Tree of Life Hospice LLC

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure an initial comprehensive assessment was completed no later than five calendar days after the election of hospice care. CLINICAL RECORD 4: The patient elected the hospice benefit on 02/04/2026. The initial psychosocial assessment was completed on 02/10/2026 (6 days after election of benefit). A review of the clinical record revealed no documented evidence of missed visit notes or care coordination notes to explain the delay in the completing the psychosocial assessment as part of the comprehensive assessment. During an interview with the Registered Nurse/Administrator/Director of Nurses (Personnel Record 5) on 08/04/2026, she stated that they have been educated several times to document the reason for not completing the comprehensive assessment within the 5-day window; this one just slipped through.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical record reviews, the organization did not ensure the individualized plan of care was reviewed and documented by the IDG at least every 15 calendar days. CLINICAL RECORD 2: The patient elected the hospice benefit on 12/01/2025. The first Interdisciplinary Group (IDG) date was 12/22/2025, 21 days after admission. There was no documented evidence that the IDG reviewed, revised, and documented the individualized plan of care within 15 calendar days of the patient electing the hospice benefit. CLINICAL RECORD 9: The patient elected the hospice benefit on 03/25/2025. The benefit period 01/19/2026 to 03/19/2026 had documented IDG meetings dated 01/14/2026, 02/16/2026 (33 days), 03/02/2026, and 03/16/2026. The clinical record review did not contain documented evidence that the IDG reviewed, revised, and documented the individualized plan of care as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. During an interview with the Registered Nurse/Administrator/Director of Nurses (Personnel Record 5) on 08/04/2026, she stated, “I reviewed that time period and that it was when I lost my mother and was overwhelmed. The IDG was conducted; it just did not get added to the electronic medical record.””

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to: assess the quality of care and services provided by the hospice aide; and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical record reviews of patients who elected hospice aide services, the agency did not ensure hospice aide supervision by a registered nurse occurred in the patient’s home at least every 14 days. CLINICAL RECORD 3: The patient elected the hospice benefit on 07/15/2026. The Interdisciplinary Group completed a plan of care for the benefit period 07/15/2026 to 10/12/2026 that included aide frequency of two times a week for one week, then five times a week. The first documented hospice aide visit was dated 07/16/2026; no hospice aide supervisory visits were documented as of 08/04/2026 (a total of 20 days after the first aide visit). During an interview with the Registered Nurse/Administrator/Director of Nurses (Personnel Record 5) on 08/04/2026, she stated, “I do not know why the supervision had not been documented, but she knew it had been completed and would provide education to the clinical staff on the requirements.””

“It is required that the hospice assess the skills and competencies of all individuals providing care, including volunteers providing services, and, as necessary, provide in-service training and education programs where required. This standard was not met as evidenced by interview and personnel record review. In 2 of 9 (22%) personnel records reviewed, the agency did not assess the skills and competencies of individuals that provided care. Personnel Record 1: The Registered Nurse was hired on 10/01/2024. The personnel record review revealed a copy of the agency’s initial competency dated 10/01/2024. The competency was not filled out completely; the self-assessment portion was the only part of the form completed; the rest was blank. The personnel record did not have documented evidence that the agency assessed the skills and competencies of the nurse. Personnel Record 4: The Chaplain was hired on 06/10/2025. There was no documented evidence in the personnel record that a competency assessment was completed. During an interview with the Registered Nurse/Administrator/Director of Nurses (Personnel Record 5) on 08/05/2026, she stated she was unable to find the competencies, but they would review the process to ensure the competencies are completed in a timely manner.”

“It is required that the hospice obtain a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by document review and interview. In 2 of 5 (40%) contract reviews, the agency did not ensure that the contract included the requirement that all contracted employees who have direct patient contact or access to patient records must obtain criminal background checks. Contract 5: The Hospice Medical Director contract, signed on 06/06/2014, did not include evidence of a clause that required contracted employees with direct patient contact or access to patient records to obtain criminal background checks. Contract 2: The pharmacy contract, signed on 08/20/2024, did not include evidence of a clause that required contracted employees with direct patient contact or access to patient records to obtain criminal background checks. During an interview with the Registered Nurse/Administrator/Director of Nurses (Personnel Record 5) on 08/05/2026, she stated that an addendum has been completed, signed, and added to these contracts as of today.”

“It is required that the hospice designates an interdisciplinary Group (IDG) composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient/family facing terminal illness and bereavement. The IDG, in its entirety, supervises the care and services provided to the patient and family. This standard was not met as evidenced by interviews and document review revealed the agency did not ensure that the medical director attended all interdisciplinary group meetings to ensure appropriate care coordination with the team. The IDG sign-in notes for each clinical record and IDG attendance sign-in logs were reviewed from 04/01/2024 through 04/28/ 2025. The IDG sign in logs were present for every second Monday. Each IDG note in the clinical record and each IDG attendance log included the Medical Director’s signature. In an interview on 05/07/2025, the Social Worker (Employee record 4) described the interdisciplinary group (IDG) process and stated “the attendance at IDG varies, it is usually the registered nurses, the social worker, the chaplain, and sometimes the licensed vocational nurse but she is part time, sometimes the marketers and chaplain the doctor is not always here during the IDG. The administrator/DON is an RN, and she runs the meeting and then communicates with the doctor if he can’t come.” The Registered Nurse (Employee record 1) was interviewed at home visit 05/07/2025 and reported that the interdisciplinary group (IDG) is held every two weeks and that all of the disciplines are there and discuss each patient. RN reported that if the physician cannot be present, then the Administrator/DON discusses everything with him. In interviews, the Chaplain (Employee record # 6), the RN (Employee record 1), and associate director all reported that sometimes the Medical Director had been unable to attend IDG, and that he was updated right away following the group meeting. The same staff had experienced that he had been accessible to them when they needed orders. All believed that he had responded within 15 minutes. Alternate Administrator (Employee record (2) stated in an interview on 05/07/2025,” If the Medical Director can not attend the IDG (interdisciplinary group), he still comes in that day, gets a full report, and then signs the IDG roster and addresses any care plan updates needed.” The Administrator/Director of Nursing (DON) (Employee record 5) stated in an interview on 05/07/2025, “ I have already spoken to the Medical Director about getting an alternate in case he can not be here. I called him today, and he was in the middle of intubating someone and had to call me back.” The Administrator/DON stated that she collaborates and reviews the IDG discussion for each patient with the medical director when he has been unable to attend the IDG meeting before making changes to the POC or initiating orders. In a phone interview on 05/07/2025, the Medical Director (Employee record 7) stated that “if for some reason I am not able to attend IDG, I get a report as soon as I am available and go through any issues I need to address.” He verified his involvement in directing the care when he had missed a meeting.”