the Agency's staff personnel files. Owner #1 stated and confirmed Agency was not able to provide personnel files for review. Unable to verify availability and qualification of staff to provide home health services.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on observation and staff interview the Agency failed to ensure the Administrator was appointed by the governing body, responsible for day to day operations, ensures the HHA employs qualified personnel and was available at all times during the operating hours of the agency. Findings include: 1. The Ageny failed to ensure the Administrator was appointed by the governing body. (G0946) 2. The Agency failed to ensure the Adminstrator was responsible for all day to day operations. (G0948) 3. The Administrator failed to ensure the HHA employs qualified personnel. (G0952) 4.The Agency failed to ensure the Administrator was available during all operating hours. (G0956) The cumulative effect of these practices have the ability to affect all administrative and clinical operations of the Agency.

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) Standard: Administrator. The administrator must: (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on staff interview, the Agency failed to provide Governing Body minutes Appointing the Administrator. Findings include: 1. During the entrance interview on 04/09/26 at 11:30 AM with Administrator, the Administrator stated she has been the Agency Administrator since March 2026. 2. During an Interview on 04/09/26 at 1:45 PM with the Administrator and Owners #1 and #2, a request was made to review the Administrator's personnel file and Governing minutes. Owner #1 stated and confirmed Agency was not able to provide documents and files for review.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on observations and staff interviews, the Administrator failed to conduct and be responsible for the Agency's day to day operations. Findings include: 1. Upon arrival to Agency location on 04/09/26 at 9:00 AM it was observed the building directory did not include the name of the Agency. The suite for the Agency had a different Home Health Agency's name on the office door. 2. On 04/09/26 at 9:00 AM the Agency's telephone number was called. The Agency's answering service, indicated it was for the other Agency and was not aware of the name or direct contact information for Immaculate's administrator. 3. The Agency office was empty and shared with another Home Health Agency. 4. The following clinical records were reviewed via electronic medical record on 04/10/26: Pt. #1 SOC 01/18/26 Pt. #2 SOC 1/29/26 Pt. #3 SOC 01/20/26 Pt. #4 SOC 11/12/25 Pt. #5 SOC 01/22/26 Pt. #6 SOC 01/13/26 Pt. #7 SOC 01/21/26 Pt. #8 SOC 12/23/25 Pt. #9 SOC 12/27/25 The Clinical records for Pts. #1, 2, 3, 6, 7, 8, and 9 included PsOC with the SOC date that included the Agency's name with a dba (doing business as) name in the "Branch name and Address" section of the PsOC. There was no other documentation presented that confirmed whether the Agency had a dba. The Agency name listed on the Department issued license does not include a dba. 5. During an interview with the Administrator on 04/09/26 at 11:30 AM, the Administrator stated and confirmed she has been the Administrator since March 2026, the office was a shared office with another Home Health Agency, the office did not include any Agency documents for review and that the answering service was answering calls for the other Agency.

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 observations and staff interview the Administrator failed to provide documentation indicating Agency employs qualified personnel. Findings include: 1. During the survey entrance on 04/09/26 at 11:30 AM it was observed that Agency office had no office equipment or files. 2. During the entrance interview on 04/09/26 at 11:30 AM, the Administrator stated Agency provides SN, Aide by direct staff and PT, OT, ST and MSW by contract services. 3. On 04/09/26 at 1:45 PM request was made to the Administrator for Agency staff personnel files and contractual agreements for review. The Administrator stated and confirmed she was not able to provide requested files and contracts for review.

Available during all operating hours CFR(s): 484.105(b)(3) The administrator or a pre-designated person is available during all operating hours. This ELEMENT is not met as evidenced by: Based on observation and staff interview, the Agency Administrator of Designee was not available during all operating hours of the Agency. Findings include: 1. Upon arrival to Agency location for complaint survey on 04/09/26 at 9:00 AM, the Administrator or an adminstrator designee was not present at Agency address. 2. On 04/09/26 at 9:00 AM surveyor called Agency telephone number and spoke with answering service. Answering service was not able to make immediate contact with the Administrator. 3. Administrator arrived at Agency location on 04/09/26 at 11:30 AM. The Adminsitrator or designee failed to be available during all operating hours of the Agency.

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on clinical records review and staff interview, Agency failed to authenticate clinical records and failed to retain clinical records beyond 6 months. This has the potential to affect all Patients receiving care from the Agency. Findings include: 1. The Agency failed to authenticate clinical records. (G 1024) 2. The Agency failed to retain clinical records for 5 years. (G 1026) The cumulative effect of these systemic practices resulted in the Agency’s inability to properly authenticate clinical records and maintain availablity of clinical records to ensure patients safety and health.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on clinical records review and staff interview, in 5 of 9 patients (Pts. #1, 2, 5, 6, & 7) admitted in January 2026, the Agency failed to ensure Plans of Care were authenticated by physician signatures. Findings include: 1. During the entrance interview on 04/09/26 at 11:30 AM, the Agency Owner #2 stated the Agency completes clinical documentation electronically and that access will be provided. 2. The following clinical records were reviewed on 04/10/26 and lacked Plans of Care with authenticating physician signatures Pt. #1 SOC 01/18/26 Pt. #2 SOC 01/29/26 Pt. #5 SOC 01/22/26 Pt. #6 SOC 01/13/26 Pt. #7 SOC 01/21/26 3. During the interview at 11:30 AM on 04/09/2026 with the Administrator, DON and Owners #1 and #2 it was stated all clinical documents were in the patient clinical records on the EMR. No other clinical documents were provided.

Retention of records CFR(s): 484.110(c)(1)(2) Standard: Retention of records. (1) Clinical records must be retained for 5 years after the discharge of the patient, unless state law stipulates a longer period of time. (2) The HHA's policies must provide for retention of clinical records even if it discontinues operation. When an HHA discontinues operation, it must inform the state agency where clinical records will be maintained. This STANDARD is not met as evidenced by: Based on staff interview and clinical records review, the Agency failed to provide clinical records for review prior to November 2025. Findings include: 1. During the entrance interview on 04/09/26 at 11:30 AM, Owner #2 stated the Agency has electronic documentation for clinical records. During same interview Owner #2 stated the Agency has a census of approximately 10 patients since December 2025. Owner #2 stated he has no information of patients before that time. 2. The Agency provided electronic access to total of 9 patients, 1 active and 8 discharged patients. There were no clinical records available with a start of care date prior to November 2025. 3. The above findings were confirmed during interviews with the Administrator, Owners #1 and #2 at 1:45 PM.