Every finding on record at Walla Walla Community Hospice

Based on record review and interview, the agency failed to update its policies and procedures to remain compliant with state licensing requirements for 3 of 12 personnel files reviewed (Staff #603, Staff #604, and Staff #608). Failure to maintain and implement policies and procedures consistent with state home health regulations puts patients at risk of physical and/or psychological harm from inadequate or substandard care. . --- References: WAC 246-335-625 Personnel, contractor, and volunteer policies. The applicant or licensee must develop and operationalize personnel, contractor, and volunteer policies and procedures that describe: (3) References for personnel, contractors, and volunteers. Findings included: 1. Record review of the agency's policy and procedure (P&P) titled, "Hiring New Staff," (Policy No. HR.H15, Undated) lacked the requirements for reference checks prior to employment. 2. Record reviews on 3 of 8 personnel files showed: a. Staff #603 was hired on 10/23/19. There was no documentation in the staff record to show that the agency completed reference checks prior to employment. b. Staff #604 was hired on 06/11/19. There was no documentation in the staff record to show that the agency completed reference checks prior to employment. c. Staff #608 was hired on 08/07/18. There was no documentation in the staff record to show that the agency completed reference checks prior to employment. 3. On 10/12/23 at 11:30 AM, Surveyor #6 interviewed the agency's Administrative Operations and Compliance Officer (Staff #601) about the missing documentation of reference checks in the employee files. Staff #601 acknowledged the findings, and stated that the agency was unable to provide the missing documents. .