Every finding on record at Paradigm Living Concepts, LLC

Upon patient record review, 1 of 9 (Patient #3) 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: Patient 3: The medication profile contains an order for Melatonin 3mg, the patient is taking Melatonin 10mg as per home visit finding. Caregiver states patient has had this medication for a couple of weeks. Corrected on site.

Upon patient record review, 1 of 9 (Patient #1) 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: The SN documented down grading the patient's diet to mechanical soft due to dysphagia on 7/20/24. The SN did not implement a risk for aspiration care plan. Corrected on site.

Upon patient record review, 3 of 9 (Patient #1,3,5) 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 1: The POC 8/10/24 contains an order to cleanse the ear and to apply Aquaphor to the ear. There was no frequency or solution ordered to cleanse the ear with. Corrected on site. Patient 3: The POC 5/10/24 contains an order for Melatonin 3mg, the patient is taking Melatonin 10mg as per home visit finding. Corrected on site Patient 5: The POC 5/6/24 contains an order for a foley catheter to be placed with out a directive for the size french or balloon size. Corrected on site

Upon patient record review, 1 of 9 (Patient #2) 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 2: The SN documented 7/22/24 that patient has a rollator and a fall mattress. These items have not been added to the POC.

Upon patient record review, 1 of 9 (Patient #1) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 1: The SN documented on 8/10/24 pt has skin breakdown on the ear. There was no risk skin impairment care plan initiated. Corrected on site.

Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Patient 3: The SN documented on 8/16/24 that the patient stated "I had to grab on to the coffee table so I would not fall". There was no incident report filed. Administrator agreed agency considered this occurrence as a fall.

Upon personnel record review, 1 of 13 (Personnel #5) 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 5: The personnel file did not contain evidence of the aide's competency included the Shampoo, sink, tub, and bed.

Upon patient record review 1 of 9 (Patient #2) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 2: The aide POC contained a directive to shampoo the hair the first visit of the week. There is evidence the aide performed shampooing on 7/29 & 8/1, 8/5 & 8/8, 8/14 & 8/15. There is no evidence the aide called the RN to gain permission to shampoo the hair twice weekly.

Upon patient client record review, 4 of 9 (Patient #2,3,4,6) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 2: The SN documented on 7/29 "cg" the approved abbreviation for caregiver is CG. On 8/5 the SN documented wc, the approved abbreviation is w/c. On 8/19 the SN documented FN, the approved abbreviation is FSN. Patient 3: The SN documented on 5/21 "d/t" this is not an approved abbreviation. Patient 4: The SN documented on 8/19 "ABT". This is not an approved abbreviation. Patient 6: The SN documented on 5/3/24 "Writer called xxx NP". There is no NP named xxx.