Every finding on record at Tree of Life Hospice LLC

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.

It is required that the hospice Emergency Preparedness (EP) training program includes the following: 1. For all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles; 2. Demonstration of staff knowledge of emergency procedures; 3. EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years; a) More frequent training occurs if there is a significant update of EP policies and procedures; 4. A periodic review and rehearsal of the hospice’s EP plan with hospice employees (including non-employee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others; and 5. Documentation of each training including the date(s), participants, and content. This standard was not met as evidenced by personnel record review and interview. In 11 of 11 (100%) personnel records reviewed, the agency did not ensure employees were provided with Emergency Preparedness training upon hire and at least every two years. Personnel Record 1: Director of Nursing/Administrator date of hire 5/8/2014. The personnel record contained no documented evidence of Emergency Preparedness training upon hire and every two years. Personnel Record 2: Alternate Administrator date of hire 6/3/2016. The personnel record contained no documented evidence of Emergency Preparedness training upon hire and every two years. Personnel Record 3: Registered Nurse date of hire 9/18/2-23. The personnel record contained no documented evidence of Emergency Preparedness training upon hire and every two years. Personnel Record 4: Licensed Vocational Nurse date of hire 5/9/2014. The personnel record contained no documented evidence of Emergency Preparedness training upon hire and every two years. Personnel Record 5: Nurse Practitioner date of hire 7/14/2015. The personnel record contained no documented evidence of Emergency Preparedness training upon hire and every two years. Personnel Record 6: Medical Social Worker date of hire 11/15/2021. The personnel record contained no documented evidence of Emergency Preparedness training upon hire and every two years. Personnel Record 8: Hospice Aide date of hire 5/5/2014. The personnel record contained no documented evidence of Emergency Preparedness training upon hire and every two years. Personnel Record 7: Hospice Aide date of hire 10/29/2021. The personnel record contained no documented evidence of Emergency Preparedness training upon hire and every two years. Personnel Record 9: Chaplain date of hire 2/4/2022. The personnel record contained no documented evidence of Emergency Preparedness training upon hire and every two years. Personnel Record 10: Medical Director date of hire 2/4/2022. The personnel record contained no documented evidence of Emergency Preparedness training upon hire and every two years. Personnel Record 11: Volunteer date of hire 6/5/2014. The personnel record contained no documented evidence of Emergency Preparedness training upon hire and every two years. Alternate Administrator stated in an interview, "I didn't have Emergency Preparedness training for the staff on my radar. I didn't know we had to." 11 of 11 (100%) of personnel records reviewed revealed that the agency did not ensure that all employees were provided with Emergency Preparedness training upon hire and at least every two years.

It is required that hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG [interdisciplinary group] in collaboration with the attending physician (if any), the patient or patient representative, and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review, document review, and interview. In 3 of 14 (21%) clinical records reviewed, the agency did not ensure hospice care and services followed the individualized plan of care. Agency policy 11.6.1 Timely Submission of Patient Documentation [no date] stated in part, "Itineraries, with all visit reports attached, must be submitted the next scheduled workday, not exceeding three (3) business days. All patients visit reports from contract personnel must be submitted within three (3) business days from the date of the visit." Clinical Record 1: The patient elected the hospice benefit on 6/23/2022, with terminal diagnoses of Alzheimer's disease and stage 4 pressure ulcer to the sacrum. The plan of care dated 8/17/2023 through 10/15/2023 included orders for skilled nurse (SN) visits once a week for three weeks [1wk3]. As of the date of clinical record review on 9/27/2023, the clinical record contained no documented evidence of SN visit notes for the week of 9/17/2023 to 9/23/2023. Clinical Record 2: The patient elected the hospice benefit on 12/7/2022, with terminal diagnosis of Alzheimer’s disease. The plan of