Every finding on record at Grace Hospice

Based on staff interview and record review the agency failed to obtain criminal background checks on 1 of 5 volunteers (V1) reviewed who had direct contact with patients. This had the potential to affect all patients currently receiving hospice services. --- Findings include: Review of V1's volunteer file identified V1 completed orientation on 2/26/22. The file contained no documentation to support a criminal background check was completed for V1. During an interview on 4/12/23 at 9:40 a.m., the director of volunteer services (DVS) stated she was unable to find documentation to support a background check had been completed for V1. DVS added V1 had completed unsupervised visits with patients since 9/13/22. During an interview on 4/12/23 at 2:09 p.m., the director of hospice services stated all volunteers are required to have a criminal background check prior to starting patient visits. The director added that background checks are necessary to help protect patients receiving volunteer visits as part of their hospice care team. The facility policy, Volunteers - Personnel Records (undated), included, "Each volunteer personnel file contains:...criminal background check information (for patient care volunteers)."