Every finding on record at Carrington Hospice Care Inc

Based on record review and interview, the agency failed to obtain a criminal background check in accordance with state requirements on 2 (Volunteer Coordinator D and Chaplain B/Bereavement Coordinator) of 2 unlicensed employees, hired in July 2025, that had direct client contact or access to patient records. The failure placed the patients at risk of abuse, neglect, or exploitation. --- Review of Texas Administrative Code, Chapter 558 read in part..."558.855 Criminal Background Checks...a hospice must conduct a criminal history check on all hospice employees and volunteers with direct client contact or access to client records to verify each employee's or volunteer's criminal history report does not include a conviction that bars employment under Texas Health and SafetyCode..." Review of Texas Health and Safety Code read in part..."Title 2 Health. Subtitle G. Licensed and Other Regulation. Chapter 142. Home and Community Support Services. Subchapter A. Home and Community Support Services license. Sec. 142.001. Definitions. In this chapter...(12) Home and Community Support Services agency means a person who provides home health, hospice, habilitation, or personal assistance services for pay or other consideration in a client's residence, an independent living environment, or another appropriate location..." Review of Texas Health and Safety Code read in part..."Title 4. Health Facilities. Subtitle B. Licensing of Health Facilities. Chapter 250. Nurse Aide Registry and Criminal History checks of Employees and Applicants for employment in certain facilities serving the elderly, persons with disabilities, or persons with terminal illnesses. Sec. 250.001. Definitions. In this chapter...(3) Facility means...(C) a home and community support services agency licensed under Chapter 142...Sec. 250.002. Information obtained by facility, regulatory agency, or private agency. (a) A regulatory agency or a financial management services agency on behalf of an individual employer is entitled to obtain from the Department of Public Safety of the State of Texas Criminal history record information maintained by the Department of Public Safety that relates to a person who is...(3) an applicant for employment at or an employee of a facility licensed under Chapter 142 whose employment duties would or do involve direct contact with a consumer in the facility...Sec. 250.004. Criminal History record of Employees. (a) Identifying information of an employee in a covered facility or of an employee of an individual employer shall be submitted electronically, on disk, or on a typewritten form to the Department of Public Safety to obtain the person's criminal conviction record when the person applies for employment..."  Review of the agency's employee roster provided by the Alternate Administrator/Supervising Nurse (hire date 7/17/2025) listed the following employees and their date of hire: Volunteer Coordinator D was hired on 7/18/2025.Chaplain B/Bereavement Coordinator was hired on 7/18/2025. Volunteer Coordinator D:Review of Volunteer Coordinator D's personnel record revealed an application for employment. The application indicated that Volunteer Coordinator D was available to start on 7/17/2025. The application contained a question asking if the applicant had worked with them (the agency) before. Volunteer Coordinator D left the question blank. The application contained a work history that indicated that Volunteer Coordinator D worked at Agency Z since July 2021. Volunteer Coordinator D's personnel record contained the following: Volunteer Coordinator D signed a job description titled Hospice Volunteer Coordinator dated 7/17/2025. The Volunteer Coordinator job description included participation in the care planning process; documents on the Plan of Care for all patients receiving volunteer services; reviews and documents on the individualize plan of care as frequently as the client's condition required by no less frequently that every 15 days.  Volunteer Coordinator D had orientation on 7/17/2025. Volunteer Coordinator D signed a document titled "Statement of Employability" (statement was blank) on 7/17/2025. The statement did not indicate that a criminal history check had been performed and did not indicate if Volunteer Coordinator D was employable.  During the review of Volunteer D's personnel record for Volunteer Coordinator D, the surveyor noted that there were documents dated from 5 months to 4 years prior to Volunteer Coordinator applying for employment at the hospice. The personnel record contained the following:W-4 dated 7/26/2021 (4 years prior to application).An employee occurrence report dated 2/28/2025 indicating the occurrence happened with Agency Z (5 months prior to application).Tuberculosis screening dated 10/7/2022 (2.5 years prior to application).Hepatitis B vaccination, declination, dated 10/7/2022 (2.5 years prior to application).Staff Acknowledgement of Self Screening Process dated 10/19/2021 (3.5 years prior to application).Hepatitis B Vaccination signed 3/28/2022 (3 years prior to application).Mileage reimbursement dated 5/19/2022 with Agency Z (3 years prior to application).An addendum to Influenza Vaccine dated 9/20/2022 (approximately 3 years prior to application)   Chaplain B/Bereavement Coordinator:Review of Chaplain B/Bereavement Coordinator's personnel record revealed an application for employment that was undated. The application indicated that Chaplain B/Bereavement Coordinator was available to start employment on 7/17/2025. The application contained a question asking if the applicant had worked with them (the agency) before. Chaplain B/Bereavement Coordinator had answered the question 'No' The application contained a work history that indicated that Chaplain B/Bereavement Coordinator worked at Agency Z since 1/21/2020. Chaplain B/Bereavement Coordinator's personnel record contained the following: Chaplain B/Bereavement Coordinator signed jobs descriptions for Chaplain/Pastoral Counselor/Spiritual Caregiver and Bereavement Coordinator on 7/19/2025. The Bereavement Coordinator job description indicated that the Bereavement Coordinator would work in the office and in homes. The Chaplain/Pastoral Counselor/Spiritual Caregiver job description indicated that the Chaplain would work in patient homes and would assess the Hospice patient. Chaplain B/Bereavement Coordinator had orientation on 7/18/2025.  