care dated 8/4/2023 through 10/2/2023 included an order for the SN one to seven times per week for two months. Clinical record review revealed a SN visit dated 8/30/2023 and the next SN visit was dated 9/13/2023, 14 days after the visit dated 8/30/2023. The next SN visit was dated 9/27/2023, 14 days after the visit dated 9/13/2023. The SN did not follow the plan of care for SN visit frequency. Clinical Record 5: The patient elected the hospice benefit on 3/3/2023, with terminal diagnoses of unspecified lump in left breast and heart failure. The plan of care dated 8/30/2023 included an order for SN visit frequency one to three times a week for two months. Clinical record review revealed a SN visit dated 8/30/2023 and the next SN visit was dated 9/13/2023, 14 days after the visit dated 8/30/2023. The next SN visit was dated 9/27/2023, 14 days after the SN visit dated 9/13/2023. The SN did not follow the plan of care for SN visit frequency. During an interview, the Director of Nursing stated, "We have been struggling with staff getting their documentation turned in timely." 3 of 14 (21%) clinical records reviewed revealed that the agency did not ensure that hospice care and services were provided consistant with the individualized plan of care.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review and document review. In 4 of 14 (29%) clinical records reviewed, the agency did not ensure the individualized plan of care included a detailed statement of the scope and frequency of services. Agency policy 9.12.1 IDG Care Planning Process [no date] stated in part, the plan of care will include "a detailed statement of scope and frequency of services necessary to meet the specific patient and family needs, visit ranges may be used to ensure the most appropriate level of service is provided to the patient. Visit ranges with small intervals are acceptable e.g., 1-3 visits/week/2-4 visits a week." Clinical Record 2: The patient elected the hospice benefit on 12/7/2022, with terminal diagnosis of Alzheimer’s disease. The plan of care dated 8/4/2023 through 10/2/2023 included an order for skilled nurse (SN) visit frequency “1-7/wk. 2 mo. [one to seven times a week for two months].” The frequency of SN visits was not individualized to the patient and family needs and did not follow the agency’s policy guidelines for visit frequencies with small intervals. Clinical Record 4: The patient elected the hospice benefit on 8/22/2023, with terminal diagnosis of Alzheimer’s disease. The plan of care dated 8/22/2023 through 11/19/2023 included an order for SN frequency of visits one to five times per week for one quarter. The frequency of SN visits was not individualized to the patient and family needs and did not follow the agency’s policy guidelines for visit frequencies with small intervals. Clinical Record 5: The patient elected the hospice benefit on 3/3/2023, with terminal diagnoses of unspecified lump in left breast and heart failure. The plan of care dated 9/12/2023 through 11/19/2023 included an order for SN frequency of visits one to five times per week for one quarter. The frequency of SN visits was not individualized to the patient and family needs and did not follow the agency’s policy guidelines for visit frequencies with small intervals. Clinical Record 9: The patient elected the hospice benefit on 9/15/2023, with terminal diagnoses of muscular dystrophy and osteogenesis imperfecta. The plan of care dated 9/15/2023 through 12/13/2023 included an order for SN visit frequency one to five times a week for one quarter. The frequency of SN visits was not individualized to the patient and family needs and did not follow the agency’s policy guidelines for visit frequencies with small intervals. During an interview, the Administrator/Director of Nursing and the Alternate Administrator agreed that a visit frequency that spanned more than 2 days was not consistent with policy. 4 of 14 (29%) records reviewed revealed that the agency did not ensure that the individualized plan of care included a detailed scope and frequency that demonstrated the individual patient needs and was consistent with agency policy.