Every finding on record at Harmony Hospice Care LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy and drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 19 (16%) clinical records reviewed revealed that the agency did not ensure that the documented comprehensive assessment included a drug profile that contained the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The agency's policy, Medication Orders (10/24/2024) read in part, "Upon admission, a comprehensive medication reconciliation will be conducted. The nurse completing the admission will review and document all medication including prescription medications, over-the-counter medications, vitamins, and herbal supplements. The nurse will verify medication doses, routes, and frequencies with the patient, family/caregivers, and/or facility staff and coordinate with the prescribing physician if there are any discrepancies or concerns. The Hospice Care Team will perform medication reconciliation for each patient every 30 days to verify, review, and document all medications that the patient is currently taking." Clinical Record 7: The comprehensive assessment completed on 10/24/2023 included Oxygen at 3.5 LPM. Oxygen was not included in the medication profile (effective on 10/24/2023) and as a result, Oxygen was not included in the medication review. Clinical Record 9: The comprehensive assessment dated 05/02/2024 included an order for Oxygen. Oxygen was not included in the medication profile (effective on 05/02/2024) and as a result, oxygen was not included in the medication review. Clinical Record 15: The comprehensive assessment dated 10/20/2023 included an order for Oxygen. Oxygen was not included in the medication profile (effective on 10/20/2023) and as a result, was not included in the medication review. In an interview with the Director of Nursing (DON)and the Assistant Director of Nursing (ADON) on 11/07/2024, the DON and ADON, after reviewing the medication profiles agreed that the medication reconciliation/reviews did not include all medications.

It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, includes all services necessary for the palliation and management of the terminal illness, including medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed revealed the agency did not ensure that each patient’s individualized written plan of care included medical supplies and appliances necessary to meet the needs of the patient. Clinical Record 2: The patient was admitted on 08/21/2024 with a diagnosis of Senile Degeneration of the Brain. The Plan of Care (POC) dated 08/21/2024 to 11/18/2024 documented bowel and bladder incontinence as functional limitations, however, the incontinence supplies and appliances necessary to meet the needs of the patient were not included. During an interview with the Administrator and Director of Nursing (DON) on 11/07/2024, the DON agreed that the supplies should have been in the plan of care but were not included.

It is required that hospice aides are assigned to a specific patient by a registered nurse 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 11 of 19 (58%) clinical records reviewed revealed that the agency did not ensure that the RN provided specific care instructions for the aide to follow. Clinical Record 1: The patient was admitted on 09/10/2024 with a diagnosis of Dysphagia, Esophageal Stricture, Atrial Fibrillation (on an anticoagulant), and was on oxygen. The aide care plan effective 09/10/2024 to 11/08/2024 did not include aspiration, bleeding, or oxygen precautions. Clinical Record 2: The patient was admitted on 08/21/2024 with a diagnosis of Senile Degeneration of the Brain, Vascular Dementia, and Congestive Heart Failure, and was on Oxygen. The aide care plan, dated 08/21/2024, did not include oxygen precautions. Furthermore, that aide care plan included the following aide tasks that were assigned to be performed, “as needed” with no indication and no identified decision maker: dressing the patient, assisting with elimination, making the bed. Clinical Record 3: The patient was admitted on 03/20/2024 with diagnoses that included Senile Dementia, Atrial Fibrillation (on an anticoagulant), and Chronic Obstructive Pulmonary Disease (COPD) and was on oxygen. The aide care plan for the certification period of 09/16/2024 to 11/14/2024 did not include bleeding precautions or oxygen precautions. Clinical Record 5: The patient was admitted on 05/13/2024 with a diagnosis of Hypertensive Heart Failure and taking the antiplatelet, Aspirin 81 mg. Bleeding precautions were not included in the aide care plan, dated 05/13/2024. Clinical Record 6: The patient was admitted on 04/12/2024 with diagnoses that included End Stage Dementia and Heart Failure with oxygen and anticoagulation therapy. The aide care plan for the certification period of 10/09/2024 to 12/07/2024, did not include bleeding or oxygen precautions. Clinical Record 9: The patient was admitted on 05/02/2024 with a diagnosis of protein-calorie malnutrition. The patient also had an order for oxygen therapy, however, the aide care plan for the certification period of 07/31/2024 to 10/28/2024 did not include oxygen precautions. Furthermore, that aide care plan included the following aide tasks that were assigned to be performed, “as needed” with no indication and no identified decision maker: hair care, peri care, and oral care. Clinical Record 10: The patient was admitted on 07/18/2024 with a diagnosis of Cerebral Infarction affecting the dominant right side and was on oxygen therapy. For the certification period of 07/18/2024 to 10/15/2024 the aide care plan did not include oxygen precautions. Clinical Record 11: The patient was admitted on 07/13/2024 with diagnoses that included Unspecified Cerebral Infarction, Dysphagia, Atrial Fibrillation with anticoagulation therapy. The aide care plan for the certification period of 07/13/2024 to 10/10/2024. did not include bleeding or aspiration precautions. Clinical Record 12: The patient was admitted on 06/25/2024 with diagnoses that included Dementia and Seizure Disorder. For the certification period of 09/23/2024 to 12/21/2024, the aide care plan did not include seizure precautions. Furthermore, that aide care plan included the following aide tasks were assigned to be performed, “as needed” with no indication and no identified decision maker: ambulation, commode, and elimination. Clinical Record 14: The patient was admitted on 07/15/2024 with diagnoses that included Malignant neoplasm of the Cerebrum except lobes and ventricles and was on dexamethasone. For the certification period of 07/15/2024 to 10/12/2024 the aide care plan did not include seizure precautions. Clinical Record 18: The patient was admitted on 06/24/2024 with diagnoses that included Hypertensive Heart Disease with Failure, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease with oxygen therapy, Atrial Fibrillation with anticoagulation therapy, and Dysphagia. The aide care plan effective 06/24/2024 to 09/16/2024 did not include aspiration, bleeding, or oxygen precautions. In an interview with the Director of Nursing (DON) on 11/07/2024, the DON stated after reviewing the aide care plans that the care plans did not include the safety measures but was unable to state why the safety measures had not been included. All precautions were noted on the plan of care but not included in the information provided to the hospice aides on their care plan.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. This standard was not met as evidenced by document review and interview. A review of the Volunteer Cost Savings document and interview revealed the agency did not ensure that volunteers were used in day-to-day administrative and/or direct patient care roles that, at a minimum, equaled five percent of the total patient care hours of all paid hospice employees and contract staff. The reported Volunteer Cost Savings were: January 2024 (1.06%); February 2024 (1.35%); March 2024 (1.74%); April 2024 (2.24%); May 2024 (1.91%); June 2024 (2.52%); July 2024 (2.11%); August 2024 (2.01%); September 2024 (1.71%); and October 2024 (2.53%). During an interview, on 11/08/2024, the Volunteer Coordinator stated that they lost several volunteers after COVID-19; many of whom retired and are not volunteering at this time.

