Every finding on record at Dahlia Hospice

It is required that the hospice obtains 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. 1 of 5 (20%) applicable contracts reviewed where contracted staff would have access to patient records or have patient contact, it was revealed that the hospice did not ensure that the contractual language contained the requirement for background checks to be performed. Contract 2: The corporate contract effective 2/28/2023 did not include the language that any staff that would be in contact with hospice patients or hospice patient records was required to have a background check performed. Personnel Record 1: In an interview with the Administrator on 4/13/2023, it was confirmed that the PT/ST/OT contract was, in fact missing the language requiring the background check of the therapy staff. Document 1: Personnel Administration, Categories/Qualifications of Personnel, Policy No. 1-002.1, effective date January 2023, reads, "Contract Staff—Individuals or groups of individuals who perform organization services as directed in a written agreement. Contract staff are not considered employees for purposes of overtime, longevity, benefits, etc. However, contract staff are subject to all position qualifications and competency requirements." Personnel Administration, Personnel Record Content, Policy No. 1-006.1 with the effective date of January 2023, reads "Purpose: To specify the content of the personnel files for direct employees and contract hospice staff...Per Diem/Contract Hospice Personnel...The content of the personnel files for per diem and contract hospice personnel will include: Criminal Background Check, if applicable, and a copy of the criminal record statement (LIC 508 form) (kept in separate file)." Leadership, Written Agreements for Contracted Services, Policy No. 4-020, effective January 2023, reads, "The responsibility of the contracted individual or organization to adhere, as appropriate, to applicable policies and personnel qualifications, including criminal background checks and Medicare Conditions of Participation and hospice when providing care..."