Every finding on record at Kalispell Regional Medical Center 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 2/12/26. The facility completed a review of their EP plan in 6/2025. No deficiencies were cited.

A recertification survey was completed for the Home Health Agency by the Certification Bureau on 2/12/26. Standard level deficiencies were cited. Abbreviations: ADL – Activities of Daily Living CVP – Central Venous Pressure EHR - Electronic Health Record G-Tube – Gastrostomy Tube HEP – Home Exercise Program IADL – Instrumental Activities of Daily Living KT Tape - Kinesiology Therapeutic Tape OASIS - Outcome and Assessment Information Set OT - Occupational Therapy POC - Plan of Care RD – Registered Dietitian PRN - As Needed PT - Physical Therapy RN - Registered Nurse ROC - Resumption of Care ROM – Range of Motion SN - Skilled Nursing SOC - Start of Care UTI - Urinary Tract Infection

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the agency failed to complete and submit OASIS data for all payor sources for a Start of Care Comprehensive Assessment and Recertification Assessment for 3 (#’s 1, 11, and 13) of 17 patients sampled. This deficient practice had the potential to affect the overall quality of care provided to all patients regardless of their payor source. Findings include: 3. During an observation on 2/10/26 at 12:48 p.m., at the agency office locked doors a man was stopped from entering by two staff members. The man stated he was there to get a pill box because he had done it before. The man was fidgeting and pacing while he told them he was [patient #11] when asked and restated he needed a pill box. Patient #11 stated, “I’m trying to avoid an emergency here.” One staff member returned to the office to verify he was a patient while the other staff member asked him to go out and find a place to sit with her. He stated he really would rather stand, adding, “I need to move around.” During an interview on 2/11/26 at 3:10 p.m., staff member A stated she did not find any information in the agency policies specifying skilled versus nonskilled services provided. During an interview on 2/12/26 at 10:48 a.m., 2/12/26 staff member A stated when the updated changes to the regulation and Oasis data assessment requirements released the agency team determined for patients on [specific payor] for nonskilled services would not have a full Oasis assessment completed regularly or on recertifications. Staff member A stated the pillbox refill was not a skilled service and was only done by agency nurses due to staffing and the agency felt it fell under ‘personal care services’. Review of patient #11’s visit notes showed he also came to the agency office on 1/2/26, asking agency staff when they would have the next appointment to set up his medications as he was running out soon. Review of patient #11’s EHR showed he started on services 4/15/25 with recertifications starting on: -6/19/25, a full Oasis assessment was not completed and submitted. -8/19/25, a full Oasis assessment was not completed and submitted. -10/18/25, a full Oasis assessment was not completed and submitted. -12/16/25, a full Oasis assessment was not completed and submitted. 1. Patient #1 had a SOC date of 10/22/25, with a payor source of Triwest TPA, a third-party administrator (TPA) and network manager that partners with the Department of Veterans Affairs (VA). Review of patient #1’s Skilled Nursing Admission Assessment, dated 10/22/25, and Recertification Assessment, dated 12/16/25, did not include a comprehensive assessment with the OASIS data items for OASIS E-1. During an interview on 2/11/26 at 11:15 a.m., staff member A, stated patient #1 was a “Triwest (VA) patient” and did not receive skilled services which required the completion of the OASIS. Review of patient #1’s Plan of Care, dated 10/21/25 and 12/16/25, showed patient #1 was receiving skilled nursing services which included wound care to bilateral lower extremities for congenital ichthyosis (genetic disorder characterized by thickened, scaly, and dry skin due to defective cornification. It results from genetic mutations affecting skin barrier function. Key symptoms include widespread scaling, itching, and potential infections, managed with daily hydration, lubrication, and medications). The patient’s plan of care also included regular skilled nursing services to complete skin assessments, wound monitoring, lower extremity measurements, and the administration of topical medications and dressing changes. Ordered by the provider to be completed two times a week by a skilled nurse. 2. Patient #13 had a SOC date of 12/5/25, with a payor source of Triwest TPA, a third-party administrator (TPA) and network manager that partners with the Department of Veterans Affairs (VA). Review of patient #1’s Skilled Nursing SOC Assessment, dated 12/5/25, and Skilled Nursing Recertification Assessment, dated 2/2/26, did not include a comprehensive assessment with the OASIS data items for OASIS E-1. Review of patient #13’s SOC Skilled Nursing Assessment, dated 12/5/25, showed, “Skilled nursing needs include RN will provide Medication supervision/instruction, diagnosis education and assessment, home safety assessment and fall prevention education. Assist with pill box set up. [Patient #13’s] goal is to have assistance with pill box set up, barrier to care include history of noncompliance, lack of assistance at home for medication administration. PT will follow with eval and orders to treat. RN will return 3-4 [times with four weeks], then every 2 weeks for pill box fills until end of certification period…” [sic] Review of patient #13’s Physical Therapy Evaluation, dated 12/9/25, showed, “…[Patient #13] would benefit from formal, skilled PT for 2-3 visits within 4 weeks and an additional 3-4 visits within 5 weeks for training in functional mobility including transfers and gait/stairs, static/dynamic balance, HEP/strengthening and activity tolerance and provide [caregiver and physical therapy] education in order to reduce fall risk and increase independence within home. [Patient #13] would also like to manage pain with ice/warm packs, KT Tape, and manual therapy including soft tissue mobilization and Grade I-IV joint mobilization as needed to facilitate mobility…” Review of patient #13’s Veteran’s Affairs Assessment of ongoing skilled need for home health, dated 1/21/26, showed an approval for the following services, “[Patient #13] continues to have a skilled nursing need for assistance with pill box refills and medication management. Nursing is currently seeing him every two weeks to fill his pill boxes and order refills from the VA pharmacy as needed. [Patient #13] has been making progress with physical therapy but would benefit from ongoing services as well. He did have a recent right shoulder/upper arm injury and has just received a thera-cane. For the next episode beginning 2/3/26 [Skilled Nursing] to see patient [four to five times a week within 9 weeks] for assessment of [vital signs, central venous pressures, weight, pain, diabetes mellitius stability] general status and safety with pill box refills every two weeks, and education in disease management and medications as needed… [Patient #13] would benefit from continued Physical Therapy for training in balance, strength/ROM, functional mobility and HEP and provide education and pain interventions (ice/heat, KT and manual)as needed. PT would like to continue at [five to six times within 9 weeks] in order to reduce fall risk and burden on caregivers…” Review of patient #13’s Skilled Nursing Recertification Assessment, dated 2/2/26, showed, “[Patient #13] …is being recertified today due to his ongoing skilled need for assistance with his pill box refills and medication management as well as ongoing assessments of CVP, pain and diabetic status. He is making progress with physical therapy and will benefit from ongoing skilled therapy interventions as well in the next episode of care…”