It is required that a hospice aide provides services: ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. In 4 of 5 (80%) records reviewed, in which the hospice aide was accepted, the agency did not ensure that the hospice aides were compliant with completing tasks and visits as assigned in the hospice plan of care and/or physician’s orders.. Clinical Record 3 Aide care plan, effective 3/15/22, ordered five visits per week with the following tasks to be completed "every visit": complete bed bath, skin care/lotion, elimination care (diaper change). Documentation on the following visits revealed the hospice aide did not complete all of these tasks: 4/15/22, 4/19/22, 4/20/22, 4/26/22, 4/27/22, 4/28/22, 4/29/22, 5/3/22, 5/4/22, 5/5/22, 5/6/22, 5/10/22, 5/11/22, and 5/13/22. In the "note" section the aide documented the reason for not completing the task as "task already completed". The administrator reviewed this record and reported that at the dates coincided with a change in aide assignments and the new aide made the visits later in the day. The administrator agreed that the aide did not provide the services as ordered and that the care plan should have been updated. Clinical Record 0 Aide care plan, effective 7/17/22, ordered four visits per week, the week of 7/17/22 the aide documented five completed visits. The administrator was unable to locate order changes for the fifth visit. Clinical Record 2 Aide care plan, effective 4/26/22, ordered five visits per week, with the agency week starting on Sunday. The weeks of 5/29/22 and 6/5/22 there were 4 visits documented as made. The administrator reviewed the clinical record and was unable to locate documentation of reason for the missed visit or changes to the orders. The administrator does note that the week of 5/29/22 was a holiday week and that is why the visits were decreased, there were no documented changes to the orders or patient/family refusals for that week. Clinical Record 1 Aide care plan, effective 5/15/22, ordered five visits per week. The weeks of 5/29/22 and 7/3/22 there were four visits documented as made. The administrator reported that those were holiday weeks and that is why the visits were decreased. There was no documentation for order changes or patient/family refusals for the missed visits. During an interview with the administrator, on 7/26/22, it was confirmed that in these records the aides did not follow the established plan of care and that changes to the visit frequency, even in holiday weeks, needed to have supportive documentation.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: Prescription and over-the-counter (OTC) drugs; Supplements; Herbal remedies; Other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: The effectiveness of drug therapy; Drug side effects; Actual or potential drug interactions; Duplicate drug therapy; Drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effecs of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by a review of clinical records, agency policies, observation, and interview. 6 of 13 (46%) clinical records reviewed revealed that the drug profile was not updated per hospice policy and procedure and minimally at the time of each comprehensive assessment and when new medications were added to the medication profile. Agency policy titled, "Comprehensive Assessment-Content" (reviewed 2/1/21), stated in part: "The comprehensive assessment of the patient consists of discipline specific assessment tools that address the following factors: a review of all the patient's prescription and over the counter drugs, herbal remedies and other alternative treatments that could affect drug therapy." Agency policy titled, "Medications-Management" (effective 2/7/19), stated in part: "The medication profile includes all prescription, over the counter drugs, vitamins and herbal alternative supplements." Record #53089: A review of interdisciplinary team meeting (IDT) documentation dated 3/12/21 revealed that the patient was started on Zyprexa 2.5 mg every morning, and this medication was not included on the medication list. As a result, a review of the updated medication profile, including drug side effects, actual or potential drug interactions and duplicate drug therapy was not completed. Record #35114: The patient was admitted to service on 1/28/21. The initial and ongoing nursing comprehensive assessments through the patient's date of death on 2/22/21, revealed the patient was receiving Oxygen continuously at 2-5L/min per nasal cannula. This medication was not included on the medication list. Record #93819: The comprehensive nursing assessment dated 2/25/21 documented that the patient was receiving Oxygen at 5L/min per nasal cannula. This medication was not included on the medication list. Record #10697: The patient was admitted to service on 8/24/21. A home visit was conducted on 12/1/21 at 7:15 am in the skilled nursing facility (SNF) where the patient resided. A review of the SNF medication profile revealed that the patient was ordered Oxygen 2L/min per nasal cannula as needed, dated 7/29/21. An Oxygen concentrator was noted present in the patient's room. In addition, a review of treatment orders present in the SNF revealed that on 9/26/21, Nystatin Cream and Zinc Cream were ordered to be applied after each incontinent episode for treatment of an area with a skin rash. These medications were not included on the hospice medication profile throughout the course of care. As a result, a review of the updated medication profile including drug side effects, actual or potential drug interactions and duplicate drug therapy with these medications was not completed. Record #84619: The patient was admitted to service on 8/13/21. A home visit was conducted on 12/1/21 at 8:00 am in the Assisted Living Facility (ALF) where the patient resided. A review of the facility medication profile revealed medications that were not included on the hospice medication profile throughout the course of care. These medications included Ondansetron tablet 4 mg 1 tablet every six hours as needed for nausea dated 8/4/21 and also Triamcinolone Cream 0.1% to Bilateral lower extremities- apply three times a day for dry skin dated 8/12/21. As a result, a review of the updated medication profile including drug side effects, actual or potential drug interactions and duplicate drug therapy was not completed. Record #90448: The initial nursing comprehensive assessment narrative dated 1/24/21 documented that the patient was on Oxygen at 2L/min per nasal cannula and this medication was not included on the medication list. The Clinical Director stated in interview during a joint review of the clinical records on 12/2/21 that the patients' medication profiles did not include documentation of all medications that the patients were receiving, per the agency policy.

