Every finding on record at Benefis Community Care, Inc.

Based on the regulatory requirements and standards of 42 Code of Federal Regulations (CFR) 484.102 Emergency Preparedness (EP) Final Rule Requirement for Home Health Agencies effective 04/16/21, an EP survey was performed on 3/26/26. The facility completed a review of their EP plan on 6/27/25. No deficiencies were cited.

An unannounced recertification survey was completed by the State of Montana, Office of Inspector General, Certification Bureau on 3/26/26. Standard level deficiencies were cited.

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 interviews and record review, the agency failed to ensure patients were admitted within 48 hours from the referral date, admitted within 48 hours of the patient's return home, or on the ordering practitioner's ordered start of care date for 6 (#'s 1, 3, 4, 6, 11, and 16) of 17 sampled patients. This deficient practice resulted in a delay of care for these patients. Findings include: During an interview on 3/23/26 at 1:53 p.m., staff member C stated the agency admitted patients within 48 hours of referral or by the physician ordered start of care date. Staff member C stated if there was a patient referral the agency could not do in 48 hours the agency would check with the physician to get new orders if it was safe to wait. Staff member C stated if a referral could not wait to do the admission the agency would do a gratuitous act of citizenship to check on them before, but that it was a rare occurrence. During an interview on 3/25/26 at 1:50 p.m., staff member A stated the hospitals would send home health referrals while patients were still admitted in the hospital. The referrals would not come with ordered start of care dates and often needed other information completed for the agency to admit. Staff member A stated if the referral came at end of day on a Friday the agency did not have enough staff to cover weekends. Staff member A stated if the next Monday was already full for appointments the start of care visit would be pushed to Tuesday. 5. Review of patient #11’s Plan of Care, dated 12/1/25, showed the patient was referred to the agency on 11/26/25 and admitted to the agency on 12/1/25. Five days later. 6. Review of patient #16’s Plan of Care, dated 12/8/25, showed the patient was referred to the agency on 12/4/25 and admitted on 12/8/25. Four days later. 1. Review of patient #1's EHR referral, dated 12/11/25, showed patient #1 was referred for services on Friday, 12/12/25. Review of patient #1's Plan of Care, dated 2/14/26, showed patient #1 had a start of care date of Tuesday, 12/16/25. This start of care date was four days after the referral was received. 2. Review of patient #3's EHR referral, dated 2/16/26, showed patient #3 was referred for services on Monday, 2/16/26. Review of patient #3's Plan of Care, dated 2/25/26, showed patient #3 had a start of care date of Wednesday, 2/25/26. This start of care date was nine days after the referral was received. 3. Review of patient #4's EHR referral, dated 2/5/26, showed patient #4 was referred for services on Friday, 2/6/26. Notes indicated patient was contacted on Monday, 2/9/26, and he agreed to admission on 2/11/26. Review of patient #4's Plan of Care, dated 2/11/26, showed patient #4 had a start of care date of Wednesday, 2/11/26. This start of care date was five days after the referral was received. 4. Review of patient #6's EHR referral, dated 1/30/26, showed patient #6 was referred for services on Friday, 1/30/26. The notes indicated the family was contacted on 1/30/26 and told the family member the agency did not have a nurse available until Tuesday 2/3/26. The family member indicated, "the sooner, the better" per the notes on the referral. Review of patient #6's Oasis Start of Care, dated 2/3/26, showed patient #6 had a start of care date of Tuesday, 2/3/26. During an interview on 3/25/26 at 1:50 p.m., staff member A stated the agency did not operate on Saturday and Sunday and do not admit patients on weekends because the agency did not have the staffing capacity to staff weekends. Staff member A stated the schedule for Mondays is filled on Friday so there was usually not an opening for admits on Mondays either. Staff member A stated if the agency received a referral of Friday, the agency staff would contact the physician and notify them the referral would have to wait of be declined for admission. In addition, staff member A stated there was a period of time where she was covering management vacations for both offices and this caused additional delay times. Review of the agency's policy, "Home Health Acceptance to Service Policy, dated 2/2026, showed: - " ... c. This visit is to be scheduled 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. ..."

An Emergency Preparedness Recertification Survey was completed on 3/30/23. The agency was found to be in compliance with the regulatory requirements and standards of 42 Code of Federal Regulations (CFR) 484.22 Emergency Preparedness (EP) Final Rule Requirement for Condition of Participation for Home Health Agencies.

A recertification survey was completed 3/30/23. Standard level deficiencies were cited.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on interview and record review, the facility failed to establish and implement policies and procedures for ensuring the implementation of additional precautions to mitigate the spread of COVID-19 (Coronavirus Disease 2019) for facility staff with COVID-19 vaccine exemptions. Findings include: Review of the facility policy titled, (name of facility) Employee Immunization Program, undated, showed: -…”Procedures/Responsibilities: -I. Mandatory COVID-19 Immunization -…E. If an employee is granted deferral, they must meet with Employee Health within one-week post notification of the deferral to receive and agree to specific requirement such as wearing a simple mask while working, social distancing or other requirements. …” During an interview on 3/29/23 at 9:23 a.m., staff member L stated he was no longer required to wear personal protective equipment, such as a mask, when he entered a patient’s home. He stated the mask mandate was dropped in February and employees were not required to test for COVID-19. Staff member L stated he was not required to take any additional precautions or do anything different than an employee who was vaccinated. During an interview on 3/29/23 at 9:35 a.m., staff member E stated all unvaccinated employees were encouraged to wear a mask but were not required to wear them. She stated the mask mandate was removed for all employees on 2/20/23 due to a medium transmission rate in the county. During an interview on 3/29/23 at 10:44 a.m., staff member E stated the employees which had an exemption or deferral for the COVID-19 vaccination, received an email regarding additional precautions. Staff member E stated the guidelines for deferred or delayed employees for the COVID-19 vaccination was to self-screen for illness prior to their shift. No other precautions were identified for unvaccinated employees. During an interview on 3/29/23 at 1:37 p.m., staff member P stated she was not required to perform any additional precautions for COVID-19 at this time. She stated all employees who provided direct care to patients did the same regarding personal protective equipment. Staff member P stated she would still report to the facility if she had any signs or symptoms of illness, but self screening was required of all employees.