Every finding on record at Bebe's Nursing Care LLC

During the Health Recertification survey conducted on 02/27/2024 through 02/28/2024 at Bebe's Nursing Cae LLC, Home Health Agency provider, Emergency Preparedness was reviewed. Bebe's Nursing Cae LLC is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 484.102, Condition of Participation for Home Health Agencies.

An unannounced Recertification survey was commenced on 02/27/24 and concluded on 02/28/24 at Bebe's Home Health Agency, Inc., Home Health Agency provider. The provider was not in compliance with 42 CFR, Part 484 Subpart A-C, Conditions of Participation for Home Health Agencies. There was 1 Condition Of Participation identified in Non-Compliance: 42 Code Of Federal Regulations (CFR) Part 484.100- Compliance With Federal, State, and Local Laws and Regulations related to the health and safety of patients (G0848). The cumulative effect of the systemic practice resulted in the Home Health Agency's inability to ensure that their patient's needs would be met.

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 record review and interview, the Home Health Agency (HHA) providing Skilled Nursing services to their patients, failed to continuously maintain their Accreditation which is required in order to maintain their State Licensure. The cumulative effect of the systemic practice resulted in the Home Health Agency's inability to ensure that their patient's needs would be met. The findings include: Review of a letter to the HHA, from their Accrediting Body, reveals that the HHA's Accreditation ended on 04/29/23. Review of a letter to the HHA, from another Accrediting Body, dated 06/28/23 documents, "As of the date of this letter, BeBe's Nursing Care, LLC is officially "In Process" with (name of Accrediting Body) to obtain an accreditation survey for the Home Health Program(s). As requested, this serves as notification to Agency for Health Care Administration (AHCA). Your in-process status is in effect for a period of 180 days and will expire on December 25, 2023." During interview on 02/27/24 at 10:30 AM, the Director of Nursing/Alternate Administrator stated that she let their Accreditation expire because she did not like its terms for renewal and was going to change to another accrediting organization; that she believed they did not have enough patients for a "reaccreditation" survey to be conducted and has not been trying to get new patients "until now" due to (personal circumstances); that they have provided Private-Duty (Skilled) Nursing services to 2 patients who have been on service since 2019 and 2022 but no others in the last year; and that she believed these 2 patients to be exempt from Home Health licensure requirements because they have "Med Waivers" (their care is paid for under the Medicaid Long-Term Care Waiver), although she denied applying for such exemption.