It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcomes and reassessment of the patient’s response to care. The assessment update is completed as frequently as the condition of the patient requires yet no less frequently than every 15 days. This standard was not met as evidenced by a review of clinical records, agency policy, CMS Waiver and interview. 1 of 13 (8%) records reviewed lacked evidence that the comprehensive assessment was completed no less frequently than every 15 days. Agency policy titled, "Comprehensive Assessment of the Patient" (reviewed 2/1/21), stated in part: "The patient's comprehensive assessment is updated at a minimum every 15 days or more frequently if needed by the patient." Review of the CMS Blanket Waiver Guide (retroactive to 3/1/2020) revealed that the "timeframe for updating the assessment is extended from 15 to 21 days." Record #10697: A comprehensive assessment was completed by an RN on 9/17/21 then not again until 10/9/21, which was 22 days. Missed nursing visits were documented on 9/27/21, with a note that the visit was not completed "due to scheduling conflict", and also on 10/1/21, due to "unable to visit". The Clinical Director stated during a joint review of the clinical record on 12/2/21 that the comprehensive assessment for this patient was not completed no less frequently than every 21 days as described in the CMS Waiver. She further stated that she was not aware of the length of time between this patient's comprehensive assessment and that "should not have happened."

It is required that each patient’s individualized written plan of care: Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments; and includes all services necessary for the palliation and management of the terminal illness. This standard was not met as evidenced by a review of clinical records, agency policies, observation, and interview. 8 of 13 (61%) records reviewed contained hospice plans of care (POC) that were missing documentation of all the planned interventions being provided by staff at the facilities the patients resided, based on problems identified in comprehensive assessments, and included all services needed for palliation and management of the patients' terminal illness. Record #90448: The patient was admitted to service on 1/24/21 and expired on 2/15/21. The initial and ongoing hospice assessments identified a wound to the right heel with wound care, presence of oral thrush, and respiratory distress treated with the use of Oxygen. The patient resided in a skilled facility and these treatments were completed by facility staff. Orders for these medications and treatments were present in the patient’s facility records, however the hospice POC did not include orders for these medications and treatments. Record #35114: The patient was admitted to service on 1/31/21 and expired on 2/22/21. The initial and ongoing assessments documented the patient's use of oxygen for respiratory distress, however the hospice POC did not include orders for oxygen. Record #10697: The patient was admitted to service on 8/24/21. During a home visit completed on 12/1/21 at 7:15 am, an oxygen concentrator was present in the patient’s residence. Review of nursing documentation revealed the patient had been using Oxygen at 2L/min per nasal cannula since 7/9/21. In addition, the initial comprehensive nursing assessment dated 8/24/21 noted pressure ulcers to the right and left buttocks with a wound treatment provided. Also, Interdisciplinary Team meeting notes dated 9/10/21 identified that the patient was being treated for a yeast infection. The patient resided in a facility and review of facility documents during home visit observation confirmed these treatments were completed by facility staff. Orders for these medications and treatments were present in the patient’s facility record, however the hospice POC did not include orders for these treatments. Record #84619: Review of nursing visit documentation dated 8/14/21 revealed that the patient had a wound to the right ankle and was receiving wound care to this area. Also, Music therapy was noted as provided on 8/17/21. The patient resided in a facility and review of facility documents during home visit observation confirmed these treatments and therapy were provided by facility staff. Orders for the wound care treatment and music therapy was present in the patient’s facility record, however the hospice POC did not include orders for these treatments. Record #53089: The record documented that the patient was receiving Coumadin therapy and PT/INR testing