Forrest General Home Care and Hospice

“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 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 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 automatic sprinkler system 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. the Maintenance Office, Styrofoam cups were stacked on the top shelf with less than 18 inches of clearance from the ceiling (18.3.5.4). 2. In the Kitchen Storage area, boxed supplies were also stored without maintaining the required 18-inch clearance from the ceiling (18.3.5.4). Corrected on Site-Items moved to meet 18 inch requirement for above items 1 and 2.”

“Upon observation, there was no evidence the building service equipment 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, it was observed in Mechanical Room 108, the insulation wrap on the chilled water pipe was torn and partially exposed (18.3.5.5)”

“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.”