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 interview and record review, the agency failed to ensure the start of care visit was completed within the ordered timeframe and the comprehensive assessment was completed within the 5 day requirement for 2 (#s 11 and 16) of 17 sampled patients. Findings include: During an interview on 2/12/26 at 11:18 a.m., staff member A stated the agency would not have a note or documentation for why there was a late start of care. Staff member A stated the agency would just request a new order from the patient’s provider for a new start of care date. Staff member A stated the agency had identified an area for improvement for start of care and staffing for when orders came in and agency staff were overloaded on certain days. Staff member A stated the agency was working on trying to balance so the start of care was not late and staff were not overloaded. A. Review of patient #11’s referral for services showed a referral date of 4/15/25 with a start date to be 4/17/25. Review of patient #11’s EHR showed a note from the agency requesting the new start of care to be 4/21/25. B. Review of patient #16’s referral for services showed a discharge date of 8/5/25 with a referral date of 8/6/26 for UTI and Sepsis. The ordered start of care date by 8/8/26. Review of patient #16’s EHR showed a note of an email exchange to the provider from the agency requesting a start of care be delayed to 8/11/25. The note showed, “…has agreed to sign the Home Health care orders, and that the delay in start of care on 8/11/25 will not be detrimental to the patient’s health.” It noted the patient had two emergency room visits one on 8/6/25, and one on 8/7/25, for a sacral fracture and a ground level fall before the initial 8/8/25 ordered start of care.