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene, use of gloves, mask, eye protection, or face shield depending on anticipated exposure, safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids, safe handling of soiled items in the patient’s care environment, and other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by document review, interview, and observation. In 2 of 3 (66%) home visits observations, the agency did not ensure staff followed the agency’s hand hygiene policy when providing care to the patient. Agency policy 5.7.1 Hand Hygiene Policy and Compliance Program stated in part, "Indications for hand hygiene are: before and after direct patient care, before and after each procedure, when hands are soiled, after contact with any contaminated materials, before re-entering nursing bag or patient's clean supplies. Bacteriostatic foam/gel/liquid is the preferred hand hygiene method. Staff compliance with hand hygiene with be monitored monthly." Home Visit 1/Clinical Record 1: The patient elected the hospice benefit on 6/23/2022, with terminal diagnoses of Alzheimer's disease and stage 4 pressure ulcer to the sacrum. During the home visit observation, the Registered Nurse (RN), was observed to wash hands and don exam gloves. The RN took the patient’s vital signs, then removed the gloves and donned a new pair of exam gloves without washing hands or using hand sanitizer. The RN was observed to turn the patient and untaped the depends, went to the closet to obtain a new depends and wet wipes. The nurse removed the depends, cleaned the patient, and rolled the depends into itself and placed it in the trash. The RN opened the dresser drawer and removed wound care supplies, opened a package of gauze and a bottle of normal saline. The RN wet the gauze with saline and cleaned the patient’s wound. The nurse then opened a new package of dressing supplies and applied the dressing to the patient’s wound. The nurse then replaced the new depends on the patient and repositioned the patient. The RN did not change gloves between changing depends and gathering clean dressing supplies and providing wound care. During review of the home visit, the Registered Nurse/Director of Nursing was in agreement that gloves should have been changed between removing soiled diaper, cleaning the wound area and applying the clean dressing to the wound. Home Visit 2/Clinical Record 2: The patient elected the hospice benefit on 12/7/2022, with terminal diagnosis of Alzheimer’s disease. During the home visit observation, the RN was observed to wash hands and don exam gloves. The nurse then removed the pulse oximeter from the nursing bag, took the patient’s pulse oximeter reading and returned the pulse oximeter to the nursing bag after cleaning the oximeter. The nurse then obtained the blood pressure (BP) cuff from the nursing bag, took the patient’s BP, cleaned the BP cuff, and returned it to the nursing bag and retrieved the thermometer. The RN did not change gloves or wash hands each time the nurse reentered the nursing bag. 2 of 3 (66%) of home visits observed revealed that the agency did not ensure that accepted standards of practice for infection control were consistently used for patient care.

It is required that hospice aides are assigned to a specific patient by a Registered Nurse (RN) who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 7 (29%) clinical records reviewed with hospice aide services, the agency did not ensure that written instructions for the aide included patient specific directions and needs. Clinical Record 1: The patient elected the hospice benefit on 6/23/2022, with terminal diagnoses of Alzheimer's disease and stage 4 pressure ulcer to the sacrum. The recertification assessment completed by the RN on 8/2/2023 included documentation of a stage 4 pressure wound to the sacrum. The plan of care dated 8/17/2023 through 10/15/2023 included orders for dressing changes to the sacral wound. Review of the hospice aide care plan assignment dated 8/17/2023 revealed no documentation related to the patient’s sacral wound and no guidance to the hospice aide on how to care for the wound dressing while providing bed baths to the patient or what to do if the dressing becomes dislodged, soiled, or wet. Clinical Record 11: The patient elected the hospice benefit on 5/25/2023, with a terminal diagnosis of secondary malignant neoplasm of the large intestine. The start of care comprehensive assessment completed by the RN on 5/25/2023 included documentation that the patient had an ileostomy [a surgical opening from the small intestine to the patient’s abdomen]. The hospice aide care plan assignment did not include information or guidance to the hospice aide related to caring for the patient’s ileostomy. During an interview on 9/27/2023, the Director of Nursing (DON) reported that the aide is not to get the dressing wet on patient 1. The DON confirmed that aide care plan did not give specific instruction to the aide related to the patients wound and dressings. The DON confirmed that ileostomy was delinquent on the aide care plan for record 11. 2 of 7 (29%) clinical records reviewed with a hospice aide revealed that the agency did not ensure that written instructions for the aide included patient specific directions and needs.