Every finding on record at Enlight Hospice of VA, LLC

Upon patient record review, 1 of 5 (Patient #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 2:The medication profile included entries for Senna S and Zofran. There is no evidence on the medication profile that the entry includes the indication for use of each medication.

Upon patient record review, 1 of 5 (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 medical record contains nursing documentation that the patient was admitted with a primary diagnosis of hypertensive heart disease, was on an altered diet and the medication profile included the entry of Eliquis. There is no evidence on the plan of care of problems, goals and interventions for the management of heart disease, nutrition or risk of bleeding.

Upon patient record review, 1 of 5 (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 medications and treatments. Patient 2:The plan of care included orders for Senna S and Zofran. There is no evidence on the plan of care that the order includes the indication for use of each medication.