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 agency failed to provide Dietitian services as ordered in the individualized plan of care (POC) in the patient’s place of residence for 1 (#4); and failed to provide services as outlined in the patient’s plan of care for 1 (#10); and failed to provide physical therapy services for pain management for 1(#11) of 17 patients sampled. This deficient practice increased the risk of negative outcomes for patients requiring dietary, occupational and physical therapy services. Findings include: 3. During an interview on 2/9/26 at 1:12 p.m., staff member A stated the agency determined a patients change in status by the OASIS assessments results and emergency room visits. Staff member A stated the changes identified would be followed up with a change to the plan of care and new provider orders. During an interview on 2/9/26 at 1:12 p.m., staff member A stated the agency determined a patients change in status by the OASIS assessments results and emergency room visits. Staff member A stated the changes identified would be followed up with a change to the plan of care and new provider orders. Review of patient #11’s physical therapy evaluation order showed it was requested on 10/4/25 signed by the provider on 10/9/25. Review of Physical therapy appointment calendar showed; - 10/8/25 - “missed, unable to confirm, computer glitch” -10/13/25, physical therapy evaluation for back pain for several weeks. Patient #11 went to the emergency room the week prior for it. Patient #11 wanted physical therapy for managing pain to get back to level of function. -10/16/25 – physical therapy visit, “missed, refused visit, Pt refusing all PT at this time.” No other information on readdressing pain management and physical therapy after one visit refusal. Review of the 12/15/25 recertification case conference nurse note showed patient #11 had had multiple emergency room visits and back pain through the last certification period. A. Patient #4 had a SOC date of 1/10/25, for infection following a surgical site procedure and gastrostomy (medical procedure that creates an opening (stoma) through the skin of the abdomen into the stomach, allowing for the insertion of a tube for feeding, fluids, or medications). Review of patient #4’s POC, with a certification period of 1/10/25 to 3/10/26, showed, “ Effective: 1/11/26 - 3/10/26: Referral for dietary to evaluate and treat for failure to thrive, cardiac arrhythmias, gastrostomy malfunction, bacterial Infection, abscess of abdominal wall. New Glutton, new tube feeds, new drain, new PICC line…” Review of agency provided services for patient #4, failed to show the agency provided a dietary evaluation per the ordered plan of care. During an interview on 2/12/26 at 10:47 a.m., staff member A stated patient #4 was receiving dietary services through an out-patient clinic for management of her gastrostomy and tube feeding requirements. Staff member A stated the patient’s plan of care should reflect the services being provided by the home health agency. B. Patient #10 had a SOC date of 1/23/26, with a primary diagnosis of primary diagnosis of the displaced fracture of the sixth cervical vertebrae. Review of patient #10’s Plan of Care, for certification period 1/23/26 to 3/23/26, showed, “1/24/26 - 1/28/26 – 1 [visit] Within Five Days for 5 Days - OT eval and treat for home safety, ADLs, IADLs, adaptive equipment, showering, education [Past Medical History] for [First thoracic vertebrae]…” Review of patient #10’s Occupational Therapy Evaluation, dated 1/28/26, showed, “…[patient #10] will benefit from further OT services to regain ADL/IADL function and safety while observing current precautions…” Review of patient #10’s Plan of Care, and Provider Orders, from 1/28/26 to 2/12/26, failed to show additional OT services were ordered as outlined in patient #10’s OT Evaluation Plan. Review of patient #10’s visit calendar from 1/28/26 through 2/12/26, failed to show any further OT visits were provided after the OT evaluation on 1/28/26.” During an interview on 2/12/26 at 10:47 a.m., staff member A stated it was the expectation that visits were provided as ordered in the plan of care and updated on the plan of care after discipline evaluations were completed.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the individualized plan of care was updated with the frequency and duration of visits to be made by the occupational therapy for 1 (#10) of 17 patients sampled. Findings include: Patient #10 had a SOC date of 1/23/26, with a primary diagnosis of a displaced fracture of the sixth cervical vertebrae. Review of patient #10’s Plan of Care, for certification period 1/23/26 to 3/23/26, showed, “1/24/26 - 1/28/26 – 1 [visit] Within Five Days for 5 Days - OT eval and treat for home safety, ADLs, IADLs, adaptive equipment, showering, education…” Review of patient #10’s Occupational Therapy Evaluation, dated 1/28/26, showed, “…[patient #10] will benefit from further OT services to regain ADL/IADL function and safety while observing current precautions…” Review of patient #10’s Plan of Care, for services provided from 1/28/26 to 2/12/26, failed to show OT services were ordered as outlined in patient #10’s OT Evaluation Plan and failed to include frequency and duration of OT visits to be provided to meet established goals. During an interview on 2/12/26 at 10:47 a.m., staff member A stated it was the expectation that visits were provided as ordered in the plan of care and updated on the plan of care after discipline evaluations were completed to include the frequency and duration of visits to be provided. A review of the agency's policy and procedure titled, Home Health Plan of Care, with a revision date of 5/2025, showed, "Admission Plan of Care (POC) is developed based on Comprehensive Start of Care assessment, OASIS assessment, Added Service assessment, and provider admission orders. The plan of care will include the following; B. Frequency and duration of visits to be made..."

