Paradise Hospice, Inc.

“Upon patient record review, 4 of 14 (Patient #2,6,7,8) 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 2:Medication profile contains orders for hydrocortisone cream without a site of application. Corrected on site, POC updated. Patient 6:Medication profile dated 12/4/25 contains orders for Lidocaine 4% Topical Pain patch without evidence of site of application. Corrected on site, POC updated. Patient 7:Medication profile dated 12/4/25 contains orders for Lidocaine 4% Topical Pain patch, Lidex 0.05% Topical cream, Diclofenac Sodium 1% topical gel, Bactroban 2% topical cream and hydrocortisone 2.5% topical cream, without evidence of site of application. Corrected on site, POC updated. Patient 8:Medication profile contains orders for hydrocortisone cream without a site of application. Corrected on site, POC updated.”

“Upon patient record review, 6 of 14 (Patient #1,2,4,5,6,8) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 1,2,4,5,6,8:The current Medication Record/POC includes orders for aspirin. There is no evidence of a risk for bleeding care plan with appropriate goals and interventions. Corrected on site, POC updated.”

“Upon patient record review, 4 of 14(Patient #2,6,7,8) 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:Order for hydrocortisone cream without an application site. Corrected on site, medication record updated. Patient 6:Orders for Lidocaine 4% Pain patch without a site of application. Corrected on site, medication record updated. Patient 7:Orders for Lidocaine 4% Pain patch, Lidex 0.05% Topical cream, Diclofenac Sodium 1% topical gel, Bactroban 2% topical cream and hydrocortisone 2.5% topical cream without a site of application. Corrected on site, medication record updated. Patient 8:Order for hydrocortisone cream without an application site. Corrected on site, medication record updated.”

“Upon patient record review 1 of 14 (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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 7:Current POC includes orders for Aide 2x weekly ordered 6/25/25, medical record does not show evidence of any Aide visits being completed since the time of order. Corrected on site, POC updated.”

“Upon personnel record review, 3 of 11(Personnel #5,6,8 ) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel 05:Handwashing competency evaluation and Hand Hygiene with alcohol based formulation competency evaluation are marked as direct observation (DO); Initial orientation form(s) indicate “Staff Demonstrated competency in handwashing: Yes or No , neither are marked. Competency orientation checklist/Hospice Chaplain does not show evidence of self assessment per policy or dates of completion. Core competency skill(s) 1,2,3 &4 do not indicate if employee is competent or when competency was completed. Personnel 06:Handwashing competency evaluation and Hand Hygiene with alcohol based formulation competency evaluation are marked as direct observation (DO); Initial orientation form(s) indicate “Staff Demonstrated competency in handwashing: Yes or No , neither are marked. Personnel 08:Handwashing competency evaluation AND Hand Hygiene with alcohol based formulation competency evaluation are marked as direct observation (DO); Initial orientation form(s) indicate “Staff Demonstrated competency in handwashing: Yes or No , neither are marked.”