was being completed. The patient resided in a facility these interventions were completed by facility staff Orders for interventions related to Coumadin use, lab testing and safety precautions were present in the patient’s facility records, however the hospice POC did not include interventions related to safety precautions with use of anticoagulant therapy. Record #69702: A review of the record revealed that the patient was receiving music therapy and that visits had been provided on 10/12/21, 10/19/21 and 11/10/21. The patient resided in a facility and orders for music therapy were present in the patient’s facility records, however the hospice POC did not include those orders. Record #78561: A review of the record revealed that the patient received music therapy visits on 9/23/21 and 10/19/21. The patient resided in a facility and orders for music therapy were present in the patient’s facility records, however the hospice POC did not include those orders. Record #78917: A review of the record revealed that the patient received music therapy visits on 9/22/21 and 10/19/21 The patient resided in a facility and orders for music therapy were present in the patient’s facility records, however the hospice POC did not include those orders. Agency policy titled, "Plan of Care Content" (reviewed 2/1/21) stated in part: "The plan of care includes but is not limited to: drugs and treatment necessary to meet the needs of the patient… The plan of care reflects patient and family goals and interventions that are based on the problems identified in the initial, comprehensive and updated assessments." Agency Policy titled Comprehensive Assessment-Patient Outcomes Measures (reviewed 2/1/21) stated in part "The data collected from the patient's comprehensive assessment is used to provide individualized care planning, appropriate intervention and for the coordination of services for each patient." During joint review and interview, with the Clinical Director on 12/2/21, they acknowledged that the POC's lacked evidence of all treatments and interventions the patients were receiving and confirmed that those ordered interventions were directly provided by the facilities’ staff.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency. This standard was not met as evidenced by a review of personnel records, agency policy and interview. 3 of 4 (75%) applicable personnel records reviewed for professional staff providing direct patient care revealed there was no evidence that the hospice had assessed the skills and competencies of the employees. [Records: #36293/registered nurse, #61723/social work, and #94640/spiritual care]. Agency policy, "#HR.C10, Competency Assessment" (no review date), stated in part: "As a component of the orientation process, new staff and volunteers complete a competency evaluation prior to providing care or assuming administrative responsibilities." The Clinical Director stated in interview during a joint review of the records that she did not have documentation of skills competency assessments for these individuals on hire or at any timepoint.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by a review of clinical records, agency policy and interview. 7 of 7 (100%) records reviewed for patients residing in a skilled nursing facility revealed the hospice Plans of Care did not include documentation that identified which provider would be responsible for performing specific interventions included in the plans of care [Records: #78561, #78917, #53089, #55981, #93819, #10697 and #69702]. Agency policy, "Hospice Care for Nursing Facility Residents-Hospice Plan of Care" (reviewed 2/1/21), stated in part: "The plan of care for the facility patient identifies the care and services that are needed and specifically identifies which provider is responsible for performing the respective functions that have been agreed upon and included in the plan of care." The Clinical Director stated in interview during a joint review of the clinical records on 11/30/21 that the current EMR could not document which specific interventions would be completed by the hospice staff and which would be completed by the skilled facility staff. The hospice was in the process of developing a work-around to capture this information on the hospice plans of care. Interviews and observations during home visits to patients residing in a skilled facility revealed clear understanding and coordination of patient interventions between the hospice and facility staff, resulting in patients receiving all of the care and treatments ordered.