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 agency failed to integrate orders for management of a patient’s tube feeding as ordered by other providers involved in the patient’s ordered home health plan of care for 1 (#4) of 17 patients sampled. This deficient practice increases the risk of negative outcomes associated with patients receiving orders from other providers involved in the patients plan of care. Findings include: Patient #4 had a SOC date of 1/10/25, for infection following a surgical site procedure and gastrostomy (medical procedure that creates an opening (stoma) through the skin of the abdomen into the stomach, allowing for the insertion of a tube for feeding, fluids, or medications). Review of patient #4’s referral, dated 1/8/26, showed, “additional services for dietitian consult for a new tube feed and [gastrostomy] button.” Review of patient #4’s POC, with a certification period of 1/10/25 to 3/10/26, showed, “ Effective: 1/11/26 - 3/10/26: Referral for dietary to evaluate and treat for failure to thrive, gastrostomy malfunction, bacterial Infection, abscess of abdominal wall, new tube feeds…” During an interview on 2/12/26 at 10:47 a.m., staff member A stated patient #4 was seen by an out-patient dietitian and not by the agency’s dietitian. Review of patient #4’s Out-Patient Registered Dietitian Office Visit Note, dated 1/14/26, showed, “…Patient here for initial RD visit with diagnosis of disordered eating, and weight loss, nausea and vomiting, and gastrostomy status. RD consult ordered to assist in managing her nutrition and feeding plan… Recommendations: 1. Continue current enteral feeds via g-tube of Isosource 1.5 @ 120 [milliliters an hour] for 12 hours overnight. 2. Work on consuming 3-4 small meals/snacks that are protein containing. Ideas discussed with patient and grandmother. 3. Follow-up in 1 month recommended to closely monitor weight trends. RD will continue to follow-up at future clinic appointments as needed…” [sic] Review of patient #4’s revised plan of care failed to show the integrated orders from the out-patient dietitian were not integrated into the patient’s plan and care. During an interview on 2/12/26 at 10:47 a.m., staff member A stated the patient’s plan of care should reflect all integrated services provided for the patient as ordered on the plan of care. Review of the agency policy and procedure titled, Provider Communication and Order, with a revision date of 8/2024, showed, “… a. The signed provider appointment note is attached to the home care or hospice record. b. If a provider signed copy of the appointment note is not available then the order is sent for provider signature… 5. The patient's provider is contacted as appropriate for changes in patient status or needs that indicate the plan of care should be altered…”

Based on 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, effective 11/15/17, a recertification EP survey was performed on 2/15/23. No Deficiencies were cited.

A recertification survey was completed on 2/15/23. Standard Level were cited. Abbreviations: HH - Home Health HHA - Home Health Aide OASIS - Outcome and Assessment Information Set OT - Occupational Therapy POC - Plan of Care PT - Physical Therapy PTA - Physical Therapy Assistant RN - Registered Nurse ROC - Resumption of Care SLP - Speech-Language Pathologists SN - Skilled Nursing SOC - Start of Care ST - Speech Therapy

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to accurately reflect the status of pressure ulcer at the time of a Discharge OASIS for 1 (#9) of 17 sampled patients. Findings include: Review of patient #9’s Nursing Regular Visit Note, dated 6/30/22, showed, “[Patient #9] continues to sit on coccyx and back. The spine [Pressure Ulcer] has gotten worse in the last week. Wound has become a Stage 2 [Pressure Ulcer] and is painful for [Patient]. There is a shearing type wound on his right gluteal fold. The skin in the wound and around are blanchable…” Review of patient’s #9’s Discharge OASIS, dated 7/7/22, showed: - (M1306) The patient did not have at least one unhealed pressure ulcer/injury at Stage 2 or higher. The Discharge OASIS Assessment failed to accurately reflect the status of the two Stage II pressure ulcer/injuries. During an interview on 2/14/23 at 4:20 p.m., staff member B stated clinical staff who complete the OASIS Assessments were comprehensively trained. Then any OASIS Assessments were also audited for discrepancies, and if any found, were returned to the clinician for correction. Staff member B stated the Recertification and Discharge OASIS for patient #9 were missed for accuracy.

