Every finding on record at Forrest General Home Care and Hospice

Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with Federal, state, regional, and local emergency management agencies. Agency has primary means for the above. However, there is no consistent alternate means for the following: • Federal, state, regional, and local emergency management agencies

Upon patient record review, 2 of 21 (Patients #1,2) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: During medication reconciliation on home visit the patient is taking Melatonin 20 mg at bedtime. This medication was not included on medication profile. Patient #2: During medication reconciliation on home visit the patient is taking an OTC Multivitamin daily. This medication was not included on medication profile.

Upon patient record review, 3 of 21 (Patients #4,5,16) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #4: The initial bereavement risk assessment was not timely. Patient start of care was 3/28/24 and the bereavement risk assessment was completed on 8/22/25. Patient #5: The initial bereavement risk assessment was not timely. Patient start of care was 6/10/25 and the bereavement risk assessment was completed on 7/10/25. Patient #16: There is no initial bereavement risk assessment completed to date.

Upon patient record review, 1 of 21 (Patient #2) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs Patient #2: The record reflected a MSW visit frequency of 1-3 PRN visits. This frequency did not include a baseline visit frequency for the MSW.

Upon patient record review, 2 of 21 (Patients #5,6) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #5: The record reflected that this patient had a wheelchair. This item was not included on the Plan of Care. Patient #6: The record reflected that this patient had an order for DuoNeb 0.5-2.5 3mL every 6 hours. a nebulizer machine was not included on the Plan of Care.

Upon personnel record review, 1 of 13 (Personnel #9) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) Personnel #9: The Aide Initial Competency did not have verification that the required tasks were observed/demonstrated as follows: ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Sponge, tub, and shower bath ·Toileting and elimination

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. There is no evidence in meeting records of the Governing Body appointing of the temporary administrator.

Upon observation, there is no evidence the smoke compartmentation and control of a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. New Construction During building tour, the following was observed: 1. Two ceiling tiles were missing and one ceiling tile was discolored in the Maintenance Office (18.3.7). Corrected on site (COS)-tiles replaced 2. No fire rating label observed on the door in Room AF14, Soiled Equipment Room. This deficiency was also noted as missing during the annual inspection of swinging fire doors (18.3.7.6). COS-installed seal on door assembly.

Upon observation, there was no evidence the inpatient facility has adequate supply of hot water at all times and include plumbing fixtures with control valves that automatically regulate the temperature of hot water used by patients. 1. Review of water temperature logs from January 2025 to the present showed recorded temperatures ranging from 114°F to 120°F, which do not meet the policy requirement of maintaining temperatures below 110°F as stated in the Engineering Department Systems (page 4) and Water Management Program (page 6). There was no documentation of corrective action or policy guidance specifying time frames for correction. Correction on site in process-The agency has a plan in place (while maintenance team is titrating temperature down) water is checked for a temperature <110 °F before providing any bathing/showering with all IPU patients.

Upon patient record review, 4 of 13 (Patient #1, 2, 3, 9) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy Patient 1: The medication list indicates polyethylene glycol 17g/scoop powder take 17g po daily; however, there are no instructions for reconstitution of the powdered medication. (corrected onsite) Patient 2: The medication list indicates oxygen 2L/min via nasal canula PRN; however, there is no specifier for the PRN use of the oxygen. Additionally, the patient's medication list contains several drugs for IV administration via the patient's implanted port/CVC; however, there is no evidence of either flushes or locks for maintenance of this implanted therapeutic device. It was confirmed with the IPU supervisor that SN staff members are routinely utilizing normal saline and heparin for maintenance of the CVC. (corrected onsite) Patient 3: The medication list indicates hydrocortisone 0.5% cream apply 1 applicator topically 4 x daily; however, there is no location/anatomical site specified for use of the topical cream. (corrected onsite) Patient 9: The medication list indicates glycopyrrolate 1mg tab dissolve 1 tablet in 5mL water and give 2.5mL q 6 hours & PRN; however, there is no specifier for the PRN use of the glycopyrrolate. Additionally, the medication list indicates lactulose 10g/15mL take 4.5mLs or 3g po 3 x daily; however, this infant has no suck reflex and takes all medications and feeds vis NG tube. Verified with the RN case manager that the correct route for all of this patient's medications is vis the NG tube. (corrected onsite)

Upon patient record review, 2 of 13 (Patient #2, 5) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 2: The Foley catheter order, dated 09.29.2022, indicates Insert Foley catheter once; this is an incomplete order as it does not specify the size of the Foley catheter to be used, the balloon size, how frequently the catheter should be changed, directions for ongoing care, etc. (corrected onsite) Patient 5: The Foley catheter order, dated 11.04.2022, indicates Insert Foley catheter, irrigate with 30-60 mLs NS PRN; this is an incomplete order as it does not specify the size of the Foley catheter to be used, the balloon size, how frequently the catheter should be changed, complete directions for ongoing care, etc. Additionally, there is no specifier for the PRN irrigation instructions. (corrected onsite)

Upon client record review, 2 of 13 (Patient #2, 9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: The patient's medication list contains several drugs for IV administration via the patient's implanted port/CVC; however, there is no evidence of a signed physician's order for either flushes or locks for maintenance of this implanted therapeutic device. It was confirmed with the IPU supervisor that SN staff members are routinely utilizing normal saline and heparin for maintenance of the CVC. (corrected onsite) Patient 9: The patient's medication list contains several drugs for administration via the patient's nasogastric tube; however, there is no evidence of a signed physician's order for insertion or maintenance of the NG tube. It was confirmed with the SN case manager that all medications and feeds are given via the NG tube, which nursing staff and caregivers replace routinely in the home. (corrected onsite)

Upon patient record review 1 of 9 applicable (Patient #7) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient 7: The hospice aide care plan indicates the patient should receive a shave, hair care, oral care, and nail care during each aide visit; however, during the aide visit on 10.28.2022, there is no evidence these tasks were completed.

Upon patient client record review, 1 of 13 (Patient #8) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient 8: The patient was admitted for hospice services on 09.19.2022. When the election statement was signed on 09.19.2022, the patient requested the Notification of Hospice Noncovered Services. Items, and Drugs; however, the notification form was not completed and returned to the patient by the hospice until 09.30.2022, exceeding the five day requirement.

Upon observation of the Existing Construction, there is no evidence the smoke compartmentation and control of a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. During Life Safety Code inspection of the IPU, it was observed that there were three holes in the sheetrock covered ceiling of Electrical Room 01. Each hole was of no more than 1 inch in diameter. However, these holes would potentially allow the passage of smoke or fire. All three holes were appropriately patched and mudded prior to completion of the accreditation survey. (corrected onsite) Upon observation of the Existing Construction, there was no evidence the storage of medical gases in a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. During Life Safety Code inspection of the IPU, it was observed that one of the backup oxygen cylinders in the outdoor storage area was unsecured. This cylinder was not in use. Immediately on identification of the unsecured oxygen cylinder, facilities/maintenance staff secured the cylinder appropriately with a chain. (corrected onsite)