Chaplain B/Bereavement Coordinator signed a document titled "Statement of Employability" (statement was blank) on 7/18/2025. The statement did not indicate that a criminal history check had been performed and did not indicate if Chaplain B/Bereavement Coordinator was employable.  During the review of Chaplain B/Bereavement Coordinator's personnel record the surveyor noted the personnel records contained documents that were dated, 2.5 to 5 years, prior to Chaplain B/Bereavement Coordinator applying for employment at the hospice. The personnel record contained the following:  W-4 form dated 10/7/2022 that listed Chaplain B/Bereavement Coordinator's employer as Corporation X in Irvine California (2.5 Years prior to hire at the agency).W-4 form dated 1/29/2020 (5 years prior to application) .A Hepatitis B Vaccination declination that was dated 1/29/2020 (5 years prior to application)Reference Checks-Verbal that were dated 1/23/2020 and 1/23/2020 (5 years prior to application) The agency was not able to provide to the surveyors evidence that criminal history background checks were obtained on Volunteer Coordinator D and Chaplain B/Bereavement Coordinator when they applied for employment at the agency.  During an interview on 7/23/2025 at 9:38 a.m. with the Chaplain/Bereavement Coordinator, Surveyor A asked how long the Chaplain/Bereavement Coordinator had worked for the agency. Chaplain/Bereavement Coordinator stated, "Sometime in July of 2025." During an interview  on 7/24/2025 at 9:55 a.m. with the Alternate Administrator/Supervising Nurse, Surveyor B asked who was responsible for conducting the criminal history checks. The Alternate Administrator/Supervising Nurse stated, "Corporate office does those." During an interview on 7/24/2025 at 2:50 p.m. with the Alternate Administrator/Supervising Nurse, the Alternate Administrator /Supervising Nurse was asked why the criminal history checks were not obtained on Volunteer Coordinator D and Chaplain B/Bereavement Coordinator. The Alternate Administrator/Supervising Nurse stated, "The background checks weren't run on current corporation (Corporation X) employees because they remained current corporation (Corporation X) employees." The surveyor discussed that the personnel records contained documents that were dated prior to the unlicensed employees application to the agency. The Alternate Administrator/Supervising Nurse stated that the Volunteer Coordinator and Chaplain B/Bereavement Coordinator were employed at another hospice, Hospice Z, which was another hospice agency that was owned by Corporation X. The Alternate Administrator/Supervising Nurse informed the surveyor that the agency was owned by Corporation X and Hospice Z was owned by Corporation X. The Alternate Administrator/Supervising Nurse informed the surveyor that the agency had done an orientation, statement of employability, and job description and the agency did not obtain a criminal history check because they were already currently employed with (Corporation X) when they applied to the agency. The Alternate Administrator/Supervising Nurse did not state how it could affect the agency's clients. The Alternate Administrator/Supervising Nurse gave the surveyor a document titled "Addendum (A) Personnel Files" policy that read that personnel files will service all Hospice entities under Corporation X; and All contents with Personnel files maintained will be applicable to all Corporation X hospice entities.  Review of the agency's policy titled "Background Checks," labeled HR 115, and last reviewed on 9/1/2024. The policy read in part; "Purpose To establish procedures for verification of employability and define guidelines for criminal history record information, Office of Inspector General (OIG), and System for Award management (SAM) Exclusion lists, as applicable. Note: Whenever the term "employee" is used within this policy, volunteers are included. Policy I. The Hospice will obtain a criminal background check on all Hospice Employees who have direct patient contact or access to patient records...B. Criminal background checks will be obtained in accordance with state requirements...II. The Hospice will perform background checks for verification of employability, in compliance with applicable federal, state, and local laws, on staff who have direct contact with patients and/or access to patient records...Procedure I. Criminal History Checks A. The Hospice may pay a private third-party agency to obtain criminal history record information or B. Obtain the information directly from the appropriate state specific Department of Public Safety agency...D. A criminal history check will be obtained prior to employment and per state requirements on all Hospice employees and contractors that have direct contact with patients or access to patient records..." Review of the agency's "Background Checks- Addendum," labeled HR 115-TX, and last reviewed on 4/1/2025. The policy read in part; "...Procedure I. In addition to the requirements defined in the Background Checks policy in the Human Resources section of the Administrative Policy Manual, the following requirements will be met: A. Criminal History Checks and Registry Searches...3. The Hospice will conduct a criminal history check authorized by, and in compliance with the following the Texas Health and Safety Code (HSC), Title 4, Subtitle B, Chapter 250 (relating to Nurse Aide Registry and Criminal History Checks of Employees and Applicants for employment in Certain Facilities Serving the Elderly, Persons with Disabilities, or Person with Terminal Illness) for an unlicensed applicant and unlicensed employee for employment..."