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 agency failed to ensure ordered plan of care for services provided were followed by all clinicians when missed visits occurred for 3 (#s 15, 16, and 17) of 17 sampled patients. Findings include: A review of the agency’s policy and procedure titled, Provider Communication and Orders H01002, with a revision date of 4/2022, showed: “…1. For services under the direction of a provider, an order will be obtained for, or a standing order implemented for: …b. Increase in frequency, or consistent decrease in frequency bellowed ordered frequency or range…” 1. Review of patient #15’s Plan of Care, with a certification period dated 1/10/23 to 3/10/23, showed, “Speech Therapy: 1/22/23 to 3/10/23 for three to four visits within four weeks for four weeks for cognitive/communication and swallowing training. A review of patient #15’s completed Speech Therapy visits between 1/22/23 to 2/15/23, showed visits on 2/9/23 and 2/14/23. There were no additional Speech Therapy visits completed from 1/22/23 to 2/9/23. 2. Review of patient #16’s Provider Orders, dated 1/25/23, showed, “[Occupational Therapy] 5-6 times within 6 weeks for training in ADL’s, AE, transfers, and HEP.” Review of patient Occupational Therapy Visits from 1/25/23 to 2/15/23, showed there were no visits completed in that time frame. 3. Review of patient #17’s Provider Orders dated 12/29/22, showed, Occupational Therapy was ordered for two to three visits in three weeks, followed by three to four visits in four weeks. Review of patient #17’s Occupational Visits showed no Occupational Visits were completed from 1/2/23 to 1/17/23. During an interview on 2/15/23 at 4:40 p.m., staff member B stated it was the expectation of clinicians to complete the visits as ordered by the physician. They were to notify the provider of missed visits and determine if any changes would need to be made to the patient’s plan of care in relation to the missed visits.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, staff members E and F failed to follow proper infection control practices to prevent the transmission of infections and communicable diseases, in the patient’s environment for 2 (#s 3 and 6) of 7 sampled patients. Findings include: 1. Cleaning Medical Equipment During an observation on 2/14/23 at 1:18 p.m., staff member E had completed vital signs for patient #3. Staff member E retrieved disinfecting wipes out of her medical bag, cleaned each piece of medical equipment, and then placed each item on the patient’s bedspread. There was a small plastic bag, which had held the thermometer, lying on the bedspread. The pulse oximeter and a portion of the thermometer was on the plastic bag, but the remaining equipment was in direct contact with the patient’s bedspread. Staff member E failed to place a clean barrier on a surface to place her cleaned medical equipment to dry. During an interview on 2/14/23 at 1:37 p.m., staff member E stated after she cleaned the medical equipment, she placed them on a plastic bag, on patient #3’s bed. Staff member E agreed only some of the equipment was on the plastic bag, but most was on top of patient #3’s bed. Staff member E stated the best practice for drying medical equipment after cleaning would have been to place a clean barrier down first. Staff member E stated, “I should have done that.” Review of the facility policy titled, Clinical Equipment Use and Infection Prevention, last reviewed on 1/17/23, showed: -…”3. Clinical equipment items used in home visits are cleaned with hospital approved disinfectant after use and prior to returning to clinical bag. …” The clinical/medical equipment was cleaned with a disinfectant but was not placed on a clean surface to allow dry time prior to returning the equipment to the clinical bag. Patient #3’s bedspread was not considered a clean surface and allowed the equipment to potentially be contaminated after cleaning was completed. 2. Clinical Bag Technique During an observation on 2/15/23 at 10:35 a.m., staff member F approached patient #6’s kitchen/dining table, moved some of patient #6’s personal items by pushing them back on the table, and placed his clinical bag on the table. Staff member F had not cleaned the table with any disinfecting agent or placed a clean barrier on the table under the clinical bag. During an interview on 2/15/23 at 11:15 a.m., staff member F stated he had been trained on clinical bag technique. He stated, “I understood that if it was a clean, dry surface, I don’t need a barrier. If it was a soft surface, I would lie down a barrier.” Staff member F stated he was unable to identify if patient #6’s table was a clean surface by visually looking at the table and had not wiped the table clean before the placement of his clinical bag or after the bag was removed. During an interview on 2/15/23 at 11:30 a.m., staff member B stated the facility’s policy for placement of a clinical bag in the patient’s home was on a clean, dry, hard surface. Staff member B stated the staff would identify if the surface was clean by visually looking at the surface. Review of the facility policy titled, Clinical Bag Technique & Cleaning, last reviewed on 1/17/23, showed: -…”A. The clinical bag and contents will be set down in the patient’s place of residence on a clean, dry, hard surface off of the floor. -B. If a clean, dry, hard surface off of the floor is not available, a barrier drape or similar barrier will be used to establish a clean area prior to setting down the clinical bag in the patient’s place of residence. …”