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: the most recent hospice plan of care; Hospice election form and any advance directives; Physician certification and recertification of the terminal illness; Hospice medication information; and Hospice physician and attending physician (if any) orders. This standard was not met as evidenced by a review of clinical records, agency policy and interview. 2 of 2 (100%) home visits to patients residing in a skilled nursing facility revealed that the hospice had not provided the skilled nursing facility with the most recent hospice plan of care, Hospice election form, and documentation of any advance directives, physician certification and recertification of the terminal illness, Hospice medication information and Hospice physician and attending physician (if any) orders. Agency policy, "Hospice Care for Nursing Facility Residents-Coordination of Services" (reviewed 2/1/21), stated in part: "The following information is provided to the facility: the most recent hospice plan of care specific to each patient; hospice election form and any advance directives specific to each patient; physician certification and recertification of the terminal illness specific to each patient; hospice medication information specific to each patient; and hospice physician and attending physician (if any) orders specific to each patient." Record #10697: A home visit was conducted on 12/2/21 at 7:15 am in the skilled nursing facility (SNF) where the patient resided. A review of hospice records at the SNF revealed that the patient was admitted to hospice services on 8/24/21. The SNF staff were unable to locate documentation of: a hospice plan of care for any timepoint; the Hospice election form; Physician certification and recertification of the terminal illness; Hospice medication information; and Hospice physician and attending physician orders. The hospice RN Case Manager (Staff #21916) was contacted by phone and during interview they stated that the hospice had not yet developed a system of having the hospice documents delivered to the SNF. Record #55981: A home visit was conducted on 12/2/21 at 9:00 am in the SNF where the patient resided. A review of hospice records at the SNF revealed that the patient was admitted to hospice services on 10/21/21. The SNF staff were unable to locate documentation of the Hospice election form, Physician certification of the terminal illness, Hospice medication information, and Hospice physician and attending physician orders.

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 a review of documents and interview. A review of the agency's contract with the Medical Director (effective 3/25/20), Medical Transportation (effective 9/30/21), Physical, Occupational and Speech Therapy (effective 8/26/19), Associate Medical Director (effective 3/25/20), and Durable Medical Equipment (effective 2/7/19), revealed the contracts lacked verbiage that described the requirement that all contracted employees with direct patient contact or access to patient records are to undergo a criminal background check. The Executive Director stated in interview on 11/30/21 that the required verbiage was not present in these contracts. She further stated that she would obtain contract addendums.

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. Criminal background checks are obtained in accordance with state requirements. This standard was not met as evidenced by a review of personnel records, agency policy, State Administrative Code and interview. 7 of 10 (70%) personnel records reviewed for staff hired within the last 3 years lacked evidence that state-specific background checks had been completed at the time of hire. [Record #51285, #49514, #32678, #98800, #61723, #58633 and #39664]. The state's Administrative Code stated in part that in addition to the Bureau of Criminal Investigation (BCI) check, the following six data bases are to be reviewed for any direct care employee: "(1) The 'System for Award Management' maintained by the United States general services administration, (2) The list of excluded individuals and entities maintained by the office of inspector general in the United States department of health and human services, (3) The registry of employees guilty of abuse, neglect, or misappropriation maintained by the State department of developmental disabilities, (4) The sex offender and child-victim database maintained by the State attorney general, (5) The database of inmates maintained by the State department of rehabilitation and correction, and (6) The State nurse aide registry, maintained by the State department of health." Agency policy, "#HR.C25, Criminal Background Checks" (no review date), stated in part that the hospice agency "obtains criminal background check as required by State laws and regulations." The Owner, who was the former Executive Director of the agency, was interviewed during a joint review of the personnel records, and stated that he had hired a company to run background checks for all employees, yet he did not have a list of what checks had been completed to know if they met the state's requirements. He further stated that he had contacted the company who did not provide him with a detailed list of the checks that were completed